The effect of mobile app-based self-care training on the quality of marital relations and the severity of menopausal symptoms in postmenopausal women: a clinical trial study in Iran

Menopause is a biological stage in a woman's life that is diagnosed after 12 months of permanent cessation of menstruation [1]. Menopause usually occurs between the ages of 45 and 55 and is known as a transition from one stage to another in a woman's life [2]. During this period, most women experience different changes [3]. These changes can be social, physical, and psychological [4]. Most postmenopausal women face common issues such as hot flashes, headaches, mental and physical exhaustion, sleep problems, mood changes (anxiety, depression, irritability, and stress), joint and muscle pain, osteoporosis, heart disease, bladder problems, and sexual problems [5, 6]. Some women may experience one or two mild symptoms while others may have more severe and distressing symptoms [7]. Studies have shown that hot flashes and night sweats are the main symptoms, and approximately 75% of women experience vasomotor symptoms (VMS) around the time of menopause [8]. Moderate and severe VMS causes a decrease in mood, productivity, and concentration and can significantly affect the quality of life of women [9].

Nowadays, quality of life is accepted as a multidimensional concept [10]. The quality of marital relations, which may be disturbed during menopause, is one of the dimensions of quality of life [11]. The quality of marital relations includes various dimensions of a couple's relationship, such as sexual relations, compatibility, happiness, life satisfaction, cohesion, and commitment [12‐14]. Sexual relations are among the most important aspects of marital relations that are affected during menopause [3]. One of the problems faced by women during this period is pelvic floor muscle relaxation, vaginal dryness, urinary problems, painful intercourse, sexual dysfunction, and, consequently, sexual dissatisfaction [15]. These changes, however, can be adjusted and controlled using interventions such as education and technology-based interventions, leading to an improvement in sexual performance [5, 16, 17].

Studies have shown that due to the lack of knowledge about menopause, awareness-raising and provision of knowledge to women are necessary [18]. Since women spend on average one-third of their lives in the postmenopausal period, it is very important to pay attention to their health status during this period [19]. Nurses and midwives are considered vital components of the health care team since the nature of their everyday work is such that it provides an opportunity to encourage and influence postmenopausal women to acquire correct self-care behaviors [20, 21]. Educational interventions to teach the correct principles of self-care are a necessary solution to improve health and help postmenopausal women better cope with menopause problems and personal disabilities and increase self-efficacy [14]. Like increasing awareness and modifying lifestyle, self-care can also help solve health-related problems [6]. According to the Orem model, self-care is a learned behavior that can meet the numerous needs of patients during diseases or once health deviations occur. According to this theory, humans can take care of themselves, and when this ability is compromised, the caregiver can enable them to recover their self-care ability by providing direct and compensatory care or educational-supportive care [22]. Therefore, the necessity of improving self-care ability through education is undeniable [23].

In today's world, many aspects of daily life have changed due to the integration of information and communication technology. In this regard, the use of modern methods, such as self-care training through applications, has received better reception due to its ease of use and time effectiveness [24]. On the other hand, postmenopausal women are among the fastest-growing population groups in the world, and virtual interventions have been welcomed as alternative ways for postmenopausal women to manage and cope with their symptoms [25]. The development of the mobile health (mHealth) platform to support women going through menopause is increasing around the world [7]; previous studies have confirmed the impact of mhealth on self-efficacy, quality of life, the severity of menopausal symptoms, and physical symptoms [25‐28]. Therefore, it seems very necessary to design mHealth-based programs in the national language to manage the symptoms of postmenopausal women. Despite the great importance of the topic, as far as we know, no published data has been conducted to investigate the effect of menopausal self-care training through an application on the quality of marital relationships and the severity of menopausal symptoms of postmenopausal women in Iran. Therefore, this study hypothesized that mobile app-based self-care training improves the quality of marital relations and declines the severity of menopausal symptoms in postmenopausal women. We hope that the results of this study can take a useful and constructive step towards improving the self-care behaviors of postmenopausal women in Iran and other parts of the world.

The average age of the women was 53.57 ± 3.41 and 53.93 ± 3.45 in the intervention and control groups respectively. The education level of most of the participants, 48 subjects (80%), was a high school diploma or lower. Twenty-three subjects (38.3%) were homemakers, and 40 subjects (66.6%) had an average or higher income. All research subjects had a husband and lived with their husband at the time of the study. Other demographic variables are reported in Table 1. According to the results of the independent t-test, there was no significant difference between the intervention and control groups in terms of average age, number of pregnancies, number of childbirths, and number of abortions (P > 0.05). According to the results of the chi-square test, no statistically significant difference was observed between the intervention and control groups in terms of occupation, income, and education level (P > 0.05) (Table 1).

