# The Effect of a Sexual Health Promotion Training Program on Sexual Function of Pregnant Women with Gestational Diabetes Mellitus

AUTHORS

Elahe Fayyazian 1 , Farnoosh Khojasteh 2 , * , Farshid Saeedinezhad 3 , Maryam Haghighi 4

1 School of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, Iran

2 Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

3 Community Nursing Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

4 Anesthesia Department, Paramedical School, Zahedan University of Medical Sciences, Zahedan, Iran

How to Cite: Fayyazian E, Khojasteh F, Saeedinezhad F, Haghighi M. The Effect of a Sexual Health Promotion Training Program on Sexual Function of Pregnant Women with Gestational Diabetes Mellitus. Med Surg Nurs J. 2021;10(1):e118769. doi: 10.5812/msnj.118769.

ARTICLE INFORMATION

Medical - Surgical Nursing Journal: 10 (1); e118769
Published Online: August 28, 2021
Article Type: Research Article
Accepted: August 15, 2021
Crossmark
CHECKING

### Abstract

Background: Pregnancy care and screening programs are very important, especially in high-risk pregnancies. However, few interventional studies have addressed mental and sexual health in women with gestational diabetes mellitus (GDM).

Objectives: The present study aimed to examine the effect of a sexual health promotion training program on sexual function of pregnant women with GDM referring to comprehensive health centers in Zahedan, Iran, in 2020.

Methods: This quasi-experimental study was performed on 80 pregnant women with GDM (gestational age: 24 - 30 weeks). The participants were selected using multi-stage sampling method and randomly assigned into intervention and control groups. The participants in the intervention group received sexual health promotion training in four sessions (60 - 90 minutes) two sessions per week. The participants in the control group received routine care. The demographic information questionnaire was completed by the participants at the beginning of the study, and the Female Sexual Function Index (FSFI) was administered before and four weeks after the completion of the sexual health promotion training program. The collected data were analyzed in SPSS software (version 22) using independent samples t-test, paired samples t-test, analysis of covariance (ANCOVA), and chi-square test.

Results: The results showed a statistically significant difference between the intervention and control groups in all subscales of sexual function (P < 0.05). Moreover, the results of ANCOVA for the total sexual function score showed that the women in the intervention group had significantly higher levels of sexual function (22.89 ± 3.24) compared to the women in the control group (16.78 ± 3.16) (P = 0.001).

Conclusions: Given the positive and significant effect of sexual health promotion training on the sexual function of pregnant women with GDM, it is recommended to integrate this training program in prenatal care of these vulnerable women.

Keywords

### 1. Background

Pregnancy is one of the most challenging psychological events in women’s life that can have positive and negative effects in the long run (1). During this period, the woman’s body undergoes anatomical and physiological changes for fetal growth, metabolic needs, and readiness for delivery (2). Pregnant women frequently experience physiological and metabolic changes that affect different systems in their body organs (3). Since the mother’s cardiovascular, pulmonary, immune, and metabolic systems are altered during pregnancy, maladjustment of the mother’s physiology during this period may cause abnormal birth weight or gestational diabetes mellitus (GDM) (4).

GDM is defined as the degree of blood sugar that is a metabolic disorder with first recognition during pregnancy and includes type 2 diabetes that has not been previously diagnosed and GDM that develops later in pregnancy (5). The World Health Organization (WHO) defines GDM as glucose intolerance of variable degree (6). Blood sugar is normal if the fasting blood sugar level is less than 92 and the blood sugar two hours after the meal is less than 153, but if any of them is equal to or higher than these levels, it is considered GDM (7), which is diagnosed in the second or third trimester (8).

GDM is currently the most common complication of pregnancy (5). However, its prevalence varies in different parts of the world, and the possible causes of this variation are unknown with no precise spatial classification. Nevertheless, the available data indicate that GDM is prevalent in 14% of pregnancies worldwide, accounting for approximately 18 million annual births (9). According to the estimations, 16.9% of all pregnancies worldwide (10) and 17% of all pregnancies in Iran are associated with GDM (11). Diabetes in the sensitive period of pregnancy has profound effects on the internal environment of the uterus and may impair fetal or maternal function (12).

