Synthesis, characterization, hydrolase and catecholase activity of a dinuclear iron(III) complex: Catalytic promiscuity

Article abstract of DOI:10.1016/j.jinorgbio.2015.02.017

Abstract Herein, we report the synthesis and characterization of the new di-iron(III) complex [(bbpmp)(H₂O)(Cl)Fe^III(μ-O_phenoxo)Fe^III(H₂O)Cl)]Cl (1), with the symmetrical ligand 2,6-bis{[(2-hydroxyben

Full text of DOI:10.1016/j.jinorgbio.2015.02.017

9
86
ORIGINAL RESEARCH—EDUCATION
Transtheoretical Model-based Postpartum Sexual Health
Education Program Improves Women’s Sexual Behaviors and
Sexual Healthjsm_2419 986..996
†
Jian-Tao Lee, RN, MSN, PhD* and Jia-Ling Tsai, RN, MSN
†
*
School of Nursing, Chang Gung University, Tao-Yuan, Taiwan; School of Nursing, Chang Gung University, Tao-Yuan,
Taiwan
DOI: 10.1111/j.1743-6109.2011.02419.x
A B S T R A C T
Introduction. Postpartum sexual health education was once routinely administered to postpartum women, but few
interventions were specifically described or clearly based on theory, and few sexual interventions affected women’s
sexual behaviors.
Aim. To evaluate the effectiveness of a refined theory-based interactive postpartum sexual health education program
(IPSHEP) in enhancing postpartum women’s sexual behavior and health.
Methods. For this prospective, randomized controlled trial, 250 participants were randomized to three groups.
Experimental group A received our refined theory-based IPSHEP. Experimental group B received only an interac-
tive, self-help pamphlet. The control group received routine education (a 10- to 15-minute educational talk and a
sexual health pamphlet without an interactive design). Data were collected at baseline, 3 days, 2 months, and 3
months postpartum.
Main Outcome Measure. Postpartum women’s sexual self-efficacy (SSE), diversity of sexual activity (DSA), return
to sexual activity, and sexual satisfaction (SS).
Results. Women who received our theory-based postpartum sexual health education program had significantly
greater SSE (P < 0.05) and greater DSA (P < 0.05), and tended to resume their sexual life earlier than women in the
routine teaching and interactive pamphlet-only groups (P < 0.05). However, the SS levels of postpartum women who
received our program did not differ significantly from those of women who received routine teaching or the
interactive pamphlet only.
Conclusions. Our findings suggest that a theory-based postpartum sexual health education program improved
women’s sexual health and sexual behavior and that the transtheoretical model can be translated into practice,
supporting its use to enhance the sexual health of postpartum women. Despite the lack of a significant effect on SS,
women who received our theory-based postpartum sexual health education program tended to maintain their prepreg-
nancy level of SS in early postpartum. Lee J-T and Tsai J-L. Transtheoretical model-based postpartum sexual
health education program improves women’s sexual behaviors and sexual health. J Sex Med 2012;9:986–996.
Key Words. Postpartum; Sexuality; Sexual Activity after Childbirth; Health Education; Patient Teaching; Trans-
theoretical Model
Introduction
women [1]. Nevertheless, childbearing challenges
women’s marital satisfaction and sexual life,
making the childbearing years a vulnerable stage in
women’s sexual life.
The first sexual intercourse after childbirth can
be an important step for couples to reclaim their
njoying sexuality, having a healthy baby,
becoming a competent mother, and building
E
an emotionally satisfying spousal relationship are
important reproductive health objectives for
J Sex Med 2012;9:986–996
© 2011 International Society for Sexual Medicine

Postpartum Sexual Health Education Program
987
intimate relationship [2]. Couples generally expe-
rience a significant decline in sexual activity and
intimacy from pregnancy to early postpartum, as
adaptation to motherhood takes considerable
energy and involves sleep disturbances, profound
psychosocial changes, and hormonal effects [3–5].
Most women resume sexual activity within 3
months of delivery, but 83% experience sexual
problems and 30–52.5% report painful intercourse
cational methods and media to suit patients’ inter-
ests, abilities, and cultural backgrounds, but also
whether educational strategies help patients
achieve healthy behaviors [16]. One model that
appears useful and valid for characterizing women
from diverse cultures is Prochaska’s transtheoreti-
cal model (TTM) [17,18], an integrative model of
behavior change that has been applied successfully
to such health behaviors as exercise [19], condom
use [20], and safe sexual behavior [21,22].
