The effectiveness of Pythagorean self-awareness intervention in improving the quality of sexual life of women with multiple sclerosis

Background and aims: The present study aimed to determine the effectiveness of Pythagorean self-awareness intervention in improving the quality of sexual life of women with multiple sclerosis (MS). Methods: In this quasi-experimental study, among women with MS in Isfahan province who had medical records in Ayatollah Kashani Hospital and Isfahan MS Center, 150 female patients were enrolled by convenience sampling and screened by Sexual Quality of Life-Female (SQOL-F). After screening, 46 patients, whose quality of sexual life score was lower than the mean score of 63, were randomly assigned to experimental and control groups, each comprising 23 patients. The experimental group received the Pythagorean self-awareness intervention, while the control group received no intervention. Both groups were assessed at pre-test, post-test, and two follow-up stages. The data were analyzed by multivariate analysis of covariance (MANCOVA). Results: The results revealed that the quality of sexual life of the experimental group improved after the intervention ( P < 0.001). Compared to the pre-test, a significant difference was observed in its components, namely, psychosexual feelings, sexual and relationship satisfaction, self-worthlessness, and sexual repression ( P < 0.001). Conclusion: It seems that Pythagorean self-awareness intervention effectively improves the quality of sexual life of women with MS. In addition to the overall improvement in the quality of sexual life, a significant difference was observed in its components compared to the pre-test after the intervention. Therefore, it is essential to plan psychological interventions to improve these women’s quality of sexual life.


Introduction
Multiple sclerosis (MS) is a chronic and progressive disease that causes the demyelination of the central nervous system (1); it often occurs in people aged 18-50 years who are sexually active (2) and is identified by symptoms such as movement, sensory, and sexual dysfunctions (3). Research has shown that physiological and psychological factors influence sexual function, and sometimes the interaction of these two factors (4). Sexual dysfunction is highly prevalent in women with MS and affects various aspects of quality of life (5). Despite the importance of sexual function, its dysfunction has received less attention in women (6,7). Healthy sexual function in women influences feeling healthy and improves their quality of life (8). In contrast, sexual dysfunction can negatively affect mood, relationships, daily functioning, and quality of life (9). Previous research demonstrated that various factors reduce the quality of life of patients with MS, among which sexual dysfunction causes extensive stress in their marital relationship (10,11). The quality of sexual life can be defined as how individuals evaluate their sexual relationship and their response to this evaluation (12,13).
It is noteworthy that sexual dysfunction affects the quality of sexual relations (14).
The women's sexual quality of life includes psychosexual feelings, sexual and relationship satisfaction, selfworthlessness, and sexual repression (15). Psychosexual feelings reflect women's feelings about sexual experiences, and sexual and relationship satisfaction denote the concept of the quantity and quality of sexual relationships and positive feelings about themselves and interpersonal relationships such as intimacy with their spouses. Negative emotions, including feelings of loss of femininity and guilt, signify the dimension of worthlessness in women's sexual life. The last dimension of quality of sexual life (i.e., sexual repression) includes embarrassment and abstinence from sexual activity, along with the loss of pleasure (15).
Sexual dysfunction causes complications such as frustration, disappointment, anger, and increased depression, decreasing the women's quality of life. In addition, psychological aspects are developed for the individual as a partner (16)(17)(18). Sexual function is one of the main areas of marital relationships whose dysfunction causes doubts about the love and affection of couples towards each other, increases their concern about the continuity of the relationship, and ultimately marital conflicts (19).
It seems that physical health is one of the factors affecting the quality of life, especially that of sexual life. Physical health includes knowledge-based information about health and responsibility for maintaining health and treatment. It requires practicing to reduce stress responses in the body, self-care, a healthy lifestyle, proper diet, exercise, and healthy communication with the body through the mindful enjoyment of sensory pleasures (20). Individuals with MS can enhance their well-being through diet, exercise, mindfulness, adherence to MS treatment to improve their interpersonal relationships, and the use of stress and depression management techniques (21,22).
In addition, research results demonstrated that Kegel exercises improve women's sexual function (23,24), and some studies have also reported the effectiveness of yoga on sexual function and sexual satisfaction of women with MS (25,26). However, several studies revealed that physical health improved through diet, exercise, and a healthy lifestyle, and coping strategies could reduce depression and fatigue in these patients, increase their quality of life, and indirectly enhance the quality of their sexual life (22,24,25). Therefore, the research gap is highly felt in this regard. Furthermore, from the psychological perspective, sexual dysfunction in women with MS causes mood swings and feelings of unattractiveness and changes their marital relationships and fear of sexual rejection (4).
In general, the novelty of this study lies in attempting to improve the quality of sexual life of women with MS, and the Pythagorean self-awareness intervention was used for this purpose. Thus, the question posed in this regard is whether the Pythagorean self-awareness intervention improves the quality of sexual life of women with MS.

