The Effect of Educational Intervention on Health Literacy, Self-ecacy and Quality of Life in Suburban Women of Mashhad

Background Health literacy is one of the important factors to improve menopausal quality of life that Proper and timely education and tailored to the needs of individuals, caused to improve quality of life. This study aimed to investigate the effect of educational intervention on health literacy, self-ecacy, and quality of life in women. This quasi-experimental study with the control group was performed on 107 suburban women aged 40-60 years during 2021-2022. Participants were randomly selected by substituting and selected avenue number 3 as the experimental group and 6 as the control group. instruments of this study were Iranian Health Literacy and Scherer Self-Ecacy and Menopausal Quality of Life Questionnaires. The educational intervention was performed in 4 training sessions of 95 minutes once a week.Questionnaires were completed before training, immediately after training, and 3 months later. Data were analyzed by SPSS21 and independent t-test, Kruscalovalis, and linear regression tests.


Introduction
The average life expectancy of people and the number of elderly over 60 years has increased due to improved health conditions in Iran, as in many countries of the world. Therefore, all people must live in a way that healthy old age, and to be active in the social and economic in the future(1).
Recognizing the risk factors and controlling their complications are the necessities of women's lives.
women's knowledge of these changes and understanding the reasons for them makes it easier to get through this stage. Knowledge will have a positive effect on health care and increase healthy behaviors and lead to improving their quality of life.
The person's con dence in her abilities is an important and in uential factor in the quality of life and controlling menopausal symptoms. Perceived social support has many effects on physical and mental status, life satisfaction, and various aspects of quality of life (2) The World Health Organization de nes the quality of life as perceived by individuals in their lives, in the context of the culture and value system in which they live, and about their goals, expectations, communications, and needs. The quality of life of older women in society depends on the ability to cope with economic, social, medical, and health-related challenges in the menopausal years (2). Given that inadequate health literacy is considered a global threat today. Health education aims to raise the level of health literacy that helps to make the right decisions about their health and the community health in which they live. (3) The level of health literacy is one of the most important factors in improving the quality of life in menopause, which improves with proper and timely and accordance with the needs education (4).
According to Bandura, self-e cacy is the main and important precondition for changing behavior, and a person with a high level of self-e cacy is more successful and hopeful in doing works.
Perceived self-e cacy can be de ned as the beliefs about own ability to control actions, and the level of performance, and events that affect lives. People with strong self-e cacy believe that they can do any di cult task. They see di cult tasks as challenges and struggles to become pro cient rather than threats that they must avoid. E cient people in the failures continue to strive that succeed (5).
In the study of Rachel Yolizmatores ,the relationship between health literacy, self-e cacy, knowledge, and hormone therapy behaviors between the two variables of health literacy and self-e cacy decisions, clear correlation was seen based on regression(3).
This study aimed to determine the effect of educational intervention on health literacy, self-e cacy, and improving the menopausal quality of life in 40-60 aged women in the suburbs of Mashhad.

Methods
This study was a quasi-experimental with a control group of women aged 40-60 years living in the suburbs of Mashhad. The study period was 2020-2021( gure 1). The samples size was assigned based on a similar study (6).

Inclusion criteria included:
-Persian language -satisfaction for entering the study -living in the suburbs of Mashhad -women aged 40-60.
Exclusion criteria: -unwillingness to participate in training sessions during the intervention, -incurable diseases, -absence of more than two sessions in training classes samples were 107 from the southern highlands area of the suburbs randomly by alternatives selected and, the 3rd street, exprimental group, and 6th street, as the control group, were randomly assigned( gure2). The two groups had an acceptable distance to prevent bias. Details of the training sessions give in Table 1. Questionnaires were completed before the beginning of the sessions, immediately and 3month later. In educational sessions, were done, lectures and focus groups. Practical exercises were done when necessary.
The measurement tools were health literacy short TOFLA, menopausal quality of life (MENQOL) and sherer self-e cacy questionnaires.
The TOFLA Health Literacy Questionnaire has three texts related to the instructions for preparing for the upper gastrointestinal tract x-ray, the ward, and the patient's responsibilities on the insurance policy and a standard hospitalization. Short TOFLA Health Literacy Questionnaire has 50 questions. The validity and reliability of the short health literacy questionnaire (TOFLA) has been con rmed by past studies.
Scherer's general self-e cacy questionnaire consists of 17 standard questions, which are graded on a Likert scale from Strongly Disagree (1) to Strongly Agree (5). The maximum score is 85 and the minimum is 17. This questionnaire has been translated and validated by Barati (1996). Educational texts were adjusted based on the results of the questionnaires. The educational intervention was performed in 4 sessions (Table 1). Questionnaires were completed before education and immediately and three months later. After collecting, the data were entered into a computer and analyzed by SPSS21 statistical analysis software. Finally, improvement in health literacy and self-e cacy, and quality of life these two groups were assessed and compared.  The mean score of quality of life, health literacy, and self-e cacy in the experimental group increased immediately and three months after the intervention (Table 3). Three months after the intervention, there was a signi cant relationship between health literacy and quality of life (Table 4). But there was no relationship between self-e cacy and quality of life.

