Keywords psychoeducational counseling - information–motivation–behavioral model - sexual satisfaction
- contraception violence
Palavras-chave aconselhamento psicoeducativo - modelo de informação-motivação-comportamental - satisfação
sexual - violência contraceptiva
Clinical trial registration:
https://fa.irct.ir/ Iranian Registry of Clinical Trial (IRCT20151103024866N16).
Introduction
Women play an essential role in family maintenance, which, ultimately, has a a direct
impact in the community's health; therefore, the community's health is affected when
there is a threat to a woman's health.[1 ] Family planning is a part of comprehensive reproductive health and one of the most
basic and essential healthcare system programs.[2 ] Contraception methods are essential in preventing unintended pregnancies, achieving
the desired number of children and the proper spacing between pregnancies, and preventing
high-risk pregnancies, unsafe abortions, maternal and neonatal mortality, and sexually-transmitted
infections.[3 ] The diversity of contraceptive options for women, the limited methods available
for men, and the existence of misconceptions, including gender attitudes, which consider
family planning to be solely the responsibility of women, have led men to participate
less in family planning programs.[4 ] The lack of couples' shared participation in using contraceptive methods is one
of the areas of violence in reproductive health. Reproductive coercion is a behavior
that interferes with the independent decision-making of a woman concerning reproductive
health. It may take the form of pregnancy coercion, controlling the outcome of pregnancy,
birth control sabotage, non-use of contraceptive methods, and forced use of a specific
prevention method. The choice, acceptance, and satisfaction of women with different
contraceptive methods affect their quality of life and sexual function, and different
contraceptive methods have different effects on women's sexual satisfaction.[5 ] Sexual satisfaction is an essential indicator of sexual health and is strongly associated
with empathy, love, emotions, creativity, and the frequency of sexual activity. Sexual
satisfaction is obtained from positive sexual experiences.[6 ] Feelings of failure, frustration, and insecurity due to a lack of sexual satisfaction
will likely endanger the mental health of spouses.[7 ] A review study by Maxwell et al. (2018) aimed at estimating the effect of intimate
partner violence (IPV) on women's use of contraception showed that women who experienced
IPV in the year prior to the study were 20% less likely to report the use of male
condoms.[8 ]
Intimate partner violence refers to behavior that causes physical, sexual, or mental
pain, including acts of physical animosity, sexual constraint, mental mishandling,
and controlling behaviors.[9 ] The non-participation of men in the use of contraceptive methods is one of the areas
of violence in reproductive health. Violence has shown the highest correlation with
six domains of reproductive health, including lack of use of contraceptive methods,
abortion, reproductive system diseases, poor pregnancy outcomes, and lack of use of
reproductive health services.[10 ]
The empowerment of women with communication skills that allow them to face problems,
choose the correct alternative behavior in problem-solving, and use family counseling
services can be effective in preventing or reducing IPV.[11 ]
One of the most comprehensive models for behavior change is the information-motivation-behavioral
(IMB) skills model.[12 ] According to the model, health information, motivation, and behavioral skills are
fundamental determinants of preventive behaviors and behavioral skills necessary for
taking preventive measures.[13 ] The study by Mittal et al. (2017) aimed to present a supportive intervention to
reduce HIV risk in women with a history of IPV. This supportive intervention included
the key elements of the IMB model, the theory of gender and power (TGP) model, and
family therapy. The results showed that safe sex and condom use increased at the end
of the intervention. There was a significant reduction in violence and a significant
improvement in self-esteem, anxiety, and posttraumatic stress disorder (PTSD).[13 ]
Psychoeducational counseling is another type of counseling in which clients are trained
during therapy.[14 ] Psychoeducational counseling for a particular situation or disease means providing
the patient with the necessary information to create a new mental and cognitive understanding
of what they have just encountered and helping them change their behavior; this is
an essential component of every psychotherapy program.[15 ] A study by Akbarinejad et al. (2016) investigated the effect of psychoeducational
group counseling on the postnatal sexual intimacy of lactating women. Results showed
the positive impact of group counseling on the sexual intimacy of women after their
first birth in the intervention group and increased sexual intimacy in this group.[14 ] Psychoeducational counseling is associated with education during therapy, and another
feature of this type of counseling is its emphasis on prevention. Given that one of
the structures of the IMB model is based on knowledge and cognition, both methods—psychoeducational
counseling and IMB—have a psychological and social approach. In face of the mentioned
issues, a study was conducted to compare the effect of the information–motivation–behavioral
(IMB) model and psychoeducational counseling on sexual satisfaction and contraception
method used under the coercion of the spouse in Iranian women.
