Examining the effect of the computer-based educational package on quality of life and severity of hypogonadism symptoms in males

Abstract

Objective: The objective of this study was to determine the effect of the computer-based educational package on men’s QoL and the severity of their hypogonadism symptoms.

Methods: A quasi-experimental study was conducted on 80 male employees. The data collection tool included the ‘Aging Male Symptoms’ (AMS) and ‘Short Form-36’ (SF36) questionnaires. Four sessions were held for the intervention group over a period of 4 weeks. Two months after training, QoL and the severity of hypogonadism symptoms were measured in both the intervention and control groups. The data were analyzed with SPSS 22 software and statistical tests, such as χ², independent t-test, Fisher’s exact test, and paired t-tests.

Results: Significant statistical changes were observed in the intervention group before and 2 months after the training in the QoL score in the overall dimensions of physical–psychological health and all its domains except for three domains of emotional role, social function, and pain. Furthermore, the paired t-tests showed significant differences between 2 months before and after the training in all the domains and the overall hypogonadism score in the intervention group.

Conclusions: Based on our findings, the computer-based educational package has a positive effect on QoL and reduction of hypogonadism symptoms.

Keywords:

• Hypogonadism
• quality of life
• computer-based training

Introduction

Nowadays, the increase in life expectancy has underscored the significance of quality of life (QoL) [1]. Hypogonadism is an important issue which if neglected may gravely affect men’s QoL [2]. It refers to a period in a man’s life in which testosterone hormone levels gradually fall [3]. This phenomenon usually occurs in middle age between the ages of 40 and 60 years [4,5]. Some hypogonadism symptoms are, decreased libido, increased risk of osteoporosis, memory disorders, increased visceral fat, depressed mood, insomnia, reduced muscle power, irritability, fatigue, etc. [6–8]. Free testosterone levels fall by 1–2% annually from the age of 40 years onwards [9].

The prevalence of hypogonadism among middle-aged and elderly men is on the rise [10]. The “European Menopause and Andropause Society” (EMAS) has reported the prevalence of hypogonadism among 40- to 79-year-old men at 23.3% [11]. Hypogonadism is diagnosed by measuring the plasma levels of androgens and examining the clinical symptoms with the help of screening tools such as, the Androgen Deficiency in Aging Men (ADAM) and Aging Male Symptoms (AMS) questionnaires [12,13].

One of the solutions suggested for alleviating the symptoms of hypogonadism is testosterone therapy that has certain side effects, such as, prostate enlargement, increased risk of cardiovascular diseases, elevated cholesterol levels, sleep apnea, etc. [14]. However, there is debate on the long-term use of this method [15]. On the other hand, managing one’s lifestyle can also safeguard against the changes that come about with hypogonadism [16]. Other solutions that have been put forth to reduce hypogonadism symptoms are, regular exercise, healthy nutrition, stress control, healthy sleep, and, abstinence from narcotics and alcoholic drinks [17].

Considerable reductions in androgen levels negatively affect the individual’s QoL [12,18–20]. One issue that raises the QoL of patients is the provision of educational programs [21]. There are many methods of educating individuals. One such method is electronic learning (e-learning). E-learning is one of the most important uses of information technology and has many different varieties, such as, computer-based training, web-based training, online training, network-based training and offline training [22].

Computer-based training is an educational package that is designed with the help of computer technologies in the form of texts, audio, video and other multimedia facilities [23]. The advantages of e-learning are, preventing the wastage of time, rapid learning, accessible anywhere and anytime, cost saving, interactive learning, reduction of environmental and noise pollution [24]. Thus, bearing in mind the aforementioned, and that, to our knowledge, no such study has been conducted before, we carried out this study with the goal of modifying lifestyle aimed at promoting QoL in males that are prone to hypogonadism based on clinical symptoms through computer-based training.

Methods

Study design

The current study was a quasi-experimental one that has been registered in Iran’s Clinical Trial Center (www.irct.ir) through registration code IRCT201407166777N3. The necessary licenses were acquired from the Faculty of Nursing and Midwifery and Tehran University of Medical Sciences’ (TUMS) Ethics Board (Ethics committee letter numbered 93/d/130/856).

Participants

The population under study consisted of the males employed in TUMS Faculties aged between 40 and 60 years. This environment was chosen due to the ease of access to the research samples. The study was conducted during the academic year 2014-2015.

