International Journal of Nursing Studies 111 (2020) 103768

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Effects of a nurse-led positive psychology intervention on sexual

function, depression and subjective well-being in postoperative
patients with early-stage cervical cancer: A randomized controlled
trial
Yan Shi a, Jun Cai a, Zhimin Wu b, Lian Jiang c, Guiqing Xiong c, Xiuni Gan c,∗,
Xiuying Wang d,∗∗
a
Department of Gynecology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing, 400010,
China
b
Department of Obstetrics and Gynecology, The First Affiliated Hospital of Army Military Medical University, No.30 Gaotanyan Main Street, Shapingba
District, Chongqing, 400038, China
c
Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing, 400010, China
d
Radiology Department, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing, 400010, China

article info abstract

Article history: Background: Sexual dysfunction is a common long-term complication of cervical cancer and its treatment.
Received 20 April 2020 However, due to traditional Chinese culture, there are few studies on interventions to improve sexual
Received in revised form 23 August 2020
function in China.
Accepted 26 August 2020
Objectives: To evaluate the effectiveness of a nurse-led positive psychology intervention on sexual func-
tion, depression and subjective well-being amongst postoperative patients with early-stage cervical can-
Keywords:
cer.
Uterine cervical neoplasms
Sexual dysfunction Design: A randomized controlled trial.
Depression Settings and Methods: Patients who had undergone radical hysterectomy for early-stage cervical cancer
Subjective well-being and were followed up in gynaecological clinics were recruited via convenience sampling from three ter-
Randomized controlled trial tiary hospitals in Chongqing, China. Patients who met the inclusion criteria and agreed to participate
(N = 91) were randomly assigned to a nurse-led positive psychology intervention (intervention group,
n = 46) or usual care (control group, n = 45). The Female Sexual Function Index, Self-rating Depression
Scale and Index of Well-being were used to assess sexual function, depression and subjective well-being,
respectively, at baseline and 3 and 6 months after the intervention. Data were analysed by the chi-square
test, Mann-Whitney U test, t-test and Pearson correlation analysis.
Results: Compared with participants in the control group, participants in the intervention group showed
significant improvements in sexual function (mean difference [MD]: -3.95, P = 0.005 at 3 months post-
intervention; MD: -4.36, P = 0.001 at 6 months post-intervention). In addition, at 3 and 6 months after
the intervention, the number of patients with improvements in their levels of depression and well-being
in the intervention group was higher than that in the control group (P<0.05). The Pearson correlation
analysis results showed that there was a negative correlation between sexual function and level of de-
pression in patients (r =-0.612, P<0.001) and that sexual function was positively correlated with subjec-
tive well-being (r = 0.638, P<0.001).
Conclusion: The intervention group experienced significant improvements in sexual function, depression
and subjective well-being. These findings suggest that a nurse-led positive psychology intervention should
be implemented for postoperative patients with early-stage cervical cancer.
© 2020 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

