Background
Sexual dysfunction is a common gynecological complaint among diabetic women due to its complicated effect on sexual function. Complications of diabetes in women have adverse effects on their self-image, quality of life, health, and other social relationships, thereby affecting their sexual performance [
1]. Sexual dysfunction is a heterogeneous combination of disorders including abnormalities in women’s orgasm, arousal, pain, and unknown sexual dysfunction, although various studies have reported a high prevalence of sexual dysfunction in women with diabetes compared with non-diabetic women [
2].
The prevalence of diabetes has risen significantly by 62% over the last ten years [
3]. The International Diabetes Federation (IDF) listed Egypt among the world’s top 10 countries in the number of patients with diabetes [
4] In Egypt, the prevalence of diabetes is around 15.56% among adults between 20 and 79 years of age, with an annual death of 86,478 related to diabetes [
5].
Diabetes mellitus is a chronic metabolic disease characterized by insulin deficiency and resistance. The International Diabetes Federation (IDF) estimated that 7.5 million individuals have diabetes and around 2.2 million have prediabetes in Egypt. Furthermore, reports indicate that 43% of patients with diabetes and most patients with prediabetes in Egypt are likely undiagnosed. Consequently, the complications associated with the disease are also expected to increase. These include microvascular complications such as neuropathy, nephropathy, and retinopathy, and macrovascular complications such as peripheral artery disease, stroke, and cardiovascular diseases [
6].
Diabetes is seen to be a risk factor for female sexual dysfunction because the normal female sexual response needs the integrity of the sensory and autonomic nervous system to respond to erotic stimuli, as well as of the vascular integrity which supplies the external genitalia and vagina which affected by hyperglycemia [
7]. The main cause of sexual dysfunction in women with DM is multifactorial including biological, psychological, social, and interpersonal factors [
8].
The PLISSIT model, which was described by Annon in 1974 for the first time consists of four main parts: (I) Permission (P), (II) Limited Information (LI), (III) Specific Suggestions (SS), (IV) Intensive Therapy (IT). By using the first three phases of the PLISSIT model, 80–90% of the patient’s sexual problems are solvable [
9]. Education and counseling are effective in improving women’s sexual function through the provision of knowledge and problem-solving skills. Healthy lifestyles including nutrition, exercise, and sleep by controlling blood sugar levels protect a person from free radicals and indirectly affect their sexual function by regulating the body’s blood flow [
10].
Maternity nurse care can play a critical role as a sex educator and sex counselor in this context. Also, she has an important role in assessing the knowledge about the needs for sexual health. Numerous frameworks are available for sexual advice that can help nurses implement appropriate and effective support strategies for intervention in the cases of sexual concerns and problems such as (ALARM, BETTER, PLEASURE, and PLISSIT). These models all take a somewhat different approach to sexual counseling [
11].
Recently, evidence indicates that diabetic women are at higher risk for developing sexual dysfunction compared to those without diabetes [
4]. There are several cultural and traditional hurdles to having open discussions about sexual life, especially with female health care practitioners, in Egypt, which makes it inappropriate to discuss female sexuality. Furthermore, female sexual dysfunction in diabetic patients is under-researched. It is frequently overlooked in research, with only a few studies addressing women’s sexual functioning and dysfunction in an Egyptian study [
12]. Hence, this study has been conducted to improve the knowledge of female patients with diabetes regarding sexual dysfunction and be more able to solve the sexual dysfunction problem.
Study aim
This study aims to evaluate the effect of the counseling model on female patients with diabetes regarding sexual dysfunction.
Methods
Research design
A Quasi-experimental research design (pre and post-test) was utilized to meet the aim of this study.
Study setting
The current study was conducted at the diabetic and obstetric outpatient clinic in 2 hospitals (Al-Salam General Hospital, and El-zohor Central Hospital) and five centers affiliated the Health Insurance in Port Said City. These centers were selected randomly from twenty primary health care centers representing the five districts of Port Said according to the capacity of centers and registered cases namely (El-kwait Center, Othman Center, El-arab 1 Center, El-manakh Center, and El-arab2 Center).
Study subjects
A purposive sample with total no. 178 women were included in the study according to the following criteria. A sample size of women was calculated according to the equation of Daniel (1999). Biostatistics: A foundation for Analysis in the Health Sciences. 7th edition. New York: John Wiley & Sons.
$$n = \frac{{{\rm{N}} \times {\rm{P}}\left( {1 - {\rm{P}}} \right)}}{{{\rm{N}} - 1 \times \left( {{{\rm{d}}^2} \div {z^2}} \right) + {\rm{P}}\left( {1 - {\rm{P}}} \right)}}$$
Where, N = total population (400); Z, Class standard corresponding to the level of significance equal to 0.95 and 1.96; D = error percentage (= 0.05); P = Ratio provides a neutral property = 0.50. Therefore,
$$n = \frac{{400 \times 0.5\left( {1 - 0.5} \right)}}{{(400 - 1) \times \left( {{{0.05}^2} \div 1.96} \right) + 0.5\left( {1 - 0.5} \right)}} = 162$$
The estimated sample size is 162, after adding the (10%) to avoid dropping out and/or incomplete responses or withdrawal, the final number for the sample size will be = 162 + 16 = 178.
Inclusion criteria
Two data collection instruments were used:
The face and content validity of the study tools were checked by a panel of seven experts consisting of (2 professors, 1 assistant professor, and 2 lectures from the maternity, Gynecology, and Obstetrics Nursing specialties). Professors reviewed the FSFI scale for Arabic language translation, clarity, relevance, comprehensiveness, and understanding applicability. The average proportion of Content Validity Index (CVI) for items judged relevant across the seven experts = 0.86. Comments and suggestions of the jury were considered and necessary modifications, corrections, and clarifying of the items were done accordingly.