The sample size was determined based on the research objective at a certainty level of 95%, test power of 80% and the assumption that the effect of the educational package on hypogonadal males would be at least d = 10 to be considered statistically significant. After inserting the formula and considering the possible loss of samples, the sample size was estimated at 40 for each group. The eligible individuals were randomly assigned to the two intervention and control groups. The inclusion criteria included, mastery over the Persian language, the physical and mental ability to respond to questions, having a high school or higher degree, access to a PC, the ability to work with a computer (enough to be able to use the educational package), absence of chronic diseases and psychiatric disorders, acquiring an AMS score higher or equal to 27, and lack of disability. The exclusion criteria were, lack of interest in continuing to participate in the study, incomplete answers to the questionnaire’s items, having a chronic disease and psychiatric disorders throughout the study. The data collection tool included a demographic questionnaire, the SF36 and AMS questionnaires. The demographic questionnaire (age, marital status, education etc.) contained 11 questions that had been developed by the researcher in line with the research objectives and relevant articles.

Data collection tool

The SF36 questionnaire: It is a standard questionnaire for evaluating QoL and consists of 36 items and 8 dimensions of physical function, social function, physical role, emotional role, psychological health, vitality (energy/fatigue), physical pain and general health. Its validity has been determined by concurrent validity and its reliability has been determined by internal consistency [25].

The AMS questionnaire: This self-administered questionnaire has been designed to assess the symptoms of the aging process among various groups of men under different circumstances and to assess the severity of symptoms over time and the resultant changes of androgen therapy. It has 17 items and includes the physical, psychological and sexual domains [26,27]. This inventory has been examined for its validity and reliability among the Iranian male population aged 40–65 years, where Cronbach’s α for all the domains was higher than 0.7 (0.73–0.88). A Pearson’s correlation of 0.87 between pretest and post-test showed a high correlation and acceptable reliability [28].

The intervention

Before the study began, all the contents of the educational package were developed by the researcher using books and articles relevant to hypogonadism and were approved by scientific consultants. Then, its software was developed by a software designer and was shown to eight experts and approved. Once the informed consent was taken from the subjects, the pretest began. During the pretest, the demographic and AMS questionnaires were handed out to the males aged 40–60 years to screen and assess the severity of hypogonadism symptoms. Upon completion of the questionnaire, those who had hypogonadism symptoms (an AMS score of ≥27) and possessed the inclusion criteria were enrolled in the study. At the next stage, the SF36 questionnaire was completed to determine QoL. Afterwards, the computer-based training began for those in the intervention group and the educational package was handed to the participants. The installation of the software and its method of use were verbally explained to the subjects. During every session that was held for the topic at hand, using the software, the topics were taught using the audio, video and texts. To bring about an interactive air to the educational program, at the end of each session the researcher verbally asked the participants some questions and they responded. The program was taught during four sessions over a period of 4 weeks. Apart from the first session, the remaining sessions were locked and password-protected. Every week, the researcher would go to the faculty on a specific day and give the password to the subjects. The participants were advised to use the educational package at home without limitation in duration and episodes.

The topics specified in each session were as follows:

First session: Introducing the educational package to the learners, familiarization with the hypogonadism process, its symptoms, side-effects and methods of prevention in men.

Second session: Explaining sleep disorders and difficulties in hypogonadism, stress management during hypogonadism, the significance of relaxation methods and teaching them.

Third session: Teaching healthy eating, the significance of sexual relations during hypogonadism, the significance of social relations with peers and the effect of hypogonadism on it.

Fourth session: Reduced overall strength and joint problems in hypogonadism, the significance of exercise and teaching it.

The men in the control group received no intervention. The researcher stayed in touch with the participants via email after the last intervention session. Two months after the initial test, the aforementioned questionnaires were sent again. Eventually, the results before and 2 months after the intervention were compared in both groups (therefore, it may be said that the entire study was 3 months long). To adhere to ethical principles, the educational package was given to the control group participants at the end of the study as well.

Data analysis

After data collection and coding, they were analyzed with SPSS Inc., Version 22 (Chicago, IL, USA). Descriptive statistics such as, frequency distribution, mean, percentage and standard deviation were used to describe the characteristics of the research units. Independent t-test was used to investigate the homogeneity of the two groups for their quantitative variables, and χ² and Fisher’s test were used to examine the qualitative variables. Thereafter, to achieve the specific objectives of the research, inferential statistics, independent and paired t-test were used to determine the association between before and after the intervention in the control and intervention groups. The level of significance was set at p < .05.

