Psychometric Evaluation of the Fertiqol Questionnaire Among Infertile Individuals and Couples in Uganda: Findings From a Tertiary Hospital in Peri-urban Kampala

Psychometric Evaluation of the Fertiqol Questionnaire Among Infertile Individuals and Couples in Uganda: Findings From a Tertiary Hospital in Peri-urban Kampala | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Psychometric Evaluation of the Fertiqol Questionnaire Among Infertile Individuals and Couples in Uganda: Findings From a Tertiary Hospital in Peri-urban Kampala Douglas Makumbi, Anthony Kayiira, Gilbert Tumwine, Romano N. Byaruhanga, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6901451/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Infertility, affecting approximately 1 in 6 couples globally, is associated with profound psychosocial distress for both men and women. The Fertility Quality of Life (FertiQoL) instrument is a validated tool for assessing fertility-specific quality of life. However, its psychometric properties have not been evaluated in Uganda. This study aimed to assess the psychometric properties of the FertiQoL instrument among a sample of Ugandan individuals and couples experiencing infertility. Methods: A cross-sectional study took place at the fertility clinic in a peri-urban tertiary hospital in Kampala between March and May 2023. The English version of FertiQoL was translated into Luganda using standardized forward-backward translation procedures. The English and Luganda versions were administered to 120 participants. Internal consistency was measured using Cronbach’s alpha. Exploratory and confirmatory factor analyses (CFA) assessed construct validity. Convergent validity was examined via average variance extracted (AVE). Results: The FertiQoL demonstrated acceptable internal consistency across all subscales (α > 0.70), with the relational subscale showing the highest reliability (α = 0.86). Factor loadings for all items ranged from 0.30 to 0.86. Initial AVE values indicated acceptable convergent validity for the relational (0.56) and social (0.487) subscales, while the emotional (0.387) and mind-body (0.306) subscales fell below the threshold of 0.50. CFA conducted after removing items with low factor loadings improved AVE values for emotional (0.443) and mind-body (0.416) subscales, while relational (0.655) and social (0.551) reached acceptable levels. However, model fit indices remained suboptimal (CFI = 0.686; SRMR = 0.086; RMSEA = 0.202), potentially due to the limited sample size and cultural-contextual influences on item interpretation. Conclusions: The FertiQoL demonstrated satisfactory internal consistency. Construct validity findings were mixed, with relational and social subscales showing stronger psychometric properties than emotional and mind-body domains. Further validation studies with larger, more diverse samples and iterative cultural adaptation are recommended to enhance the instrument’s applicability in the Ugandan context. Health sciences/Health care Health sciences/Medical research Quality of Life (QoL) FertiQoL Psychometric properties Uganda Infertility Figures Figure 1 Figure 2 Background Infertility is recognized by the World Health Organization (WHO) as a disease of the reproductive system, defined by failure to achieve pregnancy after ≥ 12 months of regular unprotected intercourse ( 1 ). Globally, an estimated 48 million couples and up to 186 million individuals live with infertility, underscoring its importance as a public-health concern ( 2 ). Sub-Saharan Africa carries a disproportionate burden: pooled analyses report primary- and secondary-infertility prevalences of 1.9% and 10%, respectively ( 2 ). In Uganda, population-based surveys place overall infertility prevalence at approximately 6.4% ( 3 ) with marked social and economic repercussions ( 3 ). Beyond biomedical sequelae, infertility precipitates substantial psychosocial distress. Meta-analytic and cross-sectional evidence link infertility to grief, anxiety, depression, diminished self-esteem and relationship strain, all of which converge to lower health-related quality of life (QoL) ( 4 , 5 ). Yet psychosocial needs often remain obscured within biomedical service models ( 6 ). Standardized QoL measurement is therefore essential for holistic care, program evaluation and policy formulation ( 7 ). The Fertility Quality of Life (FertiQoL) instrument—developed through international consensus and grounded in health-psychology theory—offers a fertility-specific assessment spanning emotional, mind–body, relational and social domains ( 8 ). Unlike the generic psychological instruments such as the WHO-QoL, FertiQoL gives a more accurate picture of the cognitive, behavioral, and emotional state of persons with fertility problems ( 9 ). Comparative studies in Europe, Asia and North America demonstrate good reliability and validity ( 10 ). However, psychometric performance may vary across sociocultural settings; linguistic nuance, gender norms, religious beliefs and health-system factors can influence item interpretation ( 11 ). Rigorous local validation is therefore a prerequisite to meaningful use. We recently completed a forward–backward translation and linguistic validation of FertiQoL into Luganda—the most widely spoken language in central Uganda—and published the translation protocol and cognitive-debriefing results ( 12 ). To date, however, published African studies have largely deployed the non-adapted English version without formal validation (for example, Uganda ( 13 ) and Sudan ( 14 ), and no study has examined FertiQoL psychometric properties in a Ugandan sample. This represents a critical gap, given cultural specificities in the perception and stigma of infertility. Building on the completed Luganda translation, the present study evaluates the reliability and construct validity of both the Luganda and English versions of FertiQoL among infertile individuals and couples attending a tertiary non-profit fertility clinic in peri-urban Kampala. Establishing a culturally robust measure will enable clinicians, researchers and policy-makers to monitor fertility-related QoL accurately, tailor psychosocial interventions and advance WHO’s agenda for equitable, person-centered fertility care ( 15 ). Materials and Methods Design and Setting We employed a descriptive cross-sectional design, mirroring the methodological approaches used in recent African psychometric evaluations of patient-reported outcome measures (for example, (16). Data were collected between March and May 2023 at the Fertility Clinic of St Francis Hospital Nsambya, a faith-based, private not-for-profit tertiary referral hospital located approximately 5 km south-east of Kampala’s central business district. The fertility clinic has Two consultant obstetrician-gynecologists with subspecialty training in reproductive medicine, and a team of nurses, midwives, and senior house officers provide care. The clinic manages > 200 new and follow-up infertility cases annually, most referred from internal hospital departments or external facilities. Core investigations—including semen analysis, hormonal profiling, transvaginal ultrasound, and hysterosalpingography—are delivered in collaboration with the hospital’s ISO-certified laboratory and radiology units. Couples receive structured counselling and first-line medical or minor surgical management on site. Cases requiring advanced assisted-reproductive-technology (ART) procedures are referred to specialized ART centers in Kampala, in line with national practice patterns. Study population, Sample size and Sampling The target population comprised women and men aged 18–49 years presenting with primary or secondary infertility at the St Francis Hospital Nsambya Fertility Clinic between March and May 2023. Eligible participants had to (i) understand either English or Luganda, and (ii) provide written informed consent. We excluded individuals with severe physical illness precluding interview, those with a documented major psychiatric disorder, and women who had become pregnant at the time of recruitment. Psychometric guidelines recommend a respondent-to-item ratio of 3:1 to 20:1 for exploratory and confirmatory factor analyses (17). With 24 items in the Core FertiQoL and using a respondent-to-item ratio of 5:1 this yielded a minimum of 120 participants. For completeness, we also calculated a precision-based sample size for estimating the proportion of infertility-related psychological distress, using the Kish-Leslie formula for single proportions: N = z²pq/d² (Kish Leslie 1965). Where N is the sample size, Z-score corresponding to 95% confidence interval which is 1.96, p is the proportion of patients with psychological distress and d is the standard error in estimating the true proportion which was set at 0.05. Using a study by Zubairu & Yohanna, 2017, the prevalence of psychological distress was 79.9%. p = 0.799, q = 0.201, as shown in the equation below: Substituting into the above formula we got a sample size of 247 participants. Because the clinic registers ≈ 200 infertile patients annually, we applied a finite-population correction: Adjusted sample size, n= [n/1 + n/pop] = 111. The psychometric requirement (≥ 120) therefore governed recruitment. Data collection Procedure Eligible participants were identified from clinic appointment logs covering the preceding two years. The principal investigator (PI) and two trained midwife-research assistants screened medical charts to confirm an infertility diagnosis, verify current address/telephone contacts, and exclude pregnancies or comorbid psychiatric illness. Consecutive clients meeting the eligibility criteria were telephoned and invited to attend the clinic on a routine service day. On arrival, participants received a study information sheet in English or Luganda; written informed consent was obtained before any study-related activity. Sociodemographic and clinical variables (age, sex, parity, infertility type/duration, referral source) were abstracted from the medical record and transcribed onto piloted case-report forms (CRFs). All identifiers were coded to maintain confidentiality. Participants then completed the questionnaire package in a private room. Because literacy