One of the most serious complications of GDM is a decrease in sexual function. This metabolic disorder not only can cause neurovascular injury, but also have psychological damages (13). The prevalence of sexual dysfunction in people with diabetes is about three times higher than in the general population (14). The WHO defines sexual health as a state of physical, emotional, mental, and social well-being in relation to sexuality (15). Sexual function plays an essential role in marital satisfaction. Thus, people who have satisfying sexual relations have a higher quality of life and do not fail to express love and affection to their spouse, and have more understanding and empathy in life (16). As a result, if the sexual function is impaired, quality of life and marital satisfaction are affected.

Sexual dysfunction in women is demonstrated as sexual disorders including hypoactive sexual desire disorder (HSDD), which itself involves the absence of sexual fantasies, sexual arousal disorders, orgasmic disorders, sexual pain disorders (dyspareunia), general medical disorders, substance use disorders, and unclassified sexual disorders (17, 18). Although sexual desires are innate and involuntary, sexual attitudes and behaviors can be learned. Therefore, sexual activities can have different meanings for different people and change from time to time. Accordingly, by increasing awareness, the person acquires the necessary ability to solve sexual problems (19). This awareness is gained by increased education on sexual issues.

Education is a process that starts with informing, is followed by creating motivation, and ultimately leads to improved behavior and performance (20). Health literacy is one of the most important determinants of health in the world (21), practicing health-promoting behaviors is one of the best ways to stay healthy (22), and participation is a key value for health promotion (23). Health-promoting behaviors include activities that enable people to take control of their health (22).

### 2. Objectives

Since pregnancy care and screening programs are very important, especially in high-risk pregnancies, and as few interventional studies have addressed mental and sexual health in women with GDM, the present study aimed to examine the effect of a sexual health promotion training program on the sexual function of pregnant women with GDM referring to comprehensive health centers in Zahedan, Iran in 2020.

### 3. Methods

This quasi-experimental study was conducted using a pretest-posttest design with two groups. The participants were 80 pregnant women with GDM referring to comprehensive health centers in Zahedan to receive prenatal care in 2020. The inclusion criteria were women in the age range of 18 - 40 years, gestational age of 30 - 30 weeks, the absence of physical illnesses affecting sexual function or known mental disorders, normal pregnancy, no history of pre-GDM, diagnosis of GDM based on routine tests performed according to national guidelines, no use of medications affecting glucose metabolism, the absence of sex ban, and obtaining a score of 28 or less on the Female Sexual Function Index (FSFI). The exclusion criteria were the occurrence of fetal and maternal complications or any traumatic accident during the course of study and absence or non-participation in more than one training session.

The sample size in this study was estimated as 17 individuals per group using the mean and standard deviation for sexual function in a similar study (Moradi et al., 2016) with 95% confidence interval (CI), 95% statistical test power, and based on the following formula. Given that the participants were selected using multi-stage sampling, the estimated sample size was multiplied by two. Thus, the number of participants in each group was 34 individuals. To ensure the sample adequacy and due to the possible dropouts, the sample size for each group was estimated as 40 individuals (total sample size: 80 individuals). To this end, clinics and health care centers were selected using a multi-stage method, and then the participants in each center were selected in proportion to the assigned sample size using convenience sampling (24):

Z1 – α/2 = 26.59; $X-1$ = 3.56; S1 = 1.96

Z1 – β =22.48; $X-2$= 3.00; S2 = 1.64

The data in this study were collected using two instruments: (1) the demographic information questionnaire assessed parental age; (2) the number of pregnancies, type of previous deliveries, parental occupation, parental education, body mass index (BMI), and ethnicity. Besides, the FSFI was completed by the participants as a self-report instrument.