Methods
This study was a clinical trial (IRCT20151103024866N16), and the statistical population
included all married women aged 18 to 45 years who were referred to health centers
in Kerman, a city in the south of IRAN; to receive care and family planning counseling.
The ethical committee of the university approved the study, and all women signed an
informed consent before enrollment. Convenience sampling was used for participants
who were women whose husbands did not cooperate in choosing a contraceptive method
but complained and made excuses about every method the woman used. These women were
under the coercion of spouses in contraception use, according to World Health Organization
(WHO) guidelines (refusal of specific contraceptive methods, or insistence on a particular
type of method, or resistance to contraceptive counseling, history of repeated pregnancies,
or request for a medical termination, and insistence on tubal ligation or insistence
on reversal of tubal ligation).[16 ] Based on the available sampling, each woman who applied for a contraceptive was
asked the WHO guideline questions, and if she was under the pressure of her husband
to receive a contraceptive and met the inclusion criteria, she was selected. The purpose
of the research was explained to these women, and if they were satisfied and willing,
they would enter the study ([Fig. 1 ]).
Fig. 1 CONSORT 2010 flow diagram.
The sample size needed to achieve a reliability of 1.96 and study power of 85%, based
on the results of the study by Nabavi et al. (2019), was approximately 6 participants
for each group; however, 27 people were selected to increase the study capacity and
compensate for the loss of samples.[17 ]
Because the samples were divided into 3 groups, the final sample size was 81 people.
The identified women were included in the study if they consented to participate and
had the inclusion criteria. Then, all identified persons were randomly divided through
a table of random numbers into three groups: control, psychoeducational counseling,
and the IMB model.
The inclusion criteria were married women in Kerman aged between 18 and 45, who were
the only spouse of their husbands and whose spouses were present in Kerman during
the intervention; had at least one of the criteria for violence against women regarding
contraceptive methods according to the checklist of the WHO; consented to participate
in the study; were literate; had been married for at least 1 year; had no known mental
illness; and had access to a smartphone (due to online education) and the ability
to use it. The exclusion criteria included pregnancy or participating in other psychological
counseling classes simultaneously. Reasons for discontinuation were absence in two
or more of the counseling sessions, and unwillingness to continue participation.
The research tool consisted of demographic information, a checklist for evaluating
the contraception method requested by the spouse (WHO), and a special researcher-made
questionnaire on contraceptive methods and sexual satisfaction. This questionnaire
was prepared based on scientific articles.[18 ]
[19 ]
[20 ]
[21 ] The special sexual satisfaction questionnaire examined contraceptive methods and
sexual satisfaction with 48 items. The participants expressed their satisfaction with
each item on a five-point Likert scale. The questionnaire was sent to expert professors
to assess its validity, and the content validity was also determined quantitatively
and qualitatively to determine the content validity of the questionnaire. The content
validity index (CVI) and content validity ratio (CVR) were 0.93 and 0.98, respectively,
and face validity was confirmed using experts' opinions. The questionnaire was then
presented to 30 people from the target group to determine its face validity; then,
internal consistency was determined using Cronbach α (0.855).
First, the study's objectives were explained to women who met the inclusion criteria,
and, if they wished to participate, written informed consent was obtained from them.
All three groups completed the questionnaire on sexual satisfaction, specific contraception
methods, and contraception type before the intervention, immediately after, and 1
month after the intervention. The study's objectives were first fully explained to
participants to prevent information exchange between group members. Introduction sessions
were held separately for each group. Given that information exchange is possible in
cyberspace, to prevent information exchange between participants, after dividing them
into 3 groups (control, psychoeducational, and IMB), a time interval of 2 months was
considered for each group. First, a pretest was completed for the control group, and
posttests were done 1 month later and 1 month after the initial posttest. Then a pretest
was done for the psychoeducational group; the initial posttest was done after the
three virtual counseling sessions in Skyroom; the final posttest was completed 1 month
after the intervention. The total time spent implementing the intervention and completing
the questionnaires was 6 months. In the control group, the clinic midwife provided
all routine training. In the intervention group, psychoeducational counseling sessions
were held according to a unique package of counseling sessions in 3 90-minute online
sessions 1 week apart. In the IMB model intervention group, counseling sessions were
held according to a specific package, in 4 online sessions, 120 to 190 minutes each
2 sessions per week, and all these sessions were held by the same person (the researcher).
