Patient Satisfaction and Quality-Of-Life in Vitro Fertilization Services: Development of a Validated Instrument

Patient Satisfaction and Quality-Of-Life in Vitro Fertilization Services: Development of a Validated Instrument | 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 Research Article Patient Satisfaction and Quality-Of-Life in Vitro Fertilization Services: Development of a Validated Instrument Naskhanym Chausheva, Macide Artac Ozdal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3135863/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 Recent advances in infertility therapy, such as hormone medications and in vitro fertilization (IVF), have led to an increase in the demand for IVF. North Cyprus is a new medical tourist destination, and this study aims to discover influential demographic predictors of IVF patient’s satisfaction and quality-of-life after receiving reproductive IVF services. Two questionnaires on IVF patient’s satisfaction and quality-of-life were applied on 101 patients who received service in selected IVF clinics. Parametric and non-parametric tests were implemented for statistical analysis. Results showed that the mean satisfaction level of IVF service introduction and doctor professionalism increased with increase in age, and a maximum satisfaction level was found in older patients. Doctor professionalism was another significant factor for greater satisfaction in older patients comparing young who used IVF treatment. The satisfaction on IVF services reduced by increasing level of education. IVF services has to be managed and provided based on the needs of patients from different demographic backgrounds and efforts has to be given to improve the satisfaction on fertility services. In vitro fertilization (IVF) Patient satisfaction Quality of life North Cyprus 1. Background Procreation, which includes both conception and childbirth, is arguably one of humanity’s most fundamental activities. Both sexes celebrate and take for granted the opportunity to become parents. Even though the vast majority of couples become pregnant when they expect to or even earlier if they are trying to conceive, 9% of all couples of childbearing age experience accidental childlessness [1]. It is considered emotionally taxing by most couples; their stress signs are comparable to those seen in people with cancer and other life-threatening diseases [2]. The World Health Organization classifies infertility as an illness and a serious health issue and social concern. Stigmatization due to infertility is widespread, and similar emotional responses have been recorded in various cultures [3]. Many infertile couples have become biological parents thanks to the proliferation of assisted reproductive technology and the improvement in the efficacy of infertility procedures. Recent advances in infertility therapy, such as hormone medications and in vitro fertilization (IVF), have led to a rise in the demand for infertility services [4,5] and promoted the use of medical techniques to treat infertility. Having a child of one’s own is viewed as a perfectly reasonable desire by many societies around the world [6]. Although not a recent trend, increasingly people are opting to seek medical treatment in other countries, which is known as medical tourism. Numerous websites have been devoted to assisting individuals in their quest for medical facilities overseas interested in carrying out required treatments, such as a facelift or a new child [7]. The knowledge and tools for assisted reproduction are now widely available around the globe, prompting varied responses from governments, religious institutions, and public opinion [8,9]. Traveling to another country for reproductive healthcare has become the focus of a new type of global market reproductive industry, frequently referred to as "reproductive tourism" [10]. Many different factors motivate people to travel internationally in search of IVF treatment and other forms of assisted reproduction. Cost differences between the homeland and the country of destination, ease of access in the home country (e.g., waiting times), and a non-flexible legal system, and religious, governmental, and sociocultural issues facing the availability of specific healthcare, in addition to demographic variations (e.g., longer life expectancy), and personal standards are recognized in the literature. These factors can all affect the delivery of specific health services [11, 12]. On the other hand, using a universal language, the availability of new healthcare technology environments, exceptionally skilled clinical staff, facilities of top standard (in relation to patient services and facilities), certification of the care delivered, and an advantageous and forward-moving funding culture are all components that distinguish locations in their ability to attract larger numbers of medical tourists seeking assisted reproduction care [13]. Despite the growing popularity of medical tourism, particularly for IVF procedures, the majority of studies have taken a broad EU-centric approach, with only a few studies attempting to define the issue in North Cyprus [14, 15]. The high success rates of IVF procedures in North Cyprus, along with the cheaper rates (i.e., 50% of the comparative price in European countries and nearly 25% that of the US), and the relatively liberal legislative basis trying to regulate these procedures in comparison with other countries have attracted numerous international medical tourists [16]. In the most recent research on reproductive travel, these trips have yet to be characterized. While this mode of travel has been considered, current perspectives and data on medical tourism in general have become more complicated. It also brings to light a subcategory of migratory medical tourists who need to be taken into account when conducting research on the subject. Despite the fact that there is substantial scientific literature on reproductive travel around the world, there is no practice that focuses on the mobility of migrants for medical therapy. Despite anecdotal evidence suggesting that migrants may make up a substantial portion of people who travel internationally for medical treatment [17–22]. There has been a scarcity of studies on the perspectives of infertile patients on medical and patient-centered care. The technical competence and readiness of the staff in conducting examinations and administering treatments are examples of what constitutes "medical care." Providing routine psychological support is a type of patient-centered care delivered by all staff members. Couples struggling with infertility should have access to care that is not only safe and reliable but also tailored to the needs of each individual patient [23–24]. Patient perspectives and requirements are increasingly seen as crucial determinants of healthcare quality [25–26]. In fertility treatment, however, functional outcome metrics, such as live birth rates (success) and postoperative complications (safety) continue to dominate the area of care assessment, while patient-centeredness is barely addressed. Amazingly, patient-centered care has been shown to be profitable in the treatment of chronic conditions with high emotional burden, such as infertility [27]. It is necessary to gain insight into the patient’s opinion on the treatment of infertility. The field of reproductive medicine needs to place a greater emphasis not only on "effectiveness" (the percentage of patients who become pregnant), but also on other quality parameters, most notably the degree to which patients are satisfied with the care they receive. By conducting an evaluation of patients’ perspectives, healthcare providers can gain a deeper understanding of their patients’ desires, requirements, and preferences regarding fertility services and amenities [28]. Interviews and questionnaires are commonly used to measure how satisfied patients are with their care [29–32]. This is especially crucial if doctors’ and nurses’ impressions of their patients’ experiences with treatment do not properly represent the real situation [33], because this could hinder their opportunity to make adjustments that are advantageous to their patients [34–35]. An increasing body of research suggests that infertility and its care can bring about significant social and psychological hardship and, as a result, diminish the quality of life (QoL) among people who struggle with infertility [36–39]. Therefore, QoL is an essential indicator of the impact of infertility on individuals’ daily lives. According to studies, infertility issues are one of the most distressing events one may experience [40, 41]. It is possible that the notion of health-related QoL can help shed light on which areas of life people who are contemplating IVF may be experiencing more difficulty in. The beginning of treatment may inspire hope and optimism, leading to an improvement in the QoL. Therefore, it is possible that the treatment has a favorable effect on at least some areas of health-related quality of life as well. The health-related quality of life, as experienced by the patients themselves, is becoming an increasingly popular metric when assessing the consequences of disease and treatment efficacy. In the past, infertile patients’ quality of life was measured using a variety of general self-reported instruments. Recently, skilled professionals from all around the world have collaborated to create the Fertility Quality of Life (FertiQoL) questionnaire, a disease-specific tool designed to measure QoL in infertile men and women [42]. QoL items unique to infertility issues were included in this questionnaire. The FertiQoL has been employed for infertile patients from a wide range of cultural backgrounds, and it has been converted into 26 languages [43], as well as being shown to have adequate levels of reliability and validity [44, 45]. A small number of studies have utilized FertiQoL to evaluate quality of life and identify factors connected to it in infertile couples from different demographic backgrounds. The purpose of this study was (1) to determine which factors contribute to patients’ overall satisfaction with IVF clinics in North Cyprus; (2) to identify background differences (age, education level, marital status, income, and region of residence) in the evaluation of patients’ quality of life and satisfaction infertility services received overseas in North Cyprus; and (3) to determine which factors are most likely to affect a patient’s overall experience. 2. Materials and Methods 2.1. Instrument Development and Measurement The current research is designed to explore the dimensions of IVF patient’s satisfaction and quality of life, and consequently to study their attitude toward satisfaction and quality of life by developing the survey instrument; thereby, two different surveys were planned. Based on a review of the extant knowledge in the literature, for studying IVF patient’s satisfaction, qualitative research was used to design a comprehensive questionnaire. In doing so, in-depth interviews with professionals were performed. Face-to-face interviews were conducted with a group of informants comprised of specialists and patients from IVF centers in North Cyprus. Out of 25 invitations, 14 of them agreed to participate. According to the aim of this phase, which is developing a questionnaire for IVF patient’s satisfaction, potential subjects were selected from the IVF process experienced to be completely clear for interviewees for a better contribution in the interview. Then, a personal interview by implementing open-ended questions was conducted. Following a standard method [46], each interview was directed, recorded, and finally transcribed. The average duration of the interview was 45 min. To discover the main effective factors, a qualitative Delphi approach, in addition to thematic coding and analysis, was applied to find the most influential items. Thus, as a result of the qualitative study, a questionnaire was designed to capture data based on the objectives and levels of data to be collected. To modify and confirm the questionnaire, the following three groups of experts were asked to participate: (1) two professors who majored in healthcare system management, (2) three doctors with relevant work experience in IVF centers, and (3) five nurses who were aware of IVF systems. As a result, they confirmed the content validity in measuring the concepts by offering very few modifications. Finally, 69 valid questions remained in the questionnaire (see Appendix A). Results showed that the item, “Did you go to the doctor at the appointed time?” having the lowest average among the items, and the highest average was for the item, “General information such as the foundation year of all IVF centers, the number of IVF patients received, and the number of successful businesses should be given.” For the second part of this research, which studied the quality of life of IVF patients receiving this service, the standard 24 one-option and multiple-choice questionnaire named Fertility Quality of Life Questionnaire developed by Cardiff University in 2008 was implemented (see Appendix B). Considering these results, the item with the lowest average was “has your social life been restricted due to your fertility so problems?” and the item with the highest average was “Do thoughts of infertility negatively affect your attention and concentration?”. All main scale items in both questionnaires were attitudinal measures that were evaluated on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree). 2.2. Sampling and Data Collection After confirming the survey instrument items’ validity, the surveys were conducted as the second phase of the study with the same group of respondents to gather data. As previously mentioned, the survey included two questionnaires about IVF patient’s satisfaction and quality of life. The instruments also included demographic questions, such as age, education level, marital status, perceived income adequacy, and region of residence. Education level was classified as high school, college, and university; high school is the level of compulsory education that individuals have to complete for pursuing into a college or university level of education. College is the level of education, where individuals receive education for completing an associate degree and university level education is including undergraduate studies. There was no individual included in the study who had a lower or higher level of education. Perceived income adequacy was also collected as data reflecting the respondents’ subjective evaluation of their income to meet their household expenses. Fertility levels and policies on fertility differ in different countries, therefore, it is important to classify the responses of patients according to the region of residence when studying the issues related to fertility. This study adopted a convenience sampling method. The present research recruited IVF patient service users in some IVF clinics in North Cyprus because it has recently become a new and popular medical tourist destination, and annually a considerable number of people travel to North Cyprus to receive IVF services. One of the main difficulties of conducting this type of research is accessing patients through IVF centers. It turns back to the nature of this service, which is mostly a very confidential process because of the patient’s characteristics, which is also the main aim of this study. People still are guarded about revealing their personal information, and because of that, the IVF centers keep their information very private. To overcome this difficulty, because of the authors’ practical experience in the field of IVF, with a very professional and confidential approach, the permission of some IVF clinics was taken to contact some of their patients to participate in this research. As a result, 145 women (who used or who were using the IVF service in the past 5 years) were contacted by the centers, and 126 responded. After sharing a brief description of the study, 114 agreed to participate. In total, 101 filled questionnaires were retrieved, and 13 cases were deleted because of a large proportion of response bias. Respondents voluntarily participated in the survey, and consent form was collected from all participants before starting to answer the questionnaire. 