Introduction

Sexual health literacy (SHL) refers to a set of skills, including the ability to acquire and understand sexual knowledge and to integrate information into the decision-making process related to sexual behavior. Sexual health literacy is a spectrum of sexual health literacy that encompasses diverse areas such as gender and sexual development, puberty, pregnancy, contraceptive methods, unwanted pregnancy, sexually transmitted infections, developing sexual management skills including negotiating the quality of sexuality, sexual preferences and constraints, and the positive and romantic dimensions of sexuality1,2. One of the most important components of sexual health is an individual's level of sexual awareness3. Sexual health literacy leads to improved ability to understand and assess the risks associated with sexual health, delaying first sexual experience, reducing and selecting low-risk sexual partners, seeking safe sexual experiences, reducing unintended pregnancies and sexually transmitted infections, and ultimately improving family and social health4,5,6.

Rural women encounter unique challenges that impact their sexual health literacy. These may include inadequate access to healthcare services, limited educational opportunities, cultural taboos surrounding sexuality, and gender inequalities. Moreover, the stigma associated with seeking sexual health information or services in rural communities can further hinder women's ability to access accurate and comprehensive information7. Accessing sexual health services is often more challenging for rural women compared to their urban counterparts. Geographic distance, transportation limitations, lack of healthcare facilities, and financial constraints create barriers to accessing essential sexual health services such as contraception, STI testing, and prenatal care. Additionally, the shortage of healthcare providers in rural areas exacerbates these challenges, leaving many women without access to quality sexual health care8,9.

Socioeconomic factors significantly influence rural women's sexual health literacy. Poverty, unemployment, and limited access to education can restrict women's ability to access accurate information about sexual health and reproductive rights. Economic instability may also force women to prioritize immediate needs over preventive healthcare, leading to neglect of their sexual health needs10.

Jamali' et al.5 showed that a quarter of women have low levels of sexual health literacy, where the level of sexual health literacy was related to age, education, spouse's education and economic status of the participants. In the other study, 65.5% of the participants had low level of sexual health literacy and participants from urban schools had higher level of sexual health literacy than rural schools11. The results of studies suggest that sexual health literacy is related to the rate of condom use, the likelihood of unintended pregnancy, the likelihood of engaging in high-risk sexual behavior, and sexual coercion in individuals, especially young people12,13,14. Having an optimal level of sexual health literacy increases a person's ability to analyze, judge, discuss, make decisions, and change sexual behavior, and empowers a person to ensure, maintain, and promote his or her sexual health15.

Sexual health literacy among rural women is a critical yet often overlooked aspect of public health discourse. In recent years, there has been a growing recognition of the multifaceted nature of sexual health and the profound impact it has on individuals, families, and communities. However, within the realm of rural populations, particularly among women, there exists a significant gap in understanding and addressing sexual health needs16. Despite the importance of sexual health literacy, few studies have been conducted. A prerequisite for educational planning as well as the design of intervention studies to improve sexual health literacy is to have sufficient information about the sexual health literacy level of people in the community and to identify factors associated with it. Considering the differences between urban and rural communities in the level of access to health facilities as well as cultural, social, and other differences, etc., the design of a study to assess the sexual health literacy level of married women living in rural areas seems necessary. This study aimed to offer understanding of sexual health literacy among Iranian rural women and explore the contextual factors influencing it in rural areas.

