Introduction

Menopause is a stage of women's life that marks the transition from reproductive ability to infertility. Menopause means the permanent cessation of menstruation at the end of the fertile period, which occurs due to the inactivity of ovarian. The average age of menopause is reported to be 51 years old (1). With the increase in life expectancy, more than a third of women's lives pass after menopause (2). The transition from the fertile period to the infertile period is associated with many physical and psychological symptoms (3,4). The connection between body and mind is so great that studies have shown that postmenopausal women have high levels of mental health complaints such as depression, anxiety, stress, fatigue, delays in performing daily activities and sleep disturbance (5). On this basis, mood changes, especially the emergence of anxiety, depression, stress, as well as the decline in the quality of life during the transition of menopause can be one of the most important intervention goals of psychologists and health providers As a result, this phase of women's life is called the "vulnerability window" during which physical and emotional changes can reduce the quality of women's lives (6).

Lifestyle is one of the factors influencing the severity of symptoms and problems related to menopause. A health-promoting lifestyle plays a role in disease prevention and control. Health-promoting behaviors include six areas of nutrition, physical activity, stress control, spiritual growth, improving interpersonal relationships, and responsibility for health (7). Modifying the lifestyle is necessary to improve the quality of physical and mental performance in middle-aged women. Balancing the lifestyle is the foundation of health management at this age (8).

Findings show that lifestyle modification reduces stress and anxiety, boosts self-esteem and improves sleep. In addition to improving mood disorders, a healthy lifestyle has other benefits such as lowering blood pressure and protecting against heart disease and cancer (9). Along with all the changes associated with menopause, many middle-aged women often face other challenges such as physical illness, death of spouse, caring for family members, marital problems, and children leaving home. All these cases may cause depression and stress in these women, so that many women consider menopause a stressful process which not only affects on the physical health of menopausal women, but also is effective on people's relationships, work performance, feeling of health and quality of their life (10).

When women are at middle-age they face a series of risk factors that predict a higher probability of depression symptoms in the following years of life, and these risk factors include: negative attitude towards aging, negative attitude towards menopause, negative scores of mood. (11). According to research, 60% of the quality of life is related to lifestyle and health behaviors (12). Studies show that postmenopausal women have limited knowledge about a healthy lifestyle. Also, people do not have enough knowledge and skills in managing menopause symptoms and complications, and their lives are affected by its consequences (3,13). For example, Sehati et al. (2015) in a cross-sectional study of health-promoting behaviors among postmenopausal women in Langrod city found that the scores of women's lifestyle were reported to be average and emphasized the need for planning in this field (14).

In this regard, considering the relationship of various personal and social factors with the quality of life and mental health of postmenopausal women, what seems important to improve their quality of life and mental health is an integrated look at their health issues and problems, including health service providers pay attention to issues related to menopause and holding educational and counseling classes in the field of menopause issues with a health promotion approach (15). Therefore, it seems that menopause care is the key to a healthy life in middle age and later years. These cares include education, lifestyle guidance, and evidence-based information for interventions to lead a healthy life (16). Lifestyle-related diseases are a worldwide health concern, and the underlying causes of unhealthy behavior need to be addressed, which can include negative emotional states that may not meet the criteria for diagnosing mental illness, but can perpetuate unhealthy behavior patterns (17).

Positive psychology examines strengths that enable individuals and societies to progress and can play an important role in dealing with diseases related to lifestyle (17). Positive health is one of the methods of positive psychology that brings a longer and healthier life and reduces the risk of disease and related costs. Spreading and implementing positive psychological strategies directly promotes health (18-20).

Positive psychology is a new branch of psychology that was officially founded in 2000 by Professor Martin Seligman, the president of the American Psychological Association (20).