2.3. Data Analysis Statistical analyses were performed using IBM SPSS 25.0 and the R statistical packages. The dataset was analyzed using descriptive statistics to summarize and describe the characteristics of the data. Then, for dimension reduction and grouping the relevant items in the questionnaire and ultimately extracting the main factors, exploratory factor analysis was employed. To indicate the differences between means of categorical variables in the demographic part of the questionnaires, parametric and non-parametric tests were utilized. Because of that, initially, a normality test was conducted to determine the type of non-parametric or parametric tests. Accordingly, the following tests were selected to indicate the differences in the group means: For normally distributed sample data and categorical variables with two groups, an independent t-test was decided. For non-normally distributed sample data and categorical variables with two groups, the Mann–Whitney U test was used. For normally distributed sample data and categorical variables with more than two groups, analysis of variance (one-way ANOVA) was decided. For non-normally distributed sample data and categorical variables with more than two groups, the Kruskal–Wallis H test was utilized. All dimensions of both questionnaires, which were extracted from exploratory factor analysis, were investigated based on the demographics’ categorical variables. 3. Results Table 1 provides details of the participants’ demographic characteristics. The total number of patients who participated in this survey was 101. About half of the study participants were aged under 35 (49.5%, n = 50) and the other half are aged 35 and above (50.5%, n = 51). Majority of the participants were from the Western and Eastern European region (67.3%, n = 68), While 11.9% of participants (n = 12) were from the Middle East region, 7.9% were from the Middle East region, 7.9% (n = 8) from North Africa and Africa, and 5% (n = 5) were form North America and 7.9% (n = 8) were from the Central, South, and Western Asia region. According to the results, 16.8% (n = 17) of the individuals participating in the research were college graduates, 5.9% (n = 6) were high school graduates, and 77.2% (n = 78) were university graduates. Majority of the participants were married 81.2% (n = 82) and 18.8% (n = 19) of them were single. 77.3% (n = 78) of the participants evaluated their monthly income as average, while 16.8% (n = 17) as low and 5.9% (n = 6) as high income level. Table 1 Demographic findings of the individuals participating in the research. Variables Category Frequency Percent (%) Age Below 35 50 49.5 35 and above 51 50.5 Region of residence Central, South and Western Asia 8 7.9 Europe and Eastern Europe 68 67.3 Middle East 12 11.9 North Africa and Africa 8 7.9 North America 5 5 Level of Education College 17 16.8 High school 6 5.9 University 78 77.2 Marital Status Married 82 81.2 Single 19 18.8 Level of Income Low 17 16.8 Average 78 77.3 High 6 5.9 Factor analysis is a method in statistics to extract combined factors from a bunch of variables. Through this method, it is possible to reduce the number of central variables to a minimum, which can still represent all necessary variable information [47]. In this study, the principal component analysis method was employed, and factors whose eigenvalue was higher than 1 were extracted. The values of the variables were obtained by rotating the factor matrix using the Varimax method. The results of the Kaiser-Meier-Olkin (KMO) and Bartlett’s sphericity test of the patient satisfaction scale in IVF services and quality of life are provided. According to these results, it was determined that there was a significant correlation between both questionnaire items according to the Bartlett Sphericity Test applied for the patient satisfaction and Quality of Life Scales in IVF services (χ2 = 1238.324, p < .001; χ2 = 757.421, p < .001), which were significant. The KMO statistics were applied to scale the sample adequacy, with the results being KMO PS = 0.712 and KMO QoL = 0.646. Both values were above 0.5; therefore, the sample was proven to be in adequate condition. According to the Kaiser rule, it was determined that the patient satisfaction scale in IVF services could be collected in a seven-factor structure (see Table 2 ). The variance explanation rate for the seven subfactor structures obtained was 76%. Furthermore, for the quality-of-life scale in IVF services, a four-factor structure was extracted (see Table 3 ). The variance explanation rate for the four subfactor structures obtained was 63%. Every variable corresponds to the right number of items, and all factor loadings for these items representing variables are higher than 0.6. In this scale, some of the irregular items whose loadings were remarkably close to each other were removed during the explanatory factor analysis. Table 2 indicates the reliability analysis results for the subdimensions of the patient satisfaction scale in IVF services with an explanation of the related factors. Based on these results, the first factor was labeled as “IVF Service and Mobile Application Request,” the second factor as “Clinical Staff Professionalism,” the third factor “IVF Service Introduction,” the fourth factor “Medical Treatment and Transportation,” the fifth factor “Doctor/Staff Care,” the sixth factor “IVF Counseling Service”, and the seventh factor “Doctor Professionalism.” Moreover, the alpha coefficients for each factor are acceptable (Cronbach’s alpha > .70), and all of them are considered reliable [48]. Table 2 Dimensions of patient satisfaction scale in IVF services and reliability analysis results. Factor Explanation N Cronbach’s Alpha F1 IVF Service and Mobile Application Request 6 0.704 F2 Clinical Staff Professionalism 3 0.802 F3 IVF Service Introduction 2 0.807 F4 Medical Treatment and Transportation 3 0.816 F5 Doctor/Staff Care 3 0.785 F6 IVF Counseling Service 2 0.744 F7 Doctor Professionalism 2 0.732 Table 3 shows the reliability analysis results for the sub-dimensions of the quality-of-life scale for IVF patients with the explanation of the related factors. These factors were constructed as “emotional,” “mind–body,” “social,” and “relational,” and the reliability results showed that all four factors are reliable, since the alpha values are greater than 0.7. The overall reliability of the Quality-of-Life Scale is 0.852, indicating that the scale is wholly reliable in the target population. Table 3 Dimensions of Quality-of-Life Scale in IVF services and reliability analysis results. Factor Explanation N Cronbach’s Alpha F1 Emotional 6 0.733 F2 Mind body 6 0.782 F3 Social 6 0.863 F4 Relational 6 0.884 In Table 4 , the comparative outcomes of patient satisfaction dimensions are reported based on the categorical variables in this research. There is a statistically significant difference between IVF service introduction (p-value = 0.044 < .05) according to the age groups of individuals by mean rank (MR) = 46.56 and standard deviation (SD) = 0.91 in those aged below 35 versus MR = 55.53 and SD = 0.88 in those aged 35 and above. Doctor Professionalism scores of individuals at the age of 35 and above (MR = 59.30 and SD = 0.74) are significantly (p-value = 0.003 < .01) higher than those of individuals who are under 35 years (MR = 42.87 and SD = 0.85). Clinical staff professionalism scores are significantly (p-value = 0.005 < .01) different in patients from different regions of residence, with the highest score in those from Central, South, and Western Asia (MR = 75.6 and SD = 2.10). Those with university-level education have significantly greater clinical staff professionalism scores (p-value = .001 < .01) compared to those with lower education levels (MR = 61.77 and SD = 2.21). IVF service and mobile application request (MR = 53.92 and SD = 1.78, p-value = 0.035 < .01) and doctor professionalism score (MR = 54.81 and SD = 0.81, p-value = 0.004 < .01) were greater in married participants. Clinical staff professionalism (p-value = .009 < .01) and doctor professionalism (p-value = .036 < .01) categories are significantly differed in terms of the income level of participants. Clinical staff professionalism scores are the highest in those with higher income level (MR = 61.33 and SD = 2.99. Doctor professionalism scores are the highest in those with the lowest level of income (MR = 56.58 and SD = 0.75). Table 4 Comparative results of the dimensions of patient satisfaction based on the demographic characteristics of participants. Variable Category IVF Service and Mobile Application Request Clinical Staff Professionalism IVF Service Introduction Medical Treatment and Transportation Doctor/Staff Care IVF Counselling Service Doctor Professionalism Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Age Below 35 50.85 (1.73) 46.84 (2.30) 46.56 (0.91) 49.31 (2.09) 48.84 (1.27) 51.29 (1.17) 42.87 (0.85) 35 and above 51.15 (2.14) 54.02 (2.60) 55.53 (0.88) 52.66 (1.55) 53.12 (1.38) 50.72 (1.41) 59.30 (0.74) p-value 0.962 0.206 0.044 0.558 0.453 0.92 0.003 Region of residence Central, South and Western Asia 53.50 (1.85) 75.6 (2.10) 57.56 (0.71) 45.75 (0.03) 63.44 (1.36) 30.25 (1.67) 64.06 (0.74) Europe and Eastern Europe 50.67 (1.96) 51.40 (2.33) 47.13 (0.91) 52.02 (1.71) 49.13 (1.38) 53.54 (1.22) 47.96 (0.86) Middle East 48.04 (2.08) 33.95 (2.27) 58.75 (1.16) 54.04 (2.44) 50.54 (1.14) 52.83 (1.41) 44.917 (0.718) North Africa and Africa 60.75 (2.05) 58.69 (2.55) 57.56 (0.71) 48.69 (2.49) 65.44 (1.06) 57.06 (1.04) 59.500 (0.71) North America 43.00 (1.79) 25.80 (2.17) 64.00 (0.00) 41.90 (2.19) 34.50 (1.00) 35.60 (0.89) 72.50 (0.89) p-value 0.828 0.005 0.161 0.902 0.236 0.132 0.134 Level of Education High school 64.33 (0.75) 13.08 (1.23) 55.42 (0.82) 60.17 (1.72) 54.75 (1.47) 42.33 (1.03) 54.75 (1.27) College 50.29 (1.57) 50.93 (2.35) 46.56 (0.93) 40.94 (2.18) 46.71 (1.18) 38.88 (1.23) 61.09 (0.69) University 50.13 (2.06) 61.77 (2.21) 51.53 (0.91) 52.49 (1.74) 51.65 (1.35) 54.31 (1.30) 48.51 (0.83) p-value 0.507 0.001 0.616 0.23 0.767 0.083 0.22 Marital Status Married 53.92 (1.78) 51.03 (2.50) 52.23 (0.89) 51.19 (1.90) 50.80 (1.32) 49.63 (1.33) 54.81 (0.81) Single 38.42 (2.28) 48.26 (2.32) 45.68 (2.32) 50.18 (1.59) 51.87 (1.36) 56.90 (1.08) 34.58 (0.77) p-value 0.035 0.705 0.252 0.894 0.886 0.304 0.004 Level of Income Low 43.97 (2.34) 48.58 (2.43) 55.45 (0.69) 39.59 (1.44) 58.62 (1.50) 51.91 (0.97) 56.58 (0.75) Average 52.34 (1.88) 55.38 (2.43) 49.65 (0.95) 52.18 (1.94) 49.20 (1.31) 50.80 (1.34) 50.88 (0.79) High 53.50 (1.38) 61.33 (2.99) 55.42 (0.82) 68.00 (1.17) 52.83 (0.98) 51.00 (1.60) 50.60 (0.86) p-value 0.543 0.009 0.533 0.083 0.461 0.989 0.036 Note- Significant p-values are indicated in bold. As the results display in Table 5 , quality of life dimensions is also different in terms of the demographic characteristics of participants in this research including age, marital status, region of residence, education level, and income level. I accordance of the findings of this study shown in Table 5 , there is a statistically significant difference for emotional factor (p-value = .031 < .05), mind-body (p-value = .004 < .01), and relational (p-value = .022 < .05) according to the age groups of the participants, with greater emotional scores of individuals aged 35 and above are (MR = 53.61 and SD = 3.21) than those of individuals under 35 (MR = 47.51 and SD = 3.25), higher mind-body scores of individuals with 35 and above (MR = 52.70 and SD = 4.08) than those of individuals under 35 (MR = 49.33 and SD = 3.98), and finally for relational scores were higher in those under 35 (MR = 50.29 and SD = 2.50) compared to those aged 35 and above (MR = 44.82 and SD = 2.32). Emotional scores of the respondents significantly differed (p-value = .049 < .05) among those from different regions of residence, with greater emotional scores in those from central, south, and western Asia compared to those from other regions (MR = 73.50 and SD = 2.48). Furthermore, relational scores are significantly different (p-value = .023) were the highest in those with high-income level (MR = 68.25 and SD = 1.47) compared to those with average-income (MR = 48.72 and SD = 2.40) and low-income level (MR = 34.25 and SD = 2.39). Table 5 Comparative results of the dimensions of quality-of-life scale based on the demographic characteristics of participants. Emotional Mind Body Social Relational Variables Category Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Mean Rank (SD) Age Below 35 47.51 (3.25) 49.33 (3.98) 53.75 (3.07) 50.29 (2.50) 35 and above 53.61 (3.21) 52.70 (4.08) 48.30 (3.05) 44.82 (2.32) p-value 0.031 0.004 0.267 0.022 Region of residence Central, South and Western Asia 73.50 (2.48) 59.81 (2.98) 42.44 (2.26) 39.79 (3.08) Europe and Eastern Europe 50.02 (2.92) 50.95 (3.81) 48.99 (3.08) 49.23 (2.44) Middle East 45.33 (3.75) 48.292 (5.26) 53.625 (3.39) 46.136 (1.79) North Africa and Africa 34.938 (2.97) 41.06 (4.75) 63.50 (3.25) 40.50 (2.17) North America 59.25 (5.92) 60.00 (4.06) 65.70 (2.92) 50.70 (3.13) p-value 0.049 0.484 0.455 0.843 Level of Education High school 46.50 (4.04) 37.25 (2.32) 42.17 (3.72) 28.25 (2.32) College 49.47 (2.86) 49.21 (3.10) 47.19 (2.61) 42.79 (2.55) University 50.98 (3.29) 52.45 (4.30) 52.53 (3.13) 50.25 (2.35) p-value 0.932 0.452 0.587 0.144 Marital Status Married 51.35 (3.43) 49.99 (4.20) 50.07 (3.01) 46.76 (2.39) Single 46.87 (2.22) 55.37 (3.19) 55.03 (3.33) 50.64 (2.53) p-value 0.544 0.541 0.37 0.575 Level of Income Low 53.60 (3.12) 51.53 (3.90) 50.51 (3.01) 34.25 (2.39) Average 51.58 (3.67) 67.75 (4.15) 74.17 (1.23) 48.72 (2.40) High 36.06 (3.24) 42.68 (4.44) 45.09 (3.47) 68.25 (1.47) p-value 0.065 0.256 0.105 0.023 Note- Significant p-values are indicated in bold. 4. Conclusion While past research has found correlations between patient demographics and satisfaction levels, the literature is lacking in its ability to explain the mechanisms behind these correlations. It is unclear whether the observed associations are the result of genuine variations in the care provided to different patient subgroups or whether they simply reflect disparities in patient values and needs. If healthcare institutions treat people in the same manner, then the connections that have been identified between demographic factors and satisfaction levels suggest that patients’ perceptions of service quality are impacted by the needs and expectations that have emerged over time. The results of this study indicated that age is a substantial antecedent of patient satisfaction with the introduction of IVF services and with the professionalism of doctors. Previous research has shown conflicting results, considering the nature of the relationship between patients’ age and satisfaction [49–50]. The finding of this study showed that the average degree of patient satisfaction with the introduction of IVF services improved with patient age, with the highest levels of satisfaction occurring in patients who were 35 and older. Similarly, doctor professionalism is another significant factor of greater satisfaction in older patients in comparison with youngsters who used IVF treatment. Lack of experience (and perhaps unreasonable demands) with healthcare institutions may account for younger individuals’ lower satisfaction ratings [51–54]. For patient education level, patients who had a higher level of education reported a higher level of satisfaction