The Socio-Cultural Contexts of Women's Sexual and Reproductive Health Literacy in Iran: A Qualitative Study

The Socio-Cultural Contexts of Women's Sexual and Reproductive Health Literacy in Iran: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Socio-Cultural Contexts of Women's Sexual and Reproductive Health Literacy in Iran: A Qualitative Study hosna faridi, farideh khalajabadi farahani, minoor Lamyian, fazlollah ahmadi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6234753/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2025 Read the published version in Reproductive Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background and Objective: This study aimed to explore the socio-cultural contexts of women's sexual and reproductive health literacy in Kurdistan, Iran. Methods: In-depth semi-structured interviews were conducted with 17 women aged 18 to 45 who visited selected clinics in Sanandaj, Kurdistan, Iran. Participants were recruited through purposive sampling between April 20 and November 16, 2024. The qualitative data were analyzed using directed qualitative content analysis based on the model proposed by Hsieh & Shannon (2005) and processed using MAXQDA software, version 22. Findings: The socio-cultural context of women's sexual and reproductive health literacy was extracted into three main categories: customs and traditions, socio-cultural norms and beliefs, and economic conditions. Customs and traditions, including marriage-related customs, the importance of virginity, female genital mutilation, gender roles, and sexual relations restrictions during mourning periods, influence sexual and reproductive health literacy by shaping traditional norms, imposing behavioral constraints, and enforcing social obligations. Socio-cultural norms and beliefs, including gender beliefs, perceptions of sexual behavior, and social contexts, play a role in shaping individuals' perspectives on sexual and reproductive topics, their willingness to discuss these issues and their behaviors. Lastly, economic conditions and financial constraints significantly impact access to sexual and reproductive health information, health literacy, utilization of services, and choices related to women's sexual and reproductive health. Conclusion: Designing educational programs and developing sexual and reproductive health policies with consideration of socio-cultural contexts can help reduce cultural taboos, enhance the effectiveness of interventions, and improve sexual and reproductive health in society. Health literacy sexual and reproductive health literacy socio-cultural factors Iranian women qualitative research Figures Figure 1 Introduction Health literacy is an overarching concept, meaning it is not limited to individual health capabilities but also considers the role of healthcare systems and the surrounding environment. Health literacy is shaped by a range of individual, social, structural, and cultural factors, contextual and historical factors, different health services[ 1 – 3 ] and emerging technologies[ 4 ] . Promoting sexual and reproductive health literacy among women of reproductive age is of great importance, especially since these women play multiple roles as wives and mothers [ 5 ]. Health literacy is a dynamic concept with various dimensions. One of these dimensions is sexual and reproductive health literacy. Enhancing sexual and reproductive health literacy is a key strategy for improving women's reproductive health and well-being [ 6 , 7 ]. Sexual and reproductive health literacy plays a critical role in empowering women to make informed decisions regarding sexual and reproductive health. This concept is not merely limited to their awareness of sexual relationships, menstrual cycles, or contraception methods, but extends to skills and abilities that enable individuals to search for, understand, evaluate, and ultimately apply related information [ 8 ]. Increasing sexual and reproductive health literacy can significantly contribute to reducing negative outcomes such as sexually transmitted infections, unintended pregnancies, and maternal mortality [ 9 ]. Sexual and reproductive health literacy is influenced by various factors, including cultural beliefs, personal attitudes, access to information, and social norms. Regarding the multifaceted nature of sexual health literacy, Martin (2017) has provided a definition which considers sexual health literacy as a combination of knowledge, beliefs, attitudes, motivations, and skills that help individuals access, understand, evaluate, and apply sexual health information in social, sexual, online, and healthcare contexts. This helps individuals make decisions and judgments about sexual health, public health, relationships, and well-being[ 10 ]. This concept goes beyond basic knowledge of sexual facts and includes the ability to manage sexual relationships and healthcare, engage in discussions and persuasion in cases of sexual coercion, use protective strategies, and address moral stigmas related to sexually transmitted infections, sexual identities, and social norms of sexual behavior [ 10 ].Women require accurate information in all areas of sexual and reproductive health, making it essential to offer interventions that meet these needs and help improve sexual health literacy (SHL) [ 11 ]. In support of this, the World Health Organization (2023) has