{"paper_id":"b535b258-bd05-4805-bdad-a194537205b5","body_text":"ARTICLE | Article in Press\nScientific Reports https://doi.org/10.1038/s41598-026-73552-1\nScientific Reports\nThis Article in Press is shared early to give you faster access to new research. It is citable and carries a permanent DOI. \nThe final edited version will replace it automatically.\nEffect of nursing care program on healthy lifestyle \nbehaviours and quality of life in women with \nendometriosis: a randomised controlled trial\nAyse Gul Bursa · Nevin Sahin\nReceived: 26 February 2025 / Accepted: 23 September 2026\n© The Author(s) 2026\nAbstract\nThis study was conducted to determine the effect of Endometriosis Nursing Care Program (ENCP), developed \nin line with Health Promotion Model for women with endometriosis, on women's quality of life and healthy \nlifestyle behaviours. This prospective, single-centre, randomized controlled trial was conducted with 46 women \ndiagnosed with endometriosis who applied to the Endometriosis Outpatient Clinic of a training research hos -\npital. Women with an Endometriosis Health Profile Questionnaire-5 (EHP-5) score ≥ 22 indicating reduced \nquality of life were included. Participants were randomly assigned to an intervention group (n = 23) receiving \nEndometriosis Nursing Care Program (ENCP) or a control group (n = 23) receiving routine care. The ENCP \nconsisted of two individual 60-min sessions delivered two weeks apart. The primary outcome was change \nin quality of life measured by EHP-5. Secondary outcomes included healthy lifestyle behaviours measured \nby Health Promoting Lifestyle Profile II (HPLP-II). Data were analysed using parametric or non-parametric \nstatistical tests, as appropriate. Statistical significance was set at p < 0.05. Forty-six women completed the \nstudy (23 intervention, 23 control). The mean EHP-5 score in the intervention group decreased significantly \nfrom 61.8 ± 11.4 to 32.1 ± 18.7; Cohen's d = − 1.71, p < 0.001 after the intervention, while no significant change \nwas observed in the control group ( p > 0.05). HPLP-II total scores significantly increased in the ENCP group \n(132.04 ± 19.81 vs 164.17 ± 18.83; Cohen's d = 1.58, p < 0.001). ENCP significantly improved quality of life in \nwomen with endometriosis and resulted in increased scores on healthy lifestyle behaviours. Structured nursing \ninterventions may play an important role in comprehensive endometriosis care.\nTrial registration NCT05402943 Date of registration: 02.06.2022.  h t t p s : / / c l i n i c a l t r i a l s . g o v / s t u d y / N C T 0 5 4 0 2 \n9 4 3 ? t e r m = N C T 0 5 4 0 2 9 4 3 & r a n k = 1     .  \nKeywords Endometriosis · Health promotion model · Healthy lifestyle behaviours · Nursing care · Quality \nof life\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nIntroduction\nEndometriosis is a chronic disease defined by the settlement of the endometrial gland and stroma, which form \nthe innermost layer of the uterus, anywhere in the body 1. Although endometriosis, which negatively affects the \nphysical, mental and social well-being of women, is mainly seen during the reproductive period, it can also be \nseen in preadolescent, perimenopausal and postmenopausal periods 2,3. Its estimated prevalence is around 10% \nworldwide, corresponding to 176 million women 2. Although the etiology of endometriosis is not fully known, \nmany theories have been produced to explain its formation. The most accepted of these theories is Sampson's \ntheory of retrograde menstruation,It is believed that the endometrial tissues which shed during menstruation settle \nin the peritoneal cavity through the tubes with reverse flow and maintain their vitality4.\nThe most common symptoms of endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain and infer-\ntility. However, it may cause symptoms related to the organ system in which it is located 2,3. The quality of life \nof women with endometriosis is greatly impaired due to the chronic pain they experience. Diagnosis is often \ndelayed, and treatment is typically long-term. The fact that it may cause infertility and negatively affect work \nand family relationships are important causes of concern. Women often require support to adapt to living with \nendometriosis. Women who do not receive adequate support or who lack sufficient knowledge about the disease \nmay experience feelings of loneliness, disappointment, and social isolation4–6.