∗
Corresponding author: Xiuni Gan, Nursing Department, The Second Affiliated
Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Yuzhong District, Chongqing, 40 0 010, China; phone: 086-135-9417-
Chongqing, 40 0 010, China; 8416
∗∗
Xiuying Wang, Radiology Department, The Second Affiliated E-mail addresses: ganxn@163.com (X. Gan), 851720412@qq.com (X. Wang).
Hospital of Chongqing Medical University, No.74 Linjiang Road,
https://doi.org/10.1016/j.ijnurstu.2020.103768
0020-7489/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
2 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768
What is already known about the topic?
• Radical hysterectomy negatively affects the sexual function and
psychological health of cancer patients, and the effects can per-
sist for a long time.
• Psychological intervention can improve outcomes for survivors
of radical hysterectomy.
• There are few studies on sexual function intervention after rad-
ical hysterectomy of cervical cancer.
What this paper adds
• Compared to control group participants, participants receiving a
nurse-led, positive psychology-based, multidisciplinary team in-
tervention showed significant improvements in sexual function
and psychological health at 3 and 6 months after the interven-
tion.
• Sexual function affects depression (negative correlation) and
subjective well-being (positive correlation).
• A nurse-led, positive psychology-based, multidisciplinary team
intervention should be considered for postoperative patients
with early-stage cervical cancer.
1. Introduction
Cervical cancer is the fourth most frequent cancer in the
world and the fourth leading cause of cancer death in women
(Bray et al., 2018). According to the data of the World Health
Organization (WHO), there were 570,0 0 0 new cases of cervical
cancer worldwide in 2018, accounting for 6.6% of the incidence
of cancer amongst women. Approximately 90% of deaths from
cervical cancer occur in low- and middle-income countries (World
Health Organization, 2019). Cervical cancer ranks second in terms
of incidence and mortality behind breast cancer in settings char-
acterized by lower Human Development Index scores (Bray et al.,
2018). In China, approximately 130,0 0 0 cases of cervical cancer are
identified each year (Tian, 2013). Early-stage diagnoses are most
common in patients with cervical cancer: 57.3% are stage I, 33.9%
are stage II, and 4.3% are stage III or IV (Zhang, Sun, Ding, and
Hua, 2020). In recent years, the incidence of cervical cancer has
increased amongst younger women, but with the advancement of
effective screening methods and treatment methods, the prognosis
of cervical cancer is significantly better than it was previously,
and the overall 5-year survival rate is 70% (Allemani et al., 2018).
Thus, younger patients have significant additional life expectancy
after treatment completion and therefore face years of potential
treatment-related side effects, especially sexual dysfunction. The
sexual health of survivors is considered an important component
of quality of life (Ye, Yang, Cao, Lang, and Shen, 2014).
Currently, the main treatment options for cervical cancer in-
clude surgery or concurrent chemoradiotherapy (Small et al., 2017).
Several studies have confirmed the long-term effects of surgery
and radiation therapy on sexual behaviour. Frequent side effects in-
clude a shortened and inelastic vagina, reduced vaginal lubrication,
and reduced sexual arousal (Serati et al., 2009), as well as dys-
pareunia, lymphedema, vaginal stenosis, fistula and so on (Ye et al.,
2014), and these symptoms last for many years (Le Borgne et al.,
2013; Ye et al., 2014). It is estimated that 50% of survivors receiving
treatment suffer from long-term sexual dysfunction (Brotto et al.,
2012) and that 63% suffer from depression (Bae and Park, 2016).
Unfortunately, most patients do not undergo treatment due to the
influence of traditional Chinese culture. Chinese people are usu-
ally viewed as sexually conservative, and there is still a lack of
knowledge about sexuality. One study showed that Chinese peo-
ple’s references to sexual issues were often veiled and that only
a few expressed their views about bodily attraction or described
concrete sexual behaviours (Huang, 2017). Another study indicated
that many patients thought that treating disease was the most im-
portant element and that discussion of sex was optional; because
patients were embarrassed to talk about sex, many patients did not
consult health care workers about sexual issues (Shi et al., 2020).
In addition, research has shown that health care workers do not
pay enough attention to patients’ sexual problems because of a
lack of time, a lack of professional knowledge or a lack of system-
atic treatment plans (Shi et al., 2020).
Providing positive psychotherapy for cancer patients can im-
prove the quality of their sex lives (Krychman and Mill-
heiser, 2013). It is important to build a multidisciplinary team
of sexual health care groups to integrate attention to the sexual
health of patients into holistic care (Pieters, Kedde, and Bender,
2018). However, very few studies have explored nurse-led, positive
psychology-based, multidisciplinary team interventions.
The idea of a nurse-led positive psychology intervention is de-
rived from the framework of well-being theory, which was pro-
posed by Martin Seligman, who is the American “father of posi-
tive psychology”. The well-being theory framework consists of five
independent elements: positive emotion (P), engagement (E), re-
lationships (R), meaning (M), and accomplishment (A). The first
letters of the five elements together form the word PERMA, so
the well-being theory framework is called the PERMA model
(Seligman, 2011). Currently, the PERMA model is mainly used in
education (Wingert, Jones, Swoap, and Wingert, 2020), while there
have been few reports regarding the application of the model in
medical research. One study showed that the application of the
PERMA model in a positive psychological intervention improved
the mood and quality of life of hospitalized patients with ac-
quired immune deficiency syndrome (AIDS) (Gu, Fan, Gao, and
Zeng, 2017); however, the use of the model with cervical cancer
patients is unclear. The application of the PERMA model in inter-
ventions can have a good effect on patients, especially those who
have particular diseases and suffer from psychological trauma. Cer-
vical cancer patients usually have more serious sexual psycholog-
ical problems than do other cancer patients due to the nature of
their disease, and sexual psychological problems are also a major
cause of their sexual dysfunction (Zhang et al., 2020). Therefore, it
is necessary to apply the PERMA model in their treatment and pro-
vide tailored psychological and physiological guidance for patients.
Recently, our research team developed a nurse-led positive psy-
chology intervention based on the PERMA model; it is a multi-
disciplinary team intervention programme for the management of
the sexual health of cervical cancer patients that is implemented
through WeChat. Our intervention programme, which has been
validated by a panel of experts and patient advisers, includes four
stages following the PERMA model: Stage 1 (sexual psychological
rehabilitation guidance), stage 2 (sexual physiological rehabilitation
guidance), stage 3 (sexual technique guidance) and stage 4 (com-
prehensive guidance). This study aimed to examine the feasibility
of the programme and its effects on cervical cancer patients’ sexual
function and psychological health.
2. Method
2.1. Study design
The study was designed as a single-blind randomized con-
trolled trial with repeated measures to determine the effect of
a 4-week intervention for patients with cervical cancer who had
been treated with a radical hysterectomy. The Consolidated Stan-
dards of Reporting Trials (CONSORT) statement for the study de-
sign and reporting was adopted from Schulz, Altman, and Mo-
her (2010) (Schulz et al., 2010).
 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768 3