#### 3.1. Female Sexual Function Index (FSFI)

This index was developed by Rosen et al. (2000) to measure female sexual function. It contains 19 items that measure sexual function in six independent domains: (1) desire (2 items), (2) arousal (4 items), (3) lubrication (4 items), (4) orgasm (3 items), (5) satisfaction (3 items), and (6) pain (3 items). The respondents are asked to choose the best option that shows their sexual function during the last four weeks. The answers are scored on a five-point Likert scale ranging from 0 to 4 (0 = never, 1 = rarely, 2 = occasionally, 3 = frequently, or 4 = almost always). To normalize the domains, the scores of each domain are added together and then multiplied by the corresponding factor load shown in Table 1. After the domains are normalized, the minimum and maximum scores for each domain are 1 and 6, respectively. The minimum and maximum scores for the whole index are obtained, and the sum of the scores for the six domains are equal to 2 and 36, respectively. Higher scores indicate better sexual functions in each domain and overall (25). The reliability and validity of the FSFI in Iran were assessed and confirmed by Mohammadi et al. (2008). To determine the validity of the index, its content validity was assessed using the content index of the instrument. The reliability of the instrument was evaluated and confirmed by calculating the Cronbach’s alpha coefficient, and the corresponding value was 0.87 (26). The reliability of the instrument in the present study was checked by measuring its internal consistency for the whole index, and the Cronbach’s alpha was 0.72.

Table 1. Scoring the Index Items
Desire 21 - 50.61.26
Arousal 40 - 50.306
Lubrication40 - 50.306
Orgasm 30 - 50.406
Satisfaction 30 - 5 or 1 - 50.40.86
Pain30 - 50.406
Total 19--236

After obtaining an ethics code from the Ethics Committee of Zahedan University of Medical Sciences and obtaining permission from officials of the University and affiliated health centers, the participants were selected using multi-stage sampling. Since Zahedan has five districts, we selected two centers from each district by drawing lots. To this end, the city was first divided into five northern, southern, eastern, western, and central districts, and two health care centers were selected randomly from each district (10 centers in total). From the two selected centers in each district, one center was allocated to the intervention group and one center to the control group. Then, in each center, eight women who met the inclusion criteria were selected using convenience sampling. Next, a list of all pregnant women with GDM in each center was prepared using the data from the electronic systems of selected health centers, and they were contacted by phone. Necessary information was given to them about the objectives of the study. If they agreed to participate in the study, they were enrolled in the study after obtaining a written informed consent. Before the intervention, the participants in the intervention and control groups completed the two questionnaires. Moreover, the FSFI was administered again in both groups four weeks after the completion of the sexual health promotion training program.

Given the COVID-19 outbreak, the pregnant women in the intervention group were divided into small groups, each with 4 to 5 members. Then, they were invited to participate in the counseling sessions by telephone. The location of the training program was chosen upon the participants' agreement, and four sexual health promotion counseling training sessions (two 60- to 90-minute sessions per week) were held in the clinic or the School of Nursing and Midwifery in Zahedan by maintaining social distancing and observing health protocols such as wearing masks and gloves due to the coronavirus disease 2019 (COVID-19) pandemic. The instructions provided in the training sessions are presented in Table 2. To answer the possible questions and address the concerns of the participants in the intervention group after the intervention, a direct telephone line was provided to them. Four weeks after the completion of the intervention, the participants in both groups were asked to complete the FSFI. During this period, the participants in the control group received only routine training and care in the centers.

Table 2. The Instructional Content of the Training Program
Session The Instructional Content
1An overview of the anatomy and physiology of the male and female reproductive system and its changes during pregnancy in simple language and based on participants’ perceptions, psychological changes in different stages of pregnancy, sexual response cycle in men and women, changes in the sexual response cycle in pregnancy, common sexual misconceptions, and challenging them through group discussions.
2Exploring the attitudes towards sexual activity in pregnancy, a review of pregnancy-specific sexual disorders, the role of sex in marital relationships, and demonstrating effective and safe situations for sexual activity in pregnancy.
3Managing pregnancy stress by practicing and applying stress reduction techniques such as imaging and progressive muscle relaxation, listening to music, managing emotions and using problem-focused coping mechanisms, and training to manage anxiety-related thoughts through distraction and positive self-talk.
4Providing information on effective health care and lifestyles to cope with GMD by reviewing GMD and its complications, permitted physical activity training, proper diet training, self-care training, and psychological aspects of GMD, including worries and stress and their impact on women’s mental and sexual health.