Finally, immediately after the intervention and 1 month later, the participants in
the 3 groups completed the questionnaire. The psychoeducational counseling and IMB
program packages were designed, prepared, and implemented using various resources
216 people were surveyed to participate in the study, of which 135 were either not
eligible or unwilling to participate in the study. Eighty-one people were included
in the study. By lot, they were divided into three groups (one was a control group
and two were intervention groups). Since the intervention was performed on and offline,
we did not have any sample drop, and, finally, the analysis was performed on 81 people.
Data were analyzed using the IBM SPSS Statistics for Windows, version 22 software
(IBM Corp. Armonk, NY, USA). Quantitative variables were described by mean and standard
deviation, and qualitative variables were defined by frequency and frequency percentage.
The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to evaluate the normality
of dependent variables (sexual satisfaction and changes in contraceptive methods).
Due to the abnormality of data distribution, the Friedman test was used to examine
the trend of changes. The nonparametric equivalent of one-way analysis of variance,
Kruskal-Wallis, was used for comparison ([Chart 1 ]).
Chart 1
Psychoeducational counseling content and information–motivation–behavioral model
Session
Objective
Content
Psychoeducational counseling package
First
Introduction and awareness
Informing people about violent behaviors, teaching contraception methods
Second
Identifying sexual misconceptions
Teaching to improve sexual relations, expressing the importance of sex, talking about
sexual misconceptions, extensive training on contraception methods
Third
Effective communication and assertiveness
Assertiveness skill training, communication styles, effective communication skills
training
Information–motivation–behavioral package
First
Identifying distorted dimensions in sex
Defining contraception methods and the benefits and harms of each method, defining
spousal violence in contraception, defining sexual satisfaction and sexual satisfaction
related to contraception.
Second
Motivational dialogue
Conducting a motivational interview to accept or change the contraception method to
make it voluntary and increase sexual satisfaction
Third
Efficient sexual dialogue with the spouse
Improving perceived individual skills and self-efficacy
Fourth
Activate assertive behaviors
Activating avoidance behaviors and improving assertiveness skills by increasing motivation
and behavioral skills
Results
The mean age of participants was 32.59 ± 7.04. There was no statistically significant
difference between the three groups regarding age, education, occupation, breastfeeding,
weight, number of pregnancies, etc. The three groups were similar in demographic characteristics
([Table 1 ]).
Table 1
Comparison of the distribution of qualitative and quantitative demographic variables
between the intervention and control groups
Variables
Group
P -value[* ]
Psychoeducation
N (%)
IMB
N (%)
Control
N (%)
Women education
High school education
2 (7.4%)
2 (7.4%)
3 (10%)
0.9
Diploma
13 (48.1%)
13 (48.1%)
11 (36.7%)
University education
12 (44.4%)
12 (44.4%)
16 (53.3%)
Women job
Housekeeper
19 (70.4%)
15 (55.6%)
20 (66.7%)
0.34
Employee
6 (22.2%)
7 (25.9%)
9 (30%)
self-employment
2 (7.4%)
5 (18.5%)
1 (3.3%)
Spouse education
High school education
3 (11.1%)
7 (25.9%)
5 (18.5%)
0.22
Diploma
12 (44.4%)
13 (48.1%)
9 (30%)
University education
12 (44.4%)
7 (25.9%)
16 (53.3%)
Spouse job
permanent job
15 (55.6%)
13 (48.1%)
14 (46.7%)
0.83
Temporary job
10 (37%)
13 (48.1%)
15 (55.6%)
workless
2 (7.4%)
1 (3.3%)
1 (3.3%)
Variable
Mean ± SD
Mean ± SD
Mean ± SD
P
-value[** ]
Age
7.255 ± 34.44
7.704 ± 32.04
31.30 ± 6.199
0.22
Age of onset of sexual activity
4.029 ± 23.19
3.652 ± 21.52
3.151 ± 22.27
0.24
Parity
1.368 ± 2.89
1.812 ± 2.85
1.654 ± 2.77
0.89
Abbreviation: IMB, information-motivation-behavioral.
* Chi-square.