The theory of positivism in positive psychotherapy was first founded by Dr. Seligman regarding well-being. Dr. Seligman categorized happiness and well-being into five scientifically measurable areas of learning: Positive emotions; Engagement; Relationships; Meaning; and Accomplishment. By joining the first letter of each of these five parts, the word (PERMA) is obtained (21). The conducted researches show that the accomplishment of the three dimensions of PERMA (positive emotions, engagement and meaning) has a high correlation with reducing the rate of depression and increasing satisfaction (22-24). Positive psychology focuses on the main clinical issues such as depression, anxiety, eating disorders, suicidal thoughts, and behavioral problems (21). These independent lines of research clearly show the effect of positive psychological therapeutic interventions in reducing symptoms. With the use of focused structures (such as gratitude, hope, kindness, forgiveness), positive psychological therapeutic interventions can be used in active treatment or adjuvant treatment used in a wide range of physical problems such as cardiovascular problems, brain damage, type 2 diabetes and breast cancer (21).

Positive psychotherapy is a therapeutic approach that uses people's abilities, virtues and skills to neutralize and deal with symptoms, weaknesses and deficiencies of people, and thereby helps in understanding complicated situations and experiences in an efficient way (21). Based on this approach, the strategies that help clients to build a pleasant, attractive and meaningful life are called positive interventions (25). Positive psychotherapy exercises will help to achieve individual abilities from multiple perspectives, and then a set of these exercises will help to create something in the individual which is called " practical knowledge"; The purpose of practical knowledge is to help a person deal with challenging situations more efficiently; In other words, when there are different ways to deal with an important challenge, the best way should be chosen (21). Positive psychotherapy teaches how to use our abilities depending on the situation. In fact, in some situations, negative emotions such as sadness and anxiety can be more compatible than positive emotions, especially when a person's survival is at risk. Also, sometimes expressing anger in order to protect one's interests will be much more efficient than expressing satisfaction and agreement (21).

Many researches have been done in support of this psychological approach to improve the quality of life, including the effect of positive psychology on positive relationships and increasing success and well-being and improving depression symptoms (26), control of anger and rumination in married women with marital dissatisfaction (27), its effect on the lifestyle that develops health and self-regulation (28), and reducing depression, stress and increasing happiness in infertile women (29). Positive psychotherapy improves well-being and lifestyle (30).

Positive psychotherapy can also have significant benefits, including emotional well-being and improved quality of life (31). The goal of positive psychology is to increase positive emotions, cognitions and behaviors and empower a person to become better and makes a person able to navigate the inevitable challenges and negative emotions which occur in life (31,32).

The link between lifestyle and positive psychology can improve all the main elements of a healthy lifestyle, including a complete diet, appropriate physical activity levels, adequate and quality sleep, and emotional and overall well-being (33,34). Along with a healthy lifestyle, positive psychology interventions can cause mental and psychological well-being (35). Activities supporting positive psychology can facilitate healthy behaviors and improve physiological health. Adding such activities to clinical care can improve achieving the physical, social and emotional elements of health defined by the World Health Organization, including 1- long life and quality of life 2- reducing care costs 3- reducing the attrition rate of service providers (35).

Women form half of the population of any society and with the increase in life expectancy, more than a third of women's lives pass after menopause. The physical and mental health of women has a direct relationship with functioning of the family, and considering the importance of the role of women in the family and their central emotional and psychological role, reducing the complications and problems of menopause is important for them and has a direct effect on the family and, in turn, on the society. Women's health is an important factor in ensuring the health of the family and society, therefore, efforts to improve their physical and mental health at the level of society can be effective in improving the quality of society's health. Therefore, the present study was conducted with aim to determine the effect of psychological intervention with a positive approach on the health-promoting lifestyle of postmenopausal women, so that its findings can be used to design positive psychological interventions to improve the lifestyle of postmenopausal women.

Materials and Methods

This randomized controlled clinical trial was conducted between 2022 and 2023 on 70 postmenopausal women referred to the comprehensive health centers of Urmia city that were eligible for the research and consented to participate in the study.

This study was registered in the IRCT system with the code IRCT20220710055428N1. The sample size was calculated as 70 samples based on the study of Ensan et al. (2019) with 95% confidence and considering z1-α/2=1.96, z1-ß =0.85 (36).