\nPrevious research has demonstrated that women with endometriosis often experience reduced quality of life \ndue to persistent pain, psychological stress, and limitations in social and occupational functioning. Although \nmedical and surgical treatments are commonly used, supportive care interventions aimed to improving lifestyle \nbehaviours and symptom management remain limited. Nursing-based educational and behavioural interventions \nmay help women better manage symptoms, adopt healthier lifestyle behaviours and improve quality of life. The \nHealth Promotion Model provides a theoretical framework for designing such interventions. However, evidence \nregarding structured nursing care programs for women with endometriosis remains scarce. Therefore, this ran -\ndomized controlled trial aimed to evaluate the effect of an Endometriosis Nursing Care Program developed based \non the Health Promotion Model on quality of life and healthy lifestyle behaviours in women with endometriosis.\nMaterials and methods\nStudy design\nThis study was designed as a prospective, single-centre, randomized controlled trial reported in accordance with \nCONSORT guidelines.\nSetting and sample\nThe study was conducted at the Endometriosis Outpatient Clinic of a training and research hospital in Türkiye \nbetween May 2021 and May 2022. Women aged 20–45 years diagnosed with endometriosis were assessed for \neligibility. Endometriosis diagnosis was confirmed according to national clinical guidelines and based on previ-\nous laparoscopic diagnosis or clinical evaluation documented in medical records. Participants scoring ≥ 22 on \nthe Endometriosis Health Profile Survey (EHP-5), indicating reduced quality of life, were included. According \nto previous validation studies of the EHP-5 scale, a score of 22 or higher indicates reduced quality of life among \nwomen with endometriosis. G* Power (3.1) program was used to calculate the sample size. According to the \nstatistical analysis based on the results of the validity and reliability study of the EHP-5 questionnaire conducted \nby Selcuk et al.7 sample size calculation was made. With an estimated medium to large effect size of 0.80 based \non Selcuk et al.7, one-tailed test, α = 0.05, power of 0.80, and a 1:1 allocation ratio, the minimum sample size was \n42 participants (n = 21 for each group). To account for potential attrition, the calculated sample size was increased \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nby approximately 24%, resulting in the recruitment of 52 participants. In the intervention group, one participant \nbecame pregnant and two participants relocated to another city. In the control group, three participants became \npregnant during the study period. Consequently, the final analysis included 46 participants, with 23 women in the \nintervention group and 23 women in the control group. Participant recruitment, randomization, follow-up, and \nanalysis are illustrated in the CONSORT flow diagram (Fig. 1)8. The study was reported in accordance with the \nCONSORT guidelines for randomized controlled trials.\nSampling inclusion and exclusion criteria\nWomen diagnosed with endometriosis, of reproductive age, and with an EHP-5 score ≥ 22 were eligible for \ninclusion. Women with communication impairments or diagnosed with a psychiatric disease were not included. \nWomen who became pregnant during the study (n = 4) were excluded from the study. The intervention was con-\nducted face-to-face; therefore, participants who relocated outside the city during the study period were excluded \nfrom the study.\nRandomization\nParticipants were randomly assigned to either the intervention or control group using a computer-generated ran-\ndom allocation sequence with a 1:1 allocation ratio. No restrictions, such as blocking or stratification, were \napplied. The randomization sequence was generated by an independent researcher who was not involved in \nparticipant recruitment or intervention delivery. Eligible participants were enrolled by the principal investiga -\ntor before group allocation was revealed. To ensure allocation concealment, group assignments were placed in \nsequentially numbered, opaque, sealed envelopes. After enrolment, each participant selected an envelope, and \nFig. 1 CONSORT 2010 flow diagram of participant recruitment, randomization, follow-up, and per-protocol analysis.\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nonly the researcher responsible for allocation opened the envelope to reveal the group assignment. Participants \nwere not informed about the allocation sequence or assignment procedure before randomization.\nMeasures and instruments\nDemographic and health questionnaire\nThe questionnaire was developed based on the literature and consisted of six sections comprising 50 questions \ncovering participants' sociodemographic characteristics, general medical history, obstetric history, menstrual his-\ntory, endometriosis history, sexual history, and infertility history9–11.