Midlife is a pivotal period in women's lives as a bridge between youth and old age, and menopause and loss of fertility is the most critical event all women experience in this period (1). This new phase of life brings about numerous symptoms and complications (2), and hormonal fluctuations following the onset of menopause predispose women to such psychosocial disorders as insomnia, fatigue, irritability, poor concentration, forgetfulness, depression, and anxiety (2). In this period, we are witnessing a decline in women's happiness as a result of mental disorders, decreased social activity, marital status, and physical illnesses.
Happiness is a positive emotional state characterized by satisfaction, joy, and contentment bringing such traits as holding positive beliefs, positive emotions, and lack of negative emotions. In other words, happiness is a prerequisite for inviting joy and pleasure into life, which leads to desirable outcomes and promotes life satisfaction (3). Considering the influential factors on happiness, Lyubmirsky (2001) pointed to material/external and internal factors. During menopause, we are witnessing a decline in women's happiness as a result of mental disorders, decreased social activity, marital status, and physical illnesses (4). In this regard, we can refer to "empty nest syndrome" as another consequence of menopause which threatens the mental health of women and causes many problems, such as depression and sexual dysfunction. Therefore, it is of utmost importance to treat and prevent this syndrome (5,6).
Empty Nest Syndrome is a persistent pervasive sense of loneliness, sadness, or grief parents, especially mothers, experience when their children leave home. As soon as the children leave home, the couple strives to give meaning to their life or relationship. During this period, some negative emotions and stress are manifested, which is recognized as "empty nest syndrome" which can lead to depression among the elderlies if efficient measures are not implemented (7). The prevalence rates of empty nest syndrome in China and Beijing are reported as 25% and 35%, which is estimated to rise to 90% by 2030. In Iran, the prevalence of this syndrome is reported to be 40% (8).
Postmenopausal women constitute a large part of society, and their health guarantees the well-being of family and society; therefore, it is necessary to take efficient measures to optimize marital life and mitigate social problems (9). These interventions can include training and counseling. Training cannot receive the necessary feedback owing to its one-sided nature, while counseling is more effective, especially when performed according to a specific protocol (10). One of the counseling approaches is Solution-focused brief therapy (SFBT) (11) which centers on the notion that humans are inherently capable of solving problems; nonetheless, this ability is impaired in the face of problems and conflicts (12); therefore, it is known as hope counseling.
In their study, Shakermi et al. (2013) showed that brief solution-focused couple therapy improved the quality of marital relationships (13). Davoodi et al. (2012) concluded that solution-focused counseling was effective only on the dimension of marital adjustment and had no effect on other dimensions, such as agreement and satisfaction (1). Although there is disagreement over the actual number of parents suffering from empty nest syndrome, the number of empty-nest elderlies is projected to soar in the future along with the economic growth.
It is an agreed-upon fact that women are the mainstay of the family, and the population of postmenopausal women is on the rise. Moreover, menopause coincides with other changes in family structure, such as children leaving home, which exert dramatic effects on women's happiness. That is to say, one of the daunting challenges of women during menopause is empty nest syndrome which brings numerous problems, such as depression; therefore, it is of paramount importance to seek effective solutions for the prevention and treatment of this syndrome.
In light of the aforementioned issues, the present study aimed to assess the effect of a solution-focused group counseling approach on the happiness of postmenopausal women with empty nest syndrome in Mashhad, Iran, in 2019.
Materials and Methods
This randomized, single-blind placebo-controlled clinical trial was conducted to investigate the effect of the solution-focused group counseling approach on happiness in postmenopausal women with empty nest syndrome. Najafi and Daneshamuz health centers in Mashhad were selected as the research setting due to the high referral of postmenopausal women and sufficient space for holding training sessions. All eligible postmenopausal women were examined and 80 postmenopausal women were selected as the sample. The sample size was determined based on the studies conducted by Davoodi et al. (2012) (14) and Monemian et al. (2016) (11) using the following formula.