The collected and coded data were analyzed using SPSS software (version 24). To this end, the data were summarized using descriptive statistics such as frequency (percentage), mean (± SD), minimum, and maximum. To compare the pre- and post-intervention mean scores in each group and between the groups, the paired samples t-test, and independent samples t-test were used, respectively. Moreover, to compare the frequency of the qualitative variables in the two groups, the Monte Carlo, Fisher, and chi-square tests were used. Analysis of covariance (ANCOVA) was also run to determine the effectiveness of the intervention and control the effect of the pretest. All statistical procedures were performed at the significance level of less than 0.05 (P < 0.05).

### 4. Results

Given the number of participants in each of the intervention and control groups, the data from 40 pregnant women with GDM were analyzed. As shown in Table 3, the participants and their husbands in the intervention and control groups were in their 20s and 30s, respectively. Moreover, the participants in both groups had married on average for more than seven years. The mean fasting blood sugar of the participants in both groups was within the normal controlled range. The results of the independent samples t-test showed that there was no significant difference between the two groups in terms of age and marriage length. Besides, the results of the chi-square and Mont Carlo tests showed no significant differences in terms of other qualitative variables (P < 0.05).

Table 3. A Comparison of the Demographic Characteristics of the Participants in the Two Groups a
VariablesGroupsP-Value
InterventionControl
Woman’s age 28.50 ± 6.0928.98 ± 5.030.77
Husband’s age 33.73 ± 5.7334.08 ± 4.980.77
Marriage length 7.58 ± 3.887.30 ± 2.910.72
BMI27.68 ± 1.9227.54 ± 2.190.86
Number of pregnancies 2.73 ± 1.122.85 ± 0.860.99
Fasting blood sugar 96.78 ± 11.68101.18 ± 14.730.07
Type of delivery0.11
Natural12 (0.30)12 (0.30)
C-section20 (0.50)26 (0.65)
Nulligravida8 (0.20) 82 (0.5)
History of abortion 0.64
No26 (0.65)24 (0.60)
Yes14 (0.35)16 (0.40)
Occupation 0.47
Unemployed25 (5.62)28 (0.70)
Employed15 (5.37)12 (0.30)
Education 0.98
Middle school12 (0.30)22 (0.55)
Secondary school23 (5.57)14 (0.35)
Higher education5 (5.12)4 (0.10)
Husband’s education 0.21
Illiterate2 (0.5)3 (5.7)
Middle school9 (5.22)15 (5.37)
Secondary school12 (0.30)5 (5.12)
Higher education17 (5.42)17 (5.42)
Type of pregnancy 0.39
Planned34 (0.85)31 (5.77)
Unplanned6 (0.15)9 (5.22)
Husband’s occupation 0.49
Unemployed0 (0.0) 02 (5)
Employed40 (100)38 (95)

a Values are expressed as mean ± SD or No. (%).

Table 4 shows the sexual function scores for the pregnant women with GDM in the intervention and control groups before the intervention (3.09 ± 0.86 and 2.86 ± 72, respectively) and after the intervention (3.75 ± 0.93 and 2.98 ± 0.55, respectively). The results of the independent samples t-test indicated no significant difference between the two groups in sexual function and its domains before the intervention (P > 0.05). However, significant differences were found between the two groups in sexual function and its domains after the intervention (P <0.05). The results of the paired samples t-test showed that the scores for sexual function and its domains (except for satisfaction and desire) significantly increased for the participants in the two groups after the intervention compared to the pre-intervention stage (P < 0.05). Given the significant differences in the mean scores of sexual function between the two groups before the intervention, the results of ANCOVA to control the significant effect of the pre-intervention scores showed that the mean scores of sexual function were significantly higher for the participants in the intervention group compared to the control group (P = 0.001) (Table 5).