2.2. Participants and setting so on; regular care was provided by outpatient doctors and nurses
when the patients came to outpatient clinics for follow-up. At this
Participants were recruited via convenience sampling. The study time, the paper version of the cervical cancer health education
was conducted at three tertiary hospitals in Chongqing, China. Ter- form and telephone counselling services were also provided.
tiary hospitals are relatively high-level hospitals in China, and the
number of patients with cervical cancer in the three tertiary hos-
2.5. Intervention group
pitals was sufficient to ensure an adequate sample size for the
study. Patients who had undergone radical hysterectomy for early-
Participants in the intervention group received a 4-week PERMA
stage cervical cancer and were followed up in gynaecological clin-
model-based multidisciplinary team intervention programme in
ics were recruited from November 2018 to June 2019. Inclusion
addition to usual care. The intervention team consisted of 7 mem-
criteria for patients were as follows: 1) an age of 18 to 50 years
bers; the team was led by nurses and involved collaboration
old; 2) a diagnosis of stage IA1-IIA2 cervical cancer according to
amongst multidisciplinary experts, including specialist nurses, gy-
the International Federation of Gynaecology Reported and Obstet-
naecologists, psychological counsellors and rehabilitation physio-
rics standard (Bhatla and Denny, 2018); 3) a history of radical hys-
therapists. The multidisciplinary team was divided into 3 groups:
terectomy; 4) an end time of treatment ≥3 months and resump-
Group A consisted of 1 nurse and 1 psychological counsel-
tion of sexual activity; 5) proficiency in the use of WeChat; and
lor, Group B consisted of 1 nurse and 1 rehabilitation physiother-
6) voluntary participation in the study. The exclusion criteria were
apist, and Group C consisted of 1 nurse and 1 gynaecologist. The
as follows: 1) mental or cognitive disorder; 2) comorbidity with
intervention was tailored according to the initial evaluation status
cardiovascular and cerebrovascular diseases or other tumours af-
of each patient. The intervention included four stages (4 weeks of
fecting the sexual lives of patients; 3) diagnosis with recurrent tu-
intensive instruction). Each stage lasted one week (with the inter-
mours; or 4) loss to follow-up or inability to cooperate with the
vention administered twice a week, 45–60 min each time); each
experimenter due to physical reasons.
of the three multidisciplinary team groups made plans for patients
A total of 112 patients were assessed for eligibility; 4 patients
at each stage, and patients were required to follow the plan. All
did not meet the inclusion criteria, 6 patients refused to partici-
instructions were provided through the WeChat platform, and re-
pate, and 2 patients were excluded for other reasons. One hundred
ferral services were provided if a face-to-face conversation or treat-
patients agreed to participate. After patients signed an informed
ment was required.
consent form, a research nurse coded each patient according to
The specific implementation process of each stage was as fol-
the order of follow-up, and a computer was used to generate a ta-
lows. 1) Stage 1 emphasized the maintenance of positive emotion
ble of random numbers. Each patient code was assigned a random
by providing sexual psychological rehabilitation guidance, which
number, and then the random numbers were sorted from small to
included building good relationships through emotional communi-
large. The patients with codes corresponding to the first 50 ran-
cation, analysing patients’ psychological problems and conducting
dom numbers were assigned to the PERMA model-based multi-
counselling, and using videos or pictures to explain female repro-
disciplinary team intervention group (intervention group), and the
ductive organ anatomy and the positive role of sex to allow pa-
patients with codes corresponding to the last 50 random numbers
tients to develop positive emotions about sex. The P stage was
were assigned to the usual care group (control group). However,
carried out by group A. 2) Stage 2 focused on the experience of
the patients were not told which group they belonged to. The sam-
a sense of immersion by providing sexual physiological rehabilita-
ple size was estimated based on the primary outcome, i.e., the Fe-
tion guidance, which included sexual yoga and pelvic floor rehabil-
male Sexual Function Index score, of the preliminary experiment.
itation exercises. The nurses guided patients through the exercises
After the intervention, the Female Sexual Function Index score in
using videos or pictures. This stage was carried out by group B.
the control group was 22.81 [standard deviation (SD) =2.07], and
3) Stage 3 aimed to build a harmonious relationship between the
the Female Sexual Function Index score in the intervention group
sexes by providing instruction in sexual techniques, which included
was 27.45 (SD=0.88). The SD of the difference between the two
explaining sexual behaviour and sex support tools and introduc-
groups was 5.56 based on the calculation formula for sample con-
ing communication skills for sexual relationships between couples.
tent estimation based on two mean numbers under a group design.
This stage was carried out by group C. 4) Stage 4 focused on setting
A total of 74 participants were required to detect a difference be-
goals and experiencing a sense of accomplishment. The compre-
tween the two groups at a 5% (2-sided) significance level with a
hensive guidance included two points: first, to help patients anal-
power of 80%. Considering the possibility for loss to follow-up, the
yse the meaning of their own lives by guiding them to set goals
sample size was increased to 100, allowing for a 20% attrition rate.
for disease recovery, life, study or work; second, to help patients
to identify their own advantages and encourage them to perform
2.3. Ethical considerations
advantage utilization exercises and experience the sense of accom-
plishment generated by advantage utilization. This stage was car-
The study was approved by the Ethics Committee of Second
ried out by group A. Fig. 1 shows an outline of the delivery of the
Affiliated Hospital of Medical University in Chongqing, China (No.
intervention.
2019.26). It was registered with the Chinese Clinical Trial Registry
with identifier ChiCTR20 0 0 034806. All patients received both writ-