in terms of clinical staff’s professionalism compared to patients who had a lower level of education. This indicates that the mean level of satisfaction for staff skills is higher in patients who had a higher level of education. One argument could be that people’s critical thinking and expectations rise in parallel with their level of education. As this study found, a higher level of education may lead to a more critical assessment of the professionalism of medical professionals on the basis of the individual’s knowledge and preferences which is consistent with prior research [55, 56, 57, 58, 59, 60, 61, 63] that higher socioeconomic status and education levels were associated with higher levels of satisfaction with fertility treatment among both men and women. In a similar manner, the patients’ marital status was found to associate with their overall satisfaction level in terms of IVF service and mobile application requests and doctor professionalism. Overall, the results of this study are consistent with those of earlier research showing that single patients were less satisfied with IVF services, than married patients [64–66]. For providing better treatment centered on the patient, those who provide medical services should look for ways to get patients more involved in and concerned about their own health. It is possible that using apps designed to run on smart devices could be one method to boost patient involvement with medical services. Apps have been used to educate patients about ways to improve their health, involve them in monitoring illness treatments, and assist them in more properly adhering to treatment regimens. Based on the findings of this study, lower-income and lower-educated patients are less satisfied with their IVF treatment. For example, they were less likely to be satisfied with the doctors’ and clinical staff’s professionalism, which is in line with the findings of previous studies [67–70]. Assuming that customer satisfaction is the result of a positive evaluation of a product or service after it is purchased could provide some insight into this issue [71]. The level of customer satisfaction can be determined by contrasting the customer’s expectations with the actual results; if the actual performance is superior, the customer is satisfied. The phenomenon of perceptions being greater than actual achievement is the root cause of dissatisfaction [72]. Customer satisfaction is affected by his perception of the service’s quality [73]. Thus, people with higher educational levels and income who used IVF services in North Cyprus expected the doctor and clinical staff professionalism to be outstanding. In the current study, we showed that patients from different regions of residence reported significantly different levels of satisfaction with the professionalism of clinical staff. People from central, south, and western Asia had the highest levels of satisfaction compared to individuals from other regions. Studies have shown that there are geographically and culturally differences in fertility levels and approaches to fertility treatment [74]. People from other cultures therefore, have varying cultural norms, expectations, and experiences with fertility services, which impact on how satisfied they are with their IVF treatment [75]. A secondary objective of this research was to investigate the QoL and the demographic characteristics connected to it in patients receiving IVF in North Cyprus. According to the findings of the study, a relatively young age is a determinant of a lower score in the emotional and mind–body domains of quality of life. Older patients in contrary, exhibited a lower rank in the relational subcategory of QoL. It is likely that the importance of childbearing among infertile older couples could have a more detrimental impact on their relationships. This would be one explanation for the linkage between being older and having a worse relational quality of life domain score. These results are comparable to those found in earlier investigations [76–77]. In addition, the results of this research showed that living in different regions was a potential indicator of quality of life in the emotional subdimension. The patients from central, south, and western Asia, North America, Europe and Eastern Europe, the Middle East, and North Africa and Africa received the highest to lowest level of emotional scores, respectively. This could be due to the fact that people come from different cultural backgrounds and have different expectations of society, both of which contribute to the stigma associated with infertility issues and childlessness. Finally, patients with a higher income are more likely to have a higher QoL on the relational aspect. 4.1. Limitations and Future Studies Like all the studies, there are some potential limitations in conducting this research that should be considered when interpreting our findings. First, not every relevant variable could have been included in the analysis. Therefore, generalization difficulties may arise due to the influence of unknown parameters. For instance, patients were selected from a variety of IVF clinics, so differences in care providers were not considered. This can be considered in future research. Second, based on the nature of IVF services, most centers are unwilling to help researchers with their surveys because of confidentiality matters, and this causes problems in accessing patients and collecting data. Third, since the data were collected during the COVID-19 pandemic, the number of patients was considerably lower because of travel restrictions. 4.2. Implications The dramatic rise in the provision of reproductive services across international borders (also known as cross-border reproductive care, or CBRC) has created unique opportunities for countries and organizations that provide IVF services. Since the medical tourism sector is expanding rapidly, despite visible signs of political and economic instability, medical tourism, including IVF, which places significant demand on healthcare services delivered in North Cyprus, can become another engine of economic development. The United Nations World Tourism Organization reports that in contrast to the sales of all other categories of tourism, medical tourism has not experienced a fall during the economic downturn [78]. People are increasingly selecting medical tourism as a viable and cost-effective option for a well-deserved break, during which they may focus on their physical and mental health. The expansion of medical tourism, particularly IVF tourism, is one of the most essential areas for growth in North Cyprus, as it will allow the region to fully capitalize on its basic research capacity and strengthen the significance of the tourism business. The results of this study have massive implications for both the routine procedures performed in IVF facilities and for future research. All reproductive clinics can use the insights gained from this study to determine and prioritize improvement activities that are patient-centered and focus on quality enhancement. This research suggests that the average fertility clinic should place a premium on addressing patient needs. This suggests that efforts should be directed toward creating more complex models for modifying patient satisfaction findings. If, for instance, the predictive power of some demographic and clinical factors is based on the fact that they are correlated with patients’ expectations, then a more precise and refined evaluation of patients’ expectations will allow more accurate correction. When asked specifically what contributed most to their level of satisfaction with their care, our respondents most frequently cited their trust in their physicians’ technical abilities. This indicates that patients place a higher importance on the technical skills of their doctor and are prepared to sacrifice emotional fulfillment in exchange for the hope that their infertility treatment will be effective and lead to the birth of a child. This goes against what was previously believed about how people arbitrate the care they receive. Others have found that patients are most satisfied with their care when they start to feel better or when they like their doctor’s attitude and style of communicating with them [79]. It is possible that people with infertility make up a distinct community that is more knowledgeable than other categories of patients about the many treatments available for infertility. This could explain why they place such a high value on technical ability and expertise. People may not genuinely rate the actual quality of care that they obtain; rather, they may evaluate the manner in which the care that they receive is provided [80]. People will attribute high levels of technical skill to an expert if the treatment they receive from that specialist is provided in a pleasant and knowledgeable manner. It can be concluded that patients who are having treatment for infertility may be quite flexible and welcome numerous treatments if they have confidence in a particular doctor’s ability to properly treat them. Clinicians and IVF center personnel need to be sensitive to the needs and desires of their patients, considering each person’s background and level of comprehension of the operations they will undergo. Declarations Author Contributions: Conceptualization, N.C. and M.A.O.; Methodology, N.C. and M.A.O.; Software, N.C.; Validation, N.C. and M.A.O.; Formal Analysis, N.C.; Investigation, N.C. and M.A.O.; Resources, N.C.; Data Curation, N.C.; Writing—Original Draft Preparation, N.C.; Writing—Review & Editing, M.A.O.; Visualization, M.A.O.; Supervision, M.A.O. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and was approved by the European University of Lefke Ethics Committee, with number ÜEK/43/01/09/1920/03, 10.09.2019. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Conflicts of Interest : The authors declare no conflict of interest. References Johansson M, Adolfsson A, Berg M, Francis J, Hogström L, Janson PO, …, HELLSTRÖM AL. Gender perspective on quality of life, comparisons between groups 4–5.5 years after unsuccessful or successful IVF treatment. Acta Obstet Gynecol Scand, 201089(5), 683–91. Souter VL, Hopton JL, Penney GC, Templeton AA. Survey of psychological health in women with infertility. JPOG. 2002;23(1):41–9. Lukse MP, Vacc NA. Grief, depression, and coping in women undergoing infertility treatment. Volume 93. Obstetrics & Gynecology; 1999. pp. 245–51. 2. Beck-Gernsheim E. From the pill to test-tube babies: New options, new pressures in reproductive behavior. Healing technology: Feminist perspectives, 1989, 23–40. de Wit A, Banta D. Diffusion of in-vitro fertilization in the Netherlands and England: An exploratory study. Int J Technol Assess Health Care. 1991;7(4):574–84. Strathern M. Reproducing the future: essays on anthropology, kinship and the new reproductive technologies. Manchester University Press.; 1992. Davies T. Cross-border reproductive care: quality and safety challenges for the regulator. Fertil Steril. 2010;94(1):e20–2. Inhorn MC. Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Soc Sci Med. 2003;56(9):1837–51. Inhorn MC, Birenbaum-Carmeli D. Assisted reproductive technologies and culture change. Annu Rev Anthropol. 2008;37:177–96. Whittaker A. Global technologies and transnational reproduction in Thailand. Asian Stud Rev. 2009;33(3):319–32. Connell J. Medical tourism: Sea, sun, sand and… surgery. Tour Manag. 2006;27(6):1093–100. Yildiz MS, Khan MM. Opportunities for reproductive tourism: cost and quality advantages of Turkey in the provision of in-vitro Fertilization (IVF) services. BMC Health Serv Res. 2016;16:378. https://doi.org/10.1186/s12913-016-1628-7 . Gray HH, Poland SC. Medical tourism: crossing borders to access health care. KIEJ. 2008;18(2):193–201. Gomes LBM, Siqueira MHB, de Castro EC. Outcomes of GnRH agonist triggering in assisted reproductive technology: a systematic review. Reprodução & Climatério. 2017;32(2):104–8. Duguet AM, Boyer-Beviere B. Preimplantation genetic diagnosis: the situation in France and in other European countries. Eur J Health Law. 2017;24(2):160–74. Ishihara O, Adamson GD, Dyer S, de Mouzon J, Nygren KG, Sullivan EA, …, Mansour R. International committee for monitoring assisted reproductive technologies: world report on assisted reproductive technologies, 2007. Fertil Steril. 2015;103(2):402–13. Kahn SM. Reproducing Jews: A cultural account of assisted conception in Israel. Duke University Press; 2000. Nahman M. Materializing Israeliness: difference and mixture in transnational ova donation. Sci as Cult. 2006;15(3):199–213. Inhorn MC, Birenbaum-Carmeli D. Assisted reproductive technologies and culture change. Annu Rev Anthropol. 2008;37:177–96. Deomampo D. (2008, November). Kinship and international surrogacy: Making families in India in the age of globalization. In American Anthropological Association 107th Annual meeting, San Francisco (pp. 19–23). Vora K. (2008, November). Selling potential: surplus fertility and biocapital in the production of transnational Indian surrogacy. In American Anthropological Association 107th Annual Meeting. San Francisco (pp. 19–23). Whittaker A, Speier A. Cycling overseas”: care, commodification, and stratification in cross-border reproductive travel. Med Anthropol. 2010;29(4):363–83. Corrigan JM, Donaldson MS, Kohn LT, Maguire SK, Pike KC. Crossing the quality chasm. A new health system for the 21st century. Washington, DC: Institute of Medicine. National Academy of Sciences; 2001. Van Empel IW, Nelen WL, Hermens RP, Kremer JA. Coming soon to your clinic: high-quality ART. Hum Reprod. 2008;23(6):1242–5. Cleary PD. The increasing importance of patient surveys: Now that sound methods exist, patient surveys can facilitate improvement. BMJ. 1999;319(7212):720–1. Groenewegen PP, Kerssens JJ, Sixma HJ, et al. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005;5:16. https://doi.org/10.1186/1472-6963-5-16 . Verhaak CM, Smeenk JMJ, Evers AA, Kremer JA, Kraaimaat FW, Braat DDM. Women’s emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update. 2007;13(1):27–36. Coulter A, Ellins J. Patient-focused interventions: a review of the evidence. Volume 1. London: Health Foundation; 2006. Halman LJ, Abbey A, Andrews FM. Why are couples satisfied with infertility treatment? Fertil Steril. 1993;59(5):1046–54. Souter VL, Penney G, Hopton JL, Templeton AA. Patient satisfaction with the management of infertility. Hum Reprod (Oxford England). 1998;13(7):1831–6. Schmidt L. Infertile couples’ assessment of infertility treatment. Acta Obstet Gynecol Scand. 1998;77(6):649–9. Haagen EC, Hermens RP, Nelen WL, Braat DD, Kremer JA, Grol RP. Subfertile couples' negative experiences with intrauterine insemination care. Fertil Steril. 2008;89(4):809–16. Aarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112–8. Arnetz BB. Staff perception of the impact of health care transformation on quality of care. IJQHC. 1999;11(4):345–51. Jung HP, Wensing M, Olesen F, Grol R. Comparison of patients’ and general practitioners’ evaluations of general practice care. Qual Saf Health Care. 2002;11(4):315–9. Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigating quality of life and health-related quality of life in infertility: a systematic review. JPOG. 2010;31(2):101–10. Dancet EA, Nelen WL, Sermeus W, De Leeuw L, Kremer JA. Hooghe, T. M. The patients' perspective on fertility care: a systematic review. Hum Reprod Update. 2010;16(5):467–87. Schmidt L. Infertility and assisted reproduction in Denmark. Dan Med Bull. 2006;53(4):390–417. Verhaak CM, Smeenk JMJ, Evers AA, Kremer JA, Kraaimaat FW, Braat DDM. Women’s emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update. 2007;13(1):27–36. Freeman EW, Boxer AS, Rickels K, Tureck R, Mastroianni L Jr. Psychological evaluation and support in a program of in vitro fertilization and embryo transfer. Fertil Steril. 