Consequently, the sample size was estimated at 36 cases in each group which increased to 40 subjects considering a 10% sample attrition. Inclusion criteria were as follows: 1) Iranian nationality, 2) residing in Mashhad, 3) the age range of 50-50 years old, 4) a minimum of high school education, 5) providing written consent to participate in the study, 6) currently living with a spouse, 7) the absence of normal menstruation for at least one year, 8) all or one of the children departing home due to marriage, military service, work, or education, 9) being diagnosed with empty nest syndrome by a psychologist or psychiatrist, 10) absence of any physical or mental illness, and 11) no history of hysterectomy or oophorectomy. On the other hand, the exclusion criteria entailed: 1) unwillingness to continue participation in the study, 2) absence in more than one session of counseling, and 3) participation in other training and counseling programs on happiness.
The participants were selected via convenience sampling among all women referring to Najafi and Daneshamooz health centers within April 2019-August 2019. They were then randomly allocated to two groups: intervention (solution-focused counseling) and control. Random allocation was performed using SAS software. A SAS-generated random number sequence was performed for the two groups. In this way, firstly, the mentioned sequence was prepared; thereafter, during sampling, each participant who met the inclusion criteria was assigned to the relevant group based on this sequence until data saturation.
The instruments used in the current study were: subject selection checklist, personal-midwifery information form, and Oxford Happiness Questionnaire. In this study, in order to further ensure the content validity, after obtaining the approval of the advisors and supervisors, it was provided to a group of faculty members to be assessed. Furthermore, the reliability of the Happiness Questionnaire was confirmed rendering a Cronbach's alpha coefficient of 92%. At the commencement of the study, the research was approved by the Ethics Committee of Mashhad University of Medical Sciences, a written letter of introduction from Mashhad School of Nursing and Midwifery was submitted to the provincial health deputy, and permission was obtained from the officials; thereafter, the clients completed the informed consent form. Subsequently, all the included women who met the inclusion criteria and were diagnosed with empty nest syndrome were regarded as the participants and completed the personal-midwifery information form and Oxford happiness questionnaire.
In the intervention group (solution-focused counseling group), participants in five groups of eight received six 90-minute group counseling sessions based on a solution-focused approach on a weekly basis in the training classes of health centers with the presence of a master of counseling in midwifery and a psychologist, as well as the psychologist or psychiatrist of the center. The contents of the sessions were as follows: Session 1: Introduction, problem determination, determining the objectives of the consultation sessions, session 2: defining and highlighting exceptions, using graded scale questions, session 3: reviewing assignments and summaries from the previous session, using miraculous questions and talking about the future, finding a positive story in life, using solution-focused questions, highlighting abilities and talents, session 4: Reviewing the assignments of the previous week, using the important word "instead", using the master key technique, using graded questions, session 5: Reviewing the assignments of the previous session, summarizing the topics, taking the post-test, and session 6: using the experiences of one of the subjects with empty nest syndrome
The participants in both groups also received the routine care provided in health centers (integrated middle-aged health care). Finally, in both groups (control and intervention), immediately after the intervention, the Oxford Happiness Questionnaire was completed again by each subject. At the end of the sessions, the participants in both groups received some gifts. It is noteworthy that five subjects were excluded from the study ( two cases from the control group due to noncooperation, as well as three subjects from the intervention group due to absence in counseling sessions (n=2) and unwillingness to continue cooperation (n=1)).
After data collection, the forms were coded and entered into the computer, and after ensuring data entry accuracy by the second pass entry (entry made by the second person), the data were analyzed in SPSS software (version 24). The independent t-test was used to evaluate the homogeneity of quantitative intervening variables with normal distribution in the two groups. Mann-Whitney and Chi-square tests were used for quantitative variables without normal distribution and qualitative variables, respectively. A 95% confidence interval was considered in all tests; therefore, cases with P
The results of the independent t-test showed no statistically significant difference between the two groups in terms of mean age (P=0.066).