varies, the FertiQoL was administered as self-report with researcher assistance on request; items were read verbatim for respondents who preferred an interview-assisted format, replicating the approach used by Naamala et al. (2021) for HRQoL assessments in Uganda. Average completion time was 15–20 minutes. On finishing, respondents could ask infertility-related questions and were offered brief counselling or referral as appropriate. Completed forms were reviewed for missing data, sealed in tamper-proof envelopes and stored in a locked cabinet accessible only to the PI. FertiQoL Instrument The Fertility Quality of Life (FertiQoL) questionnaire was developed jointly by ESHRE and ASRM experts to capture fertility-specific health-related quality of life (8). It comprises: Core module (24 items): four 6-item subscales—Emotional (sadness, resentment, grief), Mind/Body (cognition, physical symptoms, behavior), Relational (partnership dynamics), Social (social inclusion, expectations, support), Optional Treatment module (10 items): Environment and Treatment Tolerability subscales—not used in this study because majority of participants were not yet receiving fertility treatment. Furthermore, the core module has general relevance and applicability across the population, irrespective of whether the individuals were undergoing or planning to undergo treatment, making it an essential component of the study’s methods. Items are presented in random order and rated on a 5-point Likert scale (0 = very poor to 4 = excellent). Subscale and overall scores are linearly transformed to 0–100, with higher values indicating better quality of life. The English original and the forward–backward Luganda translation previously validated by our group (12) were offered; participants chose their preferred language. Data Management and Statistical analysis Data management Completed case-report forms were reviewed daily for legibility, completeness and internal consistency by the principal investigator. Verified data were double-entered into EpiData 3.1, exported to Stata 17 (StataCorp, College Station, TX, USA) for descriptive analyses, and to R 4.2.2 (packages tidyverse , psych , lavaan ) for psychometric modelling. Discrepancies between the two entry files were resolved by reference to source documents. Descriptive statistics Continuous variables analyzed as mean ± SD or median (IQR) depending on normality. Categorical variables analyzed as frequencies and percentages; bar charts or pie charts for visualization. Reliability Internal-consistency reliability of each FertiQoL subscale was assessed with Cronbach’s α; values ≥ 0.70 were deemed acceptable (18) Construct validity Because FertiQoL has a predefined four-factor structure, we performed confirmatory factor analysis (CFA) using robust maximum-likelihood estimation. Model adequacy was judged against conventional thresholds (10, 18) as showed in Table 1: Table 1 Recommended threshold values for goodness-of-fit indices used in confirmatory factor analysis Fit index Criterion for good fit χ² / df < 3 (informative only) Comparative fit index ( CFI) ≥ 0.90 Tucker Lewis index ( TLI) ≥ 0.90 Standardized root mean square residuals (SRMR) ≤ 0.08 Root-mean square error of approximation (RMSEA) ≤ 0.08 (≤ 0.06 for “close” fit) with 90% CI Standardized factor loadings ≥ 0.30 were considered meaningful; items loading < 0.30 were examined for potential removal. Convergent and discriminant validity For convergent validity, the Average Variance Extracted (AVE) and Composite Reliability (CR) were computed for each latent factor: AVE ≥ 0.50 and CR ≥ 0.70 indicate adequate convergence. For discriminant validity, the Fornell-Larcker criterion: the square root of each factor’s AVE had to exceed its squared correlation with every other factor (i.e., AVE > shared variance). All analyses used two-tailed tests with α = 0.05. Results Description of study participants Participant flow and recruitment Review of fertility clinic registers identified 387 clients who met the criteria for infertility and had attended the service in the preceding two years. After verification of contact details, 160 individuals (41%) were successfully reached and screened for eligibility. Twenty-seven clients were excluded: Eighteen women were pregnant at the time of contact and 9 individuals declined participation, citing lack of time or interest. The remaining 133 attended the study visit; all but 13 provided complete data, yielding a final analytic sample of 120 participants (90.2% completion among those who attended). All 120 respondents completed the full 24-item Core FertiQoL questionnaire and were included in the psychometric analyses. Figure 1 summarizes the recruitment process. Baseline demographic characteristics of the participants Participants had a mean age of 33 years (SD = 7.9). Most were female (78.7%), married or partnered (99.2%), and had secondary education (55.8%), as shown in Table 2. Fertility-related characteristics of the participants Just over half of the participants presented with secondary infertility (n = 66, 55.0%). The mean ± SD duration of infertility was 5.4 ± 4.7 years, and couples had been in their current relationship for an average of 6.4 ± 4.7 years. Seventeen respondents (14.2%) were in a new partnership in which at least one partner already had a child from a previous relationship, as shown in Table 3. At the time of interview, the etiology of infertility remained undiagnosed in 53 participants (44.0%), underscoring the diagnostic gap in routine care. Psychometric evaluation of the FertiQoL Internal consistency Cronbach’s α coefficients demonstrated good reliability across the four Core FertiQoL domains (α = 0.72–0.86), comfortably exceeding the ≥ 0.70 criterion recommended for patient-reported outcome measures, indicating satisfactory reliability. The Relational domain showed the strongest internal coherence (α = 0.86). Confirmatory factor analysis (CFA) Factor loadings, which represent the correlation between an individual item(question) and its corresponding latent construct(subscale), were evaluated. Typically, a factor loading exceeding 0.3 indicates moderate correlation, with higher loadings signifying stronger associations. A robust ML CFA tested the theorized four-factor structure (24 items, N = 120). Although factor loadings met or exceeded this thresshold, Item loadings ranged 0.30–0.86; item 20 (“family support”) had the weakest association with its latent factor, fit indices indicated that the baseline model required modification, as shown in Table 4, and Fig. 2. The initial 24-item CFA yielded χ² = 952.4, df = 246, p < 0.001, indicating lack of exact fit. Absolute and comparative fit indices corroborated poor model performance: RMSEA = 0.155 (90% CI 0.144–0.166), CFI = 0.673, and TLI = 0.637, all outside accepted cut-offs. Only the SRMR = 0.083 fell within the ≤ 0.08 criterion, confirming that overall fit was sub-optimal. Convergent and discriminant validity Average Variance Extracted (AVE) confirmed adequate convergence for the Relational (0.56) and Social (0.49) factors, but Emotional (0.39) and Mind-Body (0.31) failed to reach the ≥ 0.50 benchmark, as shown in Table 5. Because Emotional and Mind-Body also shared high interactor correlations, Fornell–Larcker criteria for discriminant validity were not fully met. Model refinement Given the poor model fit and inadequate discriminant validity, a confirmatory factor analysis(CFA) was re-estimated after excluding items with standardized factor loadings below 0.5 ( i.e. Q4,Q12,Q18,Q24,Q20 and Q10). This was in line with previous psychometric work involving the FertiQoL (10). The re-calculated AVE values demonstrated improvement, particularly for the emotional and mind-body subscales (Emotional = 0.44; and Mind-Body = 0.42). The AVE values for the relational and social subscales improved to satisfactory levels (Relational = 0.66; Social = 0.55) and composite reliability for all factors exceeded 0.70, as shown in Table 6. Nevertheless, global fit remained below conventional thresholds (CFI = 0.686; RMSEA = 0.202; SRMR = 0.086), suggesting residual misspecification—most likely a consequence of limited sample size (< 5 respondents / item) and potential cultural nuance in item interpretation. Table 4 Standardised factor loadings and Cronbach’s Alpha for the different FertiQoL Subscales Sub-scale Item Standardized factor loadings R- Squared Standardised - Alpha Total - Loadings Emotional Q4 0.39 0.15 0.79 3.70 Q7 0.54 0.29 Q8 0.78 0.61 Q9 0.67 0.44 Q16 0.73 0.54 Q23 0.60 0.35 Mind-Body Q1 0.69 0.47 0.73 3.17 Q2 0.74 0.55 Q3 0.62 0.38 Q12 0.45 0.20 Q18 0.32 0.11 Q24 0.35 0.12 Relational Q6 0.85 0.73 0.86 4.33 Q11 0.83 0.69 Q15 0.66 0.43 Q19 0.83 0.69 Q20 0.30 0.09 Q21 0.86 0.74 Social Q5 0.57 0.33 0.84 4.06 Q10 0.36 0.13 Q13 0.81 0.66 Q14 0.84 0.71 Q17 0.66 0.44 Q22 0.81 0.65 Table 5 Discriminant validity of the Fertiqol Emotional Mind-body Relational social Emotional 1.000 Mind-body 0.968 1.000 Relational 1.029 1.135 1.000 Social 0.762 0.714 0.930 1.000 Table 6 Psychometric properties of the Luganda/English Core FertiQoL. *Items Q4, Q10, Q12, Q18, Q20 and Q24 removed (standardized loading < 0.50). Sub-scale Cronbach’s α Initial AVE AVE after item deletion* Emotional 0.74 0.39 0.44 Mind-Body 0.72 0.31 0.42 Relational 0.86 0.56 0.66 Social 0.78 0.49 0.55 Discussion This study assessed the psychometric properties (reliability and validity) of the Luganda and English versions of the FertiQoL questionnaire among infertile individuals and couples at Tertiary referral peri-urban Hospital, Uganda. The analysis incorporated both men and women; however, no gender-based comparisons were conducted due to a limited male sample size. The scope of the study was restricted to evaluating psychometric attributes and did not directly explore the quality of life (QoL) of the participants, aligning with the objective to validate the tool rather than measure QoL. Participants had a mean age of 33.6 years (SD = 7.9), consistent with findings from other studies employing the FertiQoL ( 8 , 14 ). Notably, the majority of participants were older than 35 years, reflecting broader demographic shifts towards later childbearing among reproductive-aged women