Results

The results depicted in Table 1 indicate that the two groups were demographically homogenous (age, marital status, education, etc.).

Table 1. The absolute and relative frequency distributions of demographic traits in the control and intervention groups.

Group personal and background traits	Control	Intervention	Test results (p value)
Age	48.1 ± 5.28	47.27 ± 4.29	.445
Marital status	32 (80%) married	34 (95%) married	.556
Education	21 (52.5%) diploma	21 (52.5%) academic	.655
Academic discipline	33 (82.5%) non-medical	30 (75%) non-medical	.412
Economic status	23 (57.5%) weak	22 (55%) weak	.822
Smoking status	29 (72.5%) no	30 (75%) no	.799
Smoking in the past	22 (55%) no	23 (57.5%) no	.822
Numbers of hours of sleep in 24 h	17 (42.5%) 7–9 h	18 (45%) 7–9 h	.908

Paired t-test results for all the domains and the overall QoL score (p > .05) indicated no statistically significant difference before and after the intervention in the control group (Table 2). On the other hand, in the intervention group, statistical differences were observed before and after the intervention in the following: physical function, physical role, energy/fatigue, emotional well-being, general health, the overall physical health scale, the overall psychological health scale, and the overall QoL score. The results of this statistical test showed no significant changes in the emotional role, social function and pain domains in the intervention group after the intervention (p > .05) (Table 3).

Table 2. Comparing the mean and standard deviation of QoL dimension scores before and 2 months after the training in the control group.

Group dimension	Before the intervention		Two months after the intervention		Paired t-test results
	Mean	Standard deviation	Mean	Standard deviation
Physical function	67.47	25.93	67.60	24.66	DF = 39, t =  −0.17, p = .86
Physical role	63.85	30.32	64.48	30.29	DF = 39, t =  −0.57, p = .57
Emotional role	66.37	37.02	66.66	36.20	DF = 39, t =  −0.23, p = .81
Energy/fatigue	58.50	19.37	58.87	18.01	DF = 39, t =  −0.47, p = .63
Emotional well-being	60.85	19.92	60.92	19.18	DF = 39, t =  −0.18, p = .85
Social function	61.46	21.87	61.77	21.60	DF = 39, t =  −0.44, p = .66
Pain	64.31	23.42	64.37	22.90	DF = 39, t =  −0.07, p = .94
General health	50.75	19.75	51.62	18.99	DF = 39, t =  −0.55, p = .58
Overall physical health scale	61.59	17.63	62.02	17.41	DF = 39, t =  −0.81, p = .42
Overall psychological health scale	61.79	18.73	62.06	17.57	DF = 39, t =  −0.53, p = .59
Overall QoL score	61.69	16.15	62.04	15.41	DF = 39, t =  −1.12, p = .26

Table 3. Comparing the mean and standard deviation of QoL dimension scores before and two months after the training in the intervention group.

Group dimension	Before the intervention		Two months after the intervention		Paired t-test results
	Mean	Standard deviation	Mean	Standard deviation
Physical function	67.52	19.87	73.51	18.33	DF = 39, t =  −3.36, p = .002
Physical role	63.75	29.39	73.12	25.56	DF = 39, t =  −2.73, p = .009
Emotional role	66.66	32.02	70	30	DF = 39, t =  −1.27, p = .21
Energy/fatigue	58.87	16.38	63.37	13.88	DF = 39, t =  −2.85, p = .007
Emotional well-being	60.70	16.02	66.10	17.84	DF = 39, t =  −2.82, p = .007
Social function	61.35	19.02	62.28	19.16	DF = 39, t =  −0.47, p = .63
Pain	64.62	20.54	65.62	19.18	DF = 39, t =  −0.51, p = .61
General health	51	18.12	58.12	18.38	DF = 39, t =  −3.51, p = .001
Overall physical health scale	61.72	14.04	67.59	12.87	DF = 39, t =  −4.86, p < .001
Overall psychological health scale	61.89	12.15	65.44	12.47	DF = 39, t =  −3.16, p = .003
Overall QoL score	61.81	10.47	66.51	9.09	DF = 39, t =  −5.23, p < .001

Paired t-test results for all the domains and the overall hypogonadism score (p > .05) indicated no statistically significant difference before and after the intervention in the control group. However, the results of this test indicated statistically significant differences for all the domains and the overall hypogonadism score (p < .05) before and after the intervention in the intervention group (Table 4).