The results of the independent t-test and Mann-Whitney test indicated that the two groups were not statistically significant and were homogeneous regarding the mean menarche age (P=0.581), gravida (P=0.939), the number of children (P=0.675), menopausal age (P=0.185), the time elapsed since menopause (P=0.678), and body mass index (P=0.343) (Table 1)
The mean score of happiness at the beginning of the study and before the intervention in the two groups was not statistically significant. After the intervention, the mean happiness score in the counseling group significantly differed from
that obtained in the control group (P=0.001; Table 2).
Based on the results of the Mann-Whitney tests, at the commencement of the study, the two groups did not have a statistically significant difference in terms of happiness dimensions (life satisfaction, self-esteem, actual well-being, contentment, and positive mood). Nevertheless, after the intervention, the results of statistical tests pointed out that the two groups significantly differed regarding dimensions of life satisfaction (P<0.001), self-esteem (P<0.001), actual well-being (P<0.001), contentment (P= 0.022), and positive mood (P=0.025) (Table 3).
Based on the results, the mean score of happiness in the solution-focused counseling group (40.7) was higher than that obtained in the control group (36.2). Disorders that occur during menopause and its associated factors, such as empty nest syndrome, may reduce the quality of life, general health, happiness, and life expectancy. Some researchers believe that happy people are biased in information processing toward optimism and happiness (15, 16).
Afjoland et al. (2013) in their study entitled "Effectiveness of solution-focused approach on happiness and marital satisfaction of married women in Darab" reported that in the intervention group, eight sessions of solution-focused counseling increased happiness (17). The results of the referred study are consistent with the present study, and both studies used the Oxford Happiness Questionnaire and counseling. Nevertheless, in the study by Afjoland, married women were assessed as a statistical population, while our study examined postmenopausal married women with empty nest syndrome.
Fotoorehchi et al. (2018) in their study entitled "Effectiveness of group counseling based on reality therapy on marital satisfaction and happiness of women during the empty nest" reported that group counseling based on reality therapy was effective in increasing women's happiness during the empty nest stage (18). The results of this study are in line with the findings of the present study in which solution-focused group counseling was effective in the elevation of happiness in the intervention group; nonetheless, the type of counseling was different in the two studies.
In the same context, Dashtizadeh et al. (2015) performed a study to assess the effectiveness of brief solution-focused therapy on depression symptoms in women and pointed to the effectiveness of this type of counseling in the reduction of depression symptoms (19). The results of the mentioned study are in agreement with those obtained in the present study despite the differences in the measured variables. As illustrated by the results of the present study, the two groups had statistically significant differences in the dimensions of life satisfaction, self-esteem, actual well-being, contentment, and positive mood so that the scores of each of the abovementioned dimensions increased after the intervention in the solution-focused counseling group.
Moreover, in accordance with the findings of the current study, solution-focused counseling increased the happiness scores in its five dimensions in the study by Afjoland et al. (2013) (17). In fact, solution-focused counseling is known as hope counseling since it instills in the clients the hope of a better and healthier life and increases their happiness (19). The strength of the current study lies in its use of the solution-focused counseling model that gives clients the ability to solve their problems. One the other hand, one of the notable limitations of this study was the existence of individual, cultural, and emotional differences that may have affected the responses.
The current study aimed to investigate the effect of group solution-focused counseling on happiness in postmenopausal women with empty nest syndrome. As evidenced by the obtained results, it can be concluded that this counseling can be used to improve the happiness of postmenopausal women due to a statistically significant increase in the mean total happiness score of postmenopausal women after the intervention in the solution-focused counseling group.
This study was extracted from a master's thesis in midwifery counseling approved by the Ethics Committee of Mashhad University of Medical Sciences (School of Nursing and Midwifery) with the ethical code of IR.MUMS.NURSE.REC.1398.002. Our deepest appreciation goes to Mashhad University of Medical Sciences for financially supporting this research project, all participants, and the staff of selected health centers in Mashhad for their sincere cooperation.
Conflicts of interest
Authors declared no conflicts of interest.