Methods

This cross-sectional study was conducted from January to May 2021 in Benaroyeh region and six sub-villages, Fars Province, Iran. That people go toward center (Benaroyeh) for health services. The sample size is based on a preliminary study with the number of 50 people and based on the sample size formula for the proportion (Estimating a proportion) and using the statistics and sample size software, taking into account the first type error (α) equal to 0.05 and the ratio (p). Equal to 0.12 according to the pilot conducted and the error (d) was equal to 0.05, a sample size of 163 was obtained, and considering a 20% dropout, 195 patients were determined for the sample size, and finally 200 patients were analyzed. The study population included married women of reproductive age in the region of Benaroyeh and research units of married women of reproductive age related to the health center. They were selected by convenience sampling method. Inclusion criteria were: married women of reproductive age 15–45 years, with minimum literacy, no medical and paramedical education and no employment in health centers. The exclusion criteria were incomplete completion of the questionnaire. The present study was conducted after obtaining the approval of the ethics committee in biomedical research of Tarbiat Modares University of Tehran and with the ethics code IR. MODARES.1398.205. All methods used in this study adhered to the Declaration of Helsinki. After assuring the participants that the information would remain confidential and obtaining written informed consent from each participant (All participants in this study were over 18.), they were asked to complete the questionnaires. There were no missing data as the research units completed the questionnaires. Data collection tools in this study included two questionnaires: (1) Reproductive Demographic Characteristics questionnaire. (2) Sexual Health Literacy for Adults (SHELA) questionnaire developed by Maasoumi et al.17. This questionnaire consists of 40 questions and measures four domains, including accessibility skills (questions 1–7), reading and comprehension skills (questions 8–25), analysis and evaluation skills (questions 26–30), and application skills (questions 31–40). The response to each question is on a five-point Likert scale from “strongly disagree” to “strongly agree”. The raw score of each area is obtained from the algebraic sum of the answers to the questions of the same area, then the following formula is used to convert the raw scores of the areas into a range of 0–100.

The total score of the tool for each person is calculated in such a way that the scores of all fields are added together after converting to a range of zero to 100 and divided by the number of fields, i.e. the number of four.

Participants are classified into four levels based on their total score. “Inadequate” level (score 0–50), “problematic” level (score 50–66), “sufficient” level (score 66–84), and “excellent” level (score 84–100). Excellent and sufficient levels were considered desirable levels of sexual health literacy, and inadequate and not very adequate levels were considered unfavorable levels of sexual health literacy. To calculate the total score: the scores of the subtests are collected on the basis of zero to 100 and divided by the number of subtests. The content validity ratio (CVR) and content validity instrument index (CVI) were 0.84 and 0.81, respectively. The internal consistency of the instrument with Cronbach's alpha index for the identified factors ranged from 0.84 to 0.94. Intraclass correlation based on ICC index calculation ranged from 0.90 to 0.9717.

Data were analyzed by descriptive and inferential statistics using SPSS 16 software. Descriptive statistics including frequency, percentage, mean and standard deviation were used to assess the sexual health literacy of women in reproductive ages. Covariance (with a significance level of 0.05) was used to investigate the relationship between demographic- reproductive factors and sexual health literacy score. The normality of the data: To check the normality of data distribution, we used statistical tests such as Shapiro–Wilk and Kolmogorov–Smirnov. In addition, Q-Q plots were also used to visually check the normality of the data. Levene's Test was used to check the homogeneity of variances.

Results

A total of 200 married women in reproductive ages were studied. The results revealed that the mean age of the research units was 31.65 ± 5.95 years and the mean age of the spouses was 38.67 ± 6.7 years. Most of the research units were housewives (81.5%) with less than university education (78%). The mean age at marriage was 18.93 ± 4.62 years and the mean duration of marriage was 12.18 ± 6.65 years. Most research units (54.5%) did not use any modern contraception method. People (51%) reported a history of 1–2 pregnancies. Most participants reported a history of vaginal delivery (43.5%). The highest percentage obtained for sexual information acquisition was the Internet and social networks (33.5%). Table 1 provides more details on the reproductive demographic characteristics of the research units. The results of Table 2 indicate that the mean total score of sexual health literacy is 75.64 ± 12.81. Also, 82.5% of the research units had a desirable level of sexual health literacy.

Table 1 Qualitative characteristics of demographic-reproductivity and sexual health literacy level of research units (n = 200).
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Table 2 Frequency and leveling of sexual health literacy and its areas (n = 200).
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The mean score for the access field was 74.04 ± 18.25, the reading and comprehension field was 77.34 ± 14.2, the analysis- evaluation field was 71.87 ± 17.76, and the application skill field was 79.02 ± 12.79. The results of univariate analysis of covariance reported in Table 3 reveal that the mean score of sexual health literacy of people without university education is 5 scores lower than that of people with university education (P = 0.021) and the mean score of sexual health literacy in housewives is 5.17 scores lower than in employed people (P = 0.026). The mean score of sexual health literacy of people whose spouses were unemployed was 10.104 scores lower than that of their spouses who were self-employed (P = 0.016) and there was no difference between the sexual health literacy scores of other occupations. For each more pregnancy, the mean score of sexual health literacy dropped by 1.21 scores (P = 0.046). The sexual health literacy score of women who gave birth by both methods was 7.956, which was lower than that of people who had no history of delivery (P = 0.050), and the difference between the mean score of sexual health literacy of other delivery methods was not statistically significant (P > 0.05).