** Kruskal-Wallis test.
The results showed that the mean sexual satisfaction score immediately after the intervention
was statistically significant between the three groups (p < 0.01). According to the Kruskal-Wallis test, the mean sexual satisfaction score
1 month after the intervention was significantly different among the three groups
(p < 0.01). The sexual satisfaction score increased 1 month after the intervention in
the psychoeducational and IMB group, and the increase in sexual satisfaction was more
significant in the IMB group ([Table 2 ]).
Table 2
Mean and standard deviation of sexual satisfaction score before the intervention,
after the intervention and one month after the intervention three groups
Sexual satisfaction
Mean ± SD
P -value[* ]
Psychoeducation
IMB
Control
Before intervention
22.73 ± 166.66
18.43 ± 167.62
18.08 ± 169.33
0.97
After intervention
16.85 ± 184.37
13.01 ± 190.29
15.38 ± 167.30
0.001<
One month after intervention
16.48 ± 189.25
11.05 ± 203.48
15.49 ± 166.13
0.001<
P -value[** ]
0.001<
0.001<
0.71
Abbreviation: IMB, information-motivation-behavioral.
* Kruskal-Wallis test.
** Friedman test.
The mean score of sexual satisfaction in the psychoeducational intervention group
increased 1 month after the intervention compared to immediately after the intervention,
and the difference was significant (p = 0.03); in the IMB group, the sexual satisfaction increased significantly 1 month
after the intervention compared to immediately after the intervention (p < 0.01), but there was no statistically significant difference between the 2 intervention
groups in sexual satisfaction (p = 0.1). However, the mean score in the IMB group was higher than in the psychoeducational
intervention group. Using each contraception method in the three groups (control,
psychoeducational, and IMB intervention) was measured before, immediately after, and
1 month after the intervention. The Mann-Kendall statistical test showed that changes
in the contraception method in the psychoeducational group were significant (p = 0.02) ([Table 3 ]).
Table 3
Frequency distribution of contraceptive methods before intervention, after intervention
and one month after intervention in three groups
Group
Contraceptive method
Before intervention
After intervention
One month after intervention
P -value[* ]
Psychoeducation
Withdrawal
14 (51.85%)
8 (29.62%)
8 (29.62%)
0.02
Condom
6 (22.22%)
11 (40.74%)
11 (40.74%)
Combined oral pills
5 (18.51%)
4 (14.81%)
4 (14.81%)
Medroxyprogesterone asetat
1 (3.7%)
2 (7.4%)
2 (7.4%)
IUD
1 (3.7%)
2 (7.4%)
2 (7.4%)
IMB
Withdrawal
13 (48.14%)
10 (37.03%)
5 (18.51%)
0.07
Condom
5 (18.51%)
8 (29.62%)
9 (33.33%)
Combined oral pills
5 (18.51%)
5 (18.51%)
6 (22.22%)
Medroxyprogesterone asetat
1 (3.7%)
1 (3.7%)
2 (7.4%)
IUD
3 (11.11%)
3 (11.11%)
5 (18.51%)
Control
Withdrawal
14 (51.85%)
14 (51.85%)
15 (50%)
1
Condom
9 (33.33%)
9 (33.33%)
8 (29.62%)
Combined oral pills
5 (18.51%)
5 (18.51%)
5 (18.51%)
Medroxyprogesterone asetat
1 (3.7%)
1 (3.7%)
2 (7.4%)
IUD
1 (3.7%)
1 (3.7%)
1 (3.7%)
Abbreviation: IMB, information-motivation-behavioral; IUD, intrauterine device.
* Kendall test.
Discussion
According to the present study results, the sexual satisfaction level in the two intervention
groups increased significantly, which shows that both psychoeducational counseling
and IMB counseling increased women's sexual satisfaction.
In the study by Alirezaei et al. (2022), the sexual satisfaction of infertile couples
increased after psychological intervention, which was consistent with our study.[22 ] However, due to the long duration of psychological intervention (6 months) compared
to IMB counseling (2 weeks) and psychoeducational counseling (3 weeks), it seems that
the counseling methods in the present study provide a more appropriate interpretation.