In order to carry out the sampling, first, a list of all comprehensive health centers in Urmia city was prepared from the city health center, and then it was divided into three levels: rich, partly rich and poor. A comprehensive health center was selected from all three levels using a cluster method. In the next step, from each selected center, eligible postmenopausal women were selected from the SIB system (Family health information recording system) and each was assigned a code from the random number table, and 70 people were randomly included in the study according to the postmenopausal women covered by each center. Then, they were randomly assigned to two intervention and control groups (35 in intervention and 35 in control). To hide random allocation, sequentially numbered, sealed, opaque envelopes (SNOSE) were used, and the people in each group had no communication with the other group. In this way, 35 A cards belonging to the control group and 35 B cards belonging to the intervention group were placed inside sealed opaque envelopes. At the beginning of the study, in the case of inclusion criteria, each person chose one of the envelopes and entered one of the control or intervention groups based on its content.

In this research, the inclusion criteria were: age 45-60 years (at least 12 full months have passed since their last menstruation), no smoking and alcohol consumption, willingness to participate in the study, having a contact number for follow-up, living in cities and villages around Urmia, having literacy, not suffering from mental illnesses that require hospitalization (such as psychosis), and not receiving medication or any treatment for menopausal symptoms. Exclusion criteria include: travel or change of living location during the intervention period, more than two absences in the sessions, and participating in other psychological treatments at the same time. If any person did not meet the criteria for entering the study or did not agree to participate in the study, the next person was replaced.

Walker's Health-Promoting Lifestyle Profile is a tool for multi-dimensional assessment of health-promoting lifestyle. This questionnaire consists of 54 items that are a combination of 2 classes and 6 subclasses, including class 1: health responsibility (8 questions), physical activities (9 questions) and eating habits (10 questions), and class 2: spiritual growth (9 questions), interpersonal communication (10 questions) and stress management (8 questions). Each item is scored on a Likert scale. Each question includes 4 options which are scored as never (1), sometimes (2), often (3) and always (4). The range of the total health promoting lifestyle score is 54 to 216 and a separate score can be calculated for each subscale. So that for the subscale of responsibility for health, the score range is 8 to 32, physical activity is 9 to 36, eating habits is 10 to 40, spiritual growth is 9 to 36, and interpersonal communication is 10 to 40, and for the stress management subscale, the range of scores is 8 to 32. The score of each subscale is obtained from the average scores of the answers given to the questions of the same subscale. The higher score indicates the higher health-promoting lifestyle (37).

The validity and reliability of the Persian version of the health-promoting lifestyle by Mohammadi Zeydi and colleagues, Cronbach's alpha coefficient was obtained for responsibility of health (0.86), for physical activity (0.79), for nutrition (0.81), for spiritual growth (0.64), for interpersonal relationships (0.75), for stress management (0.91), and for the whole questionnaire (0.82). In this study, the content validity of the Persian version of this questionnaire was qualitatively conducted by a panel of experts consisting of a group of experts and specialists in the field of the research topic. The composition of this panel was psychology (n=2), nursing (n=2), health education (n=3), management (n=2), medicine (n=1 person) and nutrition (n=1) (38). Also, in the study of Mohammadi Zeydi et al., exploratory and confirmatory factor analysis was used for construct validity, and the results of confirmatory factor analysis in HPLPII (6 factors) based on the measurement model were obtained as GFI=0.91, CFI=0.96, RMSEA=0.045, AGFI=0.71 and all correlations between items were significant and the range of correlations was from 0.27 to 0.86; and the findings showed that the confirmatory factor analysis based on the 6-factor model obtained from exploratory factor analysis has a good fit with the obtained data and the findings according to a) internal agreement through Cronbach's alpha and item-total correlation, b) the observed pattern of correlations in the tool, c) the results of the exploratory and confirmatory factor analysis in the models extracted from the factor structure of Persian version of HPLPII has positive support (38).

Before conducting the research, demographic characteristics were recorded. After giving the necessary explanations about the objectives and methods of the research to the participants, the questionnaires were completed during the stages before the intervention and then 10 days after the completion of the intervention sessions in the control and intervention groups by researcher.