ten and oral information regarding the purpose of the research 2.6. Instruments
prior to the study. The patients were informed that they were free
to withdraw during the study at any time for any reason without 2.6.1. Demographic and clinical information questionnaire
any need for explanation and that the confidentiality of the data Demographic and clinical information was collected at baseline
sets would be maintained. using a questionnaire; demographic information included age,
marital status, place of residence, education level, occupation and
2.4. Usual care (control) group family income, and clinical information included clinical stage,
treatment, postoperative time, time until the resumption of sexual
Patients in the usual care (control) group received regular care, activity and frequency of sexual activity. Example questions are
which included health education about cervical cancer disease as follows: Have you actively consulted your health care workers
knowledge, medication, diet, exercise, lifestyle, psychology, sex and about sex questions? Have you obtained knowledge of sex through
4 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768
Fig. 1. Intervention pathway of the intervention group.
the network or other channels? Have you discussed sexual issues
with your spouse or partner after treatment?
2.6.2. Female sexual function index
The Female Sexual Function Index contains 19 items covering
six aspects of sexual life (sexual arousal, sexual desire, vaginal lu-
brication, orgasm, pain in sexual intercourse, and satisfaction with
sex) (Rosen et al., 20 0 0). Each aspect is assessed with several
multiple-choice items. The minimum score is 2 points, and the
maximum score is 36 points. The higher the total Female Sexual
Function Index score is, the better the patient’s sexual quality of
life, and the lower the score is, the worse the patient’s sexual qual-
ity of life. In this study, the internal consistency of the Chinese ver-
sion of the Female Sexual Function Index was good, and the over-
all Cronbach’s alpha coefficient was 0.862. The Cronbach’s alpha
coefficients for each subdimension were 0.855, 0.773, 0.892, 0.871,
0.824, and 0.875.
2.6.3. Self-rating depression scale
The Self-rating Depression Scale was developed by William W.K.
Zung in 1965 (Zung, Richards, and Short, 1965). The scale contains
20 items that reflect subjective feelings of depression. According
to the results for the Chinese version, the threshold values of the
SDS score were 53 for no depression, 53–62 was classified for mild
depression, 63–72 for moderate depression, and > 72 for severe
depression. The Self-rating Depression Scale was previously trans-
lated into Chinese and validated (Wang, Cai, and Xu, 1986). In this
study, the total Cronbach’s alpha coefficients and retest reliability
of the scale were 0.792 and 0.843, respectively.
2.6.4. Index of well-being
The Index of Well-Being was developed by Campbell et al. in
1976 (Campbell, 1976). It measures the current level of subjective
well-being and consists of two parts: the Overall Emotion Index
scale (8 items) and Life Satisfaction scale (1 item). Each item is
scored on a seven-point scale, and the total score is calculated
by averaging the first eight items and then adding the score of
the last item multiplied by 1.1. The total score ranges from 2.1
to 14.7, which can be divided into three levels: scores of 2.1–6
indicate low well-being, scores of 6.1–10 indicate moderate well-
being, and scores of 10.1–14.7 indicate high well-being. The In-
dex of Well-Being was previously translated into Chinese and vali-
dated; the Chinese version is widely used, and there have system-
atic empirical studies conducted on the psychometrics of the scale
(Li et al., 20 0 0). In this study, the total Cronbach’s alpha coeffi-
cient and retest reliability of the scale were 0.886 and 0.894, re-
spectively.
2.7. Data collection
Two investigators were responsible for the collection of data,
including the collection of the general data of patients and the
administration of the Female Sexual Function Index, Self-rating
Depression Scale and Index of Well-Being. Before collecting the
data, the two investigators were trained by the researcher, and the
reliability and validity of the questionnaires were measured. Eight
relevant experts with a bachelor’s degree or above and an associate
senior title or above were selected to consult on the questionnaire.
After two rounds of evaluation, the content validity index of the
questionnaire was obtained. Then, 20 respondents were randomly
selected for a preliminary survey to check the reliability and
validity of the questionnaire. These respondents were randomly
assigned to the intervention group and the control group, with
10 people in each group. The reliability of the Chinese versions of
the measures was evaluated in the psychometric papers cited. The
Female Sexual Function Index, Self-rating Depression Scale and
Index of Well-Being were administered before the intervention
(T0) and 3 (T1) and 6 months (T2) after the intervention. The
investigator sent the electronic version of the questionnaire to the
participants via WeChat and provided the necessary instructions.
The participants logged into WeChat and completed the question-
naire anonymously. The completion time was 25–30 min, and the
network automatically screened out unqualified questionnaires.
2.8. Data analysis
Data analysis was performed using the statistical software pack-
age IBM SPSS for Windows 22.0. Descriptive statistics were used
to analyse patient demographic and clinical characteristics at base-
line. Demographic and clinical data and measurements at baseline
were compared between groups with the chi-square test for nom-
inal data, the Mann-Whitney U test for ordinal data and the t-test
for continuous data. Pearson correlation analysis was used to anal-
yse the correlation between sexual function and depression and
subjective well-being. Statistical significance was set to a standard
of P < 0.05.
3. Results
3.1. Participant demographics and clinical characteristics
Of the 100 participants, 91 patients completed the 6-month
study (intervention group, n = 46; control group, n = 45). This
was the result of a loss of participants in both groups during the
6-month follow-up period due to withdrawal (intervention group,
n = 3; control group, n = 2), loss to follow-up (intervention group,
 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768 5

