Introduction
Diabetes is one of the most common chronic diseases worldwide which can have debilitating effects and shorten people's lifespan by multi- organs damage. One of the long-term complications of diabetes is sexual dysfunction. Treatment for sexual dysfunction include drug therapy and psychological interventions. Various psychological interventions, including mindfulness-based cognitive therapy (MBCT) have been introduced for treating women's sexual dysfunctions. The MBCT includes cognitive behavioral therapy along with mindfulness-based stress reduction therapy provided at 8 sessions. This therapy is usually provided face-to-face, but recently internet-based approach has been introduced as a new method. Social media is one of the online ways for providing counselling by health care providers. The usefulness of social media in promoting outcomes related to women's health has been reported. The effectiveness of mindfulness training in improving women's sexual function has been observed in previous studies. Considering the high prevalence of diabetes and it's subsequent effect on sexual function and sexual distress, the present study aims to investigate the effect of MBCT using social media on sexual function and sexual distress of women with diabetes.

Methods
This randomized controlled trial was conducted from October 2022 to October 2023. Participants were 72 married women of reproductive age diagnosed with diabetes and suffered from sexual dysfunction. Inclusion criteria were willingness to participate in the study, being married, having diabetes diagnosed by a physician, sexual dysfunction based on a score ≤19 in the Female Sexual Function Index (FSFI-6), having sex with spouse in last 3 months, age 15-49 years, and having a smartphone with access to the Internet and social media. Recruitment was done using multi-stage sampling procedure. Written informed consent was obtained from women. They were randomly assigned to two groups of intervention and control using the block randomization method. The MBCT was provided individually using social media platform (Ita, Rubika, WhatsApp) in eight sessions, once a week. 
Demographic form, FSFI-6, female sexual distress scale- revised (FSDS-R), and the mindful attention and awareness scale (MAAS) were used to collect data. Study variables were measured before, immediately after, one month after, and three months after the intervention. Data were analyzed in SPSS software, version 24. To assess the difference in the mean scores of sexual function, sexual distress, and mindfulness between the study groups at different time points, repeated measures analysis of variance and analysis of covariance were used. Cohen's d was calculated to assess the intervention effect size. The significance level was set at 0.05.

Results
The study groups were similar in terms of demographic variables, except for the educational level of women and their spouses at baseline assessment. Therefore, the effects of these covariates were controlled. The results of the study showed that the mean scores of FSFI-6 and MAAS in the intervention group were significantly higher than in the control group after the intervention, while the FSDS-R score of the intervention group was significantly lower than that of the control group after the intervention. The intervention had a large effect on increasing sexual function, decreasing sexual distress, and increasing mindfulness in all post-intervention phases. 

Conclusion
The findings of the present study showed that online MBCT can improve the sexual function and mindfulness of women with diabetes and reduce their sexual distress. Therefore, healthcare providers can use this intervention to improve diabetic women's sexual function and reduce their sexual distress. Additionally, considering the effectiveness of the intervention provided using social media, healthcare providers can deliver this intervention virtually.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC. 1401.117) and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20220726055556N1). Written informed consent was obtained from all participants.

Funding
The paper was extracted from a master’s thesis. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors contributions
Conceptualization, Data Curation and writing original Draft: Zainab Alimoradi and Mina Fathi; Methodology: Zainab Alimoradi, Nasim Bahrami, and Mohammad Ebrahim Sarichloo; Formal Analysis: Zainab Alimoradi; Investigation: Mina Fathi and Leila Modarresnia; Supervision: Zainab Alimoradi; review & editing: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the participants for their cooperation in this study.

References

1. Mukhtar Y, Yunusa U, Galalain A. A modern overview on diabetes mellitus: A chronic endocrine disorder. European Journal of Biology. 2020; 5(2):1-14. [Link]
2. Rahmanian E, Salari N, Mohammadi M, Jalali R. Evaluation of sexual dysfunction and female sexual dysfunction indicators in women with type 2 diabetes: A systematic review and meta-analysis. Diabetology & Metabolic Syndrome. 2019; 11:73. [DOI:10.1186/s13098-019-0469-z] [PMID]
3. Khamseh ME, Sepanlou SG, Hashemi-Madani N, Joukar F, Mehrparvar AH, Faramarzi E, et al. Nationwide prevalence of diabetes and prediabetes and associated risk factors among iranian adults: Analysis of Data from PERSIAN cohort study. Diabetes Therapy. 2021; 12(11):2921-38. [DOI:10.1007/s13300-021-01152-5] [PMID]
4. Kandjani AS, Hosseinpour MR, Daneshamooz H, Shoja H, Nikniaz L. Sexual dysfunction prevalence in women with type 2 diabetes mellitus. Advances in Bioscience and Clinical Medicine. 2018; 6(4):15-9. [DOI:10.7575/aiac.abcmed.v.6n.4p.15]
5. Ranjbaran M, Chizari M, Matori Pour P. [Prevalence of female sexual dysfunction in Iran: Systematic review and meta-analysis (Persian)]. Journal of Sabzevar University of Medical Sciences. 2016; 22(Special Issue):1117-25. [Link]
6. Karimi-Valoujaei S, Hasani-Moghaddam S, Kashi Z, Yousefi S, Sharifnia SH, Khani S. [Effective factors on sexual dysfunction in women with diabetes: A systematic review (Persian)]. Clinical Excellence. 2020; 10(1):71-85. [Link]
7. Mousavi SI, Alizadeh T, Sheikh MR, Yavari M. [Frequency of psychiatric disorder symptoms in diabetic patients of Yasuj City in 2014 (Persian)]. Journal of Neyshabur University of Medical Sciences. 2016; 4(10):65-71. [Link]
8. Kizilay F, Gali HE, Serefoglu EC. Diabetes and sexuality. Sexual Medicine Reviews. 2017; 5(1):45-51. [DOI:10.1016/j.sxmr.2016.07.002] [PMID]
9. Muniyappa R, Norton M, Dunn ME, Banerji MA. Diabetes and female sexual dysfunction: Moving beyond” benign neglect”. Current Diabetes Reports. 2005; 5(3):230-6. [DOI:10.1007/s11892-005-0014-3] [PMID]
10. Soleimani MA, Bahrami N, Yaghoobzadeh A, Parker A, Chan YH. Sexual distress and sexual function in a sample of Iranian women with gynecologic cancers. European Journal of Oncology Nursing. 2018; 35:47-53. [DOI:10.1016/j.ejon.2018.05.007] [PMID]
11. Ali R, kamal H,  Hassan HE, Abd El Salam S. Impact of an Educational Program on Sexual Distress Associated With Cervical Cancer. Journal of Applied Health Sciences and Medicine. 2021; 1(1):30-42. [Link]
12. Stephenson KR, Meston CM. Differentiating components of sexual well-being in women: Are sexual satisfaction and sexual distress independent constructs? The Journal of Sexual Medicine. 2010; 7(7):2458-68. [DOI:10.1111/j.1743-6109.2010.01836.x] [PMID]
13. Miller MK, Smith JR, Norman JJ, Clayton AH. Expert opinion on existing and developing drugs to treat female sexual dysfunction. Expert Opinion on Emerging Drugs. 2018; 23(3):223-30. [DOI:10.1080/14728214.2018.1527901] [PMID]

14. Saei Ghare Naz M, Rostami Dovom M,  Ramezani Tehrani F. [Modern pharmacological treatments of sexual dysfunction in women: A narrative review (Persian)]. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2021; 23(9):69-84. [DOI:10.22038/ijogi.2020.17388]
15. Mestre-Bach G, Blycker GR, Potenza MN. Behavioral therapies for treating female sexual dysfunctions: A state-of-the-art review. Journal of Clinical Medicine. 2022; 11(10):2794. [DOI:10.3390/jcm11102794] [PMID]
16. Mohamadpour S, Tajikzadeh F, Aflakseir A. The efficacy of mindfulness-based cognitive therapy on self-efficacy and anxiety among epileptic patients. Archives of Neuroscience. 2017; 4(2):e39060. [DOI:10.5812/archneurosci.39060]
17. Basson R. Sexual function of women with chronic illness and cancer. Women’s Health. 2010; 6(3):407-29. [DOI:10.2217/WHE.10.23] [PMID]
18. Johannsen M, O’Connor M, O’Toole MS, Jensen AB, Zachariae R. Mindfulness-based cognitive therapy and persistent pain in women treated for primary breast cancer: Exploring possible statistical mediators: Results From a randomized controlled trial. The Clinical Journal of Pain. 2018; 34(1):59-67. [DOI:10.1097/AJP.0000000000000510] [PMID]
19. Guillet AD, Cirino NH, Hart KD, Leclair CM. Mindfulness-based group cognitive behavior therapy for provoked localized vulvodynia: A randomized controlled trial. Journal of Lower Genital Tract Disease. 2019; 23(2):170-5. [DOI:10.1097/LGT.0000000000000456] [PMID]
20. Manicavasgar V, Parker G, Perich T. Mindfulness-based cognitive therapy vs cognitive behaviour therapy as a treatment for non-melancholic depression. Journal of Affective Disorders. 2011; 130(1-2):138-44. [DOI:10.1016/j.jad.2010.09.027] [PMID]
21. Cunningham JE, Shapiro CM. Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review. Journal of Psychosomatic Research. 2018; 106:1-12. [DOI:10.1016/j.jpsychores.2017.12.012] [PMID]
22. Sommers-Flanagan J, Sommers-Flanagan R. Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. New Jersey: John Wiley & Sons; 2018. [DOI:10.1002/9781394258963]
23. Sipe WE, Eisendrath SJ. Mindfulness-based cognitive therapy: Theory and practice. The Canadian Journal of Psychiatry. 2012; 57(2):63-9. [DOI:10.1177/070674371205700202] [PMID]
24. Hucker A, McCabe MP. An online, mindfulness-based, cognitive-behavioral therapy for female sexual difficulties: Impact on relationship functioning. Journal of Sex & Marital Therapy. 2014; 40(6):561-76. [DOI:10.1080/0092623X.2013.796578] [PMID]
25. Carr CT, Hayes RA. Social media: Defining, developing, and divining. Atlantic Journal of Communication. 2015; 23(1):46-65. [DOI:10.1080/15456870.2015.972282]
26. Stellefson M, Paige SR, Chaney BH, Chaney JD. Evolving role of social media in health promotion: Updated responsibilities for health education specialists. International Journal of Environmental Research and Public Health. 2020; 17(4):1153. [DOI:10.3390/ijerph17041153] [PMID]

27. Mohammadi F, Bahrami N, Alimoradi Z. [The effect of telemidwifery counseling on breastfeeding self-efficacy in primiparous women during the COVID-19 Pandemic (Persian)]. Avicenna Journal of Nursing and Midwifery Care. 2023; 31(2):124-33. [DOI:10.32592/ajnmc.31.2.124]
28. Farsi D. Social media and health care, Part I: Literature review of social media use by health care providers. Journal of Medical Internet Research. 2021; 23(4):e23205. [DOI:10.2196/23205] [PMID]
29. Chen J, Wang Y. Social media use for health purposes: Systematic review. Journal of Medical Internet Research. 2021; 23(5):e17917. [DOI:10.2196/17917] [PMID]
30. Isidori AM, Pozza C, Esposito K, Giugliano D, Morano S, Vignozzi L, et al. Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction. The Journal of Sexual Medicine. 2010; 7(3):1139-46. [PMID]
31. Lin CY, Potenza MN, Broström A, Blycker GR, Pakpour AH. Mindfulness-Based Cognitive Therapy for Sexuality (MBCT-S) improves sexual functioning and intimacy among older women with epilepsy: A multicenter randomized controlled trial. Seizure. 2019; 73:64-74. [DOI:10.1016/j.seizure.2019.10.010] [PMID]
32. Farajkhoda T, Sohran F, Molaeinezhad M, Fallahzadeh H. The effectiveness of mindfulness-based cognitive therapy consultation on improving sexual satisfaction of women in reproductive age: A clinical trial study in Iran. Journal of Advanced Pharmacy Education & Research. 2019; 9(S2):151-60. [Link]
33. Ghassami M, Shairi MR, Asghari Moghadam MA, Rahmati N. [The study of the psychometric properties of the 6-item version of the female sexual function index (FSFI-6) amongest Iranian women (Persian)]. Nursing and Midwifery Journal. 2014; 12(7):532-43. [Link]
34. Derogatis L, Clayton A, Lewis-D'Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. The Journal of Sexual Medicine. 2008; 5(2):357-64. [DOI:10.1111/j.1743-6109.2007.00672.x] [PMID]
35. Azimi Nekoo E, Burri A, Ashrafti F, Fridlund B, Koenig HG, Derogatis LR, et al. Psychometric properties of the Iranian version of the female sexual distress scale-revised in women. The Journal of Sexual Medicine. 2014; 11(4):995-1004. [DOI:10.1111/jsm.12449] [PMID]
36. Ryan RM, Brown KW. Why we don’t need self-esteem: On fundamental needs, contingent love, and mindfulness. Psychological Inquiry. 2003; 14(1):71-6. [Link]
37. Nooripour R, Ghanbari N, Hoseinian S, Vakili Y, Dobkins K. Psychometric Validation of the Farsi Version of the Mindful Attention Awareness Scale (MAAS) in a sample of Iranian Students in the USA. International Journal of Mental Health and Addiction. 2021; 21:729–39. [DOI:10.1007/s11469-021-00617-9]
38. Imbens GW, Rubin DB. Causal inference in statistics, social, and biomedical sciences. Cambridge: Cambridge University Press; 2015. [DOI:10.1017/CBO9781139025751]
39. Copay AG, Subach BR, Glassman SD, Polly DW Jr, Schuler TC. Understanding the minimum clinically important difference: a review of concepts and methods. The spine Journal: Official Journal of the North American Spine Society. 2007; 7(5):541-6. [DOI:10.1016/j.spinee.2007.01.008] [PMID]
40. Sedaghat AR. Understanding the Minimal Clinically Important Difference (MCID) of patient-reported outcome measures. Otolaryngology--Head and Neck Surgery. 2019; 161(4):551-60. [DOI:10.1177/0194599819852604] [PMID]
41. Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991; 59(1):12-9. [DOI:10.1037/0022-006X.59.1.12] [PMID]
42. Yanti I, Suryani L, Kinanti RR. Interest of midwives in providing midwifery services through teleconsultation in the pandemic time of Covid-19. PalArch’s Journal of Archaeology of Egypt/Egyptology. 2020; 17(9):7619-27. [Link]
43. Moradi M, Geranmayeh M, Mirmohammadali M, Mehran A. [The effect of sexual counseling on sexual function in women with type 2 diabetes mellitus (Persian)]. Hayat. 2016; 22(2):148-58. [Link]
44. Kazemzadeh Atoofi M, Naziry G, Mohammadi M, Behzadipour S. [Effect of mindfulness based sexual relationship therapy on orgasm quality and sexual function in women with orgasmic disorder: A clinical trial (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2023; 28(4):410-23. [DOI:10.32598/ijpcp.28.4.4370.1]
45. Keshvari B, Jenaabadi H, Karbalaei Herafteh F. [The effectiveness of mindfulness-based cognitive therapy on anxiety in people with borderline personality disorder (Persian)]. Islamic Lifestyle with a Focus on Health. 2020; 3(5):162-70. [Link]
46. Mirmahdi SR, Razaali M. [The effectiveness of mindfulness-based cognitive therapy on resilince, emotion regulation and life expectancy among women with diabetes2 (Persian)]. Quarterly Journal of Health Psychology. 2019; 7(28):167-83. [Link]
47. Kabat-Zinn J. Full Catastrophe Living, Revised Edition: How to cope with stress, pain and illness using mindfulness meditation. Massachusetts: Little, Brown Book Group; 2013. [Link]