\nEndometriosis health profile questionnaire-5 (EHP-5)\nIt is the short version of the Endometriosis Health Profile Questionnaire-30 (EHP-30), created in 2004, which \nwas first developed by Jones et al. in 2001 to assess the impact of Endometriosis on women's quality of life. The \nEHP-5 questionnaire consists of core (pain, control and powerlessness, emotional well-being, social support and \nbody image) and modular (work life, relationship with children, sexual life, health professionals, treatment and \ninfertility) sections. Each item is scored as 0, 1, 2, 3 and 4 on a four-point scale and corresponds to the options \nnever, rarely, sometimes, often and always, respectively. The total score ranges from 0 to 44. An increase in the \nscore obtained from EHP-5 is an indicator of a decrease in quality of life12. Women who scored 22 and above on \nthe scale were considered to have a low quality of life. The Turkish validity and reliability study of the question-\nnaire was conducted in 2015 and Cronbach’s alpha value was found to be 0.885 for the core section and 0.896 for \nthe modular section7 In this study, Cronbach’s alpha value was found to be 0.657 for the core section and 0.764 \nfor the modular section.\nHealth promoting lifestyle Profile II (HPLP-II)\nIt was developed by Walker et al. in 1987 in line with Pender's Health Promotion Model13. The scale was revised \nin 1996 and named Health Promoting Lifestyle Profile II (HPLP-II), which consists of six factors and 52 items. \nThe scale comprises six subscales: health responsibility, physical activity, nutrition, self-actualization, interper -\nsonal relations and stress management. This scale is used to determine healthy lifestyle behaviours and measure \nthe effectiveness of interventions in this direction. On a 4-point Likert scale, the lowest score is 52 and the highest \nscore is 208. An increase in the scale score is an indicator of increased healthy lifestyle behaviours14. The Turkish \nvalidity and reliability study of the scale was conducted by Bahar et al. in 2008. The Cronbach Alpha coefficient \ndetermined in the Turkish version and in this study was found to be 0.92 at a high level of reliability15.\nFeedback form for endometriosis nursing care program\nThe feedback form was developed by the researchers from 16 questions in line with the literature16. The content \nof the form, which consists of 16 questions in total, includes women's satisfaction with the program, its effect on \nendometriosis-related symptoms, the status of doing the recommended practices, the reason for not doing them, \nand suggestions for improving the ENCP Program.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nData collection and procedure\nData collection\nThe study was conducted among women who applied to the Endometriosis clinic and were diagnosed with \nendometriosis. Participants were approached individually by the researcher, and written informed consent was \nobtained. It was explained that they could withdraw from the study at any time. Women with an EHP-5 score ≥ 22, \nindicating reduced quality of life, were included in the study. Eligible participants were scheduled for the first \nintervention session. The sessions were delivered individually in a face-to-face format. Before randomization, \npotential participants who met the eligibility criteria were told that there was a study on endometriosis. No \ninformation about ENCP was given. None of the participants knew that they would receive possible care for \nendometriosis. ENCP sessions were conducted individually by a researcher trained in endometriosis care in two \nsessions lasting approximately 60 min, two weeks apart. Outcome measurements were conducted eight weeks \nafter completion of intervention. The study design and intervention procedure are illustrated in Fig. 2.\nEndometriosis nursing care program developed in line with the Health Promotion Model\nThe Health Promotion Model was developed by Pender in 1987 and revised in 1996. The aim of the model is to \nexplain the components of healthy lifestyle behaviours and to evaluate the factors that may affect the individual's \nexperiences and perceptions of health behaviours 16. ENCP was developed by researchers in line with Pender's \nHealth Promotion Model17,18. ENCP was created in accordance with the three components of the Health Promo-\ntion Model (individual characteristics, behavior-specific concepts/effects, and behaviour emergence), personal -\nized according to women's experiences and individual characteristics, and implemented through one-on-one, \nFig. 2 Study design and intervention procedure\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nface-to-face sessions. In the model, all aspects of healthy lifestyle behaviours—nutrition, physical activity, sleep, \nsexual life, stress management, and interpersonal relationships—were addressed in the sessions. ENCP sessions \nwere conducted by a researcher who was a nurse specializing in women's health and trained in endometriosis \ncounselling and health promotion interventions. ENCP sessions were scheduled at times convenient for par -\nticipants. ENCP was completed with two approximately 60-min sessions, two weeks apart. The applied ENCP \ncontent and modules are shown in Table 1.