Participants
The statistical population of the present study comprised all women with MS in Isfahan province who had a medical record in the Isfahan MS center from 2020 to 2021, of whom 150 cases were screened by convenience sampling using Sexual Quality of Life-Female (SQOL-F) with the mean score of 63. Then, 46 of these patients whose SQOL-F score was lower than the mean were randomly divided into experimental and control groups. The inclusion criteria were being in the age range of 19-45, having a sexual partner, showing consent to participate in the study, having no mental disorders and chronic physical illnesses other than MS that affect the mood and insights of patients, and having a minimum literacy (junior high school). On the other hand, the exclusion criteria were the absence of more than two sessions during the intervention, pregnancy, divorce or separation from the spouse, recurrence of the disease, lack of doing the assignments, and unwillingness to continue the intervention.

Instrument
SQOL-F: It is a self-report measure to assess the effect of sexual dysfunction on women's quality of sexual life and includes 18 items, and its sub-scales are psychosexual feelings, sexual and relationship satisfaction, selfworthlessness, and sexual repression (27). The total score is in the range of 18-108 or 0-90, whose higher scores indicate a better sexual quality of life (27). SQOL-F was validated in Iran by Roshan Chesli et al (28); its Cronbach's alpha reliability coefficient was 0.93, and the split-half reliability of its sub-scales ranged between 0.86 and 0.93. Regarding the content validity rate (CVR) and content validity index of the questionnaire, Roshan Chesli et al (28) inquired experts' ideas and their judgment of factor loadings and their relevance. The CVR obtained in their study was 0.89, and all items were identified as relevant by judges.

Procedure
The Pythagorean group intervention, which was developed by Darviri et al (1) and included eight onehour sessions, was used to enhance physical health and subsequently improve the quality of sexual life of women with MS. Both groups were assessed by pre-test, posttest, and two follow-up phases. It is noteworthy that the control group received the same intervention at the end of the study. Informed consent was obtained from the participants before conducting the study. The description of the intervention sessions is provided in Table 1. The data were analyzed by multivariate analysis of covariance (MANCOVA), and the assumptions were checked before conducting the analysis.

Results
MANCOVA was used to determine the effectiveness of Pythagorean self-awareness intervention in improving the components of quality of sexual life (i.e., psychosexual Table 1

Intervention sessions
1. Healthy lifestyle cognitive education (related to smoking, diet, exercise, and sleep), stress management, and self-efficacy 2. Diaphragmatic breathing exercises with the help of biofeedback, as well as tips on diet, exercise, and sleep 3. Evaluation sessions and group discussions on practical topics or ideas that may have arisen in recent days 4. Five minutes of diaphragmatic breathing a day 5. Training on memory 6. Lecture on lifestyle 7. Lecture on interpersonal relationships 8. Final evaluations feelings, sexual and relationship satisfaction, selfworthlessness, and sexual repression) of women with MS. Table 2 presents the descriptive statistics of both groups' pre-test, post-test, and follow-up scores of sexual quality of life components. Table 2 lists the descriptive statistics of the two groups in the pre-test, post-test, and follow-up stages. According to the results, the two groups differed in the post-test and follow-up stages, whose significance was checked by inferential statistics. After checking the assumptions, MANCOVA was performed on post-test and follow-up scores by controlling pre-test scores. The results of this analysis are summarized in Tables 3 and 4.   Table 3 reveals a significant difference between the experimental and control groups in at least one of the dependent variables (F = 11.6, P < 0.001). The one-way analysis of covariance was used to find the difference ( Table 4).
As shown in Table 4, the one-way analysis of covariance is significant for all components. The test power also indicates the adequacy of the sample size. The pairwise comparison was employed to find the difference between the means of the experimental and control groups (Table 5).
Based on data in Table 5, the experimental group scored higher in all components of quality of sexual life in the post-test, first, and second follow-up stages. Overall, these  findings confirmed the effectiveness of this intervention in improving the components and the total score of the quality of sexual life.