The effectiveness of behavioral change pro-
grams may be increased by framing them with the
TTM, which assumes that individuals evolve
through five stages (precontemplation, contempla-
tion, preparation, action, and maintenance) of
considering or adopting a health-related or health-
promoting behavior. The model also describes 10
change processes (consciousness raising, self-
reevaluation, self-liberation, counterconditioning,
stimulus control, reinforcement management,
helping relationships, dramatic relief, environ-
mental reevaluation, and social liberation) [18,23],
which can be employed in interventions to facili-
tate behavior change and progression through the
stages. By using the change processes identified as
most useful at a particular stage (i.e., matched
treatment), behavior change is facilitated more
successfully than by using the same intervention
techniques with everyone, regardless of change
stage [23,24].
[
6,7].
In Taiwan, the custom of “doing the month”
places a taboo on sexual intercourse during the
month after childbirth [8] and produces a sexual
approach-avoidance conflict for women. On one
hand, the taboo reinforces their fear that sexual
intercourse will adversely affect normal body
repair after childbirth. On the other hand, they
feel obligated to satisfy their husband’s desire, and
fear not meeting his needs. Due to this cultural
practice, combined with improper contraceptive
knowledge and fear of unexpected pregnancy [9],
Taiwanese women tend to delay returning to
sexual activity or may have difficulty deciding to
resume sexual life. Postpartum women in Western
culture may also have less sexual interest and
inhibited performance because of fatigue, perineal
pain, decreased vaginal lubrication, and fears of
injuring a healing wound or becoming pregnant
again [10]. These sexual problems may have a
midterm or long-term negative impact on
women’s physical and mental health and on their
relationships and family development [1,11].
Therefore, we used the TTM as the basis for
developing an interactive postpartum sexual health
education program (IPSHEP) that met the sexual
education needs of postpartum Taiwanese women
[9,25] and enhanced their sexual health knowledge
(SHK), sexual attitudes, and sexual self-efficacy
(SSE) [26]. Based on our process evaluation of the
IPSHEP, we revised its pamphlet and added an
educator’s guide booklet. This refined IPSHEP
was recently shown to effectively improve Taiwan-
ese women’s contraceptive health [36].
Sexual education has been found in the litera-
ture reviews to benefit sexual health and behavior
[
12,13], suggesting that sexual health education
would relieve unnecessary pressure on women’s
and couples’ sexual life. Although sexual education
has been one aspect of routine postpartum educa-
tion [14], it does not meet postpartum women’s
needs as it is limited to the timing of first postnatal
intercourse and contraceptive use [1]. However,
the effectiveness of postpartum education has
seldom been questioned, its effectiveness on sexual
behavior has not been established in randomized
controlled trials (RCTs) [14], and few interven-
tions were specifically described or are clearly
based on theory.
Aim
The aim of this study was to evaluate the effective-
ness of a refined theory-based IPSHEP on post-
partum women’s sexual behavior and health, i.e.,
SSE, diversity of sexual activity (DSA), return to
sexual activity (RSA), and sexual satisfaction (SS).
RCTs provide evidence about intervention
effects but no insight into why an intervention is
effective. If an intervention is not based on theory
and offers no empirical evidence, one cannot
predict which components are essential for its
effect [15]. To promote effective patient education,
educational theories must consider not only edu-
Methods
This study was part of a prospective RCT research
project conducted from 2005 to 2007 to evaluate
J Sex Med 2012;9:986–996

9
88
Lee and Tsai
Postpartum women who met study criteria
N=305)
(
Postpartum women who agreed to participate
N=250)
(
Random Assignment
Experimental A
n=70)
Experimental B
Control group
(
(n=92)
(n=88)
Pretest
Measure SHK, SHA
IPSHEP intervention
Routine teaching
(Traditional individual
teaching & pamphlet)
Interactive pamphlet
only
(
Assess learning stage, interactive
pamphlet, & individual education)
Posttest
After intervention and before discharge (3 days postpartum), measure
SHK, SHA, SSE
Experimental A (n=70)
Experimental B (n=92)
Control group (n=88)
Follow-up test at 2 months postpartum
Measure SHK, SHA, SSE, RSA
Experimental A (n=50)
Experimental B (n=58)
Control group (n=62)
Follow-up test at 3 months postpartum
Measure DSA, SS, RSA
Experimental A (n=44)
Experimental B (n=52)
Control group (n=49)
Figure 1 Study design and outcome measures. After random assignment to control and experimental groups, participants
were assessed before intervention (pretest) for sexual health knowledge (SHK) and sexual health attitudes (SHAs). For
interventions, the control group received routine postpartum teaching, experimental group A received the interactive
postpartum sexual health education program (IPSHEP), and experimental group B received the interactive pamphlet only.