\nENCP group consisted of women with endometriosis who received ENCP developed in line with the Health \nPromotion Model. After all ENCP sessions were completed, a brochure containing information on healthy living \nin endometriosis prepared by the researcher was shared with ENCP group. The control group consisted of women \nwith endometriosis who did not undergo ENCP and received only routine care.\nData analysis\nThe analyses were performed using a per-protocol approach. An intention-to-treat analysis was not performed \nbecause post-intervention outcome data were unavailable for participants who became pregnant or relocated dur-\ning the follow-up period. Therefore, only participants who completed both the intervention and post-intervention \nassessments were included in the final analyses. Data were analysed using IBM SPSS Statistics for Windows, \nversion 20.0 (IBM Corp., Armonk, NY , USA). Normality of continuous variables was assessed using the Sha -\npiro–Wilk test. Between-group comparisons were performed using the independent samples t-test for normally \ndistributed variables and the Mann–Whitney U test for non-normally distributed variables. Within-group com -\nparisons were performed using the paired t-test for normally distributed variables and the Wilcoxon signed-rank \ntest for non-normally distributed variables. Statistical significance was set at p < 0.05.\nComponents \nof the model\nSteps of the \nmodel\nContents\nIndividual \nCharacter-\nistics and \nExperiences \n(1st Session)\nIndividual \ncharacteristics\nInformation about the definition of endometriosis, theories of its \noccurrence, risk factors, signs and symptoms, diagnostic tests, treat-\nment, complications,\nTalking about individual characteristics, conditions that may be risk \nfactors and the current treatment modality,\nDetermination of factors affecting quality of life,\nTalking about past experiences of relieving endometriosis symptoms\nExperiences\nBehaviour \nSpecific \nCognitive \nFactors (1st \nand 2nd \nSessions)\nBenefits Discussing the importance and benefits of healthy lifestyle behaviours \n(nutrition, physical activity, sleep, sexual life, stress management, and \nhealth responsibility) in endometriosis\nObstacles Discussing; What are the possible negative effects of healthy lifestyle \nbehaviours, what are the obstacles that an individual may face in the \nimplementation of these behaviours in daily life, what can be done to \nremove obstacles\nSelf-efficacy- \ncompetence\nAdopting the benefits of healthy lifestyle behaviours, believing that \nthey will improve quality of life, and feeling competent to take action\nInterpersonal \ninteraction\nIn this process, talking about the importance of family, friend and peer \nsupport and being together with people who will support the individual\nActivity-related \neffect\nPromoting positive thinking about initiating and maintaining \nbehaviour\nSituational effects Organization of the environment and conditions in which the indi-\nvidual lives in order to ensure the formation and maintain the healthy \nlifestyle behaviours; ensuring harmony\nBehaviour \nOutput (2nd \nSession \nand Final \nEvaluation)\nMeeting urgent \nrequirements and \npreferences\nMaking plans for; improving quality of life and creating and maintain-\ning healthy lifestyle behaviour\nPlanning for the \nbehaviour\nTable 1 Health Promo-\ntion Model Components of \nNursing Care Program in \nEndometriosis and the Steps \nof the Model.\n \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nHuman subjects protection\nEthics committee approval for the research was received from Istanbul Cerrahpasa Medical Faculty Clinical \nResearch Ethics Committee with the number 13022260-300-141369. A work permit was obtained from the rel -\nevant institutions. All participants were asked to sign voluntary consent documents. All procedures of the study \nwere carried out in accordance with the Declaration of Helsinki. After completion of data collection, participants \nin the control group were also offered the ENCP intervention for ethical reasons. The study was registered at \nClinicalTrials.gov (NCT05402943).\nResults\nThe baseline characteristics of the participants are presented in Table 2. ENCP and control groups were compa-\nrable to each other in terms of general characteristics.