| کلیدواژههای انگلیسی مقاله |
Multiple sclerosis, Nervous system diseases, Orgasm, What&,rsquo s Known Group counseling creates constructive engagement among participants. In group counseling with a client-centered approach, participants help themselves and others to solve a problem and improve a certain behavior. Counseling interventions are a good solution for the rehabilitation of sexual satisfaction in couples. What&,rsquo s New Our client-centered approach based on the GATHER principles positively influenced sexual satisfaction and intimacy in women with multiple sclerosis. Sexual satisfaction and intimacy were improved at three different time points (before, after the final session, and one month after) in the intervention group. IntroductionMultiple sclerosis (MS) is the most prevalent progressive sensory/nervous disease in young adults. MS not only affects the functioning of the sensory/nervous and motor systems but also leads to signs and symptoms of cognitive, social, and psychological problems such as high levels of depression, distress, and anxiety low quality of life (physical, mental, and sexual) and reduced effective social roles. 1,, 2, From the viewpoint of reproductive and sexual health, MS is a chronic, severe, and life-threatening disease posing family/social problems. The chances of marital problems are higher in patients with MS than in healthy populations because the onset of the disease forces the spouse to accept a change in role and adopt a new one. 3, Nearly two million people worldwide and 400,000 people in the United States are afflicted with MS, and the annual social and therapeutic cost is $2.4 million per patient. 4,, 5, In Iran, the prevalence of MS has witnessed a significant increase in recent years. 6, The frequency of MS has been reported to be 73 per 100,000 globally and 60 per 100,000 in Iran. 5,, 7, Patients with MS experience unpleasant symptoms, difficult treatment plans, drug side-effects, and increased physical, mental, and sexual disabilities. 8,, 9, In terms of sexual symptoms, a three-component conceptual model for female patients with MS has been suggested. Firstly, sexual dysfunction caused by the neurological changes of the disease directly affects the sexual feelings or responses of women, such that they may experience diminished libido as well as changes in sexual senses such as pain and burning, reduced vaginal lubrication, and decreased numbers and intensity of orgasm. Secondly, sexual dysfunction secondary to physical changes directly affects sexual responses. Thirdly, sexual dysfunction may be due to the emotional, social, and cultural effects of the disease, all of which decrease sexual satisfaction. 10, Psychological pressure and sexual symptoms due to MS lead to marital dissatisfaction, emotional divorce, or legal divorce in these patients. 10,, 11, Research has revealed that women with MS face the risk of divorce six times more than do other women, with 30% of them in dire need of personal and social support. 1,, 2, Some studies have demonstrated the positive effect of counseling on coping with MS and emotional/sexual relationships among these patients and their spouses over the course of treatment. 12, In a survey on 160 women with MS, 33% of the patients were at the highest level of sexual dissatisfaction. 13, Among interventions thought to be effective on adjustment in patients with MS, client-centered counseling programs with a psychological/behavioral approach appear to be among the most useful interventions. 14, In group counseling using a client-centered approach based on the GATHER (G, Great clients A, Ask clients T, Tell clients H, Help clients E, Explain how to use R, Return for follow-up) principles, each person helps themselves and others to solve a problem and improve a certain behavior. 15, This method is more effective probably not only because it is cost-effective in terms of time and money but also because the participants share knowledge and experience, interact spontaneously and uninhibitedly, seek effective coping strategies, and exhibit self-care behaviors. 15,- 17, A previous study examined the effect of group counseling with a client-centered approach on reducing the level of stress and depression in patients with MS, and reported an improvement in the mental health of the participants. 16, There is currently a dearth of interventional studies on sexual satisfaction among women with MS, but the existing literature contains no information on group counseling for Iranian women with MS. In addition, MS is a progressive disease, which not only imposes increasing mental and social burden on patients and their families but also lessens sexual satisfaction between couples and increases the risk of divorce. 11,, 17,, 18, Accordingly, we designed the present study to assess the effectiveness of group counseling with a client-centered approach on sexual satisfaction among women with MS.Patients and MethodsPatientsThe present parallel-group clinical trial, conducted from January 2018 to May 2019 in the MS Referral Center of Tehran (Iran), assessed 72 participants allocated to an intervention group and a control group (36 per group). Data were collected at three different time points, before the intervention (baseline), after the intervention (final session), and one month later. The inclusion criteria were comprised of being a woman aged between 18 and 45 years, being married, having been married for at least one year, scoring a maximum 5.5 on the Expanded Disability Status Scale (EDSS), and having had sexual activity in the preceding six months.The EDSS is regarded as a suitable tool to evaluate the effectiveness of clinical interventions and to monitor MS progression. Additionally, almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. 