After the appropriate intervention and before discharge, each group was assessed for SHK, SHA, and sexual self-efficacy
(SSE). At 2 months after delivery (second posttest), all three groups were assessed for SHK, SHA, SSE, and return to sexual
activity (RSA). At 3 months after delivery (third posttest), all three groups were assessed for diversity of sexual activity (DSA)
and sexual satisfaction (SS).
the effectiveness of a refined theory-based
IPSHEP. Data were collected at pretest and three
posttests at 3 days, 2 months, and 3 months post-
partum (Figure 1).
Sample and Setting
Participants were women recovering in the 69-bed
postpartum wards of a large-scale medical center
and a local hospital in northern Taiwan. Both
J Sex Med 2012;9:986–996

Postpartum Sexual Health Education Program
989
institutions had over 90% occupancy rates and
about 5,000 births annually. Postpartum women
were included if they (i) delivered a single, full-
term healthy baby (gestation age 38–42 weeks,
body weight >2,500 g, and Apgar score >8); (ii)
were admitted for <3 days; (iii) had no perinatal
complications or major chronic illness; (iv) were
married and lived with their husbands; (v) aged
peration, which is emphasized in Taiwan, and to
avoid providing too much information at once.
Individual health education (partial contents of the
pamphlets) was presented during admission in the
postpartum ward, and the remaining pamphlet
content was given to women to read at home, with
a reminder phone call to study the pamphlet. At 2
and 3 months postpartum, data were collected
from participants by mailed questionnaire.
2
0–39 years; and (vi) could read, write, and speak
Chinese. Of 305 women meeting these criteria,
50 agreed to participate and signed informed
consent.
This sample size was based on our estimate for
2
Experimental Group A: IPSHEP
Women in group A were assessed at pretest for
levels of TTM-based learning preparedness, SHK,
and sexual health attitudes (SHAs) (Figure 2). The
information on learning preparedness was used to
determine their health education strategies. In the
first stage of the IPSHEP, women were given an
interactive self-help pamphlet, “Happy Mother’s
Sex,” to read before scheduling a bedside educa-
tion appointment. In the second stage, a nurse
educator provided 10–15 minutes of individual,
interactive sexual health education at bedside
according to each woman’s readiness to learn. The
strategies used in individual, interactive sexual
health education were derived from TTM con-
structs, and outcomes (indicators) were chosen to
detect the effects of those strategies.
repeated measures within three groups, signifi-
cance level of 0.05, effect size of 0.4, and power of
8
0%. Power was calculated for the 2-month post-
test, indicating 78 participants needed in each
group [27]. Based on a previous questionnaire
response rate of 80% [27], we planned 90 partici-
pants per group.
Procedures
Before participants were recruited, the study was
approved by the study sites’ human subjects com-
mittees. A research assistant (RA) explained the
study process to participants, including the
research topic, process, purposes, and their right
to withdraw from the research. Participants then
signed consent forms. Participants were randomly
assigned to three groups: experimental A, experi-
mental B, and control. To determine which ward
rooms would first receive the program, a coin was
flipped. Participants received postpartum sexual
health education or family planning from the
researchers only. One RA blinded to group alloca-
tion administered the same questionnaires to all
groups, thus controlling the potential bias of
repeated testing. The same RA administered the
pretest and first posttest questionnaires. Data were
collected by two RAs with clinical research back-
grounds and trained using a researcher-developed
data collection protocol and manual.
To control the consistency of health education,
all health educators attended a training course in
research interventions. The individual health edu-
cation of group A and the control group was pro-
vided by licensed nurses (two educators/group)
with background in maternity care and with >1
year experience in obstetrics and gynecology.
Group A health educators received not only train-
ing in research interventions but also 16 hours of
training about the IPSHEP.
For example, women in the precontemplative
stage are not ready to learn how to promote their
sexual health, but nurses are usually unaware of
clients’ readiness and make the mistake of present-
ing all the educational materials at once. Besides
wasting the nurse’s time, this approach is ineffi-
cient because the client is not ready to accept or
think about the health information. For clients at
this stage, consciousness raising (a TTM-based
strategy) would be a better strategy to motivate
learning.
