Elsevier

Epilepsy & Behavior

Volume 68, March 2017, Pages 123-128
Epilepsy & Behavior

Theory of Planned Behavior including self-stigma and perceived barriers explain help-seeking behavior for sexual problems in Iranian women suffering from epilepsy

https://doi.org/10.1016/j.yebeh.2017.01.010Get rights and content

Highlights

  • A high proportion of women with epilepsy encounter sexual problems.

  • Women with epilepsy who had sexual problems may not seek help.

  • Theory of Planned Behavior explains seeking help behaviors for women with epilepsy.

  • Self-stigma explains non-seeking help behaviors for women with epilepsy.

  • Perceived barriers explain non-seeking help behaviors for women with epilepsy.

Abstract

Purpose

To apply the Theory of Planned Behavior (TPB) and the two additional concepts self-stigma and perceived barriers to the help-seeking behavior for sexual problems in women with epilepsy.

Methods

In this 18-month follow-up study, TPB elements, including attitude, subjective norm, perceived behavioral control, and behavioral intention along with self-stigma and perceived barriers in seeking help for sexual problems were assessed in n = 818 women with epilepsy (94.0% aged ≤ 40 years). The basic TPB model (model 1) and the TPB model additionally including self-stigma and perceived barriers (Model 2) were analyzed using structural equation modeling (SEM).

Results

Both SEM models showed satisfactory model fits. According to model, attitude, subjective norms, perceived behavioral control, and intention explained 63.1% of the variance in help-seeking behavior. Variance was slightly higher (64.5%) when including self-stigma and perceived barriers (model 2). In addition, the fit indices of the models were better highlighting the importance of self-stigma and perceived barriers in help-seeking behavior for sexual problems.

Conclusion

Theory of Planned Behavior is useful in explaining help-seeking behavior for sexual problems in women with epilepsy. Self-stigma and perceived barriers are additional factors that should be considered in future interventions aiming to adopt TPB to improve help-seeking behavior for sexual problems.

Introduction

Sexual problems have detrimental effects on an individual's quality of life and overall well-being and not only impact on mental health and self-esteem, but may further lead to emotional distress, dyadic friction, and in some extreme cases even divorce [1], [2], [3], [4], [5]. According to a recent British study, nearly one-third of men and two-thirds of women avoid sex because of their sexual problems; yet less than 25% of those who reported sexual problems actively seek help [6]. In other words, the negative influence of a sexual problem may continue because of non-help-seeking behavior and lead to termination of relationships and marriages.

Research has recently started to focus on the problem of non-help seeking for sexual problems in the general population but also in a variety of clinical samples [4], [7], [8], [9]. It is therefore important to address this issue also in women suffering from epilepsy. A number of epidemiologic studies have suggested that women with epilepsy have an elevated risk of sexual problems (> 70%) [10]. According to one such study, women with epilepsy had a significantly higher prevalence (75.3%) of sexual problems compared with the general adult population (12.0%), [11]. The range of sexual complaints in women with epilepsy is broad, with problems pertaining to libido, arousal, and orgasm problem representing those most commonly observed [12], [13]. Though impaired sexual functioning has long been known to have detrimental effects on the quality of life of the patients and on couple satisfaction, many clinicians – including neurologists – tend to ignore the importance of sexual health in patients with epilepsy and do not consider it to be a treatment priority [14].

Regarding the causes, possible risk factors for sexual problems in women with epilepsy include earlier onset of menopause, epileptic activity in cortex, certain antiepileptic drugs (AEDs), anxiety, and stigmatization [15], [16], [17], [18]. Therefore, the etiology of sexual dysfunction for women with epilepsy is most likely multifactorial, wherein neurological, iatrogenic, endocrine, psychiatric, and psychosocial factors all seem to play a role [11]. Still, the specific etiology often remains unclear and has to be evaluated individually for each case [11], [19], [20]. Given the high rates of sexual problems in women with epilepsy and the low numbers of individuals actively seeking help for their problems, expanding our knowledge on the factors influencing help-seeking behavior for sexual problems in this specific clinical sample may be of interest for clinicians and researchers and may provide them the necessary input to design more effective and holistic interventions and treatment plans.