from 1995 to 2016. Contributing factors to this shift include delayed marriage, increased educational attainment (secondary and tertiary levels), and enhanced contraceptive knowledge, accessibility, and usage ( 19 ). The lower participation rate of men aligns with known disparities in healthcare-seeking behaviors, predominantly driven by traditional masculine norms ( 20 ). The FertiQoL is documented as a sensitive, reliable, and valid measure specifically tailored to assess QoL in infertile populations compared to general QoL measures like SF-36 and WHO-BREF ( 5 ). Our results indicate that the Luganda FertiQoL questionnaire exhibits commendable reliability, with Cronbach’s alpha coefficients for the core subscales ranging from 0.73 to 0.86, signifying strong internal consistency. This reliability aligns with findings reported across diverse populations, including initial validation ( 8 , 21 ), German sample ( 22 ), and a Spanish sample ( 23 ). Confirmatory factor analysis (CFA) established the validity of the FertiQoL with satisfactory factor loadings (≥ 0.30) for all items, similar to what Boivin and co-workers demonstrated ( 8 ). Notably, Item 21 exhibited the highest factor loading (0.86), whereas Item 20 (addressing difficulties in partner communication about infertility) had the lowest loading (0.30). The variance in these loadings likely arises from cultural, social, and environmental distinctions between the Ugandan context and the European settings examined by Boivin and colleagues ( 11 ). Our findings indicated partial convergent validity within the core FertiQoL model. The relational and social subscales presented satisfactory average variance extracted (AVE), while emotional and mind-body subscales demonstrated lower AVEs, indicating partial convergence validity. These findings correspond with validation studies conducted among German and Spanish infertile populations, which similarly reported partially satisfactory convergent validity ( 10 , 23 ). Regarding discriminant validity, the subscales of the core FertiQoL showed significant, though predominantly strong, inter-correlations, thus suggesting limited discriminant validity among subscales. Similar finding have been reported with factor analysis of the fourfactor FertiQoL model (Emotional, Mind–Body, Relational, Social) revealing Pearson inter-correlations ranging from 0.21 to 0.77, indicating strong overlap among subscales (24). Furthermore, in a Spanish sample, even after excluding items with low loadings, correlations among subscales remained high enough that discriminant validity (based on AVE comparisons) was acceptable but modest, again showing overlap (25). The limited discriminant validity among the subscales of the core FertiQoL can be attributed to the inherent interconnectedness of the dimensions they measure. For instance, aspects of physical well-being (mind-body subscale) often have a direct impact on interpersonal relationships (relational subscale) due to the emotional and psychological strain associated with infertility. Similarly, the social subscale, which involves external interactions and support networks, is closely intertwined with relational dynamics, as external perceptions and societal pressures influence personal relationships. ( 26 )(Relational subscale CFA) reported a low AVE of 0.25 for Relational, below the 0.50 threshold, signifying overlap with other dimensions and limited discriminant validity. In addition, Spanish validation showed correlations between Emotional and Mind–Body, Emotional and Social, and Social and Mind–Body subscales were fairly strong, reflecting interdependence among physical, emotional, and social domains ( 25 ). These overlaps in the constructs being assessed make it challenging to achieve clear discrimination between the subscales, particularly in a context where cultural and social norms heavily shape individual experiences of infertility ( 26 , 27 ). Additionally, methodological factors such as sample size and the sensitivity of responses ( 25 , 26 ) may have further compounded these findings. The strongest correlation emerged between mind-body and relational subscales, while the weakest appeared between social and relational dimensions. Comparable strong inter-correlations between emotional and mind-body subscales have been documented previously ( 10 ). Strengths of the Study This study represents the first evaluation of the psychometric properties of the FertiQoL questionnaire among infertile individuals and couples in Uganda. A key strength is the inclusion of both male and female participants, addressing a critical gap as most infertility-related quality-of-life studies conducted in Sub-Saharan Africa have predominantly focused only on women. Limitations Several limitations should be noted. Firstly, the use of self-report measures introduces potential biases, as responses are influenced by participants' perceptions, emotional states, and willingness to disclose sensitive information. Secondly, social desirability bias may have occurred, with participants either under-reporting or over-reporting their distress levels and coping mechanisms based on their emotional condition at the time of data collection. Additionally, the FertiQoL instrument was developed within a Western cultural context, and cultural and contextual differences in Uganda may have influenced participants' interpretations and responses, potentially affecting the validity of the findings. Finally, despite including male participants, their representation remained limited, thereby restricting the comprehensive understanding of male infertility-related quality of life. Conclusion The FertiQoL questionnaire demonstrated satisfactory reliability. Concerns were noted regarding validity, as the convergent validity for the relational and social subscales was satisfactory, while the emotional and mind body scales fell below the recommended thresholds, indicating inadequate discriminant validity for these subscales. Further studies with larger sample sizes could refine the model and improve its validity. FertiQol is thus considered a reliable and valid tool for assessing the quality of life of infertile patients in Uganda. Declarations Ethics approval and consent to participate Ethical approval was granted by the Research and Ethics Committee of St. Francis Hospital Nsambya, REC Number SFHN-2023-80. Study identification numbers were used to maintain confidentiality. Written informed consent was obtained from all participants. All methods were performed in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This was a dissertation thesis for the award of Master of Medicine in obstetrics and gynecology with no specific funding. Authors' contributions DM and AK contributed equally as joint first authors. DM : Conceptualization, methodology, data collection, formal analysis, writing – original draft preparation. AK : Conceptualization, methodology, formal analysis, data interpretation, writing – original draft preparation, writing – review & editing, supervision, project administration. GT : Methodology, data collection, formal analysis, writing – review & editing. RNB : Data collection, formal analysis, writing – review & editing. SK : Methodology, formal analysis, writing – review & editing. AD : Formal analysis, writing – review & editing. NC : Methodology, writing – review & editing. MN : Data collection, data management, writing – review & editing. DZ : Formal analysis, data interpretation, writing – review & editing, supervision. All authors contributed substantially, read, and approved the final manuscript. Acknowledgements The authors gratefully acknowledge all participants who provided valuable data for this study. Special thanks go to the research assistants and support staff for their dedicated effort during data collection and management. We also extend appreciation to St Francis Hospital Nsambya and Uganda Martyrs University; Mother Kevin Postgraduate Medical School for providing logistical and administrative support essential for the completion of this research. References WHO. Infertility. 2022. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS medicine. 2012;9(12):e1001356. Zaake D, Amongin D, Beňová L, Kiwanuka SN, Nalwadda CK, Nakafeero M, et al. Prevalence, regional distribution, and determinants of infertility in Uganda between 2006 and 2016: analysis of three Demographic and Health Surveys. Journal of Global Health Reports. 2024;8:e2024008. Boivin J, Schmidt L. Infertility-related stress in men and women predicts treatment outcome 1 year later. Fertility and sterility. 2005;83(6):1745–52. Aarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Human reproduction (Oxford, England). 2011;26(5):1112–8. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian journal of reproductive medicine. 2014;12(2):131–8. Saxena S, Carlson D, Billington R, Orley J. The WHO quality of life assessment instrument (WHOQOL-Bref): The importance of its items for cross-cultural research. Quality of Life Research. 2001;10(8):711–21. Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Human reproduction (Oxford, England). 2011;26(8):2084–91. Gameiro S, Boivin J, Dancet E, de Klerk C, Emery M, Lewis-Jones C, et al. ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff. Human reproduction (Oxford, England). 2015;30(11):2476–85. Sexty RE, Griesinger G, Kayser J, Lallinger M, Rösner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health Qual Life Outcomes. 2018;16(1):233. Bujang. a step by step guide to questionnare validation research. 2022. Makumbi D, Kayiira A, Tumwine G, Byaruhanga RN, Zaake D. Translation and cultural adaptation of the FertiQoL questionnaire into Luganda: A comprehensive report. Afr J Reprod Health. 2025;29(5):29–35. Kudesia R, Muyingo M, Tran N, Shah M, Merkatz I, Klatsky P. Infertility in Uganda: a missed opportunity to improve reproductive knowledge and health. Global Reproductive Health. 2018;3(4):e24. Bayoumi RR, Koert E, Boivin J, Viswanath K, McConnell M. Quality of life of Sudanese patients attending a fertility clinic: a mixed methods study. Health Psychol Behav Med. 2021;9(1):1006–30. World Health Organization. HRP annual report 2019. Geneva: World Health Organization; 2020 2020. Naamala A, Eriksson LE, Orem J, Nalwadda GK, Kabir ZN, Wettergren L. Psychometric properties of the EORTC QLQ-C30 in Uganda. Health Qual Life Outcomes. 