In the intervention group, 35 women were divided into five groups of seven women and had six sessions of positive psychology, each session lasting 90 minutes, one session per week for a total of six consecutive weeks in comprehensive health centers selected by the researcher, while no intervention was done for the control group and

received routine services

In line with the current research  intervention, the positive psychology course taught by Dr. Martin Seligman from the University of Pennsylvania was completed by the researcher for 20 weeks online, and the documents and certificates of passing the positive psychology courses including: positive psychology, positive psychology and well-being, positive psychology and resilience, applications and interventions of positive psychology and research methods were obtained from the Pennsylvania University by the researcher. The steps of the intervention were so that the researcher, after re-introducing herself and stating the objectives of the meeting, and then getting to know more about the group members, provided information to menopausal women (21).

The summary of intervention sessions of positive psychology is given in Table 1.

Descriptive and analytical statistics were used to analyze the data. Kolmogorov Smirnov test was used to check the normality of data distribution, and independent t and paired t tests, Chi Square, and Mann Whitney were used to compare the data. SPSS16 software was employed for data analysis.

Results

The study invited 70 women to participate and undergo assessment for the inclusion and exclusion criteria. Eventually, the study included 35 women who met the eligibility criteria (Figure 1).

The normality of the data distribution was checked with the Kolmogorov Smirnov test, and only the elapsed time since menopause did not have a normal distribution. More than half of the postmenopausal women in the control group (51.4%) and in the intervention group (80.0%) had diploma and university education. 

In addition, 28.6% of them in the control group and 45.7% in the intervention group were employed. Moreover, 85.7% of the control group and 80.0% of the intervention group lived in their own house and 88.5% of them in control group and 88.6% of intervention group reported the family's income as sufficient and relatively sufficient. Also, 65.7% of their spouses in control group and 80.4% in the intervention group had a diploma or higher education and the occupation of 45.7% in control group and 37.1% in intervention group was reported as an employee. No significant differences were observed between the control and intervention groups in these aspects )Table 2).   

 The average age of women in the control group was 56.31±2.78 and in the intervention group was 54.37±3.33.  Also, the average age at menopause for women in  control group was 50.03±2.82 and in the intervention group was 50.03±2.14. No significant differences were observed between the control and intervention groups in terms of age, age at menopause, and time since menopause (Table 3).

According to the text, there was no significant difference in the variables between the two group.

According to Table 4, the mean of the total scores of health promoting lifestyle dimensions after the intervention was 136.51±22.57 in the control group and 142.00±24.20 in the intervention group.

   Based on the Independent t-test in the dimension of interpersonal communication (P=0.000) before the intervention was significant and in the dimension of health responsibility (P=0.041) after the intervention was significant, but there was no statistically significant difference in other dimensions (P>0.05).

According to Table 5, the results of the independent t-test showed a statistically significant difference in all dimensions of the health-promoting lifestyle score between the intervention and control groups (P˂ 0.05).

Discussion

The present study was performed with aim to determine the effect of positive psychology intervention on health-promoting lifestyle in postmenopausal women referred to the comprehensive health centers of Urmia city. According to the obtained results in the present study, the demographic characteristics of the participants in the intervention and control groups were homogeneous in terms of personal information, economic and social status, and history of menopause, and the increase in the health- promoting lifestyle score and its dimensions in the intervention group compared to the control group can indicate that positive psychology can affect the health-promoting lifestyle of these people.

In 2018, Malik et al. in a study aimed to investigate health-promoting behaviors and menopausal symptoms in menopausal women in rural India showed that the lifestyle modification program significantly reduced menopausal symptoms and improved health-promoting behaviors among postmenopausal women, which is in line with the results of the present study (39). In their study, the mean age of menopause was reported as 47.5 years and the mean age of menopause in the present study was reported as 50.03 years, although there was a difference between their study and the present study, and the age of menopause was slightly higher in the present study but the results were consistent. In a systematic review in 2022 aimed to evaluate the effect of psychological interventions on hot flashes caused by menopause, Samami et al. stated that psychological interventions and especially cognitive behavioral therapy and relaxation techniques potentially affect vasomotor symptoms and hot flashes in postmenopausal women, which is in line with the results of the present study (40-41).