\nTable 3 shows the comparison of the EHP-5 total and sub-dimension scores and pre-test and post-test scores of \nthe ENCP and control groups. No significant difference was found between the pre-test EHP-5 scale total score \nand sub-dimension scores in the ENCP and control groups ( p > 0.05). While no significant difference was found \nbetween the pre-test and post-test mean scores in the control group (p > 0.05), a significant difference was found \nbetween the pre-test and post-test scores and the total scores of all sub-dimensions of the EHP-5 scale in the ENCP \nTable 2 Baseline characteristics of participants of ENCP and control groups.\nVariables ENCP Group Control Group χ2 P\nn % n %\nAge\n  Between 20 and 32 years 14 66.9 13 56.5 1.000**\n  Between 33 and 45 years 9 39.1 10 43.5\nBMI\n  ≤ 24,99 13 56.5 13 56.5 1.000**\n  ≥ 25,0 10 43.5 10 43.5\nMarital status\n  Married 18 78.3 14 60.9 0.337**\n  Single 5 21.7 9 39.1\nEducational level\n  High school and below 11 47.8 10 43.5 1.000**\n  University and above 12 52.2 13 56.5\nEmployment status\n  Working 11 47.8 12 52.2 1.000**\n  Not working 12 52.2 11 47.8\nEconomic situation\n  Low 2 8.7 2 8.7 1.619 0.665*\n  Middle 15 65.2 12 52.2\n  High 6 26.1 9 39.1\nFamily type\n  Elementary family 19 82.6 20 87.0 1.000**\n  Extended family 4 17.4 3 13.0\nPain during menstrual period\n  Yes 22 95.7 17 73.9\n  Occasionally 1 4.3 6 26.1 0.96**\nPain during/after coitus\n  Yes 16 80 13 72.2 0.709**\n  No 4 20 5 27.8\n*Pearson Chi-Square Test, **Fisher Exact Test, ***Mann Whitney U Test.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\ngroup (p < 0.05). When the post-tests of the control and ENCP groups were compared, a significant difference \nwas found in the total EHP-5 scores ( p < 0.05). No significant difference was observed in the sub-dimensions of \nrelationship with children, medical profession and infertility ( p > 0.05). The post-intervention EHP-5 total score \nwas significantly lower in the ENCP group than in the control group (mean difference = − 26.1, 95% CI − 35.2 \nto − 17.0, Cohen’s d = − 1.71, p < 0.001).\nTable 4 shows the comparison of pre-test and post-test HPLP-II total score and sub-dimension scores of ENCP \nand control groups. No significant difference was found between pre-test and post-test HPLP-II total score and \nsub-dimension scores in ENCP and control groups ( p > 0.05). While there was a significant difference between \npre-test and post-test mean scores in the nutrition and self-actualization sub-dimensions in the control group, \nno significant difference was found in the other sub-dimensions ( p > 0.05). In the ENCP group, a significant \ndifference was found between pre-test and post-test in terms of all sub-dimensions and total scores of HPLP-II \n(p < 0.05). Significant differences were found in the total and all sub-dimensions in the HPLP-II post-tests of the \nTable 3 Comparison of EHP-5 scores of ENCP and control groups.\nEHP-5 Scale Sub-dimensions Pre-test Post-test Z p*\nMean Standard deviation Mean Standard deviation\nPain ENCP 69.56 24.95 33.69 33.37  − 3.530  < 0.001\nControl 63.04 27.04 54.34 28.85  − 1.384 0.16\nTest Score Z = − 0.758 p** = 0.44 Z = − 2.097 p** = 0.03\nControl and powerlessness ENCP 78.26 18.92 42.39 32.36  − 3.424 0.001\nControl 71.17 22.50 75.0 22.61  − 0.535 0.59\nTest Score Z = − 0.059 p** = 0.95 Z = − 3.297 p** = 0.001\nEmotional well-being ENCP 82.60 20.55 45.65 26.81  − 3.603  < 0.001\nControl 80.43 16.78 79.34 20.85  − 0.264 0.79\nTest Score Z = − 0.686 P** = 0.49 Z = − 3.998 P** = < 0.001\nSocial support ENCP 66.3 34.21 29.34 28.85  − 3.574  < 0.001\nControl 70.65 32.55 67.39 23.15  − 0.555 0.57\nTest Score Z = − 0.458 P** = 0.64 Z = − 3.915 P** = < 0.001\nSelf-image ENCP 58.69 40.31 29.34 29.82  − 3.272 0.001\nControl 69.56 35.32 71.73 30.43  − 0.491 0.62\nTest Score Z = − 0.906 P** = 0.36 Z = − 3.902 P** = < 0.001\nWorking life ENCP 60.86 33.56 25.0 26.11  − 3.666  < 0.001\nControl 51.08 41.61 47.82 36.08  − 0.905 0.36\nTest Score Z = − 0.722 P** = 0.47 Z = − 2.147 P** = 0.03\nRelationship with children ENCP 31.52 36.32 14.13 22.39  − 2.859 0.004\nControl 23.91 34.11 22.82 33.63  − 0.577 0.56\nTest Score Z = − 0.682 P** = 0.49 Z = − 0.532 P** = 0.59\nIntercourse ENCP 69.56 35.32 41.3 33.37  − 3.035 0.002\nControl 64.13 40.47 61.95 38.33  − 0.816 0.41\nTest Score Z = − 0.162 P** = 0.87 Z = − 2.205 P** = 0.02\nMedical profession ENCP 26.08 26.62 11.95 18.26  − 2.812 0.005\nControl 18.47 32.17 27.17 35.28  − 1.994 0.04\nTest Score Z = − 1.317 P** = 0.18 Z = − 1.254 P** = 0.21\nTreatment ENCP 66.3 33.37 34.78 31.74  − 3.224 0.001\nControl 68.47 34.72 73.91 29.65  − 0.929 0.35\nTest Score Z = − 0.365 P** = 0.71 Z = − 3.683 P** = < 0.001\nInfertility ENCP 70.65 38.17 45.65 41.73  − 3.097 0.002\nControl 60.86 45.74 58.69 45.6  − 1.414 0.15\nTest Score Z = − 0.503 P** = 0.61 Z = − 1.242 P** = 0.21\nEHP-5 total score ENCP 61.8 11.4 32.1 18.7  − 4.171  < 0.001\nControl 58.8 7.9 58.2 10.9  − 0.460 0.64\nTest Score Z = − 0.731 p** = 0.465 Z = − 4.423 p** = < 0.001\n*Wilcoxon Test, **Mann Whitney U Test.