Design

We conducted a qualitative study using nine single focus group discussions (FGDs) in January 2024 over a three-week period. FGDs are commonly used as a qualitative method to collect data and gain a deep understanding of social issues from a purposefully selected group of individuals rather than from a statistically representative sample of the general population. FGDs can stimulate discussion or debate on a research topic that requires collective perspectives and uncover the underlying meanings of those perspectives [31]. Therefore, to gather insightful data in our FGDs, we specifically recruited participants based on their experiences and their willingness to engage in open discussions to explore the barriers to maintaining a healthy lifestyle for menopausal women.

Sampling strategies

A total of 30 menopausal women, divided into three groups of ten women each, were selected from three different health centers in urban areas of Shiraz. These areas were generally classified as upscale or high- income, downtown or middle- income, and downscale or low- income areas, representing different economic levels (wealthy, relatively wealthy, and less wealthy). The participants were selected using a purposeful sampling method, as depicted in Fig. 1. These women were recruited from a randomized controlled trial (RCT) study aimed at educating them about healthy lifestyles, including a healthy diet, physical activity, menopausal health, and stress control. The RCT took place from December 2023 to January 2024 and was registered under the clinical trials registration number IRCT20230716058792N1 on 14/08/2023. Seventy women actively participated in the RCT and thirty- three of them were interested in sharing their experiences.

Fig. 1

Purposeful sampling strategy for focus group discussion with postmenopausal women

All participants in the study were women aged between 45 and 65 years old who met the scientific definition of natural menopause, having at least one year since their last menstrual period. They also had to have a minimum literacy level of the third grade of elementary education. Participants confirmed that they were not currently undergoing psychiatric treatment for mental illnesses, did not have chronic diseases such as diabetes, hypertension, heart, or kidney failure, or cancer, and had not received hormone replacement therapy for menopausal symptoms in the past 6 months. Furthermore, they had no history of hysterectomy or oophorectomy surgery and did not experience abnormal vaginal bleeding. Please refer to Table 1 for participant characteristics. Unwillingness to continue participation was considered an exclusion criterion.

Table 1 Demographic data of participating women (n = 30)Data collection

Three FGDs were conducted to explore participants’ experiences regarding barriers to a healthy lifestyle. The discussions focused on menopausal symptom management, healthy diet, and physical activity, with each topic discussed in a separate session within each group. The discussions took place in an education room at the health centers and lasted approximately two hours. Two female researchers actively participated in the discussions, with one serving as the moderator. The moderator, the first researcher, is a PhD candidate in health education and promotion with a master’s degree in midwifery and experience in conducting interviews. She facilitated the discussions. An observer, the third researcher, is an associate professor and the lead author of several qualitative studies with a PhD in health education and promotion. She assisted in the discussions. The discussions were recorded with consent using a mini voice recorder, and the observer took brief notes on each participant’s comments in response to semi-structured, open‐ended questions. The FGDs began with introductory questions related to menopaual symptom management, such as:

(a)

“When were you diagnosed with menopause?“.

(b)

“Which menopausal symptoms do you experience?“.

(c)

“How do menopausal symptoms impact your daily life?“.

(d)

“What steps have you taken to manage the symptoms of menopause?”

For the physical activity topic, the questions were:

(a)

“What is the correct definition of physical activity?“.

(b)

“How many days a week do you engage in physical activity?“.

(c)

" How long do you engage in physical activity each day?

Regarding healthy nutrition, the questions included:

(a)

“What are the food groups?“.

(b)

“What is the correct definition of a daily healthy diet?“.

(c)

“Do you follow a healthy diet?”

The closing question, “Is there any other information you want to share with me?” was answered at the end of each session.

Methods of analysis

The discussion was transcribed verbatim, and a content analysis was performed on the Persian transcripts before translation. Following Graneheim and Lundman’s method, the analysis process consisted of the following steps: (1) The recorded interviews were transcribed and read to gain an overall understanding. (2) The text was divided into meaningful units. (3) The meaningful units were extracted and encoded. (4) The initial codes were classified into subcategories based on their similarities and differences. (5) The subcategories were sorted and abstracted into categories. (6) Themes were created to link the underlying meanings in the categories [32].

During the open coding stage, all transcripts were carefully read multiple times to note participants’ experiences regarding barriers to a healthy lifestyle for menopausal women. Fifty basic codes were obtained, including 26 codes related to managing menopausal symptoms, 11 codes related to physical activity, and 13 codes related to healthy nutrition. These codes were then compared with all extracted data to identify similarities and differences. Subsequently, categories, subcategories, and themes were created (refer to Table 2).

Table 2 Examples of the analysis process in the topic of management of menopauseMethods of quality assurance

Member checking, peer debriefing, investigator triangulation, and cross-examination were used to ensure the trustworthiness, dependability, and credibility of the data. During member checking, each participant received a transcript of their coded words and was asked if the codes accurately reflected their experiences to validate the interpreted findings (credibility). Peer debriefing was conducted by the second and fourth researchers, who held frequent sessions with supervisors to report on and discuss the study’s progress and process to ensure accuracy (credibility). Additionally, some health education and promotion faculty members, who were the main authors of several qualitative studies, checked the encoding process and categories access (investigator triangulation for trustworthiness). Lastly, cross‐examination involved comparing participant’s responses or descriptions to similar situations or conditions to establish dependability.

Ethics

The study protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1402.049). Before the study commenced, participants were informed about the aim and procedure of the study and their right to withdraw their participation at any time. The researchers assured them of their anonymity, and written informed consent was obtained from each participant. Participation was strictly voluntary. This study complies with the consolidated criteria for reporting qualitative studies (COREQ) checklists [33].