emphasized the role of education and health literacy in reducing the risks associated with unintended pregnancies and sexually transmitted infections [ 12 ]. Sexual and reproductive health (SRH) is a fundamental component of overall well-being, while discussions on sexual and reproductive health are often veiled under cultural and social taboos [ 13 ]. Despite progress in global health education, sexual and reproductive topics remain overshadowed by misinformation and stigmatization [ 14 ]. For example, in many parts of the world, menstruation is still considered a topic that should not be publicly discussed, leading to a phenomenon known as "menstrual poverty" and poor menstrual health management [ 15 ]. Cultural taboos surrounding premarital sexual relationships among youth in Asian countries such as Bangladesh, India, and Pakistan significantly hinder open discussions about sexual health between young people, their parents, teachers, and healthcare providers [ 16 ]. Identifying the socio-cultural contexts surrounding sexual and reproductive health (SRH) and access to related care is crucial [ 17 ]. The context and surrounding environment of individuals should be considered in the comprehensive conceptualization of sexual and reproductive health literacy, as contextual factors can complicate individual decision-making processes in choosing healthy sexual behaviors and may have a greater impact than a lack of awareness or insufficient motivation. In other words, to better understand sexual health literacy in any given socio-cultural context, attention must be paid to the specific social, cultural, and economic context [ 10 ]. Previous research has identified various factors associated with sexual health literacy, including demographic, cultural-social, and medical-reproductive factors [ 10 , 18 – 20 ]. Among these factors, the socio-cultural contexts of individuals' lives, particularly the widespread feelings of shame and embarrassment around discussing sexual issues, have been a significant focus in previous studies. The stigma surrounding sexual topics often acts as a barrier to individuals seeking sexual health information and prevents open discussions about sexual matters and access to specialists and medical services [ 21 ]. A review study conducted in Australia clearly highlights the importance of socio-cultural context in promoting sexual health literacy and ensuring equitable access to sexual and reproductive health (SRH) information and services. This study emphasizes the need for theory-based strategies and policies that specifically address the social, cultural, and structural factors affecting youth from diverse cultural and linguistic backgrounds [ 22 ]. A qualitative study conducted to elucidate the challenges surrounding sexual health in Iran identified five predominant themes: (1) the taboo surrounding sexual issues and a general public unawareness; (2) the prevalence of unconventional sexual behaviors and their associated social harms; (3) stigma and discrimination; (4) a lack of political commitment; and (5) the absence of statistical indicators coupled with the underutilization of existing resources [ 23 ]. Addressing these challenges necessitates a comprehensive understanding of the socio-cultural norms that influence sexual health and sexual health literacy. Enhancing sexual health literacy through targeted interventions could significantly improve overall sexual health outcomes in the region [ 24 ]. To promote and achieve sexual health literacy and equitable access to SRH information and care that are culturally appropriate and meet local needs, conscious strategies and policies are needed that consider social, cultural, and structural components. Specifically, issues such as using appropriate language and refraining from verbal communication on topics related to sexual and reproductive literacy are crucial [ 22 ]. The socio-cultural contexts in which individuals are situated and the expectations placed on them play a significant role in shaping their access to and experiences with sexual health. Sexual health literacy must include awareness and critical analysis of social and cultural beliefs, attitudes, and behaviors that may negatively impact autonomy and decision-making and limit opportunities for safe sexual behaviors and decision-making [ 23 ]. Results from a qualitative study in Northern Ireland showed that formal sexual education based on traditional gender norms led to participants' inadequate awareness of sexual issues [ 24 ]. In other words, sexual health literacy goes beyond medical and biological understanding and involves critical and interactive awareness of the discourses and social and cultural structures that influence sexual aspects. This perspective helps integrate sexual knowledge with purposeful decision-making, effective communication, and empowering individuals to control their sexual experiences [ 25 ]. Despite previous studies on sexual health literacy, research that deeply explores women's interpretations of the socio-cultural contexts that may shape their sexual and reproductive health literacy is rare. The critical interpretive theoretical approach, which examines how women view traditional and cultural contexts related to sexual and reproductive health outcomes, is considered in this study. The aim of this research is to explore the socio-cultural contexts