2021;19(1):131. Gunawan J, Marzilli C, Aungsuroch Y. Establishing appropriate sample size for developing and validating a questionnaire in nursing research. Belitung Nurs J. 2021;7(5):356–60. Kline RB. Principles and Practice of Structural Equation Modeling, Fourth Edition: Guilford Publications; 2015. UDHS. The State of Uganda Population Report 2022. 2022. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. Journal of advanced nursing. 2005;49(6):616–23. Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Hum Reprod. 2011;26(8):2084–91. Sexty RE, Griesinger G, Kayser J, Lallinger M, Rösner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health and Quality of Life Outcomes. 2018;16(1):233. Ferrandis ED. Psychometric properties of the Spanish version of the FertiQoL measure in couples undergoing infertility treatment. Journal of Reproductive and Infant Psychology. 2023;42(5). Sexty R, Griesinger G, Kayser J, Lallinger M, Rösner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health and Quality of Life Outcomes. 2018;16. Bueno-Sánchez L, Alhambra-Borrás T, Bonilla-Campos A, Durá-Ferrandis E. Psychometric characteristics of core FertiQoL questionnaire in a Spanish sample of infertile women. Anales de Psicología. 2024;40:364–72. Donarelli Z, Lo Coco G, Gullo S, Salerno L, Marino A, Sammartano F, et al. The Fertility Quality of Life Questionnaire (FertiQoL) Relational subscale: psychometric properties and discriminant validity across gender. Human Reproduction. 2016;31:dew168. Woods BM, Bray LA, Campbell S, Holland A, Mrug S, Ladores S. A review of the psychometric properties and implications for the use of the fertility quality of life tool. Health Qual Life Outcomes. 2023;21(1):45. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6901451","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":522102599,"identity":"3504e0fd-a322-4dae-abd2-32a3efc0dd28","order_by":0,"name":"Douglas Makumbi","email":"","orcid":"","institution":"Uganda Martyrs University","correspondingAuthor":false,"prefix":"","firstName":"Douglas","middleName":"","lastName":"Makumbi","suffix":""},{"id":522102601,"identity":"f157093c-1c37-47dc-9747-af9a44f0461b","order_by":1,"name":"Anthony Kayiira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYFCDA4zNDz4AaTZ2gkqZYVqY2wxngLQw41ONqoW9QZoHWQAX4J/df/DBxza7fL7zBxuMbX5tk+djZmD88DEHtxaJO4eZDWe2JVvOvJHY8Di377ZhGzMDs+TMbXisuZHMJs27jdnA4AZjg3Fuz21GoBY2Zl48WuRBWv5uqzcwADpM2rLntj1BLQYgLYzbDhsYHEhskGb4cTuRoBbDG8nGhr3/jhtI3khsM+xtuJ3cxszYjNcvcjcSHz74cabagO/88ccPfvy5bTu/vfngh4/4vI8CGNvAZAOx6kHgDymKR8EoGAWjYKQAAC1XVKzH1d+IAAAAAElFTkSuQmCC","orcid":"","institution":"Uganda Martyrs University","correspondingAuthor":true,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Kayiira","suffix":""},{"id":522102602,"identity":"23ba1378-35e0-4179-b110-023081d0cec6","order_by":2,"name":"Gilbert Tumwine","email":"","orcid":"","institution":"Uganda Martyrs University","correspondingAuthor":false,"prefix":"","firstName":"Gilbert","middleName":"","lastName":"Tumwine","suffix":""},{"id":522102603,"identity":"86a1a844-1aab-49de-abfe-0872a0f120f6","order_by":3,"name":"Romano N. Byaruhanga","email":"","orcid":"","institution":"Uganda Martyrs University","correspondingAuthor":false,"prefix":"","firstName":"Romano","middleName":"N.","lastName":"Byaruhanga","suffix":""},{"id":522102604,"identity":"78d9fef7-c12a-4334-abb6-2fd9ff11ee51","order_by":4,"name":"Suzanne Kiwanuka","email":"","orcid":"","institution":"Makerere University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Suzanne","middleName":"","lastName":"Kiwanuka","suffix":""},{"id":522102605,"identity":"bd5b04ed-6565-4b8e-b0f3-6d71fc902ef1","order_by":5,"name":"Amongin Dina","email":"","orcid":"","institution":"Makerere University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amongin","middleName":"","lastName":"Dina","suffix":""},{"id":522102606,"identity":"b2ac6c0c-cf42-448f-993b-d64712c77e66","order_by":6,"name":"Nalwadda Christine","email":"","orcid":"","institution":"Makerere University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nalwadda","middleName":"","lastName":"Christine","suffix":""},{"id":522102607,"identity":"a96ef925-b590-41c3-8ea4-0f14301afea5","order_by":7,"name":"Mary Nakafeero","email":"","orcid":"","institution":"Makerere University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Nakafeero","suffix":""},{"id":522102608,"identity":"611ebbb9-9d0d-48f4-9c68-d96f8020abdd","order_by":8,"name":"Daniel Zaake","email":"","orcid":"","institution":"Makerere University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Zaake","suffix":""}],"badges":[],"createdAt":"2025-06-16 04:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6901451/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6901451/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92737343,"identity":"903fda51-7d4a-4a38-80d3-a01591e5c436","added_by":"auto","created_at":"2025-10-03 16:44:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119579,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1Flowchart.docx","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/400d47ff737389f08f09050c.docx"},{"id":92736522,"identity":"1cf0923c-4513-48d4-8f57-96edf8ccc117","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151032,"visible":true,"origin":"","legend":"","description":"","filename":"psychofertiqolmanuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/70bf8525d6bc5b86f2af7b9d.docx"},{"id":92738209,"identity":"413bcf07-4547-477f-8815-91ed6449bd7a","added_by":"auto","created_at":"2025-10-03 16:52:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":190289,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2CFAPathdiagram.docx","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/71419411e0e9fc72a7c69498.docx"},{"id":92736516,"identity":"0e467854-e807-4eb8-9c2b-3e7b5c60f655","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":11472,"visible":true,"origin":"","legend":"","description":"","filename":"a204a1cfd9d0450893caeacea68e8efa.json","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/70b101e1e19bff1068608e4c.json"},{"id":92736519,"identity":"0b63a0b0-9e54-463e-be05-db1aa8bc4431","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97926,"visible":true,"origin":"","legend":"","description":"","filename":"a204a1cfd9d0450893caeacea68e8efa1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/9f976f952a84b57cbe46c188.xml"},{"id":92736524,"identity":"dbf8e4a3-dea2-4248-8f14-ea147f49a2dc","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66198,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/9310475a40c342f661119001.jpeg"},{"id":92736523,"identity":"da0d6e72-0599-4bd0-877d-fceb4b11e0b4","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":562799,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/1e5c58f800673ddc849b2353.jpeg"},{"id":92736520,"identity":"2063993e-b66d-4014-ba7a-a47131c1b2cb","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26921,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/bf36db94c398327e7b61a498.png"},{"id":92737345,"identity":"c5514187-126e-4ea5-9531-eecc90e1f236","added_by":"auto","created_at":"2025-10-03 16:44:28","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106766,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/574a824df09a3a8aeded295a.png"},{"id":92736526,"identity":"ede95b9f-8121-4e24-a9e8-403964e7639f","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94618,"visible":true,"origin":"","legend":"","description":"","filename":"a204a1cfd9d0450893caeacea68e8efa1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/897d2202d921c5f3ac608009.xml"},{"id":92736528,"identity":"bce0b64d-b612-47b0-8eff-cb5e6330d131","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106220,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/f7c54311c668dabec6a037ea.html"},{"id":92736517,"identity":"ed720aa4-2a47-45e1-99f3-4f3176778dda","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173059,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart for participant recruitment.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/4a8762d020d3ed251a35cef4.png"},{"id":92736518,"identity":"97aab7a1-7daf-4320-b55e-dc0138732ff0","added_by":"auto","created_at":"2025-10-03 16:36:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":436742,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePath Diagram Showing Standardized Factor Loadings for Confirmatory Factor Analysis (CFA)\u003c/strong\u003e. This diagram visualizes a confirmatory factor analysis (CFA) model representing the relationship between observed variables (questionnaire items labeled Q1 to Q24) and four latent constructs: Social, Emotional, Relational, and Mind/Body. Rectangles depict observed items, while ellipses represent latent constructs. Arrows indicate factor loadings, with the numbers along each arrow signifying standardized regression weights, indicating the strength and direction of each item's relationship with its corresponding latent construct. Curved arrows and associated numbers illustrate the residual variances of each observed variable. Double-headed dashed arrows between latent constructs represent the standardized correlations among factors. Higher factor loadings closer to 1 indicate stronger associations between items and their respective latent constructs, demonstrating the validity and cohesiveness of the factor structure.