Fig. 2. CONSORT participant flowchart.

Abbreviation: CONSORT, Consolidated Standards of Reporting Trials.

n = 1; control group, n = 2) and recurrence (control group, n = 1).
Fig. 2 shows the selection process and assessments of the partici-
pants.
Demographic and clinical characteristics from the patient charts
of the 91 participants at baseline are shown in Table 1. There was
no statistically significant difference between the two groups of
patients in age, marital status, place of residence, education level,
occupation, family income, clinical stage, treatment and postoper-
ative time, time until the resumption of sexual activity, frequency
of sexual activity or other general information (P > 0.05). amongst
the 91 patients, 61.5% resumed sexual activity more than one year
after treatment. After the resumption of sexual activity or inter-
course, the frequency of sexual activity was lower than that before
treatment, and more than half (56.0%) of the patients engaged in
sexual activity less than once a month. Only 22.0% of patients took
the initiative to consult nurses or doctors about sex-related prob-
lems, 39.6% of patients acquired sexual knowledge through net-
works and other channels, and 80.2% did not discuss postoperative
sexual issues with their spouses or partners.
3.2. Comparison of female sexual function index scores between the
two groups before and after the intervention
Fig. 3 and Fig. 4 show that before the intervention, there was no
statistically significant difference in the total Female Sexual Func-
tion Index score and the scores of each dimension between the
two groups (P > 0.05). However, the total Female Sexual Function
Index score in the intervention group was significantly higher than
that in the control group 3 months (MD: −3.95, standard error
[SE]: 1.37, 95% confidence interval [CI]: −6.69 to −1.21, P = 0.005)
6 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768

Table 1
Demographic and clinical characteristics of all participants (N = 91).

