Comparison between 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: A Randomized, Clinical Trial

doi:10.21203/rs.3.rs-1597308/v1

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Research Article

Comparison between 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: A Randomized, Clinical Trial

https://doi.org/10.21203/rs.3.rs-1597308/v1

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Background: Women play an essential role in maintaining the family's health, and family planning is part of women's and families' health. The couple's mutual understanding of family planning methods is essential in selecting a contraception method. Acceptance of and satisfaction with different contraception methods can impact sexual satisfaction. The present study aimed to compare the effect of the information-motivation-behavioral (IMB) model and psychoeducational counseling on sexual satisfaction and contraception methods of women referring to health

centers in Kerman.

Methods: This trial was conducted on 81 women aged 18–45 who came to Kerman health centers from 2021 to 2022. Participants were randomly divided into three groups of 27 people (control, psychoeducational counseling, IMB method). Due to the COVID-19 outbreak, three online counseling sessions were held for the psychoeducational counseling intervention group, and four online counseling sessions were held for the IMB group. The control group received routine care from a midwife. SPSS software was used for data analysis using nonparametric Friedman and Kruskal-Wallis tests.

Results: The mean age of participants was 32.59 ± 7.04, and the majority had university degrees and were homemakers. The mean sexual satisfaction score significantly increased immediately after the intervention and one month later in the two interventional groups (P <0.001). Changes in contraception methods after intervention were significant in the psychoeducational group (P = 0.028)

Conclusion: The results indicate the positive impact of psychological counseling on women's sexual satisfaction and changing the contraception method. The results also showed that the IMB method positively impacted women's sexual satisfaction but had no impact on changing the contraceptive method.

psychoeducational counseling

information–motivation–behavioral model

sexual satisfaction

contraception

violence

The lack of couples' shared participation in using contraceptive methods is one of the areas of violence in reproductive health. Women's choice, acceptance, and satisfaction with different contraceptive methods affect their quality of life and sexual satisfaction. Psychoeducational counseling and IMB intervention were carried out on 81 women aged 18 to 45 under the coercion of their spouses for contraception use. Both of these methods could improve sexual satisfaction, but only psychoeducational counseling could change the contraceptive method, which was not of women's will.

Women play an essential role in maintaining the family members' and, ultimately, the community's health; community health is also threatened 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 use in women, the limited methods 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 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 on women's use of contraception showed that women who experienced IPV during the previous year were 20% less likely to report the use of male condoms; it also showed women who experienced IPV were less likely to report that their partners used condoms or contraceptive methods that require male participation (8). Empowerment of women when they are facing life problems, providing life skills training, familiarizing them with the underlying factors of violence and ways to avoid it, and familiarizing them with communication skills to adapt to face problems, choose the correct alternative behavior in problem-solving, and use family counseling services can be effective in preventing or reducing intimate partner violence (9).

One of the most comprehensive models for behavior change is the information-motivation-behavioral (IMB) skills model (10). According to the model, health information, motivation, and behavioral skills are fundamental determinants of preventive behaviors and behavioral skills necessary for taking preventive measures (11). The study by Mittal et al. (2017) aimed to present a supportive intervention to reduce HIV risk in women with a history of intimate partner violence. 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 post-traumatic stress disorder (PTSD) (11).

Psychoeducational counseling is also a type of counseling in which clients are trained during counseling (12). 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 (13). A study by Akbarinejad et al. (2016) investigated the effect of psychoeducational group counseling on 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 (12). Psychoeducational counseling is associated with education during counseling, 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 have a psychological and social approach. We decided to compare the effect of the IMB model and psychoeducational counseling on sexual satisfaction and contraceptive methods used under the coercion of the spouse and identify a less costly, time-consuming, and more effective method in achieving this goal.

This study was a clinical trial, and the statistical population included all married women aged 18–45 years who were referred to health centers in Kerman, a city in the south of IRAN; to receive care and family planning counseling. Then convenience sampling was used for participations who were women under the coercion of spouses in contraception use according to 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) (14). 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 her, and if she were satisfied and willing, she would enter the study.

Sample size: The sample size with a reliability of 1.96 and study power of 85% based on the results of the study by Nabavi et al. (2019) was approximately six people for each group, but 27 people were selected to increase the study capacity and compensate for the loss of samples (15).

Because the samples were divided into three 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.