Table 3 Results of univariate and multivariate analysis of covariance between the total score of sexual health literacy level and demographic-reproductivity factors of research units (n = 200).
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Discussion

This study aimed to investigate the sexual health literacy level and its relationship with demographic-reproductive factors in married women of reproductive ages. The results revealed that 82.5% of the subjects had the desired level of sexual health literacy. Despite a large portion of desirable sexual health literacy level, the average score (75.64) suggests there's room for improvement. This average score is comparable to findings in other studies on Iranian population (74.12, 68.76)5,18. This suggests a generally moderate level of sexual health literacy in this population.

According to the findings of our study, among the four areas of sexual health literacy, people obtained lower scores in the field of access skill and analysis-evaluation skill. These results can be explained by the fact that there is no source for proper formal sex education as well as sexual health literacy for any gender and age in Iran. The finding that the internet and social networks are the primary source of sexual health information is consistent with trends observed elsewhere. However, the quality of information gleaned from these sources can be questionable, but regardless of the data accuracy, Internet and social network are the only two main sources to access sexual information by the Iranian people3,19, while fewer participants in the application skill are at an undesirable level. These findings indicate that most of the subjects will use the information in their sexual life, if they receive it.

In our study, the mean score of sexual health literacy of people with university education was higher than the mean score of people with less education than university. In line with these results, Shahrahmani et al.18 showed that education has a strong relationship with the level of sexual health literacy. Due to the different educational system that manages school and university and the different educational environment and the amount of information and different educational methods, it seems that people with university education are more capable in searching, accessing and understanding content than people with less education than university. In addition, due to the absence of a university in the village, all people with university education experience independent student life in bigger cities, which can be effective on the level of sexual health literacy of people.

The results of the present study, where the mean level of sexual health literacy of employed people was higher than that of housewives. In the studies of Sadeghi (2019), Baghaei (2017), as well as Masoumy (2018), employed people had a higher level of health literacy20,21,22. Employed women better understand and implement health information as well as awareness due to experiencing more occupational conflicts. Job conflict can strengthen personal strengths. When people face the threat and management of occupational conflicts, their independence, self-confidence and decision-making power increase, these powers can help people to better understand their sexual needs and rights and indirectly increase the level of sexual health literacy.

In addition to individuals’ occupation, women whose husbands were unemployed had lower sexual health literacy scores. In Jamali's study (2020), there was no significant relationship between spouses' occupation and sexual health literacy level. In the present study, the percentage of unemployed spouses was about four times higher than Jamali et al.'s study, which can then lead to more accurate statistical results. Since unemployed people are more prone to economic hardship and are more inclined to meet their basic needs based on Maslow's line of needs, they do not pay enough attention to needs beyond primary level needs. Also, unemployment of husbands can cause marital incompatibility and problems in marital relationships as well as less coordination in family relationships, where people involved in these problems are more focused on basic needs and less look for health needs or improving their sexual health literacy.

The results of this study also indicated that women with more pregnancies have lower sexual health literacy scores. Consistent with this finding, a study by Sadeghi et al.22 indicated that participants who reported more pregnancies had lower mean health literacy scores. A possible explanation for these findings can be related to more frequent pregnancy experience due to the low levels of information about contraception methods and access to information. In addition, those who reported a history of both delivery methods had lower mean sexual health literacy scores than those who had no history of delivery. The low sexual health literacy level of these people can be due to the lower level of education and more pregnancies compared to the cesarean section and normal delivery as well as people who have no delivery. Consistent with the results of our study, in the study of Dongarwar and Salihu13, Participants who had a lower level of sexual and reproductive health literacy showed a 44% increase in the prevalence of pregnancy.