Discussion
The present study sought to determine the effectiveness of Pythagorean self-awareness intervention in improving the components of the quality of sexual life of women with MS. The results revealed the effectiveness of this intervention. It should be noted that after this intervention, a significant difference was observed in its components compared to the pre-test, in addition to the overall improvement in the quality of sexual life. Although no similar study was found in this regard, the findings are somewhat consistent with those of Najafidoulatabad et al (25) Charalampopoulou et al (32) stated that sexual dysfunction is one of the concerns of breast cancer patients. They concluded that Pythagorean self-awareness intervention improved all aspects of the quality of life, including physical, emotional, and functional aspects, and reduced breast cancer patients' concerns. Sexual dysfunction in women with MS causes negative mood swings, less interaction with a partner, feelings of unattractiveness, guilt, and fear of sexual rejection, and the components of the quality of sexual life (i.e., self-blame and sexual repression) increase, leading to a decrease in the quality of sexual life.
Furthermore, Darviri et al (1) reported that Pythagorean self-awareness intervention had beneficial effects on the physical, mental, and psychological well-being of patients with MS. In explaining these results, it can be stated that the physical and psychological well-being of patients with MS can improve their sexual function and thus the quality of their sexual life. This improves the patients' mood and their relationship with their partners resulting in a reduction in self-blame and sexual repression while an increase in the quality of sexual life.
Health is a lifelong process that makes individuals aware of themselves and their feelings, and they feel best by adopting positive behaviors and a healthy lifestyle. Therefore, the patient with MS can be on the health path by attending to the body and mind, promoting health through proper diet, exercise, and specific therapies, strengthening interpersonal relationships, and using mental and emotional techniques when faced with anxiety and depression (22).
Similarly, the Pythagorean self-awareness intervention was used in this study, whose constructs (i.e., proper diet, exercise, improving interpersonal relationships, and stresscoping techniques) are consistent with ways to promote health from the perspective of the National Association of MS. Exercise is one of the constructs of this intervention. Physical activity is recommended for patients with MS because there is ample evidence that physical activity improves muscle function, aerobic fitness, and mobility. Meta-analysis and systematic studies have shown that individuals with MS who engage in exercise and lifestyle activities (including physical activities) experience an improvement in quality of life (34)(35)(36), and exercise could enhance their quality of life (37). Citak et al (23) found that Kegel exercises positively influenced women's sexual function. Likewise, Najafidoulatabad et al (25) reported the beneficial effects of yoga on sexual function, and as a result, sexual satisfaction. Similarly, Sadeghi Bahmani et al (33) acknowledged that water sports could improve the sexual performance of women with MS.
From the psychological perspective, sexual dysfunction in women with MS causes negative mood swings, less attractiveness, changes in gender roles and patterns, difficulties in communicating with a partner, feelings of guilt, fear of rejection, or abandonment of sex (38). Therefore, these negative feelings can lead to the avoidance of sexual activity or sexual repression by creating a feeling of inadequacy and worthlessness, reducing the quality of sexual life. Previous studies revealed that exercising effectively reduced depression (39) and improved the quality of life of women with MS (40,41). It could also reduce the symptoms of fatigue (42), thus sexual desire increases with mood improvement, improving the quality of sexual life. Some researchers also studied the effect of nutrition on sexual function. Esposito et al (29) suggested that the Mediterranean diet might improve the sexual function of women with metabolic syndrome. Further, in adults with type 2 diabetes, the Mediterranean diet might alleviate the inflammatory problems and cardiovascular risk (43) and thereby improve the sexual function of patients with diabetes (29). The World Health Organization (44) stated that the quality of sexual life reflects the health status and quality of life of individuals in society. Furthermore, these two concepts have a close relationship. Therefore, it can be acknowledged that improving the quality of life can also improve the quality of sexual life.
The patients were often reluctant to answer or felt embarrassed to respond to the questions. Other limitations were the existence of uncontrolled variables in conducting the research and the use of self-report measures compared to the experimental settings. Furthermore, the data collection phase of this study coincided with the COVID-19 pandemic. Hence, obtaining permission from the medical sciences centers and the MS Association of Isfahan province was not an easy task. Due to the lower level of immunity of these patients compared to healthy individuals, these patients experienced additional stress, and the researcher helped reduce stress as much as possible with relaxation techniques. Given that this study was conducted on married women with MS in Isfahan province, caution should be exercised in generalizing the results of the present study to other regions and cities. Moreover, the participants were selected by the convenience sampling method. Last but not least, this study was performed only on women with MS and its results cannot be used to improve the quality of sexual life of male patients.

Conclusion
The results demonstrated that this intervention improved the quality of their sexual life. Based on the findings, the quality of sexual life and its dimensions, namely, sexual psychological feeling, sexual-communication satisfaction, self-worthlessness, and sexual repression improved in women with MS after the Pythagorean self-awareness intervention. Therefore sexual education and counseling should be considered one of the major healthcare issues for women with MS since it plays an important role in improving the quality of their sexual life.