19, In the current study, two neurologists were consulted, and they reported an inter-rater agreement level of Kappa of 0.79.The exclusion criteria consisted of having another chronic disease (e.g. diabetes, hypertension, and epilepsy) or psychological disease, smoking, addiction to narcotics, pregnancy, lactation, having experienced intense mental crises (e.g. death of a loved one), and hormone therapy in the preceding six months. MethodsThe study protocol was approved by the Ethics Committee of Alborz University of Medical Sciences (Code, IR.ABZUMS.REC.1397.015), and was registered with the Clinical Trials Code of IRCT20180110038302N3. Written informed consent was obtained from all the participants. First, a list of eligible participants was drawn up based on the data in the files in the MS Referral Center. The candidates were invited over the telephone to visit the center on a specified date to learn about the research objectives. Then, informed consent was obtained from eligible individuals willing to participate. The participants were selected via the convenience sampling method. Simple random allocation was done using a computer software program that generates random sequences, and the women were allocated to an intervention group and a control group.With respect to the intervention, the intervention group received client-centered group counseling in addition to routine counseling. Six consecutive weekly sessions on a specific day were offered to three groups (12 per each), with each session lasting for 60 min on average. The group counseling sessions were held in a quiet environment with a semicircle seat arrangement. The group counseling was performed in three steps, 1) introduction and action (Session 1), 2) action (Sessions 2 through 5), and 3) termination (Session 6) based on the client-centered approach and in accordance with the GATHER principles. The GATHER principles are a type of counseling method used across different cultures. 15, In the present study, group regulations and the order of domains in the counseling sessions were set in collaboration with the participants. The content of the sessions is presented in table 1,. The control group only received routine counseling, with consultations being offered individually in six sessions. SessionContent of SessionsSession 1 (introduction and action)Commencing with greetings, introduction, and establishment of rapport (G) explaining the aim of the sessions, introducing the researcher and the other members, explaining group regulations (timely attendance and confidentiality), describing the goal of the sessions, and expressing the experiences and information of peers on MS and its effects on marital relationships (A) giving a brief introduction of the female reproductive anatomy and physiology, explaining the four steps of sexual response, describing the physical and mental differences between the sexes in each step of the sexual cycle, and explaining changes in sexual functioning due to MS and offering solutions (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R)Session 2 (action)Greetings (G) reviewing the previous session&,rsquo s tasks with a checklist, discussing peer experiences and information on expressing sexual matters (eg, personal and interpersonal aspects, as well as sexual symptoms and their effects on one&,rsquo s sex life), effects of MS (eg, psychological, emotional, and social aspects) (A) encouraging self-respect, teaching how to avoid shame, underscoring the significance of happiness creation in life, increasing self-sufficiency, working on self-regard, focusing on the current capabilities, and explaining the importance of spiritual care (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R)Session 3 (action)Greetings (G) reviewing the previous session&,rsquo s tasks, discussing peer experiences, providing information on how to express sexual matters (eg, personal and interpersonal aspects, as well as sexual symptoms and their effects on one&,rsquo s sex life), and describing the prevalent and undesirable sexual symptoms of MS (A) helping the participants to identify ways of thinking, feeling, and behaving rather than negative thinking, discussing the significance of showing respect to the sexual partner, establishing an optimal environment (eg, warm showers, hygiene, tidiness, and aromatherapy with lavender in the room), discussing the effectiveness of slow and deep breathing before sex, discussing ways to enhance sexual desire, and discussing ways to reduce pain and spasms during sex (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R)Session 4 (action)Greetings (G), reviewing the previous session&,rsquo s tasks, discussing peer experiences, providing information on how to express sexual functioning and satisfaction, and discussing the effects of MS (A) correcting inaccurate beliefs regarding sex, discussing ways to improve sexual satisfaction, explaining appropriate sex positions, teaching perineal massage, and explaining