in which women's sexual and reproductive health literacy is formed in Iran. Methods Study Design: A qualitative methodology was selected to align with the aim of this study, which is to explore the social, cultural, and economic contexts of sexual and reproductive health literacy among married women of reproductive age. The research setting for this study is healthcare centers affiliated with the Kurdistan University of Medical Sciences in the western region of Iran. In this study, directed content analysis was employed. This deductive approach, introduced by Hsieh and Shannon (2005), is used to validate or develop an existing conceptual framework or theory [ 26 ]. In this method, initial coding is based on a theoretical framework or findings from similar studies. The selected theory helps the researcher predict related concepts and their relationships, upon which operational definitions for each code are developed [ 27 ]. Participants: The research population consisted of women of reproductive age who were selected through purposive sampling with maximum diversity (in terms of age, education level, place of residence, and economic status). Sampling was conducted from 17 comprehensive health centers in the city of Sanandaj, with a focus on four health centers that had a high volume of visitors. These centers are located in different areas of the city with varying social and economic levels (north, center, west, and a center in the suburbs of the city ). The inclusion criteria for the study were as follows: married, Iranian women aged 18–45 years, who self-reported having no underlying health conditions, spoke either Kurdish or Persian, and were willing to participate in the study. The participants' ages ranged from 18 to 45 years, with an average age of 33.7 years. In total, 22 women were contacted for interviews, and three of them declined due to lack of interest. Interviews with two women were also terminated at the request of their mothers or companions. Ultimately, 17 interviews were conducted with women of reproductive age, each lasting an average of 42 minutes (ranging from 29 to 55 minutes) (Table 1 ). Table 1 Demographic Characteristics of Study Participants Demographic Characteristics Category Frequency Age 18–29 years 6 30–39 years 7 40–45 years 4 Duration of Marriage (years) Less than 5 5 5–15 years 7 More than 15 5 Number of Children None 4 1 child 5 2 children 7 3 or more children 1 Education Level Primary 5 Secondary and Diploma 3 University 9 Occupation Housewife 12 Government Job 3 Self-employed 2 Household Income 10–19 million Toman 5 20–30 million Toman 9 More than 30 million Toman 3 At the time of the study, 1 million Toman was approximately equal to 17 USD.Therefore, the income categories of 10–19 million Toman, 20–30 million Toman, and more than 30 million Toman correspond to around 170–323 USD, 340–510 USD, and more than 510 USD, respectively." Data Collection Method: Data collection for this study was conducted from April 20, 2024, to November 16, 2024. The data collection method involved semi-structured in-depth interviews. The first author (HF) attended comprehensive health service centers in the cities of Kurdistan province. Information regarding women who met the eligibility criteria for the study was obtained from the midwives or health workers who had the participant’s details. Subsequently, the researcher introduced herself and explained the research objectives during a phone call with the individuals. Upon agreement, the time and location of the interview were scheduled. The interviews were conducted individually, in a private setting, within health centers approved by the participants, after obtaining informed consent. The interviews were recorded using a voice recorder with the participants' permission. At the beginning of the interviews, introductory questions were asked to help the researcher become familiar with the participants and create a friendly atmosphere. The interview process was then guided by targeted questions based on the theoretical framework of the study [ 10 ]. A developmental approach was also employed during the interviews, meaning that, in addition to confirming pre-defined concepts, sufficient space was provided for the identification of new dimensions and expansion of findings related to sexual and reproductive health literacy. For example, participants were asked: "Based on your experience, what information does sexual and reproductive health literacy include? What are the contextual factors that contribute to acquiring sexual and reproductive health literacy? Are there specific beliefs or traditions regarding sexual and reproductive health in your family or community? How do these beliefs affect women's behavior or decisions?" After each participant’s response, probing questions were asked to deepen and broaden the answers. These included: "Can you explain this further? What does that mean? ... Like what?" The interview guide questions were developed based on the research team’s opinions. At the conclusion of each interview, participants were invited to share any additional thoughts they might have. Following expressions of gratitude, the researcher discussed the potential need for follow-up interviews or further questions. In addition to voice recordings, the researcher took detailed notes using pen and paper to document participants' emotions, