Effect of nursing care program on healthy lifestyle behaviours and quality of life in women with endometriosis: a randomised controlled trial

This study was conducted to determine the effect of Endometriosis Nursing Care Program (ENCP), developed in line with Health Promotion Model for women with endometriosis, on women's quality of life and healthy lifestyle behaviours. This prospective, single-centre, randomized controlled trial was conducted with 46 women diagnosed with endometriosis who applied to the Endometriosis Outpatient Clinic of a training research hos - pital. Women with an Endometriosis Health Profile Questionnaire-5 (EHP-5) score ≥ 22 indicating reduced quality of life were included. Participants were randomly assigned to an intervention group (n = 23) receiving Endometriosis Nursing Care Program (ENCP) or a control group (n = 23) receiving routine care. The ENCP consisted of two individual 60-min sessions delivered two weeks apart. The primary outcome was change in quality of life measured by EHP-5. Secondary outcomes included healthy lifestyle behaviours measured by Health Promoting Lifestyle Profile II (HPLP-II). Data were analysed using parametric or non-parametric statistical tests, as appropriate. Statistical significance was set at p < 0.05. Forty-six women completed the study (23 intervention, 23 control). The mean EHP-5 score in the intervention group decreased significantly from 61.8 ± 11.4 to 32.1 ± 18.7; Cohen's d = − 1.71, p 0.05). HPLP-II total scores significantly increased in the ENCP group (132.04 ± 19.81 vs 164.17 ± 18.83; Cohen's d = 1.58, p < 0.001). ENCP significantly improved quality of life in women with endometriosis and resulted in increased scores on healthy lifestyle behaviours. Structured nursing interventions may play an important role in comprehensive endometriosis care. Trial 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 9 4 3 ? t e r m = N C T 0 5 4 0 2 9 4 3 & r a n k = 1 .

Endometriosis · Health promotion model · Healthy lifestyle behaviours · Nursing care · Quality of life Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1

Endometriosis is a chronic disease defined by the settlement of the endometrial gland and stroma, which form the innermost layer of the uterus, anywhere in the body 1. Although endometriosis, which negatively affects the physical, mental and social well-being of women, is mainly seen during the reproductive period, it can also be seen in preadolescent, perimenopausal and postmenopausal periods 2,3. Its estimated prevalence is around 10% worldwide, corresponding to 176 million women 2. Although the etiology of endometriosis is not fully known, many theories have been produced to explain its formation. The most accepted of these theories is Sampson's theory of retrograde menstruation,It is believed that the endometrial tissues which shed during menstruation settle in the peritoneal cavity through the tubes with reverse flow and maintain their vitality4. The most common symptoms of endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain and infer- tility. However, it may cause symptoms related to the organ system in which it is located 2,3. The quality of life of women with endometriosis is greatly impaired due to the chronic pain they experience. Diagnosis is often delayed, and treatment is typically long-term. The fact that it may cause infertility and negatively affect work and family relationships are important causes of concern. Women often require support to adapt to living with endometriosis. Women who do not receive adequate support or who lack sufficient knowledge about the disease may experience feelings of loneliness, disappointment, and social isolation4–6. Previous research has demonstrated that women with endometriosis often experience reduced quality of life due to persistent pain, psychological stress, and limitations in social and occupational functioning. Although medical and surgical treatments are commonly used, supportive care interventions aimed to improving lifestyle behaviours and symptom management remain limited. Nursing-based educational and behavioural interventions may help women better manage symptoms, adopt healthier lifestyle behaviours and improve quality of life. The Health Promotion Model provides a theoretical framework for designing such interventions. However, evidence regarding structured nursing care programs for women with endometriosis remains scarce. Therefore, this ran - domized controlled trial aimed to evaluate the effect of an Endometriosis Nursing Care Program developed based on the Health Promotion Model on quality of life and healthy lifestyle behaviours in women with endometriosis.

Study design This study was designed as a prospective, single-centre, randomized controlled trial reported in accordance with CONSORT guidelines. Setting and sample The study was conducted at the Endometriosis Outpatient Clinic of a training and research hospital in Türkiye between May 2021 and May 2022. Women aged 20–45 years diagnosed with endometriosis were assessed for eligibility. Endometriosis diagnosis was confirmed according to national clinical guidelines and based on previ- ous laparoscopic diagnosis or clinical evaluation documented in medical records. Participants scoring ≥ 22 on the Endometriosis Health Profile Survey (EHP-5), indicating reduced quality of life, were included. According to previous validation studies of the EHP-5 scale, a score of 22 or higher indicates reduced quality of life among women with endometriosis. G* Power (3.1) program was used to calculate the sample size. According to the statistical analysis based on the results of the validity and reliability study of the EHP-5 questionnaire conducted by Selcuk et al.7 sample size calculation was made. With an estimated medium to large effect size of 0.80 based on 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 42 participants (n = 21 for each group). To account for potential attrition, the calculated sample size was increased Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 by approximately 24%, resulting in the recruitment of 52 participants. In the intervention group, one participant became pregnant and two participants relocated to another city. In the control group, three participants became pregnant during the study period. Consequently, the final analysis included 46 participants, with 23 women in the intervention group and 23 women in the control group. Participant recruitment, randomization, follow-up, and analysis are illustrated in the CONSORT flow diagram (Fig. 1)8. The study was reported in accordance with the CONSORT guidelines for randomized controlled trials. Sampling inclusion and exclusion criteria Women diagnosed with endometriosis, of reproductive age, and with an EHP-5 score ≥ 22 were eligible for inclusion. Women with communication impairments or diagnosed with a psychiatric disease were not included. Women who became pregnant during the study (n = 4) were excluded from the study. The intervention was con- ducted face-to-face; therefore, participants who relocated outside the city during the study period were excluded from the study. Randomization Participants were randomly assigned to either the intervention or control group using a computer-generated ran- dom allocation sequence with a 1:1 allocation ratio. No restrictions, such as blocking or stratification, were applied. The randomization sequence was generated by an independent researcher who was not involved in participant recruitment or intervention delivery. Eligible participants were enrolled by the principal investiga - tor before group allocation was revealed. To ensure allocation concealment, group assignments were placed in sequentially numbered, opaque, sealed envelopes. After enrolment, each participant selected an envelope, and Fig. 1 CONSORT 2010 flow diagram of participant recruitment, randomization, follow-up, and per-protocol analysis. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 only the researcher responsible for allocation opened the envelope to reveal the group assignment. Participants were not informed about the allocation sequence or assignment procedure before randomization. Measures and instruments Demographic and health questionnaire The questionnaire was developed based on the literature and consisted of six sections comprising 50 questions covering participants' sociodemographic characteristics, general medical history, obstetric history, menstrual his- tory, endometriosis history, sexual history, and infertility history9–11. Endometriosis health profile questionnaire-5 (EHP-5) It is the short version of the Endometriosis Health Profile Questionnaire-30 (EHP-30), created in 2004, which was first developed by Jones et al. in 2001 to assess the impact of Endometriosis on women's quality of life. The EHP-5 questionnaire consists of core (pain, control and powerlessness, emotional well-being, social support and body image) and modular (work life, relationship with children, sexual life, health professionals, treatment and infertility) sections. Each item is scored as 0, 1, 2, 3 and 4 on a four-point scale and corresponds to the options never, rarely, sometimes, often and always, respectively. The total score ranges from 0 to 44. An increase in the score obtained