Similarly, women in the preparation stage are
ready to learn but lack sufficient self-efficacy to
promote their sexual health or to accept their
pregnant/postpartum body. Thus, reinterpreting
physical signs and symptoms of pregnancy/
postpartum (a TTM-based strategy) would be a
better strategy to increase these women’s SSE
(improve body image). Participants had an oppor-
tunity to ask questions, and the nurse educator
emphasized pamphlet elements to strengthen
through self-study. These pamphlet elements
depended on each woman’s questions and her
TTM-based stage of readiness to change.
“Happy Mother’s Sex” was developed to be
culturally appropriate for postpartum Taiwanese
women and to allow readers to dialog with
The study was conducted in two stages to mini-
mize disturbing participants’ postpartum recu-
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9
90
Lee and Tsai
Figure 2 Scheme for interactive postpartum sexual health education program (adapted with permission [26]). Strategies
were derived from transtheoretical model (TTM) constructs, and outcomes (indicators) were chosen to detect the effects of
those strategies. For example, in Course II, we used reinterpreting physical signs and symptoms (a strategy derived from the
TTM construct, self-efficacy) to promote postpartum women’s sexual self-efficacy (SSE). Women’s negative body changes
were interpreted positively to mean “the marks of a great mother” to help women accept and appreciate their body and to
enhance their self-efficacy toward sexuality. Thus, SSE became a study outcome.
instructors, to self-instruct, to self-evaluate, and
to feel involved, thus reinforcing the learning
effects [26]. The pamphlet had two main compo-
nents, contraception and postpartum sexual
adjustment, divided into seven instructional units:
the fundamentals of physical sexuality after child-
birth, preparation for postnatal sex, birth control,
psychological sexuality after childbirth, intimate
relationships, the sex life of a breast-feeding
mom, and the husband.
“Happy Mother’s Sex.” They were asked to read
the pamphlet without individual health education
or any opportunity to discuss questions.
Control Group: Routine Postpartum Sexual
Health Education
The control group was designed to answer the
question, “Does a refined theory-based IPSHEP
enhance postpartum women’s sexual behavior and
health better than noninteractive sexual health
education?” This group received the hospitals’
routine non-IPSHEP. This program comprised a
10- to 15-minute educational talk and a sexual
health pamphlet (the same content and color
printing as “Happy Mother’s Sex” but without the
interactive design), both given by the nursing staff
without formal training in interactive sexual health
education for postpartum women.
Experimental Group B: Interactive
Pamphlet Only
This group was designed to answer the question,
“
Does a refined interactive sexual health education
pamphlet effectively function instead of a nurse in
health education?” Thus, after group B women
were pretested (Figure 1), they also received
J Sex Med 2012;9:986–996

Postpartum Sexual Health Education Program
991
Main Outcome Measures
rate satisfaction with each behavior from 1 (not
satisfied at all) to 7 (very satisfied); higher scores
indicate greater satisfaction. For this study, DSA
internal consistency reliability was a = 0.74,
content validity index was 0.97, and concurrent
validity was 0.258 (P < 0.01) compared with Heth-
erington’s intimate relationship scale [32].
IPSHEP effectiveness was examined using a self-
report instrument to measure background infor-
mation and four dependent variables: SSE, RSA
(
in weeks), DSA, and SS. The SSE, RSA, and SS
subscales were previously developed [9,26,28,37];
the DSA subscale was developed for this study.
The instrument’s content validity determined by
five clinicians and three PhD-level professors was
To address the importance and strength of each
sex-related behavior, we weighted each behavior.
For masturbating each other by hand, including
genitals, the weighting factor (WF) = 9; for cunni-
lingus, WF = 8; caressing the body, excluding
genitals, WF = 7; intercourse, WF = 6; fellatio,
WF = 5; masturbating partner, WF = 4; genital
sexual stimulation, WF = 3; self-masturbation,
WF = 2; and anal sex, WF = 1. The total DSA
score is calculated by summing across items, item
satisfaction score (1–7) multiplied by its WF (1–9).
Background information included demograph-
ics (age, education level, religion, number of chil-
dren, previous unintended pregnancy, and
previous postpartum sex health education) and
clinical data (gravida, parity, delivery method,
perineal laceration, artificial abortion, and breast-
feeding method). Demographic information was
collected from participants, and clinical data were
collected from medical records.
0
.90. The face validity determined by five postpar-
tum women was 0.92. Validities and reliabilities for
each subscale are given below. Internal consistency
reliability of the overall scale was 0.67–0.85 for the
main sample in this study.