1985;43(1):48–53. Mahlstedt PP, Macduff S, Bernstein J. Emotional factors and the in vitro fertilization and embryo transfer process. JIVFET. 1987;4(4):232–6. 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. Heredia M, Tenías JM, Rocio R, Amparo F, Calleja MA, Valenzuela JC. Quality of life and predictive factors in patients undergoing assisted reproduction techniques. EJOGRB. 2013;167(2):176–80. Aarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112–8. 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. Allen J, Eboli L, Forciniti C, Mazzulla G, de Dios Ortúzar J. The role of critical incidents and involvement in transit satisfaction and loyalty. Transp Policy. 2019;75:57–69. Kim JO, Mueller CW. Factor analysis: Statistical methods and practical issues 1978, (Vol. 14). sage. Nunnally JC. An overview of psychological measurement. Clin diagnosis mental disorders, 1978, 97–146. Malin M, Hemminki E, Räikkönen O, Sihvo S, Perälä ML. What do women want? Women's experiences of infertility treatment. Volume 53. Social science & medicine; 2001. pp. 123–33. 1. Leite RC, Makuck MY, Petta CA, Morais SS. Women’s satisfaction with physicians’ communication skills during an infertility consultation. Patient Educ Couns. 2005;59:38–45. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811–8. Young GJ, Meterko M, Desai KR. Patient Satisfaction with Hospital Care: Effects of Demographic and Institutional Characteristic. Med Care. 2000;38:325–34. https://doi.org/10.1097/00005650-200003000-00009 . Young GJ, Meterko M, Desai K. R. Patient satisfaction with hospital care: effects of demographic and institutional characteristics. Med Care, 2000, 325–34. Jaipaul CK, Rosenthal GE. Are older patients more satisfied with hospital care than younger patients? J Gen Intern Med. 2003;18(1):23–30. Sabourin S, Wright J, Duchesne C, Belisle S. Are consumers of modern fertility treatments satisfied? Fertil Steril. 1991;56(6):1084–90. Hall JA, Dornan MC. (1990). Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social science & medicine, 1990, 30(7), 811–818. Quintana JM, González N, Bilbao A, et al. Predictors of patient satisfaction with hospital health care. BMC Health Serv Res. 2006;6:102. https://doi.org/10.1186/1472-6963-6-102 . Haagen EC, Hermens RP, Nelen WL, Braat DD, Kremer JA, Grol RP. Subfertile couples' negative experiences with intrauterine insemination care. Fertil Steril. 2008;89(4):809–16. Dancet EA, Nelen WL, Sermeus W, De Leeuw L, Kremer JA. Hooghe, T. M. The patients' perspective on fertility care: a systematic review. Hum Reprod Update. 2010;16(5):467–87. Schmidt L, Holstein BE, Boivin J, Tjørnhøj-Thomsen T, Blaabjerg J, Hald F, …, Nyboe Andersen A. High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi‐centre Psychosocial Infertility (COMPI) Research Programme. Hum Reprod. 2003;18(12):2638–46. Naseer M, Zahidie A, Shaikh BT. Determinants of patient's satisfaction with health care system in Pakistan: a critical review. PJPH. 2012;2(2):52–61. ttps://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/135 . Hajioff D, Birchall M. Medical students in ENT outpatient clinics: appointment times, patient satisfaction and student satisfaction. Med Educ. 1999;33(9):669–73. Pendleton DA, Bochner S. The communication of medical information in general practice consultations as a function of patients' social class. Social Sci Med Part A: Med Psychol Med Sociol. 1980;14(6):669–73. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811–8. Weisman CS, Henderson JT, Schifrin E, Romans M, Clancy CM. Gender and patient satisfaction in managed care plans: analysis of the 1999 HEDIS/CAHPS 2.0 H Adult Survey. Women's Health Issues. 2001;11(5):401–15. Afzal M, Rizvi F, Azad AH, Rajput AM, Khan A, Tariq N. Effect of demographic characteristics on patient’s satisfaction with health care facility. J Postgrad Med Inst. 2014;28(2):154–60. Sabourin S, Wright J, Duchesne C, Belisle S. Are consumers of modern fertility treatments satisfied? Fertil Steril. 1991;56(6):1084–90. Can G, Akin S, Aydiner A, Ozdilli K, Durna Z. Evaluation of the effect of care given by nursing students on oncology patients’ satisfaction. EJON. 2008;12(4):387–92. Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Soc Sci Med. 1997;45(12):1829–43. Findik UY, Unsar S, Sut N. Patient satisfaction with nursing care and its relationship with patient characteristics. Nurs Health Sci. 2010;12(2):162–9. Bolton RN, Drew JH. A longitudinal analysis of the impact of service changes on customer attitudes. JM. 1991;55(1):1–9. Churchill GA Jr, Surprenant C. An investigation into the determinants of customer satisfaction. JMR. 1982;19(4):491–504. Grönroos C. A Service Quality Model and its Marketing Implications. Eur J Mark. 1984;18(4):36–44. https://doi.org/10.1108/EUM0000000004784 . Balbo. (Fertility in Advanced Societies: A Review of Research 2013. Yousif. (Fertility Transition: Middle East and North Africa. 2001. Aarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112–8. Maroufizadeh S, Ghaheri A, Omani Samani R. Factors associated with poor quality of life among Iranian infertile women undergoing IVF. Psychol health Med. 2017;22(2):145–51. UNWTO/Etc Launch Report on Health Tourism.. https://www.unwto.org/global/press-release/2018-12-20/unwtoetc-launch-report-health-tourism . 2018, December 20, Retrieved from https://www.unwto.org/. Halman LJ, Abbey A, Andrews FM. Why are couples satisfied with infertility treatment? Fertil Steril. 1993;59(5):1046–54. Ben-Sira Z. Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory. JHSB, 1980, 170–80. Additional Declarations No competing interests reported. Supplementary Files Appendices.docx 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-3135863","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":215785750,"identity":"11ef9bdb-70d9-4dd4-a36e-a513a78ba2df","order_by":0,"name":"Naskhanym Chausheva","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYHACZmYwxd4AJAwsSNHCcwCkRYIULRIJYJKwenP244+NC2ruJK6d+fzqhh8FEgz87d0JeLVY9uQYJ8849ixx2+2csps9QIdJnDm7Aa8WgwM5zId52A6DtKTd4AFqMZDIJaDl/PPHh3n+AbXcPJN28w9RWm4kGCfztgG13GA/dps4W268MTbm7TtsvO1MDtttGQMJHsJ+OZ/+WJrn22HZbcePP7v55o+NHH97L34tMODYwMBjAGLwEKUcBOyBKeYB0apHwSgYBaNgZAEAz+hNjziogKkAAAAASUVORK5CYII=","orcid":"","institution":"European University of Lefke","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Naskhanym","middleName":"","lastName":"Chausheva","suffix":""},{"id":215785751,"identity":"b151c808-2b29-4713-95b5-67eb9b744fe3","order_by":1,"name":"Macide Artac Ozdal","email":"","orcid":"","institution":"European University of Lefke","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Macide","middleName":"Artac","lastName":"Ozdal","suffix":""}],"badges":[],"createdAt":"2023-07-03 13:59:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3135863/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3135863/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":39738977,"identity":"4d17b01d-cacd-41c2-aaad-2f18de645555","added_by":"auto","created_at":"2023-07-08 16:59:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":386130,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3135863/v1/71baa8f6-d81c-459f-a3ea-fabf3b54eca7.pdf"},{"id":39670052,"identity":"9740264a-33b9-4748-98e5-e87c79b29cd4","added_by":"auto","created_at":"2023-07-07 04:40:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24701,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-3135863/v1/9a090976ac99ef1dc26c121f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePatient Satisfaction and Quality-Of-Life in Vitro Fertilization Services: Development of a Validated Instrument\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eProcreation, which includes both conception and childbirth, is arguably one of humanity\u0026rsquo;s most fundamental activities. Both sexes celebrate and take for granted the opportunity to become parents. Even though the vast majority of couples become pregnant when they expect to or even earlier if they are trying to conceive, 9% of all couples of childbearing age experience accidental childlessness [1]. It is considered emotionally taxing by most couples; their stress signs are comparable to those seen in people with cancer and other life-threatening diseases [2]. The World Health Organization classifies infertility as an illness and a serious health issue and social concern. Stigmatization due to infertility is widespread, and similar emotional responses have been recorded in various cultures [3]. Many infertile couples have become biological parents thanks to the proliferation of assisted reproductive technology and the improvement in the efficacy of infertility procedures. Recent advances in infertility therapy, such as hormone medications and in vitro fertilization (IVF), have led to a rise in the demand for infertility services [4,5] and promoted the use of medical techniques to treat infertility. Having a child of one\u0026rsquo;s own is viewed as a perfectly reasonable desire by many societies around the world [6]. Although not a recent trend, increasingly people are opting to seek medical treatment in other countries, which is known as medical tourism. Numerous websites have been devoted to assisting individuals in their quest for medical facilities overseas interested in carrying out required treatments, such as a facelift or a new child [7]. The knowledge and tools for assisted reproduction are now widely available around the globe, prompting varied responses from governments, religious institutions, and public opinion [8,9]. Traveling to another country for reproductive healthcare has become the focus of a new type of global market reproductive industry, frequently referred to as \"reproductive tourism\" [10]. Many different factors motivate people to travel internationally in search of IVF treatment and other forms of assisted reproduction. Cost differences between the homeland and the country of destination, ease of access in the home country (e.g., waiting times), and a non-flexible legal system, and religious, governmental, and sociocultural issues facing the availability of specific healthcare, in addition to demographic variations (e.g., longer life expectancy), and personal standards are recognized in the literature. These factors can all affect the delivery of specific health services [11, 12]. On the other hand, using a universal language, the availability of new healthcare technology environments, exceptionally skilled clinical staff, facilities of top standard (in relation to patient services and facilities), certification of the care delivered, and an advantageous and forward-moving funding culture are all components that distinguish locations in their ability to attract larger numbers of medical tourists seeking assisted reproduction care [13]. Despite the growing popularity of medical tourism, particularly for IVF procedures, the majority of studies have taken a broad EU-centric approach, with only a few studies attempting to define the issue in North Cyprus [14, 15].\u003c/p\u003e \u003cp\u003eThe high success rates of IVF procedures in North Cyprus, along with the cheaper rates (i.e., 50% of the comparative price in European countries and nearly 25% that of the US), and the relatively liberal legislative basis trying to regulate these procedures in comparison with other countries have attracted numerous international medical tourists [16]. In the most recent research on reproductive travel, these trips have yet to be characterized. While this mode of travel has been considered, current perspectives and data on medical tourism in general have become more complicated. It also brings to light a subcategory of migratory medical tourists who need to be taken into account when conducting research on the subject. Despite the fact that there is substantial scientific literature on reproductive travel around the world, there is no practice that focuses on the mobility of migrants for medical therapy. Despite anecdotal evidence suggesting that migrants may make up a substantial portion of people who travel internationally for medical treatment [17\u0026ndash;22].\u003c/p\u003e \u003cp\u003eThere has been a scarcity of studies on the perspectives of infertile patients on medical and patient-centered care. The technical competence and readiness of the staff in conducting examinations and administering treatments are examples of what constitutes \"medical care.\" Providing routine psychological support is a type of patient-centered care delivered by all staff members. Couples struggling with infertility should have access to care that is not only safe and reliable but also tailored to the needs of each individual patient [23\u0026ndash;24]. Patient perspectives and requirements are increasingly seen as crucial determinants of healthcare quality [25\u0026ndash;26]. In fertility treatment, however, functional outcome metrics, such as live birth rates (success) and postoperative complications (safety) continue to dominate the area of care assessment, while patient-centeredness is barely addressed. Amazingly, patient-centered care has been shown to be profitable in the treatment of chronic conditions with high emotional burden, such as infertility [27].\u003c/p\u003e \u003cp\u003eIt is necessary to gain insight into the patient\u0026rsquo;s opinion on the treatment of infertility. The field of reproductive medicine needs to place a greater emphasis not only on \"effectiveness\" (the percentage of patients who become pregnant), but also on other quality parameters, most notably the degree to which patients are satisfied with the care they receive. By conducting an evaluation of patients\u0026rsquo; perspectives, healthcare providers can gain a deeper understanding of their patients\u0026rsquo; desires, requirements, and preferences regarding fertility services and amenities [28]. Interviews and questionnaires are commonly used to measure how satisfied patients are with their care [29\u0026ndash;32]. This is especially crucial if doctors\u0026rsquo; and nurses\u0026rsquo; impressions of their patients\u0026rsquo; experiences with treatment do not properly represent the real situation [33], because this could hinder their opportunity to make adjustments that are advantageous to their patients [34\u0026ndash;35].\u003c/p\u003e \u003cp\u003eAn increasing body of research suggests that infertility and its care can bring about significant social and psychological hardship and, as a result, diminish the quality of life (QoL) among people who struggle with infertility [36\u0026ndash;39]. Therefore, QoL is an essential indicator of the impact of infertility on individuals\u0026rsquo; daily lives. According to studies, infertility issues are one of the most distressing events one may experience [40, 41]. It is possible that the notion of health-related QoL can help shed light on which areas of life people who are contemplating IVF may be experiencing more difficulty in. The beginning of treatment may inspire hope and optimism, leading to an improvement in the QoL. Therefore, it is possible that the treatment has a favorable effect on at least some areas of health-related quality of life as well. The health-related quality of life, as experienced by the patients themselves, is becoming an increasingly popular metric when assessing the consequences of disease and treatment efficacy.\u003c/p\u003e \u003cp\u003eIn the past, infertile patients\u0026rsquo; quality of life was measured using a variety of general self-reported instruments. Recently, skilled professionals from all around the world have collaborated to create the Fertility Quality of Life (FertiQoL) questionnaire, a disease-specific tool designed to measure QoL in infertile men and women [42]. QoL items unique to infertility issues were included in this questionnaire. The FertiQoL has been employed for infertile patients from a wide range of cultural backgrounds, and it has been converted into 26 languages [43], as well as being shown to have adequate levels of reliability and validity [44, 45]. A small number of studies have utilized FertiQoL to evaluate quality of life and identify factors connected to it in infertile couples from different demographic backgrounds.