Our study is consistent with that of Akbar Nejd et al. (2020), which showed the positive
impact of psychoeducational group counseling on the sexual intimacy of lactating women,
leading to an increase in sexual intimacy.[14 ] Considering that sexual intimacy is itself a component in increased sexual satisfaction
and improvement in the quality of marital life, it can be concluded that psychoeducational
training can raise sexual satisfaction and improve other effective details of sexual
satisfaction. The study results by Tahan et al. (2020) showed that women's sexual
satisfaction increased after receiving psychoeducational counseling.[23 ] In the study by Bober et al. (2015), the sexual psychological intervention increased
sexual desire, female sexual satisfaction, and female sexual self-efficacy by increasing
the sexual information of women with ovarian cancer.[24 ] In the study by Ali Mohammadi et al. (2018), counseling based on sexual self-efficacy
on sexual functioning and sexual satisfaction of newly married women showed that sexual
self-efficacy counseling had an effect on sexual functioning but did not affect sexual
satisfaction, which was not consistent with our results.[25 ] It can be concluded that IMB counseling has a higher impact on sexual satisfaction
than sexual self-efficacy counseling, despite fewer sessions.
In the present study, the mean score of sexual satisfaction in the two psychoeducational
and IMB interventions increased after counseling. Psychoeducational counseling and
training on sexual issues and contraception methods can improve marital quality, such
as sexual satisfaction, sexual intimacy, and marital satisfaction, and increase the
use of safe contraception methods. The IMB approach is also a pattern of behavior
change and consists of three components. It helps couples obtain the necessary information
about sexual issues and contraception methods. They will be able to acquire appropriate
behavioral skills in dealing with the spouse and choosing the proper contraception
method. A comprehensive counseling approach can identify women's sexual needs, which
leads to improved behavior and change in women's behavior to promote sexual satisfaction.
The results of the study by Cavallaro et al. (2020) show that women who received systematic
counseling on family planning methods continued to use contraception methods, and
interruption of contraceptive use was lower than in the control group, which was consistent
with the results of psychoeducational counseling in our study.[26 ] In a study by Jiang et al. (2019), which examined the predictors of condom use in
Chinese gay men based on the modified IMB model, the results showed that using the
modified IMB model directly contributes to safe sexual behaviors and leads to increased
use of condoms. The results of this study were not consistent with the IMB model in
our study.[27 ] In a survey by Fullerton et al. (2013) on the effect of the IMB model concerning
condom use and hormonal methods of contraception as well as the use of both ways simultaneously
(dual protection), the results showed that the components of the IMB model support
the sexual health of young women and also contribute to dual protective behaviors
and the prevention of sexually transmitted infections and pregnancies, which was not
consistent with our study.[28 ] According to the studies, the IMB model leads to the use of safe contraception methods
and the prevention of high-risk behaviors. However, in our research, the ineffectiveness
of IMB counseling in significantly changing couples' contraception method choice could
be due to simultaneous training about sexual satisfaction and contraception methods.
The couples were in stable and permanent relationships, and the purpose of this study
is to increase sexual satisfaction related to contraception methods.
Choosing and accepting and being satisfied with different contraceptive methods can
affect the quality of life and sexual performance of women. Choosing a contraceptive
method by husband coercion can cause the non-continuation of using the method or incorrect
use, which will result in unwanted pregnancy and illegal abortions and complications.[29 ]
According to the results, it can be concluded that women whose spouses coerce them
to use specific contraception methods not only need to change their contraception
methods but increasing their knowledge about contraceptive methods sometimes leads
to their complete acceptance. So, it can create positive relationships between partners,
they were able to come to an agreement with their spouse in selecting the method of
contraception and realized that the new contraceptive method chosen by both was the
most appropriate method of contraception for them. After agreeing on the new contraceptive
method and improving interpersonal relationships with their spouse, their sexual satisfaction
also increased. Because the study was conducted during the coronavirus disease 2019
(COVID-19) outbreak and the sessions were given online, women who were under the coercion
of spouses were able to participate in the training course without leaving home and
benefit from the counseling courses without facing any resistance from their husbands,
which can be considered as the strength of the study. Due to the need for access to
smartphones to attend online courses, people from certain social and economic classes
could not participate in the counseling courses, which can be considered a limitation
of the present study.
Conclusion
Psychological counseling could improve women's sexual satisfaction and lead to change
in the contraception method, in cases on which it was not according to the women's
wishes. The results also showed that the IMB method positively impacted women's sexual
satisfaction but had no impact on changing the contraceptive method. Using appropriate
contraception to prevent unwanted pregnancy is one of the essential parts of reproductive
health, and utilization of intervention methods seems crucial. According to the results,
using one of these two intervention methods in contraceptive counseling sessions is
good.