The results indicated that there was no statistically significant relationship between age as well as economic status and sexual health literacy score of research units. Consistent with the results of the present study, in the study by Vongxay et al.11, no statistically significant relationship was reported between age and sexual health literacy level. On the other hand, in Shahrehamani's study (2023), there was a statistically significant direct relationship between age plus the economic status of individuals and the level of sexual health literacy18. In Simpson's study (2015), older students had higher sexual health literacy scores23. The findings of both studies contradict the results of the present study. The reason for this discrepancy in the results could be the difference in the living environment of the research community. The present study was conducted in a rural community. In rural communities, there is not much cultural and class gap due to more limitations on access to health facilities, traditional lifestyles, lifestyles’ similarities, age and economic status. Further, people with different economic statuses and of different ages have access to the same facilities.

In this study, Internet and social networks (33.5%) were considered the most common method of obtaining sexual information of individuals. In the study by Byansi et al.24, a large number of participants used the Internet and social networks to obtain sexual information. Also, the results of a qualitative study (Vamos 2015) revealed that most people use the Internet to access sexual information25. The results of both studies concur with the findings of the present study. In the Vongxay ’s study (2019), the main source of information on sexual health literacy of individuals was teachers. This study was conducted among students, with teachers being considered the most accessible sources of information for students11. However, in Graf's study (2015), friends were the most common source of sexual information4. The results of this study contradict with the findings of the present study. The reason for the discrepancy in these findings can be related to the sample of studies. Samples of this study were middle-aged or elderly people who had limited access to the Internet. Also, according to the year of Graf’s study (2015) and the time difference between the two studies, it can be concluded that the growth of Internet penetration and cyberspace in this interval has led more people to use the Internet.

In the present study, only 16.5% of people in health centers (midwives, doctors, and health care providers) had access to sexual information. The results of a qualitative study by Rakhshaee et al.26 showed that the sense of shame of asking about sexual issues and the lack of routine assessment of sexual health made health care providers the last source of information for women. In this regard, Svensson et al.27 reported that embarrassment and taboos related to sexual health issues created a gap in knowledge and misconceptions about sexual health. Since access to information is the first important dimension of sexual health literacy17, and since the Internet is recognized as an attractive source of health information for personal health management28, the Internet appears to be a promising potential way to enhance sexual health literacy, which, in turn, improves health5. While technological advancements offer promising avenues for disseminating sexual health information, the digital divide poses a significant challenge for rural women. Limited access to the internet, smartphones, and digital literacy skills may hinder women's ability to utilize online resources for sexual health education and information-seeking. Bridging this gap requires innovative approaches that leverage technology while addressing barriers to access and digital literacy.

One of the limitations of this study was the reluctance of many women to participate in the research due to feeling ashamed and stigmatized towards sexual issues, some of them volunteered to participate in the research after the necessary explanation regarding the confidentiality of the participants' information. Another limitation of this research it is noteworthy in the studies that only the employment status of individuals at the time of sampling has been considered and the employment history of individuals has been neglected.

Our study provides new insights into the sexual health literacy of married women of reproductive age in rural Iran. However, it is important to use these findings cautiously when applying them to other populations. Further research in diverse settings is needed to confirm and expand upon these results.

One of the strengths of this research is that this was the first study to investigate the level of sexual health literacy and its related factors in married women living in the village.

Conclusion

This research was the first study to investigate the sexual health literacy level and its related factors in married women living in rural areas. Although 82.5% of women had a good level of sexual health literacy, but the average score has room for improvement. The mean score of sexual health literacy was related to occupation, spouse’s occupation, education, number of pregnancies, and delivery history. Internet and social networks were the main sources of sexual information for people, and the quality of this information is in question. Due to the extensive use of the Internet by individuals, it is recommended that a site containing accurate and valid sexual health information affiliated with the Ministry of Health is designed in accordance with the cultural frameworks of the country and its link provided to individuals. Also, since one of the most reliable sources of sexual information is health centers, it is necessary to identify the barriers to utilizing these centers (including: stigma, judgment, privacy, etc.) and try to remove these barriers. These problems can be overcome by teaching counseling skills to health center staff. It is also recommended that a study be designed and conducted using an online questionnaire to assess the sexual health literacy level of individuals at all levels of community, not only people who refer to the centers for health care. Rural women's sexual health literacy is a multifaceted issue shaped by a complex interplay of socioeconomic, cultural, and structural factors. Efforts to address this issue must be holistic, encompassing educational, healthcare, policy, and community-based approaches. By enhancing sexual health literacy among rural women, we can empower them to make informed decisions about their sexual and reproductive health, thereby promoting overall well-being and gender equality in rural communities.