Intervention Control group

group (n = 46) (n = 45)
Variable n (%) n (%) Z/x2 p-value

Age, years −0.573 0.567

18–30 1 (2.2) 2 (4.4)
31–40 15 (32.6) 16 (35.6)
41–50 30 (65.2) 27 (60.0)
Marital status 4.880 0.181
Single 1 (2.2) 3 (6.7)
Married 39 (84.8) 37 (82.2)
Divorced 6 (13.0) 3 (6.7)
Widowed 0 (0.0) 2 (4.4)
Place of residence 0.139 0.710
Urban 30 (65.2) 31 (68.9)
Rural 16 (34.8) 14 (31.1)
Educational level −0.915 0.360
Primary school or below 20 (43.5) 23 (51.1)
Secondary/high school 13 (28.3) 12 (26.7)
Associate degree 6 (13.0) 7 (15.6)
Bachelor degree or above 7 (15.2) 3 (6.6)
Occupation type 0.376 0.828
Mental worker 10 (21.7) 8 (17.8)
Manual worker 23 (50.0) 22 (48.9)
Housewife 13 (28.3) 15 (33.3)
Monthly family income, RMB −0.657 0.511
<3000 15 (32.6) 10 (22.2)
3000–5000 19 (41.4) 23 (51.1)
5000–8000 6 (13.0) 7 (15.6)
>8000 6 (13.0) 5 (11.1)
FIGO stage −0.540 0.589
IA1/IA2 20 (43.5) 22 (48.9)
IB1/IB2/IB3 21 (45.7) 19 (42.2)
IIA1/IIA2 5 (10.8) 4 (8.9)
Treatment methods 1.743 0.627
Surgery 12 (26.1) 11 (24.4)
Operation + chemotherapy 25 (54.3) 20 (44.4)
Operation + radiotherapy 6 (13.0) 10 (22.2)
Operation + chemoradiotherapy 3 (6.5) 4 (8.9)
Postoperative time, years −1.794 0.073
<1 10 (21.7) 17 (37.8)
1–3 30 (65.2) 25 (55.6)
>3 6 (13.0) 3 (6.7)
Time of resumed sexual activity −0.769 0.442
<Half a year 6 (13.0) 8 (17.8)
Half to a year 10 (21.7) 11 (24.4)
>1 year 30 (65.2) 26 (57.8)
Frequency of sexual life −0.263 0.793
More than 4 times a week 0 (0.0) 0 (0.0)
1 to 4 times a week 7 (15.2) 5 (11.1)
Once or twice a month 12 (26.1) 16 (35.6)
Less than once a month 27 (58.7) 24 (53.3)
Have you actively consulted 0.916 0.339
your health care provider about
sex questions?
Yes 12 (26.1) 8 (17.8)
No 34 (73.9) 37 (82.2)
Whether you got knowledge of 0.264 0.608
sex through the network and
other channels?
Yes 17 (37.0) 19 (42.2)
No 29 (63.0) 26 (57.8)
Have you discussed sexual issues 0.335 0.563
with your spouse or partner after
treatment?
Yes 8 (17.4) 10 (22.2)
No 38 (82.6) 35 (77.8)

FIGO = International Federation of Gynaecology reported and Obstetrics.

and 6 months (MD: −4.36, SE: 1.20, 95% CI: −6.76 to −1.97,
P = 0.001) post-intervention]; there were also significant differ-
ences between groups in the scores of each dimension (P < 0.05)
3 and 6 months after the intervention.
3.3. Comparison of the self-rating depression scale and index of
well-being scores between the two groups before and after the
intervention
Fig. 5 shows that before the intervention, there was no statis-
tically significant difference in the number of patients with each
 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768 7

level of depression or well-being between the two groups (P >

0.05). At 3 and 6 months after the intervention, the number of pa-
tients with improved depression and well-being in the intervention
group was significantly higher than that in the control group (P <
0.05).

3.4. Relationships between the female sexual function index,

self-rating depression scale and index of well-being scores

Pearson correlation analysis results showed that there was a

Fig. 3. Comparison of the Female Sexual Function Index scores (the minimum score
is 2 points, and the maximum score is 36 points) between the two groups before
and after the intervention (mean score [SD]).
negative correlation between Female Sexual Function Index and
Self-rating Depression Scale scores (r = 0.612, 95% CI: −0.99 to
−0.57, P<0.001) (Fig. 6) and that the Female Sexual Function In-
dex score was positively correlated with the Index of Well-Being
score (r = 0.638, 95% CI: 0.15 to 0.24, P<0.001) (Fig. 7).

Fig. 4. Comparison of the scores of each dimension of the Female Sexual Function Index between the two groups before and after the intervention (mean score [SD]).
8 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768

Fig. 5. Comparison of the Self-rating Depression Scale and Index of Well-Being scores between the two groups before and after the intervention.
 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768 9

Fig. 6. Correlation analysis between the Female Sexual Function Index score and Self-rating Depression Scale score (mean score [SD]).

Fig. 7. Correlation analysis between the Female Sexual Function Index score and Index of Well-Being score (mean score [SD]).