SSE or participants’ confidence in their per-
ceived ability to perform healthy postpartum
sexual behaviors was measured by the question-
naire’s 26-item postpartum SSE subscale [26] with
three dimensions: sexual psychology, sexual
biology (e.g., self-care of perineal wound, vaginal
lubrication), and sexual communication. Item
responses are scored from 0 (no confidence) to 4
(
very confident). Higher scores indicate greater
confidence in perceived ability to perform a sexual
behavior. Total scores range from 0 to 104; inter-
nal consistency (alpha coefficient) was 0.94.
RSA was categorized as “sexual intercourse
within 2 months after childbirth” (yes/no) and
Data Analysis
“
sexual intercourse within 3 months after child-
Data were analyzed using SAS 9.1 (SAS Institute
Inc., Cary, NC, USA) and SPSS 17.0 (SPSS Inc.,
Chicago, IL, USA). Before data analysis, variables
were examined for univariate and multivariate out-
liers and normal distribution. Results were used to
transform data if needed. Participants’ character-
istics were summarized by means and percentages.
The internal consistency reliabilities of the SSE,
DSA, and SS subscales were examined by Cron-
bach’s a coefficient. Concurrent validity of the
DSA was examined by Pearson correlation coeffi-
cient. Group effects on SSE and SS scores were
assessed by generalized estimating equation meth-
odology. Significance of DSA differences among
groups was determined by one-way analysis of
variance (anova). RSA differences among groups
were determined by logistic regression. SS was
further compared by least squares difference test.
Statistical significance was considered P < 0.05,
with 95% confidence intervals reported.
birth” (yes/no). These outcomes were measured
by one self-report item (RSA assessment [9]) on
sexual activity since the last testing period. Partici-
pants were asked, “Did you and your spouse
resume sexual intercourse? If yes, please indicate
the number of weeks after the baby’s birth.”
DSA was used to evaluate postpartum women’s
interpersonal behavior with their partners regarding
sexuality. The DSA subscale is a researcher-designed
list of sex behaviors based on a review of the litera-
ture [29–31]. The initial list of 14 categories of sex
behaviors was tested in a pilot study with 23 postpar-
tum women, and its content validity was examined
by eight experts. Based on participants’ and experts’
advice, the DSA was reduced to nine categories.
From this list, participants choose sex behaviors
used with their partners and evaluate satisfaction
with each activity for the “recent 4 weeks” at 3
months postpartum. Sexual activities comprise
nine categories: (i) caressing the body, excluding
genitals; (ii) masturbating each other by hand,
including genitals; (iii) self-masturbation; (iv) mas-
turbating partner; (v) genital sexual stimulation,
outercourse; (vi) vaginal intercourse; (vii) cunnilin-
gus; (viii) fellatio; and (ix) anal sex. Participants
Results
Participant Characteristics
The 250 participants who completed the pretest
also completed one of three groups of health edu-
J Sex Med 2012;9:986–996

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92
Lee and Tsai
Table 1 Baseline characteristics of participants (N = 250)
Experimental
group A (N = 70)
Experimental
group B (N = 92)
Control group
(N = 88)
Total (N = 250)
2
Characteristic
Age (years)
N
%
N
%
N
%
N
%
c (P)
3.04 (0.80)
2
2
3
3
0–24
5–29
0–34
5–39
5
7.1
6
6.5
8
9.1
19
7.6
24
34
7
34.3
48.6
10.0
40
36
10
43.5
39.1
10.9
31
42
7
35.2
47.7
8.0
95
112
24
38.0
44.8
9.6
Highest education
Undergraduate college
College graduate
Religion
3.22 (0.20)
7.02 (0.14)
15
55
21.4
78.6
30
62
32.6
67.4
29
58
33.3
66.7
74
175
29.7
70.3
None
Buddhist/folk religion
Other
37
27
6
52.9
38.6
8.6
42
39
10
46.2
42.9
11.0
35
47
3
41.2
55.3
3.5
114
113
19
46.3
45.9
7.7
Parity
1
м2
2.46 (0.29)
10.46 (0.005)
4.59 (0.10)
1.67 (0.43)
28
42
40.0
60.0
45
47
48.9
51.1
46
42
52.3
47.7
119
131
47.6
52.4
Delivery method
Vaginal birth
Caesarean section
Previous sexual health education
Yes
No
37
33
52.9
47.1
70
22
76.1
23.9
52
36
59.1
40.9
159
91
63.6
36.4
9
61
12.9
87.1
24
68
26.1
73.9
16
72
18.2
81.8
49
201
19.6
80.4
Previous unintended pregnancy
Yes
No
27
42
39.1
60.9
16
40
28.6
71.4
25
42
37.3
62.7
68
124
35.4
64.6
cation (control, N = 88; group A, N = 70; group B,
N = 92) and the 3-day posttest (Figure 1). The
questionnaire recovery rates of the three groups at
the 3-month posttest were 55.7, 58.6, and 56.5%,
respectively (for details, see Figure 1).