from EHP-5 is an indicator of a decrease in quality of life12. Women who scored 22 and above on the scale were considered to have a low quality of life. The Turkish validity and reliability study of the question- naire was conducted in 2015 and Cronbach’s alpha value was found to be 0.885 for the core section and 0.896 for the modular section7 In this study, Cronbach’s alpha value was found to be 0.657 for the core section and 0.764 for the modular section. Health promoting lifestyle Profile II (HPLP-II) It was developed by Walker et al. in 1987 in line with Pender's Health Promotion Model13. The scale was revised in 1996 and named Health Promoting Lifestyle Profile II (HPLP-II), which consists of six factors and 52 items. The scale comprises six subscales: health responsibility, physical activity, nutrition, self-actualization, interper - sonal relations and stress management. This scale is used to determine healthy lifestyle behaviours and measure the effectiveness of interventions in this direction. On a 4-point Likert scale, the lowest score is 52 and the highest score is 208. An increase in the scale score is an indicator of increased healthy lifestyle behaviours14. The Turkish validity and reliability study of the scale was conducted by Bahar et al. in 2008. The Cronbach Alpha coefficient determined in the Turkish version and in this study was found to be 0.92 at a high level of reliability15. Feedback form for endometriosis nursing care program The feedback form was developed by the researchers from 16 questions in line with the literature16. The content of the form, which consists of 16 questions in total, includes women's satisfaction with the program, its effect on endometriosis-related symptoms, the status of doing the recommended practices, the reason for not doing them, and suggestions for improving the ENCP Program. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 Data collection and procedure Data collection The study was conducted among women who applied to the Endometriosis clinic and were diagnosed with endometriosis. Participants were approached individually by the researcher, and written informed consent was obtained. It was explained that they could withdraw from the study at any time. Women with an EHP-5 score ≥ 22, indicating reduced quality of life, were included in the study. Eligible participants were scheduled for the first intervention session. The sessions were delivered individually in a face-to-face format. Before randomization, potential participants who met the eligibility criteria were told that there was a study on endometriosis. No information about ENCP was given. None of the participants knew that they would receive possible care for endometriosis. ENCP sessions were conducted individually by a researcher trained in endometriosis care in two sessions lasting approximately 60 min, two weeks apart. Outcome measurements were conducted eight weeks after completion of intervention. The study design and intervention procedure are illustrated in Fig. 2. Endometriosis nursing care program developed in line with the Health Promotion Model The Health Promotion Model was developed by Pender in 1987 and revised in 1996. The aim of the model is to explain the components of healthy lifestyle behaviours and to evaluate the factors that may affect the individual's experiences and perceptions of health behaviours 16. ENCP was developed by researchers in line with Pender's Health Promotion Model17,18. ENCP was created in accordance with the three components of the Health Promo- tion Model (individual characteristics, behavior-specific concepts/effects, and behaviour emergence), personal - ized according to women's experiences and individual characteristics, and implemented through one-on-one, Fig. 2 Study design and intervention procedure Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 face-to-face sessions. In the model, all aspects of healthy lifestyle behaviours—nutrition, physical activity, sleep, sexual life, stress management, and interpersonal relationships—were addressed in the sessions. ENCP sessions were conducted by a researcher who was a nurse specializing in women's health and trained in endometriosis counselling and health promotion interventions. ENCP sessions were scheduled at times convenient for par - ticipants. ENCP was completed with two approximately 60-min sessions, two weeks apart. The applied ENCP content and modules are shown in Table 1. ENCP group consisted of women with endometriosis who received ENCP developed in line with the Health Promotion Model. After all ENCP sessions were completed, a brochure containing