Table 4. A Comparison of Sexual Function of the Participants in the Two Groups a
Variables StageChangesPaired Samples t-test
Pre-interventionPost-intervention
Desire
Intervention3.09 ± 0.863.75 ± 0.930.66 ± 0.670.001
Control2.86 ± 0.722.98 ± 0.550.12 ± 0.640.024
Independent samples t-testP = 0.21P = 0.001P = 0.001
Arousal
Intervention2.62 ± 0.973.24 ± 0.620.62 ± 0.430.001
Control2.16 ± 0.502.40 ± 0.620.24 ± 0.490.004
Independent samples t-testP = 0.009P = 0.001P = 0.001
Lubrication
Intervention3.09 ± 0.943.72 ± 0.620.36 ± 0.560.001
Control2.54 ± 0.732.71 ± 0.560.17 ± 0.470.02
Independent samples t-testP = 0.005P = 0.001P = 0.001
Orgasm
Intervention3.03 ± 0.824.04 ± 0.630.99 ± 0.600.001
Control2.67 ± 0.952.95 ± 0.660.28 ± 0.850.04
Independent samples t-testP = 0.07P = 0.001P = 0.001
Satisfaction
Intervention3.04 ± 0.854.21 ± 0.671.17 ± 0.540.001
Control2.78 ± 1.022.81 ± 0.790.03 ± 0.610.76
Independent samples t-testP =0.22P = 0.001P = 0.001
Pain
Intervention2.78 ± 0.823.94 ± 0.591.16 ± 0.630.001
Control2.61 ± 0.932.92 ± 0.750.13 ± 0.820.02
Independent samples t-testP = 0.39P = 0.001P = 0.001
Total score
Intervention17.65 ± 4.4122.89 ± 3.235.24 ± 2.230.001
Control15.62 ± 3.7916.78 ± 3.161.15 ± 3.130.02
Independent samples t-testP = 0.03P = 0.001P = 0.001

a Values are expressed as mean ± SD unless otherwise indicated.

Table 5. Results of ANCOVA to Compare the Post-Intervention Mean Scores of Sexual Function
Source Sum of SquaresdfMean SquareFSig.Effect SizePower
Pretest 450.421450.4299.290.0010.651
Group 457.921457.92100.940.0010.651
Error 349.29774.53
Total 33029.7080

### 5. Discussion

The data in this study showed that the sexual health promotion training program had a positive and significant effect on the overall sexual function of the pregnant women with GDM, so that sexual function and its domains were significantly improved after the intervention in the intervention group compared to the control group. To demonstrate the effectiveness of sexual health education on the promotion of sexual function, especially in pregnant women with diabetes, Mansouri et al. (2020) examined the effect of sexual health education based on the health belief model and Pender’s health promotion model on the sexual performance of women with type 2 diabetes and found that the use of both training models can significantly improve all aspects of sexual function in diabetic women, and there was no significant difference between the two groups. However, the health belief model was significantly more efficient than Pender’s health promotion model in terms of psychological stimulation (27). Nezamnia et al. (2020) examined the effectiveness of cognitive-behavioral therapy in sexual function in pregnant women, and showed that this treatment was effective in improving all domains of female sexual function two and four weeks after the psychological intervention (28). These findings are consistent with the results of the present study in terms of the impact of intervention techniques on all aspects of sexual function, while the training and intervention techniques in the two studies were slightly different.

Marvi et al. (2019) examined the effect of sexual health model training on the sexual function of women with infertility and showed that sexual health training had a significant effect on improving sexual function, including desire, lubrication, arousal, and orgasm in infertile women with serious psychological problems (29). Esposito et al. (2004) examined the effect of lifestyle change on sexual function in obese men with erectile dysfunction and found that using a healthy lifestyle improves sexual function in these men (30). Following the findings of the present study, these studies showed that psychological training of any kind can have positive and significant changes in improving the quality of sexual life of patients (31). Given that healthy lifestyle education can promote various aspects of mental health and sexual function in women of reproductive ages, sexual function can be improved with effective and standard training interventions (32).