Discusion
This study showed that education could improve the postmenopausal quality of life (7) and lifestyle and promote women's health (8). Some studies in Iran and other parts of the world indicate the negative impact of menopause on quality of life (9,10,11).
One of the main factors to improve quality of life is the improvement of lifestyle (7). Increasing knowledge about menopause can correct quality of life, reduce complications and increase self-e cacy (12). Quality of life is a perception state of physical, mental, social, and environmental health. Various variables such as personal characteristics such as age, gender, personality, education, and organizational factors such as stress experienced in the workplace, the nature of work and tasks, and social factors such as relationships between family members and co-workers have affected the quality of life.
The people with higher self-care and health care have a more positive perception of their health and experience a better quality of life (13). In various qualitative studies, as the study of the peyman and khandehroo (12), different interpretations such as satisfaction and dissatisfaction (12) identity transformation, disability, and helplessness (14) feel of aging (9) were perception. The women will have different attitudes towards menopause depending on their interpretations and consequently may have various quality of life.
In Nazarpour's study, individual and social factors aggravated menopausal complications thus were affected the quality of life (16). In addition, these imposing an economic burden on the family and society affect the menopausal quality of life (15). health literacy is another factor that affects the menopausal quality of life .World Health Organization named health literacy one of the su cient determinants of health (7). Health literacy has been offered a global issue in the 21st century (2). it is necessary to choose an educational approach to promote health literacy and quality of life by considering the abilities and skills (5).
Health education aims to raise the level of health literacy of people, to help them make the right decisions about their health and the community in which they live (3). In addition, Bandura introduces a view of human behavior in which the beliefs that people have about themselves are vital to controlling their behavior (17).
People with higher self-e cacy believe that they can do any di cult task (5). In the study of Forough Jafari et .al a direct and signi cant relationship was seen between the variables of the meaning of life and self-e cacy and body areas satisfaction and health assessment with quality of life (18).
In the study of Mostafavi in Isfahan, the level of health literacy in the elderly was very inadequate. The people with lower age, less education, less income, and more doctor visits had low health literacy (19). In Khaledian's study, there was no statistically signi cant relationship between education (p = 0.48, occupation) (p = 0.12) and the number of family members (p = 0.43) and quality of life (20),however this relationship was con rmed in the present study.
In Abdi's research, there was a statistically signi cant relationship between quality of life and job (p = 0.04) and quality of life and income (p = 0.009). The present study was certi ed too. The quality of life and health literacy gained a direct and signi cant relationship and an inverse and signi cant between the quality of life and self-e cacy.
The positive and signi cant effect of educational intervention in improving the quality of life and increasing health literacy and self-e cacy was certi ed in the khandehroo research (21). It acknowledges in this study. This increase was more signi cant in 3 months after the intervention.
The limitations of this study were the presence of covid 19 and limited communication and education of participants, the fear of covid 19 if they participated in training classes. This limitation had somewhat modi ed. This study did with individual funding. Suggestions: Using the results of such studies in the community cause women's health promotion, make them healthier and more productive for the rest of their lives, take more effective steps towards sustainable development. In addition to providing the necessary knowledge about menopausal symptoms and complications, how to deal with and adapt to them to maintain health and improve the menopausal quality of life. to Create support groups, induce a positive attitude, and promote healthier behaviors should strive in postmenopausal women.
It can also help managers of health services in controlling and reducing the complications of menopause and reducing the resulting burden on the health care system. Authorities can consider the results of this study in their policies in disease and health services management. Figure 1 (colour online) Intervention timeline for intervention Figure 2 Flow of participants through each stage of the programme