information on healthy living in endometriosis prepared by the researcher was shared with ENCP group. The control group consisted of women with endometriosis who did not undergo ENCP and received only routine care. Data analysis The analyses were performed using a per-protocol approach. An intention-to-treat analysis was not performed because post-intervention outcome data were unavailable for participants who became pregnant or relocated dur- ing the follow-up period. Therefore, only participants who completed both the intervention and post-intervention assessments were included in the final analyses. Data were analysed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY , USA). Normality of continuous variables was assessed using the Sha - piro–Wilk test. Between-group comparisons were performed using the independent samples t-test for normally distributed variables and the Mann–Whitney U test for non-normally distributed variables. Within-group com - parisons were performed using the paired t-test for normally distributed variables and the Wilcoxon signed-rank test for non-normally distributed variables. Statistical significance was set at p < 0.05. Components of the model Steps of the model Contents Individual Character- istics and Experiences (1st Session) Individual characteristics Information about the definition of endometriosis, theories of its occurrence, risk factors, signs and symptoms, diagnostic tests, treat- ment, complications, Talking about individual characteristics, conditions that may be risk factors and the current treatment modality, Determination of factors affecting quality of life, Talking about past experiences of relieving endometriosis symptoms Experiences Behaviour Specific Cognitive Factors (1st and 2nd Sessions) Benefits Discussing the importance and benefits of healthy lifestyle behaviours (nutrition, physical activity, sleep, sexual life, stress management, and health responsibility) in endometriosis Obstacles Discussing; What are the possible negative effects of healthy lifestyle behaviours, what are the obstacles that an individual may face in the implementation of these behaviours in daily life, what can be done to remove obstacles Self-efficacy- competence Adopting the benefits of healthy lifestyle behaviours, believing that they will improve quality of life, and feeling competent to take action Interpersonal interaction In this process, talking about the importance of family, friend and peer support and being together with people who will support the individual Activity-related effect Promoting positive thinking about initiating and maintaining behaviour Situational effects Organization of the environment and conditions in which the indi- vidual lives in order to ensure the formation and maintain the healthy lifestyle behaviours; ensuring harmony Behaviour Output (2nd Session and Final Evaluation) Meeting urgent requirements and preferences Making plans for; improving quality of life and creating and maintain- ing healthy lifestyle behaviour Planning for the behaviour Table 1 Health Promo- tion Model Components of Nursing Care Program in Endometriosis and the Steps of the Model. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 Human subjects protection Ethics committee approval for the research was received from Istanbul Cerrahpasa Medical Faculty Clinical Research Ethics Committee with the number 13022260-300-141369. A work permit was obtained from the rel - evant institutions. All participants were asked to sign voluntary consent documents. All procedures of the study were carried out in accordance with the Declaration of Helsinki. After completion of data collection, participants in the control group were also offered the ENCP intervention for ethical reasons. The study was registered at ClinicalTrials.gov (NCT05402943).

The baseline characteristics of the participants are presented in Table 2. ENCP and control groups were compa- rable to each other in terms of general characteristics. Table 3 shows the comparison of the EHP-5 total and sub-dimension scores and pre-test and post-test scores of the ENCP and control groups. No significant difference was found between the pre-test EHP-5 scale total score and sub-dimension scores in the ENCP and control groups ( p > 0.05). While no significant difference was found between the pre-test and post-test mean scores in the control group (p > 0.05), a significant difference was found between the pre-test and post-test scores and the total scores of all sub-dimensions of the EHP-5 scale in the ENCP Table 2 Baseline characteristics of participants of ENCP and control