The reliability of tools used in this study by the Cronbach’s alpha coefficient test to assess the internal consistency of the study tools. The internal consistency of the female sexual index was 0.91.
Pilot study
A pilot study was conducted before starting the actual data collection. The pilot study was carried out on 10% (18 women) of the total sample of diabetic female patients. These were excluded from the main study sample. The purpose of the pilot study was to test the clarity, feasibility, and applicability of the study tools and estimate the time needed to complete the tools. It also helped to find out any obstacles and problems that might interfere with the data collection process. Needed modifications were done based on the findings of the pilot study.
Ethical considerations
Approval was taken from the Research Ethics Committee of the Faculty of Nursing, Port Said University (code no. NUR 12/9/2021- 6). The purpose of the study was explained to the participants before obtaining the written consent to share in the study. A brief explanation of the study was given to assure the participants that all information obtained would be kept strictly confidential and used only for the study. Participants were informed that; they have the right to participate or withdraw from the study at any time. Code numbers instead of names of the participants were used for identification purposes. This measure ensured the participants would not be identified in the public reports.
Fieldwork
The field of the study was conducted for eight months from the beginning of February 2022 to the end of December 2022. Data was collected 2 days a week, at the diabetic and obstetric outpatient clinic in 2 hospitals (Al Salam Port Said General Hospital, Elzohor General Hospital), and in five centers in Port Said City (El-Kuwait Center, Othman Ibnafan Center, El-arab 1 Center, El-manakh center, El-arab2 center), Average number of patients per week (6 patients). The study was carried out through the following phases:
Statistical design
After completion of data collection, data was organized, tabulated, and computerized in Microsoft Excel 2021, and statically analyzed. The Statistical Package for Social Science (SPSS) version 28 was used to analyze the data on a PC. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and means, and standard deviations for quantitative variables. Cronbach alpha coefficient was calculated to assess the reliability of the satisfaction scale through its internal consistency. Qualitative categorical variables were compared using the chi-square test. The obtained outcomes were considered significant at p-value ≤ 0.05 and highly significant at p-value ≤ 0.001 while p-value > 0.05 was considered non-significant.
Discussion
A normal sex life is an important part of life and relationships. Diabetes mellitus (DM) is an important cause of sexual dysfunction both in men and women. This problem is more difficult to diagnose and treat in women than in men because of the intricacy of the female sexual response. Also, the literature is limited in addressing female sexual dysfunction (FSD) in DM, and this aspect of female health is often ignored in clinical practice in women with DM. Early screening, diagnosis, and appropriate counseling are the cornerstone for managing FSD in women with DM [
13]. So, it was very necessary to shed light on this sensitive problem through the present research using the PLISSIT model to facilitate data collection & counseling to overcome the negative consequences of that problem [
14]. The present study aimed to evaluate the effect of the sexual counseling model on the sexual dysfunction of women with diabetes & their sexual quality of life.
Regarding the medical history of the studied female patients, the present study shows that more than two-fifths of women with diabetes started from one year to five years, and more than two-thirds of them make regular examinations for diabetes. Regarding the type of diabetes, the majority of the women had type I Diabetes, and more than half of them had regular diabetes. Concerning the treatment of diabetes more than half of them used insulin in treatment, most of them have complications from diabetes and most of them suffered from chronic diseases. These results were supported by [
15] who studied the effect of the counseling model on sexual dysfunction among women with diabetes and their sexual quality of life in Minia, and mentioned that more than one-third of the studied sample had diabetes for less than 10 years & slightly three-quarters of diabetic women had type 1 diabetes mellitus who treated by insulin only. In Egypt [
16] concluded that the prevalence of sexual dysfunction is higher in type one diabetic women, compared to type two diabetes type one is more common to appear before the age of 40 years.
Regarding to pregnancy history of the studied female patients, the findings showed that most of the women had two to three times of pregnancies and more than two-thirds of them had two to three births number. Moreover, regarding the number of living children more than half of them have one to three children and most of them are cesarian. These results agreed with Gerges et al. [
10] who studied sexual dysfunction in women with diabetes in Banha and revealed that more than two-thirds of the studied women had from one to three children, in contrast to the result of the current study more than two-thirds of them were delivered with Vaginal delivery mode.
Regarding the sexual history of the studied female patients, the present findings presented that the majority of the sample hadn’t problems in sexual relationships, concerning those who have sexual problems more than one-third of them mentioned the problem started since than one year ago. Regarding circumcision, more than half performed circumcision, and more than half had irregular intercourse time. This was disagreed with Ayalew [
17]; Kirici, and Emel et al. [
18] who revealed that sexual relation problems were correlated significantly with diabetes among the studied women. Concerning circumcision the present result agreed with Abd-elatief, Mohasib, and Mohamed [
15]; and Arafa et al. [
16] who reported that the majority of the sample were circumcised.
Concerning female sexual function index (FSFI) domains; the present findings confirmed that diabetic women had a significant improvement in all domains post-educational intervention compared to pre-educational intervention. This result was the same line with Abd-elatief, Mohasib & Mohamed [
15] who reported that after 6 months of an educational program diabetic women had the highest mean score related to their female sexual function index domains & total mean scores of female sexual functions had a significant improvement from 23.8 pre-education to 29.9 after six months of education with P– ≤ 0.000. In the researcher point view it might be related to the lack of knowledge among women about sexual function and also regarding the fact that in Egypt the culture of the society it was shy and non-ethical to that woman for discussing this kind of knowledge. Another study by Mehrabi, Lotfi, Rahimzadeh, & Khoei [
19], on 100 married women aged 35–55 years old with type 2 diabetes, reported that PLISSIT model-based sexual counseling increased all domains of sexual function, except for sexual excitement and pain.
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