4. Discussion
4.1. Delay of the resumption of sexual activity, low frequency of
sexual activity, and lack of awareness of the importance of the active
discussion of sexual issues amongst postoperative patients with
cervical cancer
In this study, we found that most of the patients resumed sex-
ual activities only after a very long period and that the frequency
of sexual activity after the resumption of sexual activity was lower
than the frequency before treatment. Most patients did not take
the initiative to consult nurses or doctors about sex-related prob-
lems, and few patients acquired sexual knowledge through net-
works and other channels and discussed postoperative sexual is-
sues with their spouses or partners.
The influence of traditional Chinese culture and patients’ lack
of postoperative sexual health knowledge may explain the above-
mentioned phenomenon. Because of China’s relatively conservative
10 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768
attitudes towards sex, health care workers often spend most of
their time making diagnoses and treatment plans but show little
concern for patients’ sexual health (Ye et al., 2014). This issue is
particularly relevant in China, as reported by Zheng et al. amongst
202 nurses working in gynaecological units in China, 77.7% felt
that sexuality was too private an issue to be discussed with
patients, and only 34.2% actually discussed sexual concerns with
patients (Zheng et al., 2011). Patients rarely actively seek sexual
information, and embarrassment has been shown to be negatively
correlated with a willingness to ask for help (Bedell et al., 2017;
Vermeer et al., 2015; Zhou et al., 2016). In addition, patients
with gynaecologic cancer have been found to have a negative
sexual self-concept and negative perceptions of sexual relation-
ships and sexual function (Bae and Park, 2016). In one study,
patients thought that cervical cancer could be transmitted through
sexual activity and that sexual activity could lead to physical
damage or the recurrence of cancer, and some patients whose
genitals were removed or incomplete thought that they were not
complete women (Shi, Gan, Cai, and Wu, 2019). These findings
indicated that patients lack postoperative sexual health knowledge,
which was demonstrated in our previous study (Shi et al., 2020).
Furthermore, patients in our previous study expressed fear and
insecurity about future sexual behaviour and the long-term side
effects of treatment; they did not want to resume sexual activity
because of a fear of pain and/or diminished sexual response,
which often affected their desire for sex. These results support the
findings of the study conducted by Vermeer et al. (Vermeer et al.,
2015).
Therefore, health care professionals should improve awareness
of sexual issues, and sex-related issues should be addressed rou-
tinely. We should actively provide psychological counselling re-
garding sexual health and guidance to patients in all stages, in-
cluding admission, operation, discharge and follow-up. In addi-
tion, changing patients’ negative perceptions of sex will allow
them to resume sexual activity early to improve their quality of
life.
4.2. Effects of the intervention on the sexual function of postoperative
patients with cervical cancer
The findings of this study revealed that 3 and 6 months after
the intervention, the total FSFI scores and the scores of each
dimension in the intervention group were significantly higher
than those in the control group (P < 0.05). The scores for de-
sire, arousal, lubrication, orgasm, satisfaction, and pain in the
intervention group and the control group at 6 months were all
higher than those at 3 months. This finding suggests that sexual
function improved over time, which is probably attributable to
the functional vaginal recovery that occurs in the years after
a surgical procedure. These results support the findings of the
study conducted by Plotti et al. (Plotti et al., 2018). The largest
differences between the groups were observed for the domains
of lubrication and pain. These differences may be related to
the psychology of the patients (Bakker et al., 2017). The results
showed that the tailored intervention model that combined posi-
tive psychology theory with sexual health guidance could improve
the sexual quality of life of cervical cancer survivors. Studies
found that the quality of life and sexual function of cervical
cancer survivors were lower than those of the general population
and that treatment-related complications and sexual dysfunc-
tion significantly affected patients’ quality of life. Furthermore,
radical hysterectomy caused serious psychological disturbances
and psychosocial disorders (Wang et al., 2018; Zhou et al., 2016).
Therefore, patients should be given targeted interventions accord-
ing to their psychological characteristics and sexual status after
surgery. Especially regarding patients’ sexual psychology, sexual
psychological interventions will help patients and their spouses
adapt to and control sexual dysfunction after cancer treatment
(Afiyanti, Setyowati, Milanti, and Young, 2020). Sexual dysfunction
may also have a negative impact on the spouses of cervical cancer
survivors. Sexual problems may cause emotional estrangement
between patients and their spouses and damage their relation-
ships. The divorce rate of cervical cancer patients was found to
be 40% higher than that of other cancer patients (Afiyanti et al.,
2020).
Thus, we suggest that nurses should evaluate the sexual psy-
chology and sexual problems of patients and their spouses and
guide them to take effective measures to address adverse reactions,
achieve a harmonious sex life, enhance the husband-wife relation-
ship, maintain a happy marriage and fight together against the dis-
ease.
4.3. Effects of the intervention on the depression and subjective
well-being of postoperative patients with cervical cancer
The findings of our study showed that at 3 and 6 months after
the intervention, the number of patients with improved depres-
sion and well-being in the intervention group was significantly
higher than that in the control group (P < 0.05). These results are
consistent with a study showing that a psychological intervention
could alleviate depression and improve subjective well-being for
cervical cancer survivors (Chow, Chan, Chan, Choi, and Siu, 2014).