Inclusion and Exclusion Criteria

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 concerning contraceptive methods according to the checklist of the World Health Organization consented to participate in the study, were literate, had been married for at least one year, had no known mental illness, and had access to a smartphone (due to online education) and the ability to use it, were included in the study. Exclusion criteria included pregnancy, absence in two sessions or more of the counseling sessions, and unwillingness to continue participation.

Research Tools

The research tool consisted of demographic information, a checklist for evaluating the contraception method requested by the spouse (World Health Organization), and a special researcher-made questionnaire on contraceptive methods and sexual satisfaction. This questionnaire was prepared based on scientific articles (16-19). The special sexual satisfaction questionnaire examined the 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's α (0.855).

Research Implementation

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 one 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 three groups (control, psychoeducational, and IMB), a time interval of 2 months was considered for each group. First, a pre-test was completed for the control group, and post-tests were done one month later and one month after the initial post-test. Then a pre-test was done for the psychoeducational group; the initial post-test was done after the three virtual counseling sessions in Skyroom; the final post-test was completed one month after the intervention. The total time spent implementing the intervention and completing the questionnaires was six 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 three 90-minute online sessions one week apart. In the IMB model intervention group, counseling sessions were held according to a specific package, in 4 online sessions, 120–190 minutes each two sessions per week, and all these sessions were held by the same person (the researcher). Finally, immediately after the intervention and one month later, the participants in the three groups completed the questionnaire in the three groups. The psychoeducational counseling and IMB program packages were designed, prepared, and implemented using various resources (Table 1).

Table 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

Data Analysis

216 people were surveyed to participate in the study, of which 135 were either not eligible or unwilling to participate in the study. 81 people were included in the study. By lot, they were divided into 3 groups (one was a control group and two were intervention groups). Since the intervention was performed online and offline, we did not have any sample drop and finally the analysis was performed on 81 people. Data were analyzed using SPSS software version 22. Quantitative variables were described by mean and standard deviation, and qualitative variables were defined by frequency and frequency percentage. 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.

The mean age of women was 34.44 ± 7.25, 32.04 ± 7.7, and 31.30 ± 6.19 years for the psychoeducational intervention, IMB model intervention, and control groups, respectively. 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 2).

Table 2

Comparison of the distribution of qualitative and quantitative demographic variables between intervention and control groups
Variables		Group			p-value*
Variables		Psychoeducation N (%)	IMB N (%)	Control N (%)	p-value*
Women Education	High school education	2(7.4%)	2(7.4%)	3(10%)	0.903
	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%)	0.347
	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%)	0.227
	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%)	0.837
	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	0.225
Age of onset of sexual activity		4.029 ± 23.19	3.652 ± 21.52	3.151 ± 22.27	0.242
Parity		1.368 ± 2.89	1.812 ± 2.85	1.654 ± 2.77	0.899
Chi- square *Kruskal-Wallis test

The results showed that the mean sexual satisfaction score immediately after the intervention was 16.85 ± 184.37, 13.01 ± 190.29, and 15.38 ± 167.30 for the psychoeducational intervention, IMB model intervention, and control groups, respectively, and the difference was statistically significant (P < 0.001). Mean sexual satisfaction score one month after the intervention was 16.48 ± 189.25, 11.05 ± 203.48, and 16.49 ± 166.13 in the psychoeducational intervention, IMB model intervention, and control groups, respectively, and according to the Kruskal-Wallis test, there was a significant difference between the three groups (P < 0.001). The sexual satisfaction score increased one month after the intervention in the psychoeducational and IMB group, and the increase in sexual satisfaction was more significant in the IMB group (Table 3).

Table 3

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*
Sexual satisfaction	Psychoeducation	IMB	Control	P-Value*
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˂	0.717
Kruskal-Wallis test *Friedman test

The mean score of sexual satisfaction in the psychoeducational intervention group increased one month after the intervention compared to immediately after the intervention, and the difference was significant (P = 0.031); in the IMB group, the sexual satisfaction increased significantly one month after the intervention compared to immediately after the intervention (P < 0.001), but there was no statistically significant difference between the two intervention groups in sexual satisfaction (P = 0.154). However, the mean score in the IMB the group was higher than the psychoeducational intervention group. Using each contraception method in the three groups (control, psychoeducational, and IMB intervention) was measured before, immediately after and one month after the intervention. The Mann-Kendall statistical test showed that changes in the contraception method in the psychoeducational group was significant (P = 0.028)(Table 4).