factors affecting sexual satisfaction (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R)Session 5 (action)Greetings (G), reviewing the previous session&,rsquo s tasks, discussing peer experiences, providing information on how to express sexual functioning and satisfaction, and discussing the effects of MS (A) teaching stretching exercises (eg, hamstring muscles and the quadriceps femoris muscle), aerobics, balance exercises, pelvic-floor exercises, and Kegel exercises (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R)Session 6 (termination)Greetings (G) reviewing the previous session&,rsquo s tasks with a checklist, discussing peer experiences, and providing information on expressing general sexual symptoms and sexual satisfaction (A) summarizing general recommendations based on a review of the previous sessions (T) summarizing the solutions proposed in the group counseling and assisting in the selection of appropriate solution(s) as confirmed by the counselor (H) explaining how to implement the solutions (E) scheduling for the next session (R) (in online social networks) Table 1. Content of group counseling sessions in terms of introduction, action, and termination with a client-centered approach based on the GATHER principlesFor the purposes of ethical issues, the control group participants were offered notebooks containing the detailed content of the group counseling sessions upon the completion of the study. Based on a study by van den Akker and colleagues, the sample size for this study was set at 72 considering the formula for comparing two means belonging to a quantitative attribute in two independent populations for intervention and control groups (&,alpha =0.05, &,beta =0.1, &,micro 1=50.17, &,micro 2=37.83, SD1=8.18, SD2=8.25) and with a lost to follow-up rate of 20%. 20, n = ( Z 1-&,alpha /2 + Z 1-&,beta ) 2 ( &,sigma 1 2 + &,sigma 2 2 ) ( &,mu 1 - &,mu 2 ) 2 MeasurementA data-gathering form was used for the participants&,rsquo demographic, obstetric, and clinical characteristics. Additionally, a sexual satisfaction questionnaire was utilized. The sexual satisfaction scores before the intervention (baseline), after the final session, and one month after the intervention were measured in both intervention and control groups. The score of sexual satisfaction was measured using the Larson Sexual Satisfaction Questionnaire (LSSQ), which comprises 25 items scored on a five-point Likert scale. Each item can receive a score of 1 (never), 2 (rarely), 3 (sometimes), 4 (often), or 5 (always). 11, The increase in the sexual satisfaction score expresses an improvement in sexual satisfaction. In Iran, the internal consistency of the sexual satisfaction questions estimated with Cronbach&,rsquo s alpha was more than 0.7. The exploratory factor analysis was drawn upon to assess the construct validity of the questionnaire, and the final model of the construct of the questionnaire was confirmed by the confirmatory factor analysis. 21, Statistical AnalysisThe data were analyzed using SPSS Statistics, version 19. Data normality was checked using the Kolmogorov&,ndash Smirnov test. The nonparametric Mann&,ndash Whitney U test and the Friedman test were used for variables with non-normal distributions, whereas the parametric independent samples t test was applied for variables with a normal distribution.The a priori level of significance was set at 0.05. The statistical analyses were performed with an intention-to-treat (ITT) approach as emphasized by the CONSORT statement. To improve the reporting of the quality of trials, this statement urges that the number of participants in each group be analyzed based on the ITT principles. 22, ResultsIn this study, the demographic characteristics of 72 participants (36 per group) were analyzed. Two women in the intervention group and one woman in the control group were lost to follow-up (figure 1,). Figure 1. CONSORT diagram shows the flow of the participants through each stage of the present randomized trial.The two groups had no statistically significant differences before the intervention in terms of the mean age, the body mass index, the duration of the marriage, the spouse&,rsquo s age, pregnancy, the husband&,rsquo s desire to have sex during a month, the mean number of sexual activities during a month, the duration of the MS disease, the EDSS score, the sexual satisfaction score (table 2,), domestic violence, socioeconomic status, education level, occupation, and relationship with the spouse (table 3,). VariableIntervention Group (n=36) mean&,plusmn SDControl Group (n=36) mean&,plusmn SDP valueAge (years)34.00&,plusmn 5035.00&,plusmn 400.66a,BMI (kg/m2)26.90&,plusmn 3.2527.00&,plusmn 5.650.55b,Duration of the marriage (years)11.50&,plusmn 6.3510.60&,plusmn 5.560.26a,Spouse&,rsquo s age (years)38.30&,plusmn 6.2339.50&,plusmn 65.000.388b,Pregnancy (n)1.32&,plusmn 1.291.89&,plusmn 1.450.368b,Husband&,rsquo s desire to have sex during a month (n)8.65&,plusmn 6.228.89&,plusmn 6.330.968a,Mean number of sexual activities during a month (n)7.05&,plusmn 4.366.89&,plusmn 3.680.668b,Duration of the disease (month)82.00&,plusmn 5.5382.00&,plusmn 6.460.830a,EDSS score2.23&,plusmn 1.252.36&,plusmn 1.070.583b,Score of sexual satisfaction87.63&,plusmn 17.6780.86&,plusmn 17.200.104EDSS, Expanded Disability Status Scale BMI, Body mass index aMann&,ndash Whitney U test bIndependent t test |