The results of the present study showed that in addition to the group receiving sexual health promotion training, the participants in the control group who received no training intervention reported significant changes in their sexual function, especially in the domains of arousal, lubrication, orgasm, and pain. Perhaps factors such as receiving routine training and care during pregnancy from comprehensive health centers, possible visits to the doctor for GDM, and pregnancy progression changed the sexual function of the women in the control group.

Hashem et al. (2020) studied the effect of sexual health promotion training programs on the sexual function of pregnant women and found that implementing such training programs can significantly improve the sexual function of pregnant women. It was also shown that the sexual function of pregnant women was significantly different in each trimester (33). These findings provided empirical support for the results of the present study indicating the significant improvement in sexual function of pregnant women with increasing gestational age. However, Davari-Tanha et al. (2020) examined female sexual dysfunction in each trimester and showed that the difference in sexual function in the second trimester was less than in the first and third trimesters (34). Hajnasiri et al. also showed that increasing gestational age from the first trimester to the third trimester caused a gradual increase in sexual dysfunction in each trimester compared to the previous trimester (35). The results of these studies were not in line with the present study. Perhaps the reason for this discrepancy was that the intervention in the present study began during the first trimester of pregnancy.

According to the findings of previous studies and the present study, it can be concluded that education in women at risk of decreased sexual function, especially women with GDM, can enhance all domains of sexual function, and ultimately improve the quality of life in these women. However, despite the prohibition of discussing sexual issues in some cultures, including the Iranian community, various studies have shown that sex education is effective and sexual issues are influenced by any direct or indirect education.

Some of the limitations of this study included difficulty in talking about sexual issues and problems due to cultural norms of Iranian society, the impossibility of men’s participation in the training program, impossibility of forming larger training groups due to the COVID-19 outbreak, and not examining the retention effects of the training program in the postpartum period.

#### 5.1. Conclusion

The results of present study showed that the sexual health promotion training program promoted overall sexual function and its domains in pregnant women with GDM. Given the effectiveness of this training intervention, it is suggested that the sexual health promotion program developed in this study be integrated into pregnancy care programs for women with GDM to increase the health and well-being of this group of vulnerable women.

### References

• 1.

Ravangard R, Basiri A, Sajjadnia Z, Shokrpour N. Comparison of the effects of using physiological methods and accompanying a doula in deliveries on nulliparous women's anxiety and pain: A case study in Iran. Health Care Manag (Frederick). 2017;36(4):372-9. doi: 10.1097/HCM.0000000000000188. [PubMed: 28961642].

• 2.

Bhatia P, Chhabra S. Physiological and anatomical changes of pregnancy: Implications for anaesthesia. Indian J Anaesth. 2018;62(9):651-7. doi: 10.4103/ija.IJA_458_18. [PubMed: 30237589]. [PubMed Central: PMC6144551].

• 3.

Panicker VV, Riyaz N, Balachandran PK. A clinical study of cutaneous changes in pregnancy. J Epidemiol Glob Health. 2017;7(1):63-70. doi: 10.1016/j.jegh.2016.10.002. [PubMed: 27870929]. [PubMed Central: PMC7320517].

• 4.

Napso T, Yong HEJ, Lopez-Tello J, Sferruzzi-Perri AN. The role of placental hormones in mediating maternal adaptations to support pregnancy and lactation. Front Physiol. 2018;9:1091. doi: 10.3389/fphys.2018.01091. [PubMed: 30174608]. [PubMed Central: PMC6108594].

• 5.

McIntyre HD, Catalano P, Zhang C, Desoye G, Mathiesen ER, Damm P. Gestational diabetes mellitus. Nat Rev Dis Primers. 2019;5(1):47. doi: 10.1038/s41572-019-0098-8. [PubMed: 31296866].

• 6.