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\ncontrol and ENCP groups (p < 0.05). Similarly, the post-intervention HPLP-II total score was significantly higher \nin the ENCP group than in the control group (mean difference = 33.0, 95% CI 20.6 to 45.5, Cohen’s d = 1.58, \np < 0.001).\nAll of the women (n = 23) who received the intervention in the study reported that they were satisfied with the \nENCP and that their level of knowledge about endometriosis increased with the ENCP.\nDiscussion\nEndometriosis is a complex disease that negatively affects women's quality of life. The aim of endometriosis \ntreatment is to improve women's quality of life, reduce pain and manage endometriosis. Several studies have \ninvestigated the quality of life of women with endometriosis. Evidence regarding nursing interventions designed \nto improve quality of life remains limited. In this study, baseline characteristics were comparable between groups, \nsuggesting that potential confounding factors were similarly distributed. This similarity between groups strength-\nens the interpretation that the improvements observed in the intervention group may be related to the ENCP \nintervention.\nSince there is no definitive treatment for endometriosis, the primary goal of supportive care is to minimise \nsymptoms and improve quality of life. There are some programs developed in line with the Health Promotion \nModel in the care of cases with endometriosis 11,19. In a study aiming to evaluate the effect of nursing strategies \nin alleviating symptoms associated with endometriosis, the change in quality of life was evaluated before and \nthree months after the intervention. It was determined that strategies consisting of three components including \ndiet, exercise and stress management increased the quality of life of women in all sub-dimensions of the EHP-5 \nquestionnaire compared to the control group 11. Our findings are consistent with those reported by Yousif et \nal.11. The present study demonstrated significant improvements in quality of life, as reflected by lower EHP-5 \ntotal and subdomain scores in the ENCP group. (Before intervention: 61.8 ± 11.4 After intervention: 32.1 ± 18.7, \nTable 4 Comparison of the ENCP and control groups' HPLP-II scores.\nHPLP-II Scale Sub-dimensions Pre-test Post-test t p*\nMean Standard deviation Mean Standard deviation\nHealth Responsibility ENCP 23.0 4.49 28.30 3.33  − 7.75⸸  < 0.001*\nControl 23.26 5.31 23.13 4.84  − 0.70⸸⸸ 0.48**\nTest score t = − 0.18 p* = 0.85 t = 4.21 p* = < 0.001\nPhysical Activity ENCP 15.17 5.28 22.39 5.59  − 6.12⸸  < 0.001*\nControl 17.08 6.13 16.08 4.65 1.23⸸ 0.23*\nTest score t = − 1.13 p* = 0.26 t = 4.15 p* = < 0.001\nNutrition ENCP 20.52 3.89 25.86 4.19  − 4.20⸸⸸  < 0.001**\nControl 21.13 4.92 20.34 4.30 2.35⸸ 0.02*\nTest score t = − 0.46 p* = 0.64 Z = − 3.76 p** = < 0.001\nSelf-actualization ENCP 27.04 5.13 31.47 3.32  − 5.61⸸  < 0.001*\nControl 25.91 5.47 27.00 4.88  − 2.63⸸ 0.01*\nTest score t = 0.72 p* = 0.47 t = 3.63 p* = 0.001\nInterpersonal relations ENCP 26.60 3.34 31.30 2.75  − 4.21⸸⸸  < 0.001**\nControl 25.21 4.95 25.86 4.25  − 1.57⸸ 0.13*\nTest score t = 1.11 p* = 0.27 Z = − 4.03 p** = < 0.001\nStress Management ENCP 19.69 4.23 24.82 3.82  − 8.14⸸  < 0.001*\nControl 18.60 5.21 18.73 4.07  − 0.30⸸ 0.76*\nTest score t = 0.77 p* = 0.44 t = 5.22 p* = < 0.001\nHPLP-II Total Score ENCP 132.04 19.81 164.17 18.83  − 11.36⸸  < 0.001*\nControl 131.21 25.46 131.17 22.86 0.02⸸ 0.98*\nTest score t = 0.12 p* = 0.90 t = 5.34 p* = < 0.001\n⸸t value, *Dependent Samples, T-test, ⸸⸸Z value, **Wilcoxon Test.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\np < 0.001) (Table 3). When the post-test EHP_5 scores of the control and ENCP groups were compared, it was \nfound that there was no significant difference in the relationship with children, medical profession and infertility \nsub-dimensions. The individually delivered ENCP significantly improved the quality of life of women with endo-\nmetriosis in terms of pain, control and powerlessness, emotional well-being, social support, self-image, working \nlife, relationships with children, sexual intercourse, relationships with health professionals, treatment and infer -\ntility. However, these findings should be interpreted with caution because multiple statistical comparisons were \nperformed across the EHP-5 subdomains, which may have increased the likelihood of Type I error.