\u003c/p\u003e \u003cp\u003eThe purpose of this study was (1) to determine which factors contribute to patients\u0026rsquo; overall satisfaction with IVF clinics in North Cyprus; (2) to identify background differences (age, education level, marital status, income, and region of residence) in the evaluation of patients\u0026rsquo; quality of life and satisfaction infertility services received overseas in North Cyprus; and (3) to determine which factors are most likely to affect a patient\u0026rsquo;s overall experience.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Instrument Development and Measurement\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe current research is designed to explore the dimensions of IVF patient\u0026rsquo;s satisfaction and quality of life, and consequently to study their attitude toward satisfaction and quality of life by developing the survey instrument; thereby, two different surveys were planned. Based on a review of the extant knowledge in the literature, for studying IVF patient\u0026rsquo;s satisfaction, qualitative research was used to design a comprehensive questionnaire. In doing so, in-depth interviews with professionals were performed. Face-to-face interviews were conducted with a group of informants comprised of specialists and patients from IVF centers in North Cyprus. Out of 25 invitations, 14 of them agreed to participate. According to the aim of this phase, which is developing a questionnaire for IVF patient\u0026rsquo;s satisfaction, potential subjects were selected from the IVF process experienced to be completely clear for interviewees for a better contribution in the interview. Then, a personal interview by implementing open-ended questions was conducted. Following a standard method [46], each interview was directed, recorded, and finally transcribed. The average duration of the interview was 45 min. To discover the main effective factors, a qualitative Delphi approach, in addition to thematic coding and analysis, was applied to find the most influential items. Thus, as a result of the qualitative study, a questionnaire was designed to capture data based on the objectives and levels of data to be collected. To modify and confirm the questionnaire, the following three groups of experts were asked to participate: (1) two professors who majored in healthcare system management, (2) three doctors with relevant work experience in IVF centers, and (3) five nurses who were aware of IVF systems. As a result, they confirmed the content validity in measuring the concepts by offering very few modifications. Finally, 69 valid questions remained in the questionnaire (see Appendix A). Results showed that the item, \u0026ldquo;Did you go to the doctor at the appointed time?\u0026rdquo; having the lowest average among the items, and the highest average was for the item, \u0026ldquo;General information such as the foundation year of all IVF centers, the number of IVF patients received, and the number of successful businesses should be given.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFor the second part of this research, which studied the quality of life of IVF patients receiving this service, the standard 24 one-option and multiple-choice questionnaire named Fertility Quality of Life Questionnaire developed by Cardiff University in 2008 was implemented (see Appendix B). Considering these results, the item with the lowest average was \u0026ldquo;has your social life been restricted due to your fertility so problems?\u0026rdquo; and the item with the highest average was \u0026ldquo;Do thoughts of infertility negatively affect your attention and concentration?\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAll main scale items in both questionnaires were attitudinal measures that were evaluated on a five-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sampling and Data Collection\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAfter confirming the survey instrument items\u0026rsquo; validity, the surveys were conducted as the second phase of the study with the same group of respondents to gather data. As previously mentioned, the survey included two questionnaires about IVF patient\u0026rsquo;s satisfaction and quality of life. The instruments also included demographic questions, such as age, education level, marital status, perceived income adequacy, and region of residence. Education level was classified as high school, college, and university; high school is the level of compulsory education that individuals have to complete for pursuing into a college or university level of education. College is the level of education, where individuals receive education for completing an associate degree and university level education is including undergraduate studies. There was no individual included in the study who had a lower or higher level of education. Perceived income adequacy was also collected as data reflecting the respondents\u0026rsquo; subjective evaluation of their income to meet their household expenses. Fertility levels and policies on fertility differ in different countries, therefore, it is important to classify the responses of patients according to the region of residence when studying the issues related to fertility.\u003c/p\u003e \u003cp\u003eThis study adopted a convenience sampling method. The present research recruited IVF patient service users in some IVF clinics in North Cyprus because it has recently become a new and popular medical tourist destination, and annually a considerable number of people travel to North Cyprus to receive IVF services. One of the main difficulties of conducting this type of research is accessing patients through IVF centers. It turns back to the nature of this service, which is mostly a very confidential process because of the patient\u0026rsquo;s characteristics, which is also the main aim of this study. People still are guarded about revealing their personal information, and because of that, the IVF centers keep their information very private. To overcome this difficulty, because of the authors\u0026rsquo; practical experience in the field of IVF, with a very professional and confidential approach, the permission of some IVF clinics was taken to contact some of their patients to participate in this research. As a result, 145 women (who used or who were using the IVF service in the past 5 years) were contacted by the centers, and 126 responded. After sharing a brief description of the study, 114 agreed to participate. In total, 101 filled questionnaires were retrieved, and 13 cases were deleted because of a large proportion of response bias. Respondents voluntarily participated in the survey, and consent form was collected from all participants before starting to answer the questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS 25.0 and the R statistical packages. The dataset was analyzed using descriptive statistics to summarize and describe the characteristics of the data. Then, for dimension reduction and grouping the relevant items in the questionnaire and ultimately extracting the main factors, exploratory factor analysis was employed. To indicate the differences between means of categorical variables in the demographic part of the questionnaires, parametric and non-parametric tests were utilized. Because of that, initially, a normality test was conducted to determine the type of non-parametric or parametric tests. Accordingly, the following tests were selected to indicate the differences in the group means: For normally distributed sample data and categorical variables with two groups, an independent t-test was decided. For non-normally distributed sample data and categorical variables with two groups, the Mann\u0026ndash;Whitney U test was used. For normally distributed sample data and categorical variables with more than two groups, analysis of variance (one-way ANOVA) was decided. For non-normally distributed sample data and categorical variables with more than two groups, the Kruskal\u0026ndash;Wallis H test was utilized. All dimensions of both questionnaires, which were extracted from exploratory factor analysis, were investigated based on the demographics\u0026rsquo; categorical variables.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides details of the participants\u0026rsquo; demographic characteristics. The total number of patients who participated in this survey was 101. About half of the study participants were aged under 35 (49.5%, n\u0026thinsp;=\u0026thinsp;50) and the other half are aged 35 and above (50.5%, n\u0026thinsp;=\u0026thinsp;51). Majority of the participants were from the Western and Eastern European region (67.3%, n\u0026thinsp;=\u0026thinsp;68), While 11.9% of participants (n\u0026thinsp;=\u0026thinsp;12) were from the Middle East region, 7.9% were from the Middle East region, 7.9% (n\u0026thinsp;=\u0026thinsp;8) from North Africa and Africa, and 5% (n\u0026thinsp;=\u0026thinsp;5) were form North America and 7.9% (n\u0026thinsp;=\u0026thinsp;8) were from the Central, South, and Western Asia region. According to the results, 16.8% (n\u0026thinsp;=\u0026thinsp;17) of the individuals participating in the research were college graduates, 5.9% (n\u0026thinsp;=\u0026thinsp;6) were high school graduates, and 77.2% (n\u0026thinsp;=\u0026thinsp;78) were university graduates. Majority of the participants were married 81.2% (n\u0026thinsp;=\u0026thinsp;82) and 18.8% (n\u0026thinsp;=\u0026thinsp;19) of them were single. 77.3% (n\u0026thinsp;=\u0026thinsp;78) of the participants evaluated their monthly income as average, while 16.8% (n\u0026thinsp;=\u0026thinsp;17) as low and 5.9% (n\u0026thinsp;=\u0026thinsp;6) as high income level.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic findings of the individuals participating in the research.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eRegion of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral, South and Western Asia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEurope and Eastern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle East\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Africa and Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of Income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFactor analysis is a method in statistics to extract combined factors from a bunch of variables. Through this method, it is possible to reduce the number of central variables to a minimum, which can still represent all necessary variable information [47]. In this study, the principal component analysis method was employed, and factors whose eigenvalue was higher than 1 were extracted. The values of the variables were obtained by rotating the factor matrix using the Varimax method. The results of the Kaiser-Meier-Olkin (KMO) and Bartlett\u0026rsquo;s sphericity test of the patient satisfaction scale in IVF services and quality of life are provided. According to these results, it was determined that there was a significant correlation between both questionnaire items according to the Bartlett Sphericity Test applied for the patient satisfaction and Quality of Life Scales in IVF services (χ2\u0026thinsp;=\u0026thinsp;1238.324, p\u0026thinsp;\u0026lt;\u0026thinsp;.001; χ2\u0026thinsp;=\u0026thinsp;757.421, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), which were significant. The KMO statistics were applied to scale the sample adequacy, with the results being KMO\u003csub\u003ePS\u003c/sub\u003e = 0.712 and KMO\u003csub\u003eQoL\u003c/sub\u003e= 0.646. Both values were above 0.5; therefore, the sample was proven to be in adequate condition. According to the Kaiser rule, it was determined that the patient satisfaction scale in IVF services could be collected in a seven-factor structure (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The variance explanation rate for the seven subfactor structures obtained was 76%. Furthermore, for the quality-of-life scale in IVF services, a four-factor structure was extracted (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The variance explanation rate for the four subfactor structures obtained was 63%.\u003c/p\u003e\u003cp\u003eEvery variable corresponds to the right number of items, and all factor loadings for these items representing variables are higher than 0.6. In this scale, some of the irregular items whose loadings were remarkably close to each other were removed during the explanatory factor analysis.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e indicates the reliability analysis results for the subdimensions of the patient satisfaction scale in IVF services with an explanation of the related factors. Based on these results, the first factor was labeled as \u0026ldquo;IVF Service and Mobile Application Request,\u0026rdquo; the second factor as \u0026ldquo;Clinical Staff Professionalism,\u0026rdquo; the third factor \u0026ldquo;IVF Service Introduction,\u0026rdquo; the fourth factor \u0026ldquo;Medical Treatment and Transportation,\u0026rdquo; the fifth factor \u0026ldquo;Doctor/Staff Care,\u0026rdquo; the sixth factor \u0026ldquo;IVF Counseling Service\u0026rdquo;, and the seventh factor \u0026ldquo;Doctor Professionalism.\u0026rdquo; Moreover, the alpha coefficients for each factor are acceptable (Cronbach\u0026rsquo;s alpha\u0026thinsp;\u0026gt;\u0026thinsp;.70), and all of them are considered reliable [48].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDimensions of patient satisfaction scale in IVF services and reliability analysis results.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplanation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF Service and Mobile Application Request\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Staff Professionalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF Service Introduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical Treatment and Transportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor/Staff Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF Counseling Service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor Professionalism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the reliability analysis results for the sub-dimensions of the quality-of-life scale for IVF patients with the explanation of the related factors. These factors were constructed as \u0026ldquo;emotional,\u0026rdquo; \u0026ldquo;mind\u0026ndash;body,\u0026rdquo; \u0026ldquo;social,\u0026rdquo; and \u0026ldquo;relational,\u0026rdquo; and the reliability results showed that all four factors are reliable, since the alpha values are greater than 0.7. The overall reliability of the Quality-of-Life Scale is 0.852, indicating that the scale is wholly reliable in the target population.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDimensions of Quality-of-Life Scale in IVF services and reliability analysis results.