groups. Variables ENCP Group Control Group χ2 P n % n % Age Between 20 and 32 years 14 66.9 13 56.5 1.000** Between 33 and 45 years 9 39.1 10 43.5 BMI ≤ 24,99 13 56.5 13 56.5 1.000** ≥ 25,0 10 43.5 10 43.5 Marital status Married 18 78.3 14 60.9 0.337** Single 5 21.7 9 39.1 Educational level High school and below 11 47.8 10 43.5 1.000** University and above 12 52.2 13 56.5 Employment status Working 11 47.8 12 52.2 1.000** Not working 12 52.2 11 47.8 Economic situation Low 2 8.7 2 8.7 1.619 0.665* Middle 15 65.2 12 52.2 High 6 26.1 9 39.1 Family type Elementary family 19 82.6 20 87.0 1.000** Extended family 4 17.4 3 13.0 Pain during menstrual period Yes 22 95.7 17 73.9 Occasionally 1 4.3 6 26.1 0.96** Pain during/after coitus Yes 16 80 13 72.2 0.709** No 4 20 5 27.8 *Pearson Chi-Square Test, **Fisher Exact Test, ***Mann Whitney U Test. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 group (p < 0.05). When the post-tests of the control and ENCP groups were compared, a significant difference was found in the total EHP-5 scores ( p 0.05). The post-intervention EHP-5 total score was significantly lower in the ENCP group than in the control group (mean difference = − 26.1, 95% CI − 35.2 to − 17.0, Cohen’s d = − 1.71, p < 0.001). Table 4 shows the comparison of pre-test and post-test HPLP-II total score and sub-dimension scores of ENCP and control groups. No significant difference was found between pre-test and post-test HPLP-II total score and sub-dimension scores in ENCP and control groups ( p > 0.05). While there was a significant difference between pre-test and post-test mean scores in the nutrition and self-actualization sub-dimensions in the control group, no significant difference was found in the other sub-dimensions ( p > 0.05). In the ENCP group, a significant difference was found between pre-test and post-test in terms of all sub-dimensions and total scores of HPLP-II (p < 0.05). Significant differences were found in the total and all sub-dimensions in the HPLP-II post-tests of the Table 3 Comparison of EHP-5 scores of ENCP and control groups. EHP-5 Scale Sub-dimensions Pre-test Post-test Z p* Mean Standard deviation Mean Standard deviation Pain ENCP 69.56 24.95 33.69 33.37 − 3.530 < 0.001 Control 63.04 27.04 54.34 28.85 − 1.384 0.16 Test Score Z = − 0.758 p** = 0.44 Z = − 2.097 p** = 0.03 Control and powerlessness ENCP 78.26 18.92 42.39 32.36 − 3.424 0.001 Control 71.17 22.50 75.0 22.61 − 0.535 0.59 Test Score Z = − 0.059 p** = 0.95 Z = − 3.297 p** = 0.001 Emotional well-being ENCP 82.60 20.55 45.65 26.81 − 3.603 < 0.001 Control 80.43 16.78 79.34 20.85 − 0.264 0.79 Test Score Z = − 0.686 P** = 0.49 Z = − 3.998 P** = < 0.001 Social support ENCP 66.3 34.21 29.34 28.85 − 3.574 < 0.001 Control 70.65 32.55 67.39 23.15 − 0.555 0.57 Test Score Z = − 0.458 P** = 0.64 Z = − 3.915 P** = < 0.001 Self-image ENCP 58.69 40.31 29.34 29.82 − 3.272 0.001 Control 69.56 35.32 71.73 30.43 − 0.491 0.62 Test Score Z = − 0.906 P** = 0.36 Z = − 3.902 P** = < 0.001 Working life ENCP 60.86 33.56 25.0 26.11 − 3.666 < 0.001 Control 51.08 41.61 47.82 36.08 − 0.905 0.36 Test Score Z = − 0.722 P** = 0.47 Z = − 2.147 P** = 0.03 Relationship with children ENCP 31.52 36.32 14.13 22.39 − 2.859 0.004 Control 23.91 34.11 22.82 33.63 − 0.577 0.56 Test Score Z = − 0.682 P** = 0.49 Z = − 0.532 P** = 0.59 Intercourse ENCP 69.56 35.32 41.3 33.37 − 3.035 0.002 Control 64.13 40.47 61.95 38.33 − 0.816 0.41 Test Score Z = − 0.162 P** = 0.87 Z = − 2.205 P** = 0.02 Medical profession ENCP 26.08 26.62 11.95 18.26 − 2.812 0.005 Control 18.47 32.17 27.17 35.28 − 1.994 0.04 Test Score Z = − 1.317 P** = 0.18 Z = − 1.254 P** = 0.21 Treatment ENCP 66.3 33.37 34.78 31.74 − 3.224 0.001 Control 68.47 34.72 73.91 29.65 − 0.929 0.35 Test Score Z = − 0.365 P** = 0.71 Z = − 3.683 P** = < 0.001 Infertility ENCP 70.65 38.17 45.65 41.73 − 3.097 0.002 Control 60.86 45.74 58.69 45.6 − 1.414 0.15 Test Score Z = − 0.503 P** = 0.61 Z = − 1.242 P** = 0.21 EHP-5 total score ENCP 61.8 11.4 32.1 18.7 − 4.171 < 0.001 Control 58.8 7.9 58.2 10.9 − 0.460 0.64 Test Score Z = − 0.731 p** = 0.465 Z = − 4.423 p** = < 0.001 *Wilcoxon Test, **Mann Whitney U Test. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 control and ENCP groups (p < 0.05). Similarly, the post-intervention HPLP-II total score was significantly higher in the ENCP group than in the control group (mean difference = 33.0, 95% CI 20.6 to 45.5, Cohen’s d = 1.58, p < 0.001). All of the women (n = 23) who received the intervention in the study reported that they were satisfied with the ENCP and that their level of knowledge about endometriosis increased with the ENCP.