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/eb5cc7e8f363472528fc26bc.png"},{"id":94829097,"identity":"ef145e24-b635-4105-a6fd-78dbae16297c","added_by":"auto","created_at":"2025-10-31 07:02:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1754381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6901451/v1/f3029f7a-4191-4c93-a265-13e3d097b6bc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePsychometric Evaluation of the Fertiqol Questionnaire Among Infertile Individuals and Couples in Uganda: Findings From a Tertiary Hospital in Peri-urban Kampala\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eInfertility is recognized by the World Health Organization (WHO) as a disease of the reproductive system, defined by failure to achieve pregnancy after \u0026ge;\u0026thinsp;12 months of regular unprotected intercourse (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Globally, an estimated 48\u0026nbsp;million couples and up to 186\u0026nbsp;million individuals live with infertility, underscoring its importance as a public-health concern (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Sub-Saharan Africa carries a disproportionate burden: pooled analyses report primary- and secondary-infertility prevalences of 1.9% and 10%, respectively (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In Uganda, population-based surveys place overall infertility prevalence at approximately 6.4% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) with marked social and economic repercussions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeyond biomedical sequelae, infertility precipitates substantial psychosocial distress. Meta-analytic and cross-sectional evidence link infertility to grief, anxiety, depression, diminished self-esteem and relationship strain, all of which converge to lower health-related quality of life (QoL) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Yet psychosocial needs often remain obscured within biomedical service models (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Standardized QoL measurement is therefore essential for holistic care, program evaluation and policy formulation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Fertility Quality of Life (FertiQoL) instrument\u0026mdash;developed through international consensus and grounded in health-psychology theory\u0026mdash;offers a fertility-specific assessment spanning emotional, mind\u0026ndash;body, relational and social domains (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Unlike the generic psychological instruments such as the WHO-QoL, FertiQoL gives a more accurate picture of the cognitive, behavioral, and emotional state of persons with fertility problems (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Comparative studies in Europe, Asia and North America demonstrate good reliability and validity (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, psychometric performance may vary across sociocultural settings; linguistic nuance, gender norms, religious beliefs and health-system factors can influence item interpretation (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Rigorous local validation is therefore a prerequisite to meaningful use.\u003c/p\u003e\u003cp\u003eWe recently completed a forward\u0026ndash;backward translation and linguistic validation of FertiQoL into Luganda\u0026mdash;the most widely spoken language in central Uganda\u0026mdash;and published the translation protocol and cognitive-debriefing results (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). To date, however, published African studies have largely deployed the non-adapted English version without formal validation (for example, Uganda (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and Sudan (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and no study has examined FertiQoL psychometric properties in a Ugandan sample. This represents a critical gap, given cultural specificities in the perception and stigma of infertility.\u003c/p\u003e\u003cp\u003eBuilding on the completed Luganda translation, the present study evaluates the reliability and construct validity of both the Luganda and English versions of FertiQoL among infertile individuals and couples attending a tertiary non-profit fertility clinic in peri-urban Kampala. Establishing a culturally robust measure will enable clinicians, researchers and policy-makers to monitor fertility-related QoL accurately, tailor psychosocial interventions and advance WHO\u0026rsquo;s agenda for equitable, person-centered fertility care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eDesign and Setting\u003c/h2\u003e\n \u003cp\u003eWe employed a descriptive cross-sectional design, mirroring the methodological approaches used in recent African psychometric evaluations of patient-reported outcome measures (for example, (16). Data were collected between March and May 2023 at the Fertility Clinic of St Francis Hospital Nsambya, a faith-based, private not-for-profit tertiary referral hospital located approximately 5 km south-east of Kampala\u0026rsquo;s central business district. The fertility clinic has Two consultant obstetrician-gynecologists with subspecialty training in reproductive medicine, and a team of nurses, midwives, and senior house officers provide care. The clinic manages\u0026thinsp;\u0026gt;\u0026thinsp;200 new and follow-up infertility cases annually, most referred from internal hospital departments or external facilities. Core investigations\u0026mdash;including semen analysis, hormonal profiling, transvaginal ultrasound, and hysterosalpingography\u0026mdash;are delivered in collaboration with the hospital\u0026rsquo;s ISO-certified laboratory and radiology units. Couples receive structured counselling and first-line medical or minor surgical management on site. Cases requiring advanced assisted-reproductive-technology (ART) procedures are referred to specialized ART centers in Kampala, in line with national practice patterns.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy population, Sample size and Sampling\u003c/h3\u003e\n\u003cp\u003eThe target population comprised women and men aged 18\u0026ndash;49 years presenting with primary or secondary infertility at the St Francis Hospital Nsambya Fertility Clinic between March and May 2023. Eligible participants had to (i) understand either English or Luganda, and (ii) provide written informed consent. We excluded individuals with severe physical illness precluding interview, those with a documented major psychiatric disorder, and women who had become pregnant at the time of recruitment.\u003c/p\u003e\n\u003cp\u003ePsychometric guidelines recommend a respondent-to-item ratio of 3:1 to 20:1 for exploratory and confirmatory factor analyses (17). With 24 items in the Core FertiQoL and using a respondent-to-item ratio of 5:1 this yielded a minimum of 120 participants.\u003c/p\u003e\n\u003cp\u003eFor completeness, we also calculated a precision-based sample size for estimating the proportion of infertility-related psychological distress, using the Kish-Leslie formula for single proportions: N\u0026thinsp;=\u0026thinsp;z\u0026sup2;pq/d\u0026sup2; (Kish Leslie 1965). Where N is the sample size, Z-score corresponding to 95% confidence interval which is 1.96, p is the proportion of patients with psychological distress and d is the standard error in estimating the true proportion which was set at 0.05. Using a study by Zubairu \u0026amp; Yohanna, 2017, the prevalence of psychological distress was 79.9%. \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.799, \u003cem\u003eq\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.201, as shown in the equation below:\u003c/p\u003e\n\u003ch3\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/h3\u003e\n\u003cp\u003eSubstituting into the above formula we got a sample size of 247 participants. Because the clinic registers\u0026thinsp;\u0026asymp;\u0026thinsp;200 infertile patients annually, we applied a finite-population correction: Adjusted sample size, n= [n/1\u0026thinsp;+\u0026thinsp;n/pop]\u0026thinsp;=\u0026thinsp;111. The psychometric requirement (\u0026ge;\u0026thinsp;120) therefore governed recruitment.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eProcedure\u003c/h2\u003e\n \u003cp\u003eEligible participants were identified from clinic appointment logs covering the preceding two years. The principal investigator (PI) and two trained midwife-research assistants screened medical charts to confirm an infertility diagnosis, verify current address/telephone contacts, and exclude pregnancies or comorbid psychiatric illness. Consecutive clients meeting the eligibility criteria were telephoned and invited to attend the clinic on a routine service day.\u003c/p\u003e\n \u003cp\u003eOn arrival, participants received a study information sheet in English or Luganda; written informed consent was obtained before any study-related activity. Sociodemographic and clinical variables (age, sex, parity, infertility type/duration, referral source) were abstracted from the medical record and transcribed onto piloted case-report forms (CRFs). All identifiers were coded to maintain confidentiality. Participants then completed the questionnaire package in a private room. Because literacy varies, the FertiQoL was administered as self-report with researcher assistance on request; items were read verbatim for respondents who preferred an interview-assisted format, replicating the approach used by Naamala et al. (2021) for HRQoL assessments in Uganda. Average completion time was 15\u0026ndash;20 minutes. On finishing, respondents could ask infertility-related questions and were offered brief counselling or referral as appropriate. Completed forms were reviewed for missing data, sealed in tamper-proof envelopes and stored in a locked cabinet accessible only to the PI.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eFertiQoL Instrument\u003c/h2\u003e\n \u003cp\u003eThe Fertility Quality of Life (FertiQoL) questionnaire was developed jointly by ESHRE and ASRM experts to capture fertility-specific health-related quality of life (8). It comprises: Core module (24 items): four 6-item subscales\u0026mdash;Emotional (sadness, resentment, grief), Mind/Body (cognition, physical symptoms, behavior), Relational (partnership dynamics), Social (social inclusion, expectations, support), Optional Treatment module (10 items): Environment and Treatment Tolerability subscales\u0026mdash;not used in this study because majority of participants were not yet receiving fertility treatment. Furthermore, the core module has general relevance and applicability across the population, irrespective of whether the individuals were undergoing or planning to undergo treatment, making it an essential component of the study\u0026rsquo;s methods.