\nAll behaviours that affect the physical, mental and social well-being of individuals are defined as healthy \nlifestyle behaviours. Endometriosis negatively affects women's physical, mental and social health and impairs \ntheir quality of life. Developing healthy behaviours in women with endometriosis supports women to take more \nactive roles and responsibilities in issues that will affect their entire lives20. Although there are studies indicating \nthat developing healthy life behaviours in women with endometriosis may be beneficial, the number of studies \nexamining this issue is quite limited. Yousif et al. 11 examined the effect of the strategy they applied within the \nscope of diet, exercise and stress management, which are among healthy lifestyle behaviours. In their study, the \ntotal scores of HPLP-II showed a statistically significant increase in ENCP group after the intervention compared \nto the scores before the intervention (before: 151.42 ± 8.3, after: 160.23 ± 4.31), but no significant difference \nwas found in the control group (before intervention: 127.65 ± 9.1, after intervention: 125.46 ± 6.82)11. A study \nexamining the effect of diet, exercise and stress management training based on the Health Promotion Model on \nthe lifestyle of women with endometriosis found an increase in HPLP-II scores in women who received train -\ning (Abd-Elaziz et al. 2021). In Ghonemy and El Sharkawy 21 study, it was determined that educational training \nfor lifestyle change was effective in reducing the pain of women with endometriosis. Our findings are consis -\ntent with previous studies. A significant improvement was observed in the HPLP-II total and all sub-dimension \nscores of the ENCP group before and after the intervention (Pre-intervention: 132.04 ± 19.81 Post-intervention: \n164.17 ± 18.83, p < 0.001). Although there was no significant difference between the pre-test and post-test in \nthe HPLP-II total scores of the control group, a difference was observed in the nutrition and self-actualization \nsub-dimension scores of the post-test scores in comparison to the pre-test scores (Table 4). This finding may be \nexplained by the increased awareness generated through repeated interactions and discussions with participants \nduring the study. When the post-test scores of ENCP and control groups were analysed, it was observed that there \nwas a difference between the scores and that the intervention was effective (Table 4).\nThe ENCP implemented in the present study aimed to improve quality of life and promote healthy lifestyle \nbehaviours among women with endometriosis. As reported in previous studies, meeting women's informational \nneeds and encouraging their active participation in treatment and care enable women to take a more active role in \ndisease management20. With ENCP, women demonstrated improvements in pain, dyspareunia, work life, health \nresponsibility, physical activity, nutrition, interpersonal relationships, and stress management (Table 4). In con-\nclusion, the implemented ENCP had a positive impact on women with endometriosis, leading to increased healthy \nlifestyle behaviour scores and improved quality of life in areas such as health responsibility, physical activity, \nnutrition, self-actualization, interpersonal relationships, and stress management. By considering women's indi -\nvidual characteristics, previous experiences, perceived benefits, and barriers, ENCP may help women acquire \ndisease-related knowledge, gain a greater sense of control, and develop effective coping strategies. Educating the \ntarget group and raising awareness is an important step in eliminating endometriosis-related symptoms and early \ndiagnosis22. All women in the intervention group reported that ENCP increased their knowledge of endometrio-\nsis. These findings suggest that ENCP can support women to increase their level of knowledge and their efforts \nto accept the disease and improve their quality of life.\nOur findings are consistent with previous studies reporting that healthy lifestyle interventions, including diet, \nexercise, and stress management, improve healthy lifestyle behaviour scores in women with endometriosis. \nHowever, unlike earlier studies that typically focused on a limited number of lifestyle components, the present \nmodel incorporates multiple dimensions of healthy lifestyle behaviours, including nutrition, physical activity, \nsleep patterns, sexual health, stress management and interpersonal relationships. Moreover, the intervention was \n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nspecifically designed for women with endometriosis, which enhances its clinical relevance and applicability. \nAccordingly, this model may serve as a comprehensive and practical supportive care strategy that can be inte -\ngrated into routine clinical practice to improve the management and quality of life of women living with endome-\ntriosis. This study contributes to the limited evidence regarding structured nursing interventions for women with \nendometriosis, particularly those developed according to the Health Promotion Model. Although the intervention \ndemonstrated positive effects, it should be acknowledged that participants in the intervention group had substan-\ntially more contact time with the researcher than those in the control group. Therefore, part of the observed ben-\nefit may be attributable to increased researcher–participant interaction rather than the educational content alone. \nIn addition, the findings were based primarily on patient-reported outcome measures. Although pain was assessed \nusing the pain domain of the EHP-5, future studies incorporating objective clinical outcomes and treatment-\nrelated measures would provide a more comprehensive evaluation of intervention effectiveness.