Endometriosis is a complex disease that negatively affects women's quality of life. The aim of endometriosis treatment is to improve women's quality of life, reduce pain and manage endometriosis. Several studies have investigated the quality of life of women with endometriosis. Evidence regarding nursing interventions designed to improve quality of life remains limited. In this study, baseline characteristics were comparable between groups, suggesting that potential confounding factors were similarly distributed. This similarity between groups strength- ens the interpretation that the improvements observed in the intervention group may be related to the ENCP intervention. Since there is no definitive treatment for endometriosis, the primary goal of supportive care is to minimise symptoms and improve quality of life. There are some programs developed in line with the Health Promotion Model in the care of cases with endometriosis 11,19. In a study aiming to evaluate the effect of nursing strategies in alleviating symptoms associated with endometriosis, the change in quality of life was evaluated before and three months after the intervention. It was determined that strategies consisting of three components including diet, exercise and stress management increased the quality of life of women in all sub-dimensions of the EHP-5 questionnaire compared to the control group 11. Our findings are consistent with those reported by Yousif et al.11. The present study demonstrated significant improvements in quality of life, as reflected by lower EHP-5 total and subdomain scores in the ENCP group. (Before intervention: 61.8 ± 11.4 After intervention: 32.1 ± 18.7, Table 4 Comparison of the ENCP and control groups' HPLP-II scores. HPLP-II Scale Sub-dimensions Pre-test Post-test t p* Mean Standard deviation Mean Standard deviation Health Responsibility ENCP 23.0 4.49 28.30 3.33 − 7.75⸸ < 0.001* Control 23.26 5.31 23.13 4.84 − 0.70⸸⸸ 0.48** Test score t = − 0.18 p* = 0.85 t = 4.21 p* = < 0.001 Physical Activity ENCP 15.17 5.28 22.39 5.59 − 6.12⸸ < 0.001* Control 17.08 6.13 16.08 4.65 1.23⸸ 0.23* Test score t = − 1.13 p* = 0.26 t = 4.15 p* = < 0.001 Nutrition ENCP 20.52 3.89 25.86 4.19 − 4.20⸸⸸ < 0.001** Control 21.13 4.92 20.34 4.30 2.35⸸ 0.02* Test score t = − 0.46 p* = 0.64 Z = − 3.76 p** = < 0.001 Self-actualization ENCP 27.04 5.13 31.47 3.32 − 5.61⸸ < 0.001* Control 25.91 5.47 27.00 4.88 − 2.63⸸ 0.01* Test score t = 0.72 p* = 0.47 t = 3.63 p* = 0.001 Interpersonal relations ENCP 26.60 3.34 31.30 2.75 − 4.21⸸⸸ < 0.001** Control 25.21 4.95 25.86 4.25 − 1.57⸸ 0.13* Test score t = 1.11 p* = 0.27 Z = − 4.03 p** = < 0.001 Stress Management ENCP 19.69 4.23 24.82 3.82 − 8.14⸸ < 0.001* Control 18.60 5.21 18.73 4.07 − 0.30⸸ 0.76* Test score t = 0.77 p* = 0.44 t = 5.22 p* = < 0.001 HPLP-II Total Score ENCP 132.04 19.81 164.17 18.83 − 11.36⸸ < 0.001* Control 131.21 25.46 131.17 22.86 0.02⸸ 0.98* Test score t = 0.12 p* = 0.90 t = 5.34 p* = < 0.001 ⸸t value, *Dependent Samples, T-test, ⸸⸸Z value, **Wilcoxon Test. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 p < 0.001) (Table 3). When the post-test EHP_5 scores of the control and ENCP groups were compared, it was found that there was no significant difference in the relationship with children, medical profession and infertility sub-dimensions. The individually delivered ENCP significantly improved the quality of life of women with endo- metriosis in terms of pain, control and powerlessness, emotional well-being, social support, self-image, working life, relationships with children, sexual intercourse, relationships with health professionals, treatment and infer - tility. However, these findings should be interpreted with caution because multiple statistical comparisons were performed across the EHP-5 subdomains, which may have increased the likelihood of Type I error. All behaviours that affect the physical, mental and social well-being of individuals are defined as healthy lifestyle behaviours. Endometriosis negatively affects women's physical, mental and social health and impairs their quality of life. Developing healthy behaviours in women with endometriosis supports women to take more active roles and responsibilities in issues