\u003c/p\u003e\n \u003cp\u003eItems are presented in random order and rated on a 5-point Likert scale (0\u0026thinsp;=\u0026thinsp;very poor to 4\u0026thinsp;=\u0026thinsp;excellent). Subscale and overall scores are linearly transformed to 0\u0026ndash;100, with higher values indicating better quality of life. The English original and the forward\u0026ndash;backward Luganda translation previously validated by our group (12) were offered; participants chose their preferred language.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData Management and Statistical analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eData management\u003c/h2\u003e\n \u003cp\u003eCompleted case-report forms were reviewed daily for legibility, completeness and internal consistency by the principal investigator. Verified data were double-entered into EpiData 3.1, exported to Stata 17 (StataCorp, College Station, TX, USA) for descriptive analyses, and to R 4.2.2 (packages \u003cem\u003etidyverse\u003c/em\u003e, \u003cem\u003epsych\u003c/em\u003e, \u003cem\u003elavaan\u003c/em\u003e) for psychometric modelling. Discrepancies between the two entry files were resolved by reference to source documents.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eDescriptive statistics\u003c/h2\u003e\n \u003cp\u003eContinuous variables analyzed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median (IQR) depending on normality. Categorical variables analyzed as frequencies and percentages; bar charts or pie charts for visualization.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eReliability\u003c/h2\u003e\n \u003cp\u003eInternal-consistency reliability of each FertiQoL subscale was assessed with Cronbach\u0026rsquo;s \u0026alpha;; values\u0026thinsp;\u0026ge;\u0026thinsp;0.70 were deemed acceptable (18)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eConstruct validity\u003c/h2\u003e\n \u003cp\u003eBecause FertiQoL has a predefined four-factor structure, we performed confirmatory factor analysis (CFA) using robust maximum-likelihood estimation. Model adequacy was judged against conventional thresholds (10, 18) as showed in Table 1:\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eRecommended threshold values for goodness-of-fit indices used in confirmatory factor analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFit index\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCriterion for good fit\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2; / df\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;3 (informative only)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComparative fit index (\u003cstrong\u003eCFI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTucker Lewis index (\u003cstrong\u003eTLI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandardized root mean square residuals (SRMR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRoot-mean square error of approximation \u003cstrong\u003e(RMSEA)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;0.08 (\u0026le;\u0026thinsp;0.06 for \u0026ldquo;close\u0026rdquo; fit) with 90% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eStandardized factor loadings\u0026thinsp;\u0026ge;\u0026thinsp;0.30 were considered meaningful; items loading\u0026thinsp;\u0026lt;\u0026thinsp;0.30 were examined for potential removal.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eConvergent and discriminant validity\u003c/h2\u003e\n \u003cp\u003eFor convergent validity, the Average Variance Extracted (AVE) and Composite Reliability (CR) were computed for each latent factor:\u0026emsp;AVE\u0026thinsp;\u0026ge;\u0026thinsp;0.50 and CR\u0026thinsp;\u0026ge;\u0026thinsp;0.70 indicate adequate convergence. For discriminant validity, the Fornell-Larcker criterion: the square root of each factor\u0026rsquo;s AVE had to exceed its squared correlation with every other factor (i.e., AVE\u0026thinsp;\u0026gt;\u0026thinsp;shared variance). All analyses used two-tailed tests with \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eDescription of study participants\u003c/h2\u003e\n \u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eParticipant flow and recruitment\u003c/h2\u003e\n \u003cp\u003eReview of fertility clinic registers identified 387 clients who met the criteria for infertility and had attended the service in the preceding two years. After verification of contact details, 160 individuals (41%) were successfully reached and screened for eligibility. Twenty-seven clients were excluded: Eighteen women were pregnant at the time of contact and 9 individuals declined participation, citing lack of time or interest. The remaining 133 attended the study visit; all but 13 provided complete data, yielding a final analytic sample of 120 participants (90.2% completion among those who attended). All 120 respondents completed the full 24-item Core FertiQoL questionnaire and were included in the psychometric analyses. Figure 1 summarizes the recruitment process.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003eBaseline demographic characteristics of the participants\u003c/h2\u003e\n \u003cp\u003eParticipants had a mean age of 33 years (SD\u0026thinsp;=\u0026thinsp;7.9). Most were female (78.7%), married or partnered (99.2%), and had secondary education (55.8%), as shown in Table 2.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003eFertility-related characteristics of the participants\u003c/h2\u003e\n \u003cp\u003eJust over half of the participants presented with secondary infertility (n\u0026thinsp;=\u0026thinsp;66, 55.0%). The mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD duration of infertility was 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years, and couples had been in their current relationship for an average of 6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years. Seventeen respondents (14.2%) were in a new partnership in which at least one partner already had a child from a previous relationship, as shown in Table\u0026nbsp;3. At the time of interview, the etiology of infertility remained undiagnosed in 53 participants (44.0%), underscoring the diagnostic gap in routine care.\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cbr\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003ePsychometric evaluation of the FertiQoL\u003c/h2\u003e\n \u003cdiv id=\"Sec21\"\u003e\n \u003ch2\u003eInternal consistency\u003c/h2\u003e\n \u003cp\u003eCronbach\u0026rsquo;s \u0026alpha; coefficients demonstrated good reliability across the four Core FertiQoL domains (\u0026alpha;\u0026thinsp;=\u0026thinsp;0.72\u0026ndash;0.86), comfortably exceeding the \u0026ge;\u0026thinsp;0.70 criterion recommended for patient-reported outcome measures, indicating satisfactory reliability. The Relational domain showed the strongest internal coherence (\u0026alpha;\u0026thinsp;=\u0026thinsp;0.86).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\"\u003e\n \u003ch2\u003eConfirmatory factor analysis (CFA)\u003c/h2\u003e\n \u003cp\u003eFactor loadings, which represent the correlation between an individual item(question) and its corresponding latent construct(subscale), were evaluated. Typically, a factor loading exceeding 0.3 indicates moderate correlation, with higher loadings signifying stronger associations. A robust ML CFA tested the theorized four-factor structure (24 items, N\u0026thinsp;=\u0026thinsp;120). Although factor loadings met or exceeded this thresshold, Item loadings ranged 0.30\u0026ndash;0.86; item 20 (\u0026ldquo;family support\u0026rdquo;) had the weakest association with its latent factor, fit indices indicated that the baseline model required modification, as shown in Table 4, and Fig. 2. The initial 24-item CFA yielded \u0026chi;\u0026sup2; = 952.4, df\u0026thinsp;=\u0026thinsp;246, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, indicating lack of exact fit. Absolute and comparative fit indices corroborated poor model performance: RMSEA\u0026thinsp;=\u0026thinsp;0.155 (90% CI 0.144\u0026ndash;0.166), CFI\u0026thinsp;=\u0026thinsp;0.673, and TLI\u0026thinsp;=\u0026thinsp;0.637, all outside accepted cut-offs. Only the SRMR\u0026thinsp;=\u0026thinsp;0.083 fell within the \u0026le;\u0026thinsp;0.08 criterion, confirming that overall fit was sub-optimal.\u003c/p\u003e\n \u003cdiv id=\"Sec23\"\u003e\n \u003ch2\u003eConvergent and discriminant validity\u003c/h2\u003e\n \u003cp\u003eAverage Variance Extracted (AVE) confirmed adequate convergence for the Relational (0.56) and Social (0.49) factors, but Emotional (0.39) and Mind-Body (0.31) failed to reach the \u0026ge;\u0026thinsp;0.50 benchmark, as shown in Table\u0026nbsp;5. Because Emotional and Mind-Body also shared high interactor correlations, Fornell\u0026ndash;Larcker criteria for discriminant validity were not fully met.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\"\u003e\n \u003ch2\u003eModel refinement\u003c/h2\u003e\n \u003cp\u003eGiven the poor model fit and inadequate discriminant validity, a confirmatory factor analysis(CFA) was re-estimated after excluding items with standardized factor loadings below 0.5 ( i.e. Q4,Q12,Q18,Q24,Q20 and Q10). This was in line with previous psychometric work involving the FertiQoL (10).\u003c/p\u003e\n \u003cp\u003eThe re-calculated AVE values demonstrated improvement, particularly for the emotional and mind-body subscales (Emotional\u0026thinsp;=\u0026thinsp;0.44; and Mind-Body\u0026thinsp;=\u0026thinsp;0.42). The AVE values for the relational and social subscales improved to satisfactory levels (Relational\u0026thinsp;=\u0026thinsp;0.66; Social\u0026thinsp;=\u0026thinsp;0.55) and composite reliability for all factors exceeded 0.70, as shown in Table 6. Nevertheless, global fit remained below conventional thresholds (CFI\u0026thinsp;=\u0026thinsp;0.686; RMSEA\u0026thinsp;=\u0026thinsp;0.202; SRMR\u0026thinsp;=\u0026thinsp;0.086), suggesting residual misspecification\u0026mdash;most likely a consequence of limited sample size (\u0026lt;\u0026thinsp;5 respondents / item) and potential cultural nuance in item interpretation.