Mirghani Dirar AH, Doupis J. Gestational diabetes from A to Z. World J Diabetes. 2017;8(12):489-511. doi: 10.4239/wjd.v8.i12.489.

• 7.

National Center for Health Statistics; Center For Disease Control And Preventio. Health, United States, 2016: With chartbook on long-term trends in health. Maryland, USA: Government Printing Office; 2017.

• 8.

Guarino E, Delli Poggi C, Grieco GE, Cenci V, Ceccarelli E, Crisci I, et al. Circulating microRNAs as biomarkers of gestational diabetes mellitus: Updates and perspectives. Int J Endocrinol. 2018;2018:6380463. doi: 10.1155/2018/6380463. [PubMed: 29849620]. [PubMed Central: PMC5924999].

• 9.

Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH. The pathophysiology of gestational diabetes mellitus. Int J Mol Sci. 2018;19(11). doi: 10.3390/ijms19113342. [PubMed: 30373146]. [PubMed Central: PMC6274679].

• 10.

Coustan DR. Diagnosis of gestational diabetes. In: Rajendram R, Preedy VR, Patel VB, editors. Nutrition and diet in maternal diabetes. New Jersey, USA: Humana Press, Cham; 2018. p. 17-28. doi: 10.1007/978-3-319-56440-1_2.

• 11.

Elshahidi MH. Outdoor air pollution and gestational diabetes mellitus: A systematic review and meta-analysis. Iran J Public Health. 2019;48(1):9-19. [PubMed: 30847307]. [PubMed Central: PMC6401584].

• 12.

O'Neill K, Alexander J, Azuma R, Xiao R, Snyder NW, Mesaros CA, et al. Gestational diabetes alters the metabolomic profile in 2nd trimester amniotic fluid in a sex-specific manner. Int J Mol Sci. 2018;19(9). doi: 10.3390/ijms19092696. [PubMed: 30201937]. [PubMed Central: PMC6165183].

• 13.

Kizilay F, Gali HE, Serefoglu EC. Diabetes and sexuality. Sex Med Rev. 2017;5(1):45-51. doi: 10.1016/j.sxmr.2016.07.002. [PubMed: 27544297].

• 14.

Lue TF, Brant WO, Shindel A, Bella AJ. Sexual dysfunction in diabetes. Endotext. Massachusetts, USA: MDText.com Inc; 2017.

• 15.

Tabatabaeichehr M, Mortazavi H, Abadi MH, Moayed L. Sexual desire and related factors in middle-aged and elderly married women: A cross-sectional study in Iran. Open Access Maced J Med Sci. 2018;6(10):1906-11. doi: 10.3889/oamjms.2018.383. [PubMed: 30455772]. [PubMed Central: PMC6236044].

• 16.

Mohamadsadegh A, Kalantarkosheh M, Naeimi E. [The experience of sexual problems in women seeking divorce and women satisfied with their marriage: A qualitative study]. Journal of Qualitative Research in Health Sciences. 2020;7(1):35-47. Persian.

• 17.

Avasthi A, Grover S, Sathyanarayana Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry. 2017;59(Suppl 1):S91-S115. doi: 10.4103/0019-5545.196977. [PubMed: 28216788]. [PubMed Central: PMC5310110].

• 18.

Rochester-Eyeguokan C, Meade L. A practical approach to managing hypoactive sexual desire disorder in women with diabetes. Diabetes Ther. 2017;8(5):991-8. doi: 10.1007/s13300-017-0313-0.

• 19.

Loeser C, Pini B, Crowley V. Disability and sexuality: Desires and pleasures. Sexualities. 2017;21(3):255-70. doi: 10.1177/1363460716688682.

• 20.

Khorshidifard M, Amini M, Dehghani MR, Zaree N, Pishva N, Zarifsanaiey N. Assessment of breastfeeding education by face to face and small-group education methods in mothers’ self-efficacy in Kazeroun health centers in 2015. Women’s Health Bulletin. 2017;4(3):1-6.

• 21.

Jafari A, Peyman N. [Application of theories/models of health education and promotion in Health Literacy research: A systematic review]. J Health Lit. 2018;3(2):124-36. Persian.