that will affect their entire lives20. Although there are studies indicating that developing healthy life behaviours in women with endometriosis may be beneficial, the number of studies examining this issue is quite limited. Yousif et al. 11 examined the effect of the strategy they applied within the scope of diet, exercise and stress management, which are among healthy lifestyle behaviours. In their study, the total scores of HPLP-II showed a statistically significant increase in ENCP group after the intervention compared to the scores before the intervention (before: 151.42 ± 8.3, after: 160.23 ± 4.31), but no significant difference was found in the control group (before intervention: 127.65 ± 9.1, after intervention: 125.46 ± 6.82)11. A study examining the effect of diet, exercise and stress management training based on the Health Promotion Model on the lifestyle of women with endometriosis found an increase in HPLP-II scores in women who received train - ing (Abd-Elaziz et al. 2021). In Ghonemy and El Sharkawy 21 study, it was determined that educational training for lifestyle change was effective in reducing the pain of women with endometriosis. Our findings are consis - tent with previous studies. A significant improvement was observed in the HPLP-II total and all sub-dimension scores of the ENCP group before and after the intervention (Pre-intervention: 132.04 ± 19.81 Post-intervention: 164.17 ± 18.83, p < 0.001). Although there was no significant difference between the pre-test and post-test in the HPLP-II total scores of the control group, a difference was observed in the nutrition and self-actualization sub-dimension scores of the post-test scores in comparison to the pre-test scores (Table 4). This finding may be explained by the increased awareness generated through repeated interactions and discussions with participants during the study. When the post-test scores of ENCP and control groups were analysed, it was observed that there was a difference between the scores and that the intervention was effective (Table 4). The ENCP implemented in the present study aimed to improve quality of life and promote healthy lifestyle behaviours among women with endometriosis. As reported in previous studies, meeting women's informational needs and encouraging their active participation in treatment and care enable women to take a more active role in disease management20. With ENCP, women demonstrated improvements in pain, dyspareunia, work life, health responsibility, physical activity, nutrition, interpersonal relationships, and stress management (Table 4). In con- clusion, the implemented ENCP had a positive impact on women with endometriosis, leading to increased healthy lifestyle behaviour scores and improved quality of life in areas such as health responsibility, physical activity, nutrition, self-actualization, interpersonal relationships, and stress management. By considering women's indi - vidual characteristics, previous experiences, perceived benefits, and barriers, ENCP may help women acquire disease-related knowledge, gain a greater sense of control, and develop effective coping strategies. Educating the target group and raising awareness is an important step in eliminating endometriosis-related symptoms and early diagnosis22. All women in the intervention group reported that ENCP increased their knowledge of endometrio- sis. These findings suggest that ENCP can support women to increase their level of knowledge and their efforts to accept the disease and improve their quality of life. Our findings are consistent with previous studies reporting that healthy lifestyle interventions, including diet, exercise, and stress management, improve healthy lifestyle behaviour scores in women with endometriosis. However, unlike earlier studies that typically focused on a limited number of lifestyle components, the present model incorporates multiple dimensions of healthy lifestyle behaviours, including nutrition, physical activity, sleep patterns, sexual health, stress management and interpersonal relationships. Moreover, the intervention was Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 specifically designed for women with endometriosis, which enhances its