However, after accounting for the time effect, the
SSE of group A improved significantly more than
that of group B (P = 0.011) and the control group
(P = 0.02; Table 3). Thus, the IPSHEP signifi-
cantly improved postpartum women’s SSE more
than the interactive self-help pamphlet and tradi-
tional postpartum teaching.
Participants’ average age was 29.94 years (stan-
dard deviation [SD] = 3.58, range 20–39), and the
majority was multipara (52.4%) and had delivered
vaginally (63.6%) (Table 1). Only 19.6% had ever
received postpartum sexual health education or
related materials from professionals, highlighting
the problem of low exposure to sexual health edu-
cation. The three groups were not significantly
different at baseline in demographic and clinical
characteristics (Table 1), except for delivery
method (P < 0.01). However, comparison of par-
ticipants by vaginal birth vs. caesarean section
showed no significant differences in SHK and
SHA pretest scores (P > 0.05).
RSA
Over half of the participants (59.3%) resumed
sexual activity by 2 months. Furthermore, group
A, group B, and the control group returned to
sex, on average, at 6.42 Ϯ 0.23, 6.84 Ϯ 0.20, and
6
.88 Ϯ 0.19 weeks, respectively (Table 4). Com-
parison of groups by simple logistic regres-
sion analysis using “RSA or not” as a categorical
variable showed that group A and the control
group differed significantly (P < 0.05). That is,
group A tended to resume sexual activity earlier
than the control group (odds ratio [95% con-
fidence interval] = 0.431 [0.205–0.905]), indicat-
ing that the IPSHEP significantly decreased
women’s RSA relative to traditional postpartum
teaching.
Effects of IPSHEP
SSE
Discrepancies among SSE posttest scores of the
three groups changed over time and held true at
the 2-month follow-up. Our results also demon-
strate that, after controlling for groups, all three
interventions had positive time-varying effects on
SSE at 3 days and 2 months, indicating that all
participants’ SSE increased over time (Table 2).
DSA
At 3 months postpartum, women tended to use
intercourse (75.3%), caressing the body, exc-
luding genitals (51.4%), and masturbating each
other by hand, including genitals (46.5%). The
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Postpartum Sexual Health Education Program
993
most satisfactory sexual activities were masturbat-
ing each other by hand, including genitals
(
5.9 Ϯ 1.33), cunnilingus (5.84 Ϯ 1.53), and caress-
ing the body, excluding genitals (5.56 Ϯ 1.45)
Table 5). Comparison of DSA among groups by
one-way anova revealed significant differences
(
(
F = 3.286, P < 0.05). Post hoc test showed that
DSA of group A was significantly higher than that
of the control group (P = 0.04) and group B
(
P < 0.05). In other words, the IPSHEP signifi-
cantly improved women’s DSA relative to tradi-
tional postpartum teaching and the interactive
pamphlet only.
SS
The SS scores of group B and control group
women were significantly lower at 3 months post-
partum than before pregnancy (P < 0.05 and
P < 0.002, respectively), but the SS scores of group
A did not change (P > 0.05; Table 2). That is, SS
decreased for women who received an interactive
self-help pamphlet or traditional postpartum
teaching, but women who received the IPSHEP
tended to maintain their SS level. However, this
superior effect of the IPSHEP on SS was not sig-
nificant when the time effect was taken into
account (Table 3). These results demonstrate that
the IPSHEP maintained women’s SS scores until 3
months postpartum.
Discussion
Our findings support the importance of TTM self-
efficacy strategies in enhancing the SSE of post-
partum women. We found that postpartum
women who received the IPSHEP had signifi-
cantly greater SSE than those who received
routine teaching and the interactive self-help pam-
phlet. These findings confirm our previous finding
that the IPSHEP significantly improved postpar-
tum women’s SSE [26], demonstrate that the
TTM can be translated into practice, and support
its use to enhance postpartum women’s SSE.