Table 4

Frequency distribution of contraceptive methods before intervention, after intervention and one month after intervention in three groups
Group	Contraceptive Methode	Before intervention	After intervention	One month after intervention	P value*
Psychoeducation	Withdrawal	14(51.85%)	8(29.62%)	8(29.62%)	0.028
	Condom	6(22.22%)	11(40.74%)	11(40.74%)
	Combined Oral Pills	5(18.51%)	4(14.81%)	4(14.81%)
	Medroxy Progestrone 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%)	0.076
	Condom	5(18.51%)	8(29.62%)	9(33.33%)
	Combined Oral Pills	5(18.51%)	5(18.51%)	6(22.22%)
	Medroxy Progestrone 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%)
	Medroxy Progestrone Asetat	1(3.7%)	1(3.7%)	2(7.4%)
	IUD	1(3.7%)	1(3.7%)	1(3.7%)
*Kendall test

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 Abdolqader et al. (2014), the sexual satisfaction of infertile couples increased after psychological intervention, which was consistent with our study (20). However, due to the long duration of psychological intervention (6 months) compared to IMB counseling (2 weeks) and psychoeducational counseling (3 weeks), the counseling methods in the present study are better in terms of time and cost savings. Our study is consistent with the study by 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 (12). Considering that sexual intimacy is itself a component in increasing sexual satisfaction and improving 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 (21). 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 sexual information of women with ovarian cancer (22). In the study by Ali Mohammadi et al. (2017), 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. (23) It can be concluded that IMB counseling is more effective on sexual satisfaction than sex 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 acquire appropriate behavioral skills in dealing with the spouse and choosing the proper contraception method. A comprehensive counseling approach can identify women sexual needs, which leads to improved behavior and change in women's behavior to promote sexual satisfaction.

The results of the study by Granmayeh et al. (2005) show that women who received systematic counseling on family planning methods continued to use contraception methods, and stopping the use of contraception methods was less than the control group, which was consistent with psychoeducational counseling in our study (24). 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 (25). 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 (26). 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 methods could be due to simultaneous training about sexual satisfaction and contraception methods. That couples were in stable and permanent relationships, and the purpose of this study is to increase sexual satisfaction related to contraception methods. According to the results, it can be concluded that women who their spouses coerce to use specific contraception methods do not only need to change their contraception methods, but by obtaining information about different methods of contraception, being motivated, and changing their attitudes to more positive ones, achieving behavioral skills in communication, and creating positive relationships with their spouse, 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 themselves and their spouse was the most appropriate method of contraception for them. By agreeing on this new contraceptive method and the improved interpersonal relationships with their spouse, their sexual satisfaction also increased.

Because the study was conducted during the 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 the online courses, other people from other social and economic classes could not participate in the counseling courses, which can be considered a limitation in the present study.

psychological counseling could improve women's sexual satisfaction and change the contraception method, which was not 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 and preventing unwanted pregnancy is one of the essential parts of reproductive health, utilization of intervention methods seems crucial. According to the results, using one of these two intervention methods in contraceptive counseling sessions is good.

IMB

Information–Motivation–Behavioral

TGP

Theory of Gender and Power

PTSD

Post-Traumatic Stress Disorder

Ethics approval and consent to participate

This manuscript was derived from a project with code No 98000973. It was approved by the Ethics Committee of Kerman University of Medical Sciences, Iran (the code of ethics No. IR.KMU.REC. 1399.036) and was submitted as a clinical trial. (IRCT20151103024866N16). Written informed consent was obtained to enter the study, and also informed consent was obtained from legally authorized representatives of the illiterate participants. Participants were easy to withdraw from the study whenever they were willing. At the request of the ethics committee, the study was conducted following the Declaration of Helsinki and Ethics Publication on Committee (COPE). Special codes were used for each of the participants to ensure the information confidentiality.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used during the current study available from the corresponding author on reasonable request.

Competing interests

The authors of this study state that there is no conflict of interest.

Funding

This study did not receive any specific funding from any community funding organization, commercial or non-profit sectors

Authors’ contributions

AZ and KA designed the work and drafted the manuscript. AA and ER had prepared counselling package. FGH had full access to all of the data and took responsibility for the integrity of the data. MGH was responsible for accuracy of the data analysis. KA contributed equally to writing and revising the manuscript and approved the final manuscript. All authors have read and approved the manuscript

Acknowledgements

The authors appreciate all vulnerable women who kindly participated in this study. We also appreciate health care centers staff for their cooperation.

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No competing interests reported.

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Comparison between 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: A Randomized, Clinical Trial

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