\u003c/p\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eStandardised factor loadings and Cronbach\u0026rsquo;s Alpha for the different FertiQoL Subscales\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSub-scale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandardized factor loadings\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eR- Squared\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandardised - Alpha\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal - Loadings\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMind-Body\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelational\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDiscriminant validity of the Fertiqol\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEmotional\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMind-body\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRelational\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003esocial\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMind-body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePsychometric properties of the Luganda/English Core FertiQoL. *Items Q4, Q10, Q12, Q18, Q20 and Q24 removed (standardized loading\u0026thinsp;\u0026lt;\u0026thinsp;0.50).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSub-scale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCronbach\u0026rsquo;s \u0026alpha;\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInitial AVE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAVE after item deletion*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMind-Body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the psychometric properties (reliability and validity) of the Luganda and English versions of the FertiQoL questionnaire among infertile individuals and couples at Tertiary referral peri-urban Hospital, Uganda. The analysis incorporated both men and women; however, no gender-based comparisons were conducted due to a limited male sample size. The scope of the study was restricted to evaluating psychometric attributes and did not directly explore the quality of life (QoL) of the participants, aligning with the objective to validate the tool rather than measure QoL.\u003c/p\u003e\u003cp\u003eParticipants had a mean age of 33.6 years (SD\u0026thinsp;=\u0026thinsp;7.9), consistent with findings from other studies employing the FertiQoL (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Notably, the majority of participants were older than 35 years, reflecting broader demographic shifts towards later childbearing among reproductive-aged women from 1995 to 2016. Contributing factors to this shift include delayed marriage, increased educational attainment (secondary and tertiary levels), and enhanced contraceptive knowledge, accessibility, and usage (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The lower participation rate of men aligns with known disparities in healthcare-seeking behaviors, predominantly driven by traditional masculine norms (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe FertiQoL is documented as a sensitive, reliable, and valid measure specifically tailored to assess QoL in infertile populations compared to general QoL measures like SF-36 and WHO-BREF (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Our results indicate that the Luganda FertiQoL questionnaire exhibits commendable reliability, with Cronbach\u0026rsquo;s alpha coefficients for the core subscales ranging from 0.73 to 0.86, signifying strong internal consistency. This reliability aligns with findings reported across diverse populations, including initial validation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), German sample (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), and a Spanish sample (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConfirmatory factor analysis (CFA) established the validity of the FertiQoL with satisfactory factor loadings (\u0026ge;\u0026thinsp;0.30) for all items, similar to what Boivin and co-workers demonstrated (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Notably, Item 21 exhibited the highest factor loading (0.86), whereas Item 20 (addressing difficulties in partner communication about infertility) had the lowest loading (0.30). The variance in these loadings likely arises from cultural, social, and environmental distinctions between the Ugandan context and the European settings examined by Boivin and colleagues (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Our findings indicated partial convergent validity within the core FertiQoL model. The relational and social subscales presented satisfactory average variance extracted (AVE), while emotional and mind-body subscales demonstrated lower AVEs, indicating partial convergence validity. These findings correspond with validation studies conducted among German and Spanish infertile populations, which similarly reported partially satisfactory convergent validity (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRegarding discriminant validity, the subscales of the core FertiQoL showed significant, though predominantly strong, inter-correlations, thus suggesting limited discriminant validity among subscales. Similar finding have been reported with factor analysis of the fourfactor FertiQoL model (Emotional, Mind\u0026ndash;Body, Relational, Social) revealing Pearson inter-correlations ranging from 0.21 to 0.77, indicating strong overlap among subscales (24). Furthermore, in a Spanish sample, even after excluding items with low loadings, correlations among subscales remained high enough that discriminant validity (based on AVE comparisons) was acceptable but modest, again showing overlap (25).\u003c/p\u003e\u003cp\u003eThe limited discriminant validity among the subscales of the core FertiQoL can be attributed to the inherent interconnectedness of the dimensions they measure. For instance, aspects of physical well-being (mind-body subscale) often have a direct impact on interpersonal relationships (relational subscale) due to the emotional and psychological strain associated with infertility. Similarly, the social subscale, which involves external interactions and support networks, is closely intertwined with relational dynamics, as external perceptions and societal pressures influence personal relationships. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)(Relational subscale CFA) reported a low AVE of 0.25 for Relational, below the 0.50 threshold, signifying overlap with other dimensions and limited discriminant validity. In addition, Spanish validation showed correlations between Emotional and Mind\u0026ndash;Body, Emotional and Social, and Social and Mind\u0026ndash;Body subscales were fairly strong, reflecting interdependence among physical, emotional, and social domains (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These overlaps in the constructs being assessed make it challenging to achieve clear discrimination between the subscales, particularly in a context where cultural and social norms heavily shape individual experiences of infertility (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Additionally, methodological factors such as sample size and the sensitivity of responses (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) may have further compounded these findings. The strongest correlation emerged between mind-body and relational subscales, while the weakest appeared between social and relational dimensions. Comparable strong inter-correlations between emotional and mind-body subscales have been documented previously (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003eStrengths of the Study\u003c/h2\u003e\u003cp\u003eThis study represents the first evaluation of the psychometric properties of the FertiQoL questionnaire among infertile individuals and couples in Uganda. A key strength is the inclusion of both male and female participants, addressing a critical gap as most infertility-related quality-of-life studies conducted in Sub-Saharan Africa have predominantly focused only on women.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eSeveral limitations should be noted. Firstly, the use of self-report measures introduces potential biases, as responses are influenced by participants' perceptions, emotional states, and willingness to disclose sensitive information. Secondly, social desirability bias may have occurred, with participants either under-reporting or over-reporting their distress levels and coping mechanisms based on their emotional condition at the time of data collection. Additionally, the FertiQoL instrument was developed within a Western cultural context, and cultural and contextual differences in Uganda may have influenced participants' interpretations and responses, potentially affecting the validity of the findings. Finally, despite including male participants, their representation remained limited, thereby restricting the comprehensive understanding of male infertility-related quality of life.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe FertiQoL questionnaire demonstrated satisfactory reliability. Concerns were noted regarding validity, as the convergent validity for the relational and social subscales was satisfactory, while the emotional and mind body scales fell below the recommended thresholds, indicating inadequate discriminant validity for these subscales. Further studies with larger sample sizes could refine the model and improve its validity. FertiQol is thus considered a reliable and valid tool for assessing the quality of life of infertile patients in Uganda.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval was granted by the Research and Ethics Committee of St. Francis Hospital Nsambya, REC Number SFHN-2023-80. Study identification numbers were used to maintain confidentiality. Written informed consent was obtained from all participants. All methods were performed in accordance with relevant guidelines and regulations.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis was a dissertation thesis for the award of Master of Medicine in obstetrics and gynecology with no specific funding.