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplanation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMind body\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.782\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the comparative outcomes of patient satisfaction dimensions are reported based on the categorical variables in this research. There is a statistically significant difference between IVF service introduction (p-value\u0026thinsp;=\u0026thinsp;0.044\u0026thinsp;\u0026lt;\u0026thinsp;.05) according to the age groups of individuals by mean rank (MR)\u0026thinsp;=\u0026thinsp;46.56 and standard deviation (SD)\u0026thinsp;=\u0026thinsp;0.91 in those aged below 35 versus MR\u0026thinsp;=\u0026thinsp;55.53 and SD\u0026thinsp;=\u0026thinsp;0.88 in those aged 35 and above. Doctor Professionalism scores of individuals at the age of 35 and above (MR\u0026thinsp;=\u0026thinsp;59.30 and SD\u0026thinsp;=\u0026thinsp;0.74) are significantly (p-value\u0026thinsp;=\u0026thinsp;0.003\u0026thinsp;\u0026lt;\u0026thinsp;.01) higher than those of individuals who are under 35 years (MR\u0026thinsp;=\u0026thinsp;42.87 and SD\u0026thinsp;=\u0026thinsp;0.85). Clinical staff professionalism scores are significantly (p-value\u0026thinsp;=\u0026thinsp;0.005\u0026thinsp;\u0026lt;\u0026thinsp;.01) different in patients from different regions of residence, with the highest score in those from Central, South, and Western Asia (MR\u0026thinsp;=\u0026thinsp;75.6 and SD\u0026thinsp;=\u0026thinsp;2.10). Those with university-level education have significantly greater clinical staff professionalism scores (p-value\u0026thinsp;=\u0026thinsp;.001\u0026thinsp;\u0026lt;\u0026thinsp;.01) compared to those with lower education levels (MR\u0026thinsp;=\u0026thinsp;61.77 and SD\u0026thinsp;=\u0026thinsp;2.21). IVF service and mobile application request (MR\u0026thinsp;=\u0026thinsp;53.92 and SD\u0026thinsp;=\u0026thinsp;1.78, p-value\u0026thinsp;=\u0026thinsp;0.035\u0026thinsp;\u0026lt;\u0026thinsp;.01) and doctor professionalism score (MR\u0026thinsp;=\u0026thinsp;54.81 and SD\u0026thinsp;=\u0026thinsp;0.81, p-value\u0026thinsp;=\u0026thinsp;0.004\u0026thinsp;\u0026lt;\u0026thinsp;.01) were greater in married participants. Clinical staff professionalism (p-value\u0026thinsp;=\u0026thinsp;.009\u0026thinsp;\u0026lt;\u0026thinsp;.01) and doctor professionalism (p-value\u0026thinsp;=\u0026thinsp;.036\u0026thinsp;\u0026lt;\u0026thinsp;.01) categories are significantly differed in terms of the income level of participants. Clinical staff professionalism scores are the highest in those with higher income level (MR\u0026thinsp;=\u0026thinsp;61.33 and SD\u0026thinsp;=\u0026thinsp;2.99. Doctor professionalism scores are the highest in those with the lowest level of income (MR\u0026thinsp;=\u0026thinsp;56.58 and SD\u0026thinsp;=\u0026thinsp;0.75).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative results of the dimensions of patient satisfaction based on the demographic characteristics of participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIVF Service and Mobile Application Request\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Staff Professionalism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF Service Introduction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedical Treatment and Transportation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDoctor/Staff Care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIVF Counselling Service\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003cp\u003eProfessionalism\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Rank\u003c/p\u003e \u003cp\u003e(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean Rank\u003c/p\u003e \u003cp\u003e(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMean Rank\u003c/p\u003e \u003cp\u003e(SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.85 (1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.84 (2.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46.56 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49.31 (2.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e48.84 (1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e51.29 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e42.87 (0.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.15 (2.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.02 (2.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55.53 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52.66 (1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e53.12 (1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e50.72 (1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e59.30 (0.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.962\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eRegion of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral, South and Western Asia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.50 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.6 (2.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57.56 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45.75 (0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e63.44 (1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e30.25 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e64.06 (0.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEurope and Eastern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.67 (1.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.40 (2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47.13 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52.02 (1.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49.13 (1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e53.54 (1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e47.96 (0.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle East\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.04 (2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.95 (2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58.75 (1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54.04 (2.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e50.54 (1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e52.83 (1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e44.917 (0.718)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Africa and Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.75 (2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.69 (2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57.56 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48.69 (2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e65.44 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e57.06 (1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e59.500 (0.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.00 (1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.80 (2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e64.00 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41.90 (2.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e34.50 (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35.60 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e72.50 (0.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.902\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLevel of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.33 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.08 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55.42 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60.17 (1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e54.75 (1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e42.33 (1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e54.75 (1.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.29 (1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.93 (2.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46.56 (0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40.94 (2.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e46.71 (1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e38.88 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e61.09 (0.69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.13 (2.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.77 (2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51.53 (0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52.49 (1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e51.65 (1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e54.31 (1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e48.51 (0.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.92 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.03 (2.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52.23 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51.19 (1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e50.80 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e49.63 (1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e54.81 (0.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.42 (2.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.26 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45.68 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50.18 (1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e51.87 (1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e56.90 (1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e34.58 (0.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of Income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.97 (2.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.58 (2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55.45 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39.59 (1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e58.62 (1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e51.91 (0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e56.58 (0.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.34 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.38 (2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49.65 (0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52.18 (1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49.20 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e50.80 (1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e50.88 (0.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.50 (1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.33 (2.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55.42 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.00 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e52.83 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e51.00 (1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e50.60 (0.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote- Significant p-values are indicated in bold.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAs the results display in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, quality of life dimensions is also different in terms of the demographic characteristics of participants in this research including age, marital status, region of residence, education level, and income level.\u003c/p\u003e \u003cp\u003eI accordance of the findings of this study shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, there is a statistically significant difference for emotional factor (p-value\u0026thinsp;=\u0026thinsp;.031\u0026thinsp;\u0026lt;\u0026thinsp;.05), mind-body (p-value\u0026thinsp;=\u0026thinsp;.004\u0026thinsp;\u0026lt;\u0026thinsp;.01), and relational (p-value\u0026thinsp;=\u0026thinsp;.022\u0026thinsp;\u0026lt;\u0026thinsp;.05) according to the age groups of the participants, with greater emotional scores of individuals aged 35 and above are (MR\u0026thinsp;=\u0026thinsp;53.61 and SD\u0026thinsp;=\u0026thinsp;3.21) than those of individuals under 35 (MR\u0026thinsp;=\u0026thinsp;47.51 and SD\u0026thinsp;=\u0026thinsp;3.25), higher mind-body scores of individuals with 35 and above (MR\u0026thinsp;=\u0026thinsp;52.70 and SD\u0026thinsp;=\u0026thinsp;4.08) than those of individuals under 35 (MR\u0026thinsp;=\u0026thinsp;49.33 and SD\u0026thinsp;=\u0026thinsp;3.98), and finally for relational scores were higher in those under 35 (MR\u0026thinsp;=\u0026thinsp;50.29 and SD\u0026thinsp;=\u0026thinsp;2.50) compared to those aged 35 and above (MR\u0026thinsp;=\u0026thinsp;44.82 and SD\u0026thinsp;=\u0026thinsp;2.32). Emotional scores of the respondents significantly differed (p-value\u0026thinsp;=\u0026thinsp;.049\u0026thinsp;\u0026lt;\u0026thinsp;.05) among those from different regions of residence, with greater emotional scores in those from central, south, and western Asia compared to those from other regions (MR\u0026thinsp;=\u0026thinsp;73.50 and SD\u0026thinsp;=\u0026thinsp;2.48).\u003c/p\u003e \u003cp\u003eFurthermore, relational scores are significantly different (p-value\u0026thinsp;=\u0026thinsp;.023) were the highest in those with high-income level (MR\u0026thinsp;=\u0026thinsp;68.25 and SD\u0026thinsp;=\u0026thinsp;1.47) compared to those with average-income (MR\u0026thinsp;=\u0026thinsp;48.72 and SD\u0026thinsp;=\u0026thinsp;2.40) and low-income level (MR\u0026thinsp;=\u0026thinsp;34.25 and SD\u0026thinsp;=\u0026thinsp;2.39).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative results of the dimensions of quality-of-life scale based on the demographic characteristics of participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMind Body\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRelational\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Rank (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.51 (3.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.33 (3.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.75 (3.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.29 (2.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.61 (3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.70 (4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.30 (3.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44.82 (2.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eRegion of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral, South and Western Asia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.50 (2.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.81 (2.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.44 (2.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.79 (3.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEurope and Eastern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.02 (2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.95 (3.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.99 (3.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.23 (2.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle East\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.33 (3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.292 (5.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.625 (3.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46.136 (1.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Africa and Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.938 (2.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.06 (4.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.50 (3.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.50 (2.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.25 (5.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.00 (4.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.70 (2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.70 (3.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLevel of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.50 (4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.25 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.17 (3.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.25 (2.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.47 (2.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.21 (3.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.19 (2.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.79 (2.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.98 (3.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.45 (4.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.53 (3.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.25 (2.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.35 (3.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.99 (4.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.07 (3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46.76 (2.