Table 4. Comparing the mean and standard deviation of hypogonadism dimension scores before and 2 months after the training in the control and intervention groups.

Dimension	Group	Before the intervention		Two months after the intervention		Paired t-test results
		Mean	Standard deviation	Mean	Standard deviation
Physical	Control	17.65	4.20	17.67	4.26	DF = 39, t =  −0.37, p = .71
	Intervention	17.02	3.40	16.50	3.34	DF = 39, t  =  2.6, p = .01
Psychological	Control	12.55	3.74	12.52	3.80	DF = 39, t =  −0.33, p = .74
	Intervention	12.45	3.81	11.82	3.28	DF = 39, t  =  2.8, p = .008
Sexual	Control	11.92	3.89	11.87	3.98	DF = 39, t =  −0.62, p = .5
	Intervention	11.82	3.01	10.82	2.86	DF = 39, t =  −3.1, p = .03
Overall hypogonadism score	Control	42.12	10.25	42.07	10.38	DF = 39, t =  −0.38, p = .7
	Intervention	41.30	8.12	39.15	7.16	DF = 39, t  =  4.9, p < .001

Discussion

Male health is a topic that has not garnered enough attention. In recent decades, the assessment of reproductive health programs on one hand, and the results of Cairo’s “International Conference on Population and Development” on the other hand have expanded the dimensions of male health in the topic of reproductive health. In Iran, the Men’s Health Program is new; naturally, not many studies have been conducted on hypogonadism so far [29]. Furthermore, in spite of our efforts in finding relevant literature in Iran and other countries’ accessible databanks, no interventional study was found except for that involving testosterone therapy in hypogonadism, which makes the comparison and assessment of our results difficult. Nevertheless, we did find studies closely related to our research topic, which will be discussed below.

In the current study, the men under study had a better QoL 2 months after the intervention was carried out. In the intervention group, before and 2 months after the training, significant differences were observed in the domains of physical function, physical role, energy/fatigue, emotional well-being, general health, overall physical health scale, overall psychological health scale, and the overall QoL score. However, no significant differences were observed in the emotional role, social function, and pain domains; in other words, no change had occurred in these domains. Here, the latter three domains were less focused on in the educational content. The reasons behind this were, the large volume of content and the thesis committee’s opinions regarding the content. Moreover, physical, psychological and sexual symptoms and side-effects are seen with greater severity in hypogonadal men, which lead to reduction of QoL. This may explain why the educational intervention had no significant effect on these three domains.

Generally speaking, bearing in mind the paired t-test results, significant differences existed between the QoL scores before and after the intervention, which indicate the effect of the computer-based training on hypogonadal men’s QoL. A study conducted by Vejdani et al. [23] in 2011 on “the effect of computer-based training on epileptic adolescent’s QoL” showed similar results. The paired t-test indicated no significant change in the control group 1 month after the intervention (p = .992), whereas, the intervention group had witnessed significant change and improvement (p ≤ .001) [23]. Similar results have been observed in studies conducted elsewhere. For example, Stromberg et al. [30] performed a research titled “the effect of a single computer-based educational program session on the level of awareness, following advice and QoL among cardiac insufficiency patients”. According to the results, the level of knowledge had increased one month after (p = .05) and 6 months after the intervention (p = .03). The overall conclusion was that the computer-based educational package did raise awareness on cardiac insufficiency, but to improve the rate of following medical advice, a single session is not adequate [30]. Furthermore, based on the findings of Gustafson et al. [31], educational package users reported improvement in different QoL dimensions (dynamic life, negative feelings, cognitive function, social support and participation in health care services), reduced length of hospital stay, and shorter periods for outpatient visits. Eventually, this research concluded that a computer-based educational program could improve patients’ QoL and promote the efficient use of health care services [31]. Our results confirm the effect of the computer-based training on QoL too; in fact, it raises the QoL score. To our knowledge, no study has been conducted in Iran on the effect of computer-based training on QoL in hypogonadal men, but, studies employing a similar method on menopausal women have been found, wherein the results are consistent with ours. The results of a study titled “Examining the effect of training on menopausal women’s knowledge and QoL” conducted by Moridi et al. [32] in 2005 showed that the educational program that had been conducted through lectures and Q&A with teaching aids had significantly affected the women’s vasomotor, spiritual-psychological, social and physical dimensions and had promoted their level of awareness. Similarly, another research entitled “The effect of training on QoL of menopausal women visiting Shiraz’s Mottahari Clinic” conducted by Forouhari et al. in 2004 indicated that training through group discussions improved the women’s QoL by reducing their problems and reducing the severity of menopause [33]. Furthermore, in a research conducted by Yazdkhasti et al. [34] in 2011 aimed at investigating the effect of a structured educational program through a group support approach on menopausal women’s QoL, the researchers observed significant statistical changes in the vasomotor, physical, sexual and psycho-social dimensions of the intervention group and improvement of QoL. The differences between these studies and ours are in the target group, content, training method (computer-based training) and the research tool. All the aforementioned studies have used the “Menopause-Specific Quality Of Life” (MENQOL) questionnaire, whereas, we have used the SF36.