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eDM and AK\u003c/strong\u003e contributed equally as joint first authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDM\u003c/strong\u003e: Conceptualization, methodology, data collection, formal analysis, writing \u0026ndash; original draft preparation. \u003cstrong\u003eAK\u003c/strong\u003e: Conceptualization, methodology, formal analysis, data interpretation, writing \u0026ndash; original draft preparation, writing \u0026ndash; review \u0026amp; editing, supervision, project administration. \u003cstrong\u003eGT\u003c/strong\u003e: Methodology, data collection, formal analysis, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eRNB\u003c/strong\u003e: Data collection, formal analysis, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eSK\u003c/strong\u003e: Methodology, formal analysis, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eAD\u003c/strong\u003e: Formal analysis, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eNC\u003c/strong\u003e: Methodology, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eMN\u003c/strong\u003e: Data collection, data management, writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eDZ\u003c/strong\u003e: Formal analysis, data interpretation, writing \u0026ndash; review \u0026amp; editing, supervision.\u003c/p\u003e\n\u003cp\u003eAll authors contributed substantially, read, and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors gratefully acknowledge all participants who provided valuable data for this study. Special thanks go to the research assistants and support staff for their dedicated effort during data collection and management. We also extend appreciation to St Francis Hospital Nsambya and Uganda Martyrs University; Mother Kevin Postgraduate Medical School for providing logistical and administrative support essential for the completion of this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Infertility. 2022.\u003c/li\u003e\n\u003cli\u003eMascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS medicine. 2012;9(12):e1001356.\u003c/li\u003e\n\u003cli\u003eZaake D, Amongin D, Beňov\u0026aacute; L, Kiwanuka SN, Nalwadda CK, Nakafeero M, et al. Prevalence, regional distribution, and determinants of infertility in Uganda between 2006 and 2016: analysis of three Demographic and Health Surveys. Journal of Global Health Reports. 2024;8:e2024008.\u003c/li\u003e\n\u003cli\u003eBoivin J, Schmidt L. Infertility-related stress in men and women predicts treatment outcome 1 year later. Fertility and sterility. 2005;83(6):1745\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eAarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Human reproduction (Oxford, England). 2011;26(5):1112\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHasanpoor-Azghdy SB, Simbar M, Vedadhir A. The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian journal of reproductive medicine. 2014;12(2):131\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSaxena S, Carlson D, Billington R, Orley J. The WHO quality of life assessment instrument (WHOQOL-Bref): The importance of its items for cross-cultural research. Quality of Life Research. 2001;10(8):711\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eBoivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Human reproduction (Oxford, England). 2011;26(8):2084\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eGameiro S, Boivin J, Dancet E, de Klerk C, Emery M, Lewis-Jones C, et al. ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff. Human reproduction (Oxford, England). 2015;30(11):2476\u0026ndash;85.\u003c/li\u003e\n\u003cli\u003eSexty RE, Griesinger G, Kayser J, Lallinger M, R\u0026ouml;sner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health Qual Life Outcomes. 2018;16(1):233.\u003c/li\u003e\n\u003cli\u003eBujang. a step by step guide to questionnare validation research. 2022.\u003c/li\u003e\n\u003cli\u003eMakumbi D, Kayiira A, Tumwine G, Byaruhanga RN, Zaake D. Translation and cultural adaptation of the FertiQoL questionnaire into Luganda: A comprehensive report. Afr J Reprod Health. 2025;29(5):29\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eKudesia R, Muyingo M, Tran N, Shah M, Merkatz I, Klatsky P. Infertility in Uganda: a missed opportunity to improve reproductive knowledge and health. Global Reproductive Health. 2018;3(4):e24.\u003c/li\u003e\n\u003cli\u003eBayoumi RR, Koert E, Boivin J, Viswanath K, McConnell M. Quality of life of Sudanese patients attending a fertility clinic: a mixed methods study. Health Psychol Behav Med. 2021;9(1):1006\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. HRP annual report 2019. Geneva: World Health Organization; 2020 2020.\u003c/li\u003e\n\u003cli\u003eNaamala A, Eriksson LE, Orem J, Nalwadda GK, Kabir ZN, Wettergren L. Psychometric properties of the EORTC QLQ-C30 in Uganda. Health Qual Life Outcomes. 2021;19(1):131.\u003c/li\u003e\n\u003cli\u003eGunawan J, Marzilli C, Aungsuroch Y. Establishing appropriate sample size for developing and validating a questionnaire in nursing research. Belitung Nurs J. 2021;7(5):356\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eKline RB. Principles and Practice of Structural Equation Modeling, Fourth Edition: Guilford Publications; 2015.\u003c/li\u003e\n\u003cli\u003eUDHS. The State of Uganda Population Report 2022. 2022.\u003c/li\u003e\n\u003cli\u003eGaldas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. Journal of advanced nursing. 2005;49(6):616\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eBoivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Hum Reprod. 2011;26(8):2084\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eSexty RE, Griesinger G, Kayser J, Lallinger M, R\u0026ouml;sner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health and Quality of Life Outcomes. 2018;16(1):233.\u003c/li\u003e\n\u003cli\u003eFerrandis ED. Psychometric properties of the Spanish version of the FertiQoL measure in couples undergoing infertility treatment. Journal of Reproductive and Infant Psychology. 2023;42(5).\u003c/li\u003e\n\u003cli\u003eSexty R, Griesinger G, Kayser J, Lallinger M, R\u0026ouml;sner S, Strowitzki T, et al. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health and Quality of Life Outcomes. 2018;16.\u003c/li\u003e\n\u003cli\u003eBueno-S\u0026aacute;nchez L, Alhambra-Borr\u0026aacute;s T, Bonilla-Campos A, Dur\u0026aacute;-Ferrandis E. Psychometric characteristics of core FertiQoL questionnaire in a Spanish sample of infertile women. Anales de Psicolog\u0026iacute;a. 2024;40:364\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eDonarelli Z, Lo Coco G, Gullo S, Salerno L, Marino A, Sammartano F, et al. The Fertility Quality of Life Questionnaire (FertiQoL) Relational subscale: psychometric properties and discriminant validity across gender. Human Reproduction. 2016;31:dew168.\u003c/li\u003e\n\u003cli\u003eWoods BM, Bray LA, Campbell S, Holland A, Mrug S, Ladores S. A review of the psychometric properties and implications for the use of the fertility quality of life tool. Health Qual Life Outcomes. 2023;21(1):45.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quality of Life (QoL), FertiQoL, Psychometric properties, Uganda, Infertility","lastPublishedDoi":"10.21203/rs.3.rs-6901451/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6901451/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nInfertility, affecting approximately 1 in 6 couples globally, is associated with profound psychosocial distress for both men and women. The Fertility Quality of Life (FertiQoL) instrument is a validated tool for assessing fertility-specific quality of life. However, its psychometric properties have not been evaluated in Uganda. This study aimed to assess the psychometric properties of the FertiQoL instrument among a sample of Ugandan individuals and couples experiencing infertility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA cross-sectional study took place at the fertility clinic in a peri-urban tertiary hospital in Kampala between March and May 2023. The English version of FertiQoL was translated into Luganda using standardized forward-backward translation procedures. The English and Luganda versions were administered to 120 participants. Internal consistency was measured using Cronbach’s alpha. Exploratory and confirmatory factor analyses (CFA) assessed construct validity. Convergent validity was examined via average variance extracted (AVE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe FertiQoL demonstrated acceptable internal consistency across all subscales (α \u0026gt; 0.70), with the relational subscale showing the highest reliability (α = 0.86). Factor loadings for all items ranged from 0.30 to 0.86. Initial AVE values indicated acceptable convergent validity for the relational (0.56) and social (0.487) subscales, while the emotional (0.387) and mind-body (0.306) subscales fell below the threshold of 0.50. CFA conducted after removing items with low factor loadings improved AVE values for emotional (0.443) and mind-body (0.416) subscales, while relational (0.655) and social (0.551) reached acceptable levels. However, model fit indices remained suboptimal (CFI = 0.686; SRMR = 0.086; RMSEA = 0.202), potentially due to the limited sample size and cultural-contextual influences on item interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nThe FertiQoL demonstrated satisfactory internal consistency. Construct validity findings were mixed, with relational and social subscales showing stronger psychometric properties than emotional and mind-body domains. Further validation studies with larger, more diverse samples and iterative cultural adaptation are recommended to enhance the instrument’s applicability in the Ugandan context.\u003c/p\u003e","manuscriptTitle":"Psychometric Evaluation of the Fertiqol Questionnaire Among Infertile Individuals and Couples in Uganda: Findings From a Tertiary Hospital in Peri-urban Kampala","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 16:36:23","doi":"10.21203/rs.3.rs-6901451/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cba327fc-5959-4aab-b24a-b4c156adeabd","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55723276,"name":"Health sciences/Health care"},{"id":55723277,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-10-31T07:02:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-03 16:36:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6901451","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6901451","identity":"rs-6901451","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}