• 22.

Khodaveisi M, Omidi A, Farokhi S, Soltanian AR. The effect of pender's health promotion model in improving the nutritional behavior of overweight and obese women. Int J Community Based Nurs Midwifery. 2017;5(2):165-74. [PubMed: 28409170]. [PubMed Central: PMC5385239].

• 23.

Griebler U, Rojatz D, Simovska V, Forster R. Effects of student participation in school health promotion: A systematic review. Health Promot Int. 2017;32(2):195-206. doi: 10.1093/heapro/dat090. [PubMed: 24395957].

• 24.

Moradi M, Geranmayeh M, Mirmohammadali M, Mehran A. [The effect of sexual counseling on sexual function in women with type 2 diabetes mellitus]. Journal of Hayat. 2016;22(2):148-58.

• 25.

Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208. doi: 10.1080/009262300278597. [PubMed: 10782451].

• 26.

Mohammadi K, Heydari M, Faghihzadeh S. The female sexual function index (FSFI): Validation of the Iranian version. Payesh. 2008;7(3):269-78.

• 27.

Mansouri A, Shahramian I, Salehi H, Kord N, Khosravi F, Heidari MA. Effect of sexual health education based on health belief and pender health promotion models on the sexual function of females with type II diabetes. J Diabetes Nurs. 2020;8(1):992-1001.

• 28.

Nezamnia M, Iravani M, Bargard MS, Latify M. Effectiveness of cognitive-behavioral therapy on sexual function and sexual self-efficacy in pregnant women: An RCT. Int J Reprod Biomed. 2020;18(8):625-36. doi: 10.18502/ijrm.v13i8.7504. [PubMed: 32923929]. [PubMed Central: PMC7457155].

• 29.

Marvi N, Golmakani N, Miri HH, Esmaily H. The effect of sexual education based on sexual health model on the sexual function of women with infertility. Iran J Nurs Midwifery Res. 2019;24(6):444-50. doi: 10.4103/ijnmr.IJNMR_199_17. [PubMed: 31772919]. [PubMed Central: PMC6875883].

• 30.

Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D'Andrea F, et al. Effect of lifestyle changes on erectile dysfunction in obese men: A randomized controlled trial. JAMA. 2004;291(24):2978-84. doi: 10.1001/jama.291.24.2978. [PubMed: 15213209].

• 31.

Moshfeghy Z, Tahari S, Janghorban R, Najib FS, Mani A, Sayadi M. Association of sexual function and psychological symptoms including depression, anxiety and stress in women with recurrent vulvovaginal candidiasis. J Turk Ger Gynecol Assoc. 2020;21(2):90-6. doi: 10.4274/jtgga.galenos.2019.2019.0077. [PubMed: 31640303]. [PubMed Central: PMC7294830].

• 32.

Barati M, Soltanian A, Emdadi S, Zahiri B, Barzeghar N. Analyzing sexual health-related beliefs among couples in marriage based on the health belief model. J Educ Community Health. 2014;1(1):36-45. doi: 10.20286/jech-010136.

• 33.

Hashem S, Fatouh E, Ghonemy G. Effect of sexual health educational program on enhancing female sexual function during pregnancy. Am J Nurs Sci. 2020;8(6):588-95.

• 34.

Davari-Tanha F, A'Lam Z R, Shirazi M, Askari F, Ghajarzadeh M. Comparison of sexual function in pregnant women with different gestational age. Maedica (Bucur). 2020;15(3):335-8. doi: 10.26574/maedica.2020.15.3.335. [PubMed: 33312249]. [PubMed Central: PMC7726517].

• 35.

Safaralinezhad A, Hajnasiri H, Moafi F, Nami M. Sexual dysfunction and its related factors among pregnant women referred to health centers in Qazvin, Iran. J Health Soc Behav. 2020;3(1):27-34. doi: 10.4103/shb.shb_5_20.

• Copyright © 2021, Medical - Surgical Nursing Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.