In 2019, Mousavi et al. in a study investigating the effect of health-promoting lifestyle education on the health-promoting behaviors of postmenopausal women stated that health-promoting lifestyle training is effective on the health-promoting behaviors of postmenopausal women (42). In their study, the largest increase was in the dimension of physical activity and the smallest increase in the dimension of health responsibility, which is different from the present study in this aspect. In the current study, the greatest increase was in the dimension of interpersonal communication and the least increase in the dimension of eating habits, which can be due to the fact that the health-promoting lifestyle education has a practical aspect of applying this education, and this is while positive psychology is more focused on changing people's attitudes, and it is better to consider that the increase of positive psychology intervention sessions may have a greater impact on improving the lifestyle of menopausal women.

The results of the current research are consistent with the results of Endicott et al. (2013), Rindner et al. (2017) and Anderson et al. (2006). Endicott et al. (2013) conducted their study with aim to determine the effect of educational intervention on knowledge, health beliefs, and self-efficacy in controlling menopausal symptoms including osteoporosis. Menopausal symptoms have improved and comparing the scores of the intervention group after counseling compared to their scores in the pre-test phase and also compared to the control group significantly increased. The study of Rindner et al. in 2017 showed that the effect of group training is effective in reducing perimenopausal symptoms. In 2006, Anderson et al. in their study to determine the effect of a multi-model intervention to prevent heart disease in menopausal and postmenopausal women reported a reduction in the risk of heart disease after the intervention, which is in accordance with the results of the current research in terms of the physical dimension (3,43-44). Our results are in contrast with the findings of the study of Anjezab et al. in 2012, that examined the effect of the health-promoting life-style educational intervention on 88 middle-aged women, and no significant difference was observed in the field of nutrition. However, the mean score of other dimensions of health-promoting lifestyle increased significantly after the intervention in the intervention group (45).

According to the results obtained in this research, it seems that the changes made in this intervention in women have improved the dimension of interpersonal communication and stress management and spiritual growth, there is a possibility that the intervention affected the attitudes of women and probably this type of intervention can have more lasting effects than other interventions, and this is an important Strength of the study. It is suggested that other studies compare the effect of this type of intervention with other interventions on its long-term effects in improving the health-promoting lifestyle of postmenopausal women and other vulnerable groups.

One of the limitations of this study is that the current research was conducted in only one city, and since the cultural characteristics of any society can influence the health-promoting lifestyle of people, as well as their attitude towards menopause and even life, this issue can affect the generalizability of the results of this study. It is suggested to conduct more studies with more ethnic and cultural diversity in this region as well as in other cities, provinces and regions in order to increase the generalizability of the results of this study.

Conclusion

As evidenced by the results of the present study, positive psychology intervention can have an effect in improving health-promoting lifestyle in postmenopausal women. Therefore, the use of positive psychological intervention is recommended due to its cost-effectiveness and ease of implementation by postmenopausal women, as well as its effectiveness in improving the lifestyle of postmenopausal women.

Considering the importance of a health-promoting lifestyle in managing the symptoms and problems related to menopause, it is recommended to provide solutions for the implementation of effective trainings and interventions to improve the quality of life of women during this period.

Declarations

Acknowledgements

The authors sincerely thank the cooperation of all the personnel of health and treatment centers in Urmia, as well as the women who shared their experiences and contributed the required information to the study.

Conflicts of interest

The authors declared no conflicts of interest.

Ethical approval

This study was approved by the ethics committee of Urmia University of Medical Sciences.

Code of Ethics

The ethics code IR.UMSU.REC.1401.135 and was registered in the IRCT system with the code IRCT20220710055428N1.

Funding

This article is derived from the results of the master's thesis in the field of Counseling in Midwifery from the Faculty of Nursing and Midwifery of Urmia University of Medical Sciences, Urmia, Iran, which was approved by the Ethics Committee of Urmia University of Medical Sciences with the ethical code: IR.UMSU.REC.1401.135. The study was also registered in IRCT with code IRCT20220710055428N1. We hereby express our gratitude to the authorities of Urmia University of Medical Sciences for their scientific, ethical and financial support of this research.

Authors’ contribution

SR and SM contributed substantially in the conception and design of the study. SM and HF carried out the data collection. SM and SR analysed and interpreted the data. SM drafted the manuscript. SR reviewed the manuscript critically for important intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved’.