We found that SS at 3 months postpartum was
lower than before pregnancy among women who
received traditional postpartum teaching or an
interactive self-help pamphlet, similar to postpar-
tum women’s usual experience [3–5]. However,
women who received the IPSHEP tended to main-
tain their SS level. Therefore, the IPSHEP might
have helped postpartum women adapt to sexual life
and maintain their SS level in early postpartum
even though their SS was not significantly greater
than those who received routine teaching or the
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Lee and Tsai
Table 3 Group effects on postpartum sexual self-efficacy and sexual satisfaction
Group (z [P])
Variable
Intercept
Control
Experimental group A
Experimental group B
Experimental A vs. B
Sexual self-efficacy
Sexual satisfaction
1818.68
16.48
Baseline
Baseline
2.32 (0.02)
-0.32 (0.753)
-0.33 (0.742)
-0.98 (0.327)
2.53 (0.011)
1.45 (0.148)
Generalized estimating equation analysis was used for repeated measurements.
interactive pamphlet only. Studies are needed to
determine the factors influencing women’s SS and
to develop more strategies to improve SS consis-
tent with theories about those factors.
Nonetheless, our analysis showed that interven-
tion effects on behavioral outcomes were greater if
the intervention also successfully improved con-
ceptual mediators, indicating that interventions
are worthwhile if they target only conceptual
mediators [33]. As SSE is a predictor (or mediator)
of sexual health behavior, and the TTM-based
IPSHEP enhanced postpartum women’s SSE, the
IPSHEP has a greater chance of successfully
improving postpartum women’s SS.
after childbirth (6.42 weeks) than women in the
routine teaching (6.88 weeks) and interactive
pamphlet-only (6.84 weeks) groups. Although
women’s RSA varies greatly, the first sexual inter-
course after childbirth can be an important step for
couples to reclaim their intimate relationship [2].
Our RSA results are similar to reports that the
average time for first sexual intercourse after child-
birth was 6.98 weeks for Taiwanese women [9], the
median time was 6 weeks for UK women [34], and
the median time was 5–8 weeks for European and
U.S. women [3–7].
Our results are noteworthy because Taiwanese
postpartum women follow the cultural practice of
“doing the month,” which places a taboo on sexual
intercourse during the month after childbirth
Our results show that women who received the
IPSHEP tended to resume sexual activity earlier
[
8,9]. Thus, the IPSHEP may have helped Taiwan-
ese women learn to assess their recovery from
delivery by themselves and judge whether the
perineal wound is healed and sexual intercourse
can be resumed. Therefore, our intervention
appeared to have helped women resume sexual
activity earlier and to be less susceptible to cultural
constraints.
Women who received the IPSHEP had signi-
ficantly greater DSA at 3 months postpartum
than those who received routine teaching and an
Table 4 Postpartum women’s return to sexual activity by
group (N = 186)
Mean Ϯ SD
Odds ratio (95%
Group
(weeks)
confidence interval)
P*
A
B
6.42 Ϯ 0.23
6.84 Ϯ 0.20
6.88 Ϯ 0.19
2.32 (1.105–4.881)
1.41 (0.709–2.792)
0.026
0.328
Control
*
Significance determined relative to the control group.
SD, standard deviation.
Table 5 Diversity of sexual activity of postpartum women by group (N = 150)
Group A
Activity
Group B
Activity
Control group
Activity Score
Total
Score
M
Score
M
Activity
Score
M
Rank
Sexual activity
N
%
SD
N
%
SD
N
%
M
SD
N
%
SD
%
2
M
Caressing the body,
excluding genitals
24 64.9 5.79 1.38 24 47.1 5.6
1.63 25 46
5.26 1.3
5.95 1.2
73 51.4 5.56 1.45
3
1
Masturbating each other by 26 31.6 6.04 1.34 17 34
hand, including genitals
5.63 1.46 23 43
66 46.5 5.9
1.33
3
Self-masturbation
Masturbating partner
Genital sexual stimulation,
outercourse
4
11.8
12 34.3 5.25 1.6
14 35.9 5.21 1.93 10 20
4
2.16
6
12
4.5
5.27 1.71 12 22
5.6 2.01 15
1.52
5
9.3 5.2
1.6
15 10.9 4.6
40 28.8 5.28 1.52
32 22.4 5.25 1.92
1.68
8
5
7
8
6
7
16 32
5.33 1.3
4.88
8
2
Intercourse
Cunnilingus
Fellatio
Anal sex
35 85.4 5.34 1.97 38 74.5 5.45 1.45 37 69
5.41 1.3 110 75.3 5.4
1.56
1
6
4
9
4
2
5
9
14 37.8
16 43.2 5.63 1.71 19 38
14.7 2.55
6
1.71 11 22
5.64 1.8
5.22 1.9
14 26
16 30
5.85 1.1
5.13 1.7
39 27.7 5.84 1.53
51 36.2 5.33 1.76
5
3
2
4
2.5
2.12
0
0
0
0
7
5.1 2.86 2.27
N and % represent the frequency and percentage, respectively, of adopting a sexual behavior; M represents the mean satisfaction score for each sexual behavior.