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.87 (2.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.37 (3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.03 (3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.64 (2.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.575\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLevel of Income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.60 (3.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.53 (3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.51 (3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.25 (2.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.58 (3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.75 (4.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.17 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.72 (2.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.06 (3.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.68 (4.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.09 (3.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68.25 (1.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote- Significant p-values are indicated in bold.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWhile past research has found correlations between patient demographics and satisfaction levels, the literature is lacking in its ability to explain the mechanisms behind these correlations. It is unclear whether the observed associations are the result of genuine variations in the care provided to different patient subgroups or whether they simply reflect disparities in patient values and needs. If healthcare institutions treat people in the same manner, then the connections that have been identified between demographic factors and satisfaction levels suggest that patients\u0026rsquo; perceptions of service quality are impacted by the needs and expectations that have emerged over time.\u003c/p\u003e \u003cp\u003eThe results of this study indicated that age is a substantial antecedent of patient satisfaction with the introduction of IVF services and with the professionalism of doctors. Previous research has shown conflicting results, considering the nature of the relationship between patients\u0026rsquo; age and satisfaction [49\u0026ndash;50]. The finding of this study showed that the average degree of patient satisfaction with the introduction of IVF services improved with patient age, with the highest levels of satisfaction occurring in patients who were 35 and older. Similarly, doctor professionalism is another significant factor of greater satisfaction in older patients in comparison with youngsters who used IVF treatment. Lack of experience (and perhaps unreasonable demands) with healthcare institutions may account for younger individuals\u0026rsquo; lower satisfaction ratings [51\u0026ndash;54].\u003c/p\u003e \u003cp\u003eFor patient education level, patients who had a higher level of education reported a higher level of satisfaction in terms of clinical staff\u0026rsquo;s professionalism compared to patients who had a lower level of education. This indicates that the mean level of satisfaction for staff skills is higher in patients who had a higher level of education. One argument could be that people\u0026rsquo;s critical thinking and expectations rise in parallel with their level of education. As this study found, a higher level of education may lead to a more critical assessment of the professionalism of medical professionals on the basis of the individual\u0026rsquo;s knowledge and preferences which is consistent with prior research [55, 56, 57, 58, 59, 60, 61, 63] that higher socioeconomic status and education levels were associated with higher levels of satisfaction with fertility treatment among both men and women.\u003c/p\u003e \u003cp\u003eIn a similar manner, the patients\u0026rsquo; marital status was found to associate with their overall satisfaction level in terms of IVF service and mobile application requests and doctor professionalism. Overall, the results of this study are consistent with those of earlier research showing that single patients were less satisfied with IVF services, than married patients [64\u0026ndash;66]. For providing better treatment centered on the patient, those who provide medical services should look for ways to get patients more involved in and concerned about their own health. It is possible that using apps designed to run on smart devices could be one method to boost patient involvement with medical services. Apps have been used to educate patients about ways to improve their health, involve them in monitoring illness treatments, and assist them in more properly adhering to treatment regimens.\u003c/p\u003e \u003cp\u003eBased on the findings of this study, lower-income and lower-educated patients are less satisfied with their IVF treatment. For example, they were less likely to be satisfied with the doctors\u0026rsquo; and clinical staff\u0026rsquo;s professionalism, which is in line with the findings of previous studies [67\u0026ndash;70]. Assuming that customer satisfaction is the result of a positive evaluation of a product or service after it is purchased could provide some insight into this issue [71]. The level of customer satisfaction can be determined by contrasting the customer\u0026rsquo;s expectations with the actual results; if the actual performance is superior, the customer is satisfied. The phenomenon of perceptions being greater than actual achievement is the root cause of dissatisfaction [72]. Customer satisfaction is affected by his perception of the service\u0026rsquo;s quality [73]. Thus, people with higher educational levels and income who used IVF services in North Cyprus expected the doctor and clinical staff professionalism to be outstanding.\u003c/p\u003e \u003cp\u003eIn the current study, we showed that patients from different regions of residence reported significantly different levels of satisfaction with the professionalism of clinical staff. People from central, south, and western Asia had the highest levels of satisfaction compared to individuals from other regions. Studies have shown that there are geographically and culturally differences in fertility levels and approaches to fertility treatment [74]. People from other cultures therefore, have varying cultural norms, expectations, and experiences with fertility services, which impact on how satisfied they are with their IVF treatment [75].\u003c/p\u003e \u003cp\u003eA secondary objective of this research was to investigate the QoL and the demographic characteristics connected to it in patients receiving IVF in North Cyprus. According to the findings of the study, a relatively young age is a determinant of a lower score in the emotional and mind\u0026ndash;body domains of quality of life. Older patients in contrary, exhibited a lower rank in the relational subcategory of QoL. It is likely that the importance of childbearing among infertile older couples could have a more detrimental impact on their relationships. This would be one explanation for the linkage between being older and having a worse relational quality of life domain score. These results are comparable to those found in earlier investigations [76\u0026ndash;77]. In addition, the results of this research showed that living in different regions was a potential indicator of quality of life in the emotional subdimension. The patients from central, south, and western Asia, North America, Europe and Eastern Europe, the Middle East, and North Africa and Africa received the highest to lowest level of emotional scores, respectively. This could be due to the fact that people come from different cultural backgrounds and have different expectations of society, both of which contribute to the stigma associated with infertility issues and childlessness. Finally, patients with a higher income are more likely to have a higher QoL on the relational aspect.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Limitations and Future Studies\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eLike all the studies, there are some potential limitations in conducting this research that should be considered when interpreting our findings. First, not every relevant variable could have been included in the analysis. Therefore, generalization difficulties may arise due to the influence of unknown parameters. For instance, patients were selected from a variety of IVF clinics, so differences in care providers were not considered. This can be considered in future research. Second, based on the nature of IVF services, most centers are unwilling to help researchers with their surveys because of confidentiality matters, and this causes problems in accessing patients and collecting data. Third, since the data were collected during the COVID-19 pandemic, the number of patients was considerably lower because of travel restrictions.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Implications\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe dramatic rise in the provision of reproductive services across international borders (also known as cross-border reproductive care, or CBRC) has created unique opportunities for countries and organizations that provide IVF services. Since the medical tourism sector is expanding rapidly, despite visible signs of political and economic instability, medical tourism, including IVF, which places significant demand on healthcare services delivered in North Cyprus, can become another engine of economic development. The United Nations World Tourism Organization reports that in contrast to the sales of all other categories of tourism, medical tourism has not experienced a fall during the economic downturn [78]. People are increasingly selecting medical tourism as a viable and cost-effective option for a well-deserved break, during which they may focus on their physical and mental health. The expansion of medical tourism, particularly IVF tourism, is one of the most essential areas for growth in North Cyprus, as it will allow the region to fully capitalize on its basic research capacity and strengthen the significance of the tourism business. The results of this study have massive implications for both the routine procedures performed in IVF facilities and for future research. All reproductive clinics can use the insights gained from this study to determine and prioritize improvement activities that are patient-centered and focus on quality enhancement. This research suggests that the average fertility clinic should place a premium on addressing patient needs. This suggests that efforts should be directed toward creating more complex models for modifying patient satisfaction findings. If, for instance, the predictive power of some demographic and clinical factors is based on the fact that they are correlated with patients\u0026rsquo; expectations, then a more precise and refined evaluation of patients\u0026rsquo; expectations will allow more accurate correction.\u003c/p\u003e \u003cp\u003eWhen asked specifically what contributed most to their level of satisfaction with their care, our respondents most frequently cited their trust in their physicians\u0026rsquo; technical abilities. This indicates that patients place a higher importance on the technical skills of their doctor and are prepared to sacrifice emotional fulfillment in exchange for the hope that their infertility treatment will be effective and lead to the birth of a child. This goes against what was previously believed about how people arbitrate the care they receive. Others have found that patients are most satisfied with their care when they start to feel better or when they like their doctor\u0026rsquo;s attitude and style of communicating with them [79]. It is possible that people with infertility make up a distinct community that is more knowledgeable than other categories of patients about the many treatments available for infertility. This could explain why they place such a high value on technical ability and expertise. People may not genuinely rate the actual quality of care that they obtain; rather, they may evaluate the manner in which the care that they receive is provided [80]. People will attribute high levels of technical skill to an expert if the treatment they receive from that specialist is provided in a pleasant and knowledgeable manner. It can be concluded that patients who are having treatment for infertility may be quite flexible and welcome numerous treatments if they have confidence in a particular doctor\u0026rsquo;s ability to properly treat them. Clinicians and IVF center personnel need to be sensitive to the needs and desires of their patients, considering each person\u0026rsquo;s background and level of comprehension of the operations they will undergo.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, N.C. and M.A.O.; Methodology, N.C. and M.A.O.; Software, N.C.; Validation, N.C. and M.A.O.; Formal Analysis, N.C.; Investigation, N.C. and M.A.O.; Resources, N.C.; Data Curation, N.C.; Writing\u0026mdash;Original Draft Preparation, N.C.; Writing\u0026mdash;Review \u0026amp; Editing, M.A.O.; Visualization, M.A.O.; Supervision, M.A.O. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e The study was conducted in accordance with the Declaration of Helsinki and was approved by the European University of Lefke Ethics Committee, with number \u0026Uuml;EK/43/01/09/1920/03, 10.09.2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Informed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohansson M, Adolfsson A, Berg M, Francis J, Hogstr\u0026ouml;m L, Janson PO, \u0026hellip;, HELLSTR\u0026Ouml;M AL. Gender perspective on quality of life, comparisons between groups 4\u0026ndash;5.5 years after unsuccessful or successful IVF treatment. Acta Obstet Gynecol Scand, 201089(5), 683\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouter VL, Hopton JL, Penney GC, Templeton AA. Survey of psychological health in women with infertility. JPOG. 2002;23(1):41\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukse MP, Vacc NA. Grief, depression, and coping in women undergoing infertility treatment. Volume 93. Obstetrics \u0026amp; Gynecology; 1999. pp. 245\u0026ndash;51. 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck-Gernsheim E. From the pill to test-tube babies: New options, new pressures in reproductive behavior. Healing technology: Feminist perspectives, 1989, 23\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Wit A, Banta D. Diffusion of in-vitro fertilization in the Netherlands and England: An exploratory study. Int J Technol Assess Health Care. 1991;7(4):574\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrathern M. Reproducing the future: essays on anthropology, kinship and the new reproductive technologies. Manchester University Press.; 1992.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies T. Cross-border reproductive care: quality and safety challenges for the regulator. Fertil Steril. 2010;94(1):e20\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInhorn MC. Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Soc Sci Med. 2003;56(9):1837\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInhorn MC, Birenbaum-Carmeli D. Assisted reproductive technologies and culture change. Annu Rev Anthropol. 2008;37:177\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhittaker A. Global technologies and transnational reproduction in Thailand. Asian Stud Rev. 2009;33(3):319\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnell J. Medical tourism: Sea, sun, sand and\u0026hellip; surgery. Tour Manag. 