Sexual dysfunction is common in cancer patients and has psy-
chological, emotional and social effects, and these consequences
can eventually seriously impair quality of life and mental health
(Traumer, Jacobsen, and Laursen, 2019). After cancer treatment,
common changes to the female body include the shortening and
narrowing of the vagina, weight gain, hair loss, skin pigmentation,
etc., which seriously affect the patients’ image and self-esteem
and often lead to negative psychological effects such as self-
reproach, feelings of inferiority, pain and depression (Bakker et al.,
2017; Oldertrøen Solli, de Boer, Nyheim Solbraekke, and Thore-
sen, 2019). In one study, it was estimated that 63% of survivors
who received treatment suffered from depression (Bae and Park,
2016).
Therefore, nurses should strengthen the psychological assess-
ment of cancer patients, analyse the main causes of psychological
problems amongst patients, and provide professional psychological
guidance.
4.4. Effects of sexual function on the depression and subjective
well-being of postoperative patients with cervical cancer
In this study, we found that the sexual function of patients
was negatively correlated with depression, while sexual func-
tion was positively correlated with subjective well-being. The
higher the FSFI score was, the lower the depression; this result
is consistent with research conducted by Bae et al. (Bae and
Park, 2016). This finding indicates that therapeutic interventions
are urgently needed to provide appropriate and accurate infor-
mation for patients to improve their sexual quality of life and
thus reduce depression. Previous research has shown that affective
disorders, especially depression, loss of interest, low self-esteem,
decreased energy, and an inability to experience happiness, have
long been associated with impaired sexual function; such affective
disorders are typical symptoms of depression that can damage
sexual relationships and lead to poorer sexual quality of life
(Barata, 2017). We should recognize the severity of the impact of
depression and other negative emotions on patients’ sexual quality
of life. Some people with post-traumatic stress disorder avoid
sex to prevent sexual arousal (they may be afraid of triggering
fear-related memories) rather than being unable to be aroused
 Y. Shi, J. Cai and Z. Wu et al. / International Journal of Nursing Studies 111 (2020) 103768
(Barata, 2017). In the study, we also found that the higher the
Female Sexual Function Index score was, the higher the Index of
Well-Being score, which is in line with the study by Buczak-Stec
(Buczak-Stec, König, and Hajek, 2019). Sexuality is an important
aspect of existence, and the fulfilment of the need for intimacy can
facilitate well-being, self-esteem, and general resilience. Moreover,
it can strengthen the coping, adherence, and survivorship skills
of chronically ill patients. Sexual expression can improve psycho-
logical and physical health. Good sexual quality of life not only
fulfils the physiological needs of patients but also can strengthen
the emotional relationships between spouses, promote family
harmony, and enhance social or family well-being (Tian, 2013).
Therefore, nurses should improve their cognition of sexual
health, actively explore guidance programmes for sexual health,
and provide effective rehabilitation measures for patients to im-
prove their sexual quality of life to improve their subjective well-
being and reduce the level of depression.
4.5. Study limitations
There are some limitations to our study. First, the intervention
effect in the present study should be considered with caution given
the small sample size. Further studies using larger sample sizes are
recommended. A second limitation is that changes in sexual func-
tion and psychological improvement in postoperative patients with
cervical cancer often occur gradually, but there was a fairly short
duration of follow-up. Future studies could be conducted to iden-
tify whether ongoing support is required to maintain the positive
effect. Third, the generalizability of the findings is limited, as there
was only one study setting. Finally, all participants were under the
age of 50, and the patients’ partners were not included. Further
research will be needed to analyse the effectiveness of this inter-
vention on patients of different ages and their partners.
5. Conclusion
The sexual relationship experience of postoperative patients
with cervical cancer is poor, which has a negative impact on
their quality of life. We found that a nurse-led positive psychol-
ogy intervention (PERMA model-based multidisciplinary team
intervention) was effective for improving sexual function and
subjective well-being and reducing depression. This model is
worthy of further research and promotion, and future research
is required to explore synchronous intervention programmes for
couples. We suggest that nurses should be professionally trained
in sexual health. In clinical work, we should pay more attention
to sexual problems, and sexual health guidance should become a
routine part of nursing for cervical cancer patients or other cancer
patients. In particular, it is very important to evaluate and inter-
vene in patients’ sexual psychology. A united approach by health
professionals, the national public health sector and community
health centres is also likely necessary to ensure the successful
implementation and integration of similar interventions.
Conflict of interest
The authors declare no conflicts of interest.
Funding
This study was financially supported by the Medical Research
Project of Chongqing Health Commission of China (Grant No.
2016ZDXM008).
11
Ethical approval
This study was approved by the Ethics Committee of Second
Affiliated Hospital of Chongqing Medical University of China (No.
2019.26).
Acknowledgements
We are grateful for financial support from the Medical Re-
search Project of Chongqing Health Commission of China (Grant
No. 2016ZDXM008). We wish to thank the individuals who took
the time to participate in this study.
Author contributors
SY wrote the manuscript. CJ and WM participated in the data
collection and analysis. JL and XQ collected the data. SY, GN and
WY designed the study and revised the manuscript. GN obtained
funding. All authors read and approved the final manuscript.
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