Based on our results, among the entire population under study, 32.5% had mild, 43.75% had medium, and 23.75% had severe hypogonadism before the intervention, and the two groups were homogenous. In our study, the lowest frequency was observed for severe hypogonadism. Other similar studies have been carried out, some of which have made similar observations. For example, Ichioka et al. [35] found 22.7% men with severe hypogonadism among the 40–70-year-old Japanese males visiting multi-stage screening centers. Taher [36] examined the proportion and acceptance of hypogonadism symptoms among elderly men and observed that 54.52% had mild, 38.98% had medium and only 6.5% of the participants had severe hypogonadism. The variety of findings may be attributed to differences in lifestyles between Iranian men and those of other cultures. Although different age ranges and numbers of populations under study may also contribute to these differences.

Our results further indicate that before the training, among the three dimensions of hypogonadism, the highest and lowest scores were seen in the physical and sexual dimensions, respectively. The few studies that have examined this topic approve these findings. In 2013, Chen et al. [37] conducted a study on the association between emotional distress and severity of aging males’ symptoms, and observed that the highest scores were related to the physical dimension (16.4) and the lowest scores were gained in the sexual dimension (11.7). In line with these results, in 2015, Khosravi et al. [29] investigated the life experience of andropause in men and presented interventional solutions for promoting health; the highest and lowest scores were achieved in the physical (12.04) and sexual (8.29) dimensions, respectively. Upon comparing these results and the current study’s results, we may conclude that physical symptoms have the greatest frequency and severity, and are among males’ most important problems during hypogonadism, which warrant educational and supportive measures in this field.

Based on the current study’s results, no significant difference was observed between the mean hypogonadism dimensions of the control group before and after the intervention. On the contrary, this statistic had significantly differed in the intervention group, which indicates the effectiveness of the educational intervention. According to these results, the computer-based training reduced the severity of menopause symptoms. Becker et al. [38] examined the effect of the computer-based consultation program on promoting physical function in people affected with chronic diseases in 2011, and observed significant changes in the domains under study; emotional and cognitive attitude had also changed. So far, many interventional studies have been conducted on the effect of medical measures such as testosterone therapy on improving hypogonadism symptoms. However, we found no intervention in which computer-based or any other type of training has been used to reduce the severity of hypogonadism symptoms.

The current study has certain limitations, one of which was not measuring the serum testosterone level; the AMS screening tool was used to investigate the clinical symptoms. Another limitation is the site of study, i.e. Tehran University of Medical Sciences, which limits the generalizability of the results. Therefore, we recommend performing a similar study in another environment. Moreover, the intervention duration was short and it may be said that the intervention had a temporary effect, thus, we recommend prolonging the duration to assess the sustainability of the effect. Lastly, we are aware of the closeness of obesity to hypogonadism, however, we could not assess it in this study, hence, becoming another limitation.

Conclusions

Overall, bearing in mind the outcomes of hypogonadism and its high incidence on one hand, and the ease of executing such programs on the other, we may conclude that exploiting novel educational methods such as computer-based training is somewhat necessary for minimizing the negative effects of hypogonadism on males’ QoL. Therefore, we recommend including this educational intervention in men’s health promotion programs. Moreover, we would suggest performing a similar study with a larger sample size to achieve results that are more generalizable.

Acknowledgements

This article is the by-product of a dissertation for a master’s degree in community-based midwifery and a research project approved by Tehran University of Medical Sciences (TUMS) under number 26288, which has received financial support from the Vice Chancellor for Research. We would hereby like to thank the authorities at TUMS and all the participants for lending us their valuable time.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was funded by Tehran University of Medical Sciences and Health Services.