\nConclusions\nENCP significantly improved the quality of life in women with endometriosis and resulted in increased scores \non healthy lifestyle behaviours. Structured nursing interventions may play an important role in comprehensive \nendometriosis care. These findings contribute to the growing evidence supporting nurse-led interventions in \ncomprehensive endometriosis management and support the integration of structured nursing programs into mul-\ntidisciplinary care models.\nRecommendations\nWomen with endometriosis should be provided with comprehensive education regarding their disease and actively \ninvolved in treatment and care planning. In addition, awareness of endometriosis should be increased among both \nthe general public and healthcare professionals, and certification programmes should be implemented to improve \nthe quality of care. Future multicentre studies with larger sample sizes and longer follow-up periods are recom -\nmended to evaluate the sustainability of intervention effects. Furthermore, future research should collect detailed \ndisease-related characteristics, including disease stage, phenotype, previous surgery, hormonal treatment status, \nand infertility history.\nLimitations\nThe study has several limitations. The relatively small sample recruited from a single centre may limit the gen -\neralizability of the findings. In addition, a per-protocol analysis was performed because participants who became \npregnant or relocated after randomization could not complete follow-up assessments. Finally, the short follow-up \nperiod precluded evaluation of the long-term sustainability of the intervention effects.\nAuthor contributions Ayse Gul Bursa, Nevin Sahın.\nFunding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit \nsectors.\nData availability This study data is not shared openly to ensure the confidentiality of the participants. If necessary, it can be \nrequested from the responsible author.\nDeclarations\nCompeting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or \npublication of this article.\n\n\nArticle in Press\nScientific Reports\nhttps://doi.org/10.1038/s41598-026-73552-1\nEthics statement Ethics committee approval for the research was received from Istanbul Cerrahpasa Medical Faculty \nClinical Research Ethics Committee with the number 13022260-300-141369. A work permit was obtained from the relevant \ninstitutions. All participants were asked to sign voluntary consent documents. The study was carried out in accordance with \nthe Declaration of Helsinki. After completion of data collection, participants in the control group were offered the ENCP \nintervention and educational brochure for ethical reasons. The trial was registered at ClinicalTrials.gov (NCT05402943).\nOpen Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna-\ntional License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as \nlong as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, \nand indicate if you modified the licensed material. You do not have permission under this licence to share adapted material \nderived from this article or parts of it. The images or other third party material in this article are included in the article’s Cre-\native Commons licence, unless indicated otherwise in a credit line to the material. 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Impact of changing lifestyle on endometriosis related pain. IOSR J. Nurs. Health \nSci. 6(2), 120–129. https://doi.org/10.9790/1959-060205120129 (2017).\n 22. Ahmed, G. A. E. & Radwan, E. M. N. Educational nursing program for improving nonmedical students’ awareness \ntoward endometriosis at Zagazig University. Egyptian J Health Care 12(3), 102–115.  h t t p s : / / d o i . o r g / 1 0 . 2 1 6 0 8 / E J H C . 2 0 \n2 1 . 1 8 7 0 4 0     (2021).\nPublisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional \naffiliations.\nAuthors and Affiliations\nAyse Gul Bursa1 · Nevin Sahin2\n Ayse Gul Bursa\naysegul.bursa@fbu.edu.tr\n1 Fenerbahçe University, Istanbul, Turkey\n2 Istanbul University-Cerrahpaşa, Istanbul, Turkey","source_license":"CC0","license_restricted":false}