2006;27(6):1093\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYildiz MS, Khan MM. Opportunities for reproductive tourism: cost and quality advantages of Turkey in the provision of in-vitro Fertilization (IVF) services. BMC Health Serv Res. 2016;16:378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-016-1628-7\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1628-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGray HH, Poland SC. Medical tourism: crossing borders to access health care. KIEJ. 2008;18(2):193\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomes LBM, Siqueira MHB, de Castro EC. Outcomes of GnRH agonist triggering in assisted reproductive technology: a systematic review. Reprodu\u0026ccedil;\u0026atilde;o \u0026amp; Climat\u0026eacute;rio. 2017;32(2):104\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuguet AM, Boyer-Beviere B. Preimplantation genetic diagnosis: the situation in France and in other European countries. Eur J Health Law. 2017;24(2):160\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshihara O, Adamson GD, Dyer S, de Mouzon J, Nygren KG, Sullivan EA, \u0026hellip;, Mansour R. International committee for monitoring assisted reproductive technologies: world report on assisted reproductive technologies, 2007. Fertil Steril. 2015;103(2):402\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKahn SM. Reproducing Jews: A cultural account of assisted conception in Israel. Duke University Press; 2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNahman M. Materializing Israeliness: difference and mixture in transnational ova donation. Sci as Cult. 2006;15(3):199\u0026ndash;213.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInhorn MC, Birenbaum-Carmeli D. Assisted reproductive technologies and culture change. Annu Rev Anthropol. 2008;37:177\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeomampo D. (2008, November). Kinship and international surrogacy: Making families in India in the age of globalization. In American Anthropological Association 107th Annual meeting, San Francisco (pp.\u0026nbsp;19\u0026ndash;23).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVora K. (2008, November). Selling potential: surplus fertility and biocapital in the production of transnational Indian surrogacy. In American Anthropological Association 107th Annual Meeting. San Francisco (pp.\u0026nbsp;19\u0026ndash;23).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhittaker A, Speier A. Cycling overseas\u0026rdquo;: care, commodification, and stratification in cross-border reproductive travel. Med Anthropol. 2010;29(4):363\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorrigan JM, Donaldson MS, Kohn LT, Maguire SK, Pike KC. Crossing the quality chasm. A new health system for the 21st century. Washington, DC: Institute of Medicine. National Academy of Sciences; 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Empel IW, Nelen WL, Hermens RP, Kremer JA. Coming soon to your clinic: high-quality ART. Hum Reprod. 2008;23(6):1242\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleary PD. The increasing importance of patient surveys: Now that sound methods exist, patient surveys can facilitate improvement. BMJ. 1999;319(7212):720\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroenewegen PP, Kerssens JJ, Sixma HJ, et al. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005;5:16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6963-5-16\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-5-16\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhaak CM, Smeenk JMJ, Evers AA, Kremer JA, Kraaimaat FW, Braat DDM. Women\u0026rsquo;s emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update. 2007;13(1):27\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoulter A, Ellins J. Patient-focused interventions: a review of the evidence. Volume 1. London: Health Foundation; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalman LJ, Abbey A, Andrews FM. Why are couples satisfied with infertility treatment? Fertil Steril. 1993;59(5):1046\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouter VL, Penney G, Hopton JL, Templeton AA. Patient satisfaction with the management of infertility. Hum Reprod (Oxford England). 1998;13(7):1831\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt L. Infertile couples\u0026rsquo; assessment of infertility treatment. Acta Obstet Gynecol Scand. 1998;77(6):649\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaagen EC, Hermens RP, Nelen WL, Braat DD, Kremer JA, Grol RP. Subfertile couples' negative experiences with intrauterine insemination care. Fertil Steril. 2008;89(4):809\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnetz BB. Staff perception of the impact of health care transformation on quality of care. IJQHC. 1999;11(4):345\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung HP, Wensing M, Olesen F, Grol R. Comparison of patients\u0026rsquo; and general practitioners\u0026rsquo; evaluations of general practice care. Qual Saf Health Care. 2002;11(4):315\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigating quality of life and health-related quality of life in infertility: a systematic review. JPOG. 2010;31(2):101\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDancet EA, Nelen WL, Sermeus W, De Leeuw L, Kremer JA. Hooghe, T. M. The patients' perspective on fertility care: a systematic review. Hum Reprod Update. 2010;16(5):467\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt L. Infertility and assisted reproduction in Denmark. Dan Med Bull. 2006;53(4):390\u0026ndash;417.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhaak CM, Smeenk JMJ, Evers AA, Kremer JA, Kraaimaat FW, Braat DDM. Women\u0026rsquo;s emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update. 2007;13(1):27\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeman EW, Boxer AS, Rickels K, Tureck R, Mastroianni L Jr. Psychological evaluation and support in a program of in vitro fertilization and embryo transfer. Fertil Steril. 1985;43(1):48\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahlstedt PP, Macduff S, Bernstein J. Emotional factors and the in vitro fertilization and embryo transfer process. JIVFET. 1987;4(4):232\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeredia M, Ten\u0026iacute;as JM, Rocio R, Amparo F, Calleja MA, Valenzuela JC. Quality of life and predictive factors in patients undergoing assisted reproduction techniques. EJOGRB. 2013;167(2):176\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen J, Eboli L, Forciniti C, Mazzulla G, de Dios Ort\u0026uacute;zar J. The role of critical incidents and involvement in transit satisfaction and loyalty. Transp Policy. 2019;75:57\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JO, Mueller CW. Factor analysis: Statistical methods and practical issues 1978, (Vol. 14). sage.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNunnally JC. An overview of psychological measurement. Clin diagnosis mental disorders, 1978, 97\u0026ndash;146.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalin M, Hemminki E, R\u0026auml;ikk\u0026ouml;nen O, Sihvo S, Per\u0026auml;l\u0026auml; ML. What do women want? Women's experiences of infertility treatment. Volume 53. Social science \u0026amp; medicine; 2001. pp. 123\u0026ndash;33. 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeite RC, Makuck MY, Petta CA, Morais SS. Women\u0026rsquo;s satisfaction with physicians\u0026rsquo; communication skills during an infertility consultation. Patient Educ Couns. 2005;59:38\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung GJ, Meterko M, Desai KR. Patient Satisfaction with Hospital Care: Effects of Demographic and Institutional Characteristic. Med Care. 2000;38:325\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00005650-200003000-00009\u003c/span\u003e\u003cspan address=\"10.1097/00005650-200003000-00009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung GJ, Meterko M, Desai K. R. Patient satisfaction with hospital care: effects of demographic and institutional characteristics. Med Care, 2000, 325\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaipaul CK, Rosenthal GE. Are older patients more satisfied with hospital care than younger patients? J Gen Intern Med. 2003;18(1):23\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabourin S, Wright J, Duchesne C, Belisle S. Are consumers of modern fertility treatments satisfied? Fertil Steril. 1991;56(6):1084\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall JA, Dornan MC. (1990). Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social science \u0026amp; medicine, 1990, 30(7), 811\u0026ndash;818.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuintana JM, Gonz\u0026aacute;lez N, Bilbao A, et al. Predictors of patient satisfaction with hospital health care. BMC Health Serv Res. 2006;6:102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6963-6-102\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-6-102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaagen EC, Hermens RP, Nelen WL, Braat DD, Kremer JA, Grol RP. Subfertile couples' negative experiences with intrauterine insemination care. Fertil Steril. 2008;89(4):809\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDancet EA, Nelen WL, Sermeus W, De Leeuw L, Kremer JA. Hooghe, T. M. The patients' perspective on fertility care: a systematic review. Hum Reprod Update. 2010;16(5):467\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt L, Holstein BE, Boivin J, Tj\u0026oslash;rnh\u0026oslash;j-Thomsen T, Blaabjerg J, Hald F, \u0026hellip;, Nyboe Andersen A. High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi‐centre Psychosocial Infertility (COMPI) Research Programme. Hum Reprod. 2003;18(12):2638\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaseer M, Zahidie A, Shaikh BT. Determinants of patient's satisfaction with health care system in Pakistan: a critical review. PJPH. 2012;2(2):52\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ettps://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/135\u003c/span\u003e\u003cspan address=\"http://ttps://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/135\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajioff D, Birchall M. Medical students in ENT outpatient clinics: appointment times, patient satisfaction and student satisfaction. Med Educ. 1999;33(9):669\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePendleton DA, Bochner S. The communication of medical information in general practice consultations as a function of patients' social class. Social Sci Med Part A: Med Psychol Med Sociol. 1980;14(6):669\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeisman CS, Henderson JT, Schifrin E, Romans M, Clancy CM. Gender and patient satisfaction in managed care plans: analysis of the 1999 HEDIS/CAHPS 2.0 H Adult Survey. Women's Health Issues. 2001;11(5):401\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfzal M, Rizvi F, Azad AH, Rajput AM, Khan A, Tariq N. Effect of demographic characteristics on patient\u0026rsquo;s satisfaction with health care facility. J Postgrad Med Inst. 2014;28(2):154\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabourin S, Wright J, Duchesne C, Belisle S. Are consumers of modern fertility treatments satisfied? Fertil Steril. 1991;56(6):1084\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCan G, Akin S, Aydiner A, Ozdilli K, Durna Z. Evaluation of the effect of care given by nursing students on oncology patients\u0026rsquo; satisfaction. EJON. 2008;12(4):387\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Soc Sci Med. 1997;45(12):1829\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFindik UY, Unsar S, Sut N. Patient satisfaction with nursing care and its relationship with patient characteristics. Nurs Health Sci. 2010;12(2):162\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBolton RN, Drew JH. A longitudinal analysis of the impact of service changes on customer attitudes. JM. 1991;55(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChurchill GA Jr, Surprenant C. An investigation into the determinants of customer satisfaction. JMR. 1982;19(4):491\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGr\u0026ouml;nroos C. A Service Quality Model and its Marketing Implications. Eur J Mark. 1984;18(4):36\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/EUM0000000004784\u003c/span\u003e\u003cspan address=\"10.1108/EUM0000000004784\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalbo. (Fertility in Advanced Societies: A Review of Research 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYousif. (Fertility Transition: Middle East and North Africa. 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAarts JWM, Van Empel IWH, Boivin J, Nelen WL, Kremer JAM, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod. 2011;26(5):1112\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaroufizadeh S, Ghaheri A, Omani Samani R. Factors associated with poor quality of life among Iranian infertile women undergoing IVF. Psychol health Med. 2017;22(2):145\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNWTO/Etc Launch Report on Health Tourism.. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unwto.org/global/press-release/2018-12-20/unwtoetc-launch-report-health-tourism\u003c/span\u003e\u003cspan address=\"https://www.unwto.org/global/press-release/2018-12-20/unwtoetc-launch-report-health-tourism\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2018, December 20, Retrieved from https://www.unwto.org/.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalman LJ, Abbey A, Andrews FM. Why are couples satisfied with infertility treatment? Fertil Steril. 1993;59(5):1046\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-Sira Z. Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory. JHSB, 1980, 170\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \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":"In vitro fertilization (IVF), Patient satisfaction, Quality of life, North Cyprus","lastPublishedDoi":"10.21203/rs.3.rs-3135863/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3135863/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRecent advances in infertility therapy, such as hormone medications and in vitro fertilization (IVF), have led to an increase in the demand for IVF. North Cyprus is a new medical tourist destination, and this study aims to discover influential demographic predictors of IVF patient\u0026rsquo;s satisfaction and quality-of-life after receiving reproductive IVF services. Two questionnaires on IVF patient\u0026rsquo;s satisfaction and quality-of-life were applied on 101 patients who received service in selected IVF clinics. Parametric and non-parametric tests were implemented for statistical analysis. Results showed that the mean satisfaction level of IVF service introduction and doctor professionalism increased with increase in age, and a maximum satisfaction level was found in older patients. Doctor professionalism was another significant factor for greater satisfaction in older patients comparing young who used IVF treatment. The satisfaction on IVF services reduced by increasing level of education. IVF services has to be managed and provided based on the needs of patients from different demographic backgrounds and efforts has to be given to improve the satisfaction on fertility services.\u003c/p\u003e","manuscriptTitle":"Patient Satisfaction and Quality-Of-Life in Vitro Fertilization Services: Development of a Validated Instrument","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-07 04:40:40","doi":"10.21203/rs.3.rs-3135863/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":"38263a5b-896f-4e57-897b-2b8dc347fd87","owner":[],"postedDate":"July 7th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-07-08T16:59:17+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-07 04:40:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3135863","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3135863","identity":"rs-3135863","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}