clinical relevance and applicability. Accordingly, this model may serve as a comprehensive and practical supportive care strategy that can be inte - grated into routine clinical practice to improve the management and quality of life of women living with endome- triosis. This study contributes to the limited evidence regarding structured nursing interventions for women with endometriosis, particularly those developed according to the Health Promotion Model. Although the intervention demonstrated positive effects, it should be acknowledged that participants in the intervention group had substan- tially more contact time with the researcher than those in the control group. Therefore, part of the observed ben- efit may be attributable to increased researcher–participant interaction rather than the educational content alone. In addition, the findings were based primarily on patient-reported outcome measures. Although pain was assessed using the pain domain of the EHP-5, future studies incorporating objective clinical outcomes and treatment- related measures would provide a more comprehensive evaluation of intervention effectiveness.

ENCP significantly improved the quality of life in women with endometriosis and resulted in increased scores on healthy lifestyle behaviours. Structured nursing interventions may play an important role in comprehensive endometriosis care. These findings contribute to the growing evidence supporting nurse-led interventions in comprehensive endometriosis management and support the integration of structured nursing programs into mul- tidisciplinary care models. Recommendations Women with endometriosis should be provided with comprehensive education regarding their disease and actively involved in treatment and care planning. In addition, awareness of endometriosis should be increased among both the general public and healthcare professionals, and certification programmes should be implemented to improve the quality of care. Future multicentre studies with larger sample sizes and longer follow-up periods are recom - mended to evaluate the sustainability of intervention effects. Furthermore, future research should collect detailed disease-related characteristics, including disease stage, phenotype, previous surgery, hormonal treatment status, and infertility history.

The study has several limitations. The relatively small sample recruited from a single centre may limit the gen - eralizability of the findings. In addition, a per-protocol analysis was performed because participants who became pregnant or relocated after randomization could not complete follow-up assessments. Finally, the short follow-up period precluded evaluation of the long-term sustainability of the intervention effects. Author contributions Ayse Gul Bursa, Nevin Sahın. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability This study data is not shared openly to ensure the confidentiality of the participants. If necessary, it can be requested from the responsible author. Declarations Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Article in Press Scientific Reports https://doi.org/10.1038/s41598-026-73552-1 Ethics statement Ethics committee approval for the research was received from Istanbul Cerrahpasa Medical Faculty Clinical Research Ethics Committee with the number 13022260-300-141369. A work permit was obtained from the relevant institutions. All participants were asked to sign voluntary consent documents. The study was carried out in accordance with the Declaration of Helsinki. After completion of data collection, participants in the control group were offered the ENCP intervention and educational brochure for ethical reasons. The trial was registered at ClinicalTrials.gov (NCT05402943). Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Interna- tional License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Cre- ative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / .

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Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Authors and Affiliations Ayse Gul Bursa1 · Nevin Sahin2 Ayse Gul Bursa [email protected] 1 Fenerbahçe University, Istanbul, Turkey 2 Istanbul University-Cerrahpaşa, Istanbul, Turkey