S, standard deviation.
J Sex Med 2012;9:986–996

Postpartum Sexual Health Education Program
995
interactive self-help pamphlet. That is, the
IPSHEP might have encouraged postpartum
women to adopt multiple sexual activities at early
postpartum. These various sexual activities might
have enhanced the sexual enjoyment of the
IPSHEP group since women reporting a greater
diversity of sexual behaviors at 3 months postpar-
tum also reported more satisfaction with their
sexual relationship [35]. For many women who
never or only occasionally reach climax through
intercourse without additional clitoral stimulation,
especially during early postpartum, sexual enjoy-
ment may come from other sexual activities such as
nongenital caressing followed by vaginal inter-
course and passive manual-genital stimulation [31].
Therefore, we suggest that health professionals
offer postpartum women some examples of differ-
ent ways to express sexual passion and intimacy
within their social and cultural context. We also
suggest that future studies use DSA as an indicator
to measure women’s SS.
course, and diversity of sexual behaviors in early
postpartum. First, these results add to the body of
knowledge on sexual behavior as no previous RCT
clearly identified a theoretical basis or model for
comparing strategies to effectively communicate
sexual behaviors during postpartum. Second, this
refined theory-based IPSHEP met the sexual
needs of postpartum women, while being well
suited to current short hospital stays. Thus, one
session of our program may resolve postpartum
education problems due to limited health educa-
tion competence of staff nurses and time limita-
tions in clinical settings. Third, this RCT
demonstrates that the IPSHEP improved postpar-
tum women’s SSE and might influence the way
knowledge is translated into sexual behavior.
Fourth, this study used the TTM to classify
women by their learning preparedness, allowing
the intervention to be tailored to meet each moth-
er’s individual sexual health educational needs.
We recommend that an ideal sexual health edu-
cational program should be culturally appropriate,
theory-based, and compatible with the existing
delivery of postpartum sexual health education.
Our program included 10–15 minutes of indi-
vidual, interactive sexual health education and an
interactive self-help pamphlet. By matching sexual
health education strategies to the learning pre-
paredness of postpartum women, our program
optimized use of medical professionals’ time and
efficacy of sexual health education.
Limitations
Despite its contributions, this study has some limi-
tations. First, the sample was drawn from northern
Taiwan, precluding generalization of the results to
postpartum women from other areas of Taiwan.
Second, the generalizability of our findings may
have been compromised by attrition, despite offer-
ing incentives to keep subjects in this longitudinal
study. Third, the study was underpowered at the
second posttest (3 months) for SS with power of
0
.48–0.55 [27], even though the questionnaire
Acknowledgments
response rates for the three groups at 3 months
postpartum (56–59%) were comparable to or
better than 53% for a related study [7]. Thus, the
small sample at 3 months postpartum may not
have had enough power to detect group differ-
ences in SS. Therefore, we suggest increasing the
sample size to reach adequate power in future
studies. Fourth, the three study groups had similar
characteristics, except for one potential confound-
ing variable (delivery method), which was used to
adjust the results. Fifth, two outcome indicators,
DSA and SS, were measured only at posttest and
follow-up due to the emphasis on postdelivery
recuperation in Taiwan. Thus, no baseline data
were obtained for these indicators, and IPSHEP
effects on them should be further investigated.
Thanks to Claire Baldwin for her editing. This study
was funded by the National Science Council of Taiwan
(
NSC93-2314-B-182–077).
Corresponding Author: Jian Tao Lee, RN, PhD,
School of Nursing, Chang Gung University, 259 Wen-
Hwa 1st Road, Kwei-Shan Tao-Yuan 33302, Taiwan.
Tel: (886)3-2118395 or (886)3-2118800 ext. 5197;
Fax: (886)3-2118395 ext. 5326; E-mail: jtlee@mail.cgu.
edu.tw
Conflict of Interest: None declared.
Statement of Authorship
Category 1
(
a) Conception and Design
Jian-Tao Lee
(b) Acquisition of Data
Conclusion
Jian-Tao Lee
Overall, the IPSHEP successfully enhanced post-
partum women’s SSE, initiation of sexual inter-
(c) Analysis and Interpretation of Data
Jian-Tao Lee; Jia-Ling Tsai
J Sex Med 2012;9:986–996

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Lee and Tsai
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