The results showed that the mean score of the severity of menopause symptoms for the intervention group in the post-intervention stage was 30.27 ± 6.09, which was lower than the mean score of the control group 39.10 ± 3.71. The mean score of the severity of menopause symptoms in the post-intervention stage of the intervention group was 30.27 ± 6.09, which was lower than the pre-intervention mean score, of 36.63 ± 5.27.

The mean score of the quality of marital relations in the post-intervention stage for the intervention group was 82.90 ± 16.06, which was higher than the mean score for the control group, 71.20 ± 16.16. The mean score of the quality of marital relations in the post-intervention stage for the intervention group was 82.90 ± 16.06, which was higher than the pre-intervention mean score, 76.87 ± 15.68 (Table 2).

The results of the difference test between groups using covariance analysis showed that the use of the menopausal self-care application had a significant effect on the severity of menopausal symptoms of menopausal women and the quality of their marital relationships (P < 0.001) (Table 3).

According to the results of the Bonferroni test (Table 4), the difference in the mean score of the intensity of menopausal symptoms (intervention/control) was positive, so the mean score of the intensity of menopausal symptoms for the intervention group was significantly lower than that of the control group (P < 0.01). Therefore, the use of the self-care application during menopause reduced the severity of menopausal symptoms in menopausal women. The Bonferroni test results also showed that the difference in the mean scores of marital relationship quality (intervention/control) was negative, so the mean score of the quality of marital relationships of the intervention group was significantly higher than that of the control group (P < 0.01). Therefore, the use of the menopause self-care application improved the quality of marital relationships of menopausal women.

The results of the present study showed that the use of the self-care mobile app for eight weeks reduced the symptoms of menopause in the intervention group compared to the control group. This result is in line with the results of previous studies. For example, Park et al. (2022) [39] showed that the use of a mobile self-care program reduced menopausal symptoms and improved the self-efficacy and quality of life of women who underwent menopause following chemotherapy. The results of a study by Eun-Ok et al. (2017) [27] also showed that a web-based program to promote physical activity reduced menopausal symptoms in women. In another study, it was reported that lifestyle management training through Facebook improved the quality of life and health habits, sleep quality, and physical activity pattern of postmenopausal women [40]. Another study in Iran confirmed the effect of virtual programs on improving the quality of life, vasomotor symptoms, and physical and sexual aspects of women [26]. Although Eun-Ok et al. (2017) [27] believe that these effects may be influenced by the Hawthorn effect, other studies that reported the improving effect of mHeath and virtual programs on objective outcomes, such as waist circumference, weight, blood pressure, serum lipid levels and pain [25, 28], indicate that the effect of mHeath on health-related outcomes is more real than can be justified by the Hawthorn phenomenon.

The results of the present study also showed that the use of a self-care mobile app for eight weeks in postmenopausal women improved the quality of marital relationships of postmenopausal women in the intervention group compared to the control group. The results of the study by Kashfi et al. (2021) [26] showed that an educational program on the WhatsApp platform improved the quality of life of postmenopausal women. However, a review study reported that the results of studies on the effect of virtual programs on sexual performance were contradictory [25]. Therefore, it is suggested that studies with a large sample size be repeated so that the impact of mhealth interventions on sexual performance and the quality of marital relationships can be assessed with more certainty. The use of self-care and self-management methods may directly improve the symptoms related to the genital tract after menopause (such as vaginal dryness) or indirectly improve marital relations by reducing the severity of menopause symptoms. The severity of menopause symptoms has a direct relationship with the quality of marital relations [14].

Women spend more than one-third of their lives after menopause [19], and the severity of menopause symptoms and the quality of marital relationships affect the quality of life of their lives [14]. Therefore, they must be empowered for self-care. Since today the development of mHeath platforms to support women during menopause is increasing worldwide and women express their desire to use mobile apps to manage their menopause symptoms [7], researchers and health workers should pay attention to the design of self-care apps for postmenopausal women in the national language of each country. Given that mobile applications are attractive to people, including postmenopausal women, due to their affordability, usability at any time and place, and high quality, they can provide an opportunity for teaching self-care and implementing support programs in an innovative, efficient, and cost-effective way.

Failure to control the Hawthorne effect, inability to generalize the results to other communities and not measuring the durability of the results in the long term were the limitations of this research. The data were also collected in the form of self-report, which means that the researcher was unable to confirm their accuracy and had to trust the accuracy of the statements of the individuals. It is suggested that future research be conducted using other platforms of virtual education, for different populations and longer follow-up periods and to determine its real long-term effect.

The results showed that the implementation of the self-care training program using the mobile-based application helped improve the quality of marital relationships and reduce the severity of menopausal symptoms of menopausal women; therefore, implementing this training method along with routine care may be effective for postmenopausal women who cannot participate in face-to-face training sessions due to physical problems, distance, cost, etc.