Theory of Planned Behavior (TPB) as proposed by Ajzen [21] is a potential framework that can be used to better understand the mechanism of help-seeking behavior for sexual problems in women with epilepsy. Previous evidence has shown that TPB can be used to explain medication adherence across different populations [22], including people with epilepsy [23], and numerous recent studies have used TPB to explain help-seeking behaviors for a broad range of conditions [24], [25], [26], [27], including sexual problems [28].

Theory of Planned Behavior suggests three main factors that influence an individual's behavioral intention which subsequently affects the expression of the final behavior. The three factors are attitude (a person evaluates the positive or negative outcomes of performing the behavior), subjective norm (a person perceives whether his or her significant others approve or disapprove of the behavior), and perceived behavioral control (a person judges his or her capability to perform the behavior). Attitude and subjective norm are associated with final behaviors via behavioral intention, while perceived behavioral control seems to be indirectly (also through behavioral intention) linked to the final behavior [21], [29]. Moreover, meta-analyses which support the validity of TPB across different health behaviors demonstrate that TPB can explain 19–36% of the variance in the final behavior and 40–49% of the variance in behavioral intention [22], [30], [31], [32].

In order to maximize the explanatory potential of TPB, several additional factors such as self-stigma and perceived barriers in help seeking behavior can be incorporated in TPB. Self-stigma describes a set of negative attitudes toward help seeking [33], [34] and may restrict an individual's motivation to change the situation or work on a problem [35], [36], [37]. A study on 281 Iranian women with sexual dysfunction echoes the influence of self-stigma by showing that ~ 10% of the participants did not seek for help because of shame [9]. Another study by Vahdaninia et al. [9] reported that ~ 40% of the participants did not seek help because of time constraints. Therefore, perceived barriers (especially physical burdens) could be another reason preventing women from seeking help for sexual problems.

Because of the previously suggested potential of TPB in explaining help-seeking behavior and the recent evidence of the negative effects of self-stigma and perceived barriers on behavioral intention, we aimed to evaluate two different models that may explain help-seeking behavior for sexual problems in a sample of Iranian women suffering from epilepsy. The first model (Model 1) included elements of traditional TPB such as attitude, subjective norm, perceived behavioral control, and behavioral intention to explain variance in help-seeking behavior for sexual problems. In the second model (Model 2) the two additional factors of self-stigma and perceived barriers were incorporated.

Section snippets

Participants

This 18-month follow-up study targeted female patients with epilepsy who had been referred to three university neurology clinics in the cities of Tehran and Qazvin. Inclusion criteria were 1) being 18 years or older; 2) a confirmed diagnosis of epilepsy; 3) being married or having a partner; and 4) any kind of sexual problem as assessed by the Female Sexual Function Index (FSFI) (according to the suggested cut-off score of ≤ 26.55) [38], [39]. Patients were excluded from the study if they 1)

Results

The majority of the participants were 40 years or younger (94.0%)(Table 1). The relationship between the sociodemographic variables and the main study variables are presented in Table 2.

Model 1 including the traditional TPB elements and the demographic confounders showed an excellent fit across all indices (CFI = 0.991; TLI = 0.973; RMSEA = 0.057; WRMR = 0.851), except for the χ2 test (χ2 [df] = 7.243 [2]; p = 0.027). Because the indices indicated a good model fit, the direct associations of attitude

Discussion

Using a large sample of women with epilepsy (n = 818), our results support the potential usefulness of the TPB model to increase help-seeking behavior in women with epilepsy suffering from sexual problems. We further found self-stigma and perceived barriers to be significantly associated with help seeking behavior. Overall, our results provide important insights for the future development of theory-based interventions to address intransigent health and well-being problems in women with epilepsy.

Conclusion

Our results support the usefulness of traditional TPB factors (attitude, social norms, and perceived behavior control) to increase help seeking behavior in women with epilepsy suffering from sexual problems. Our results further highlight the importance of self-stigma and perceived barriers indicating that interventions targeting only the traditional TPB elements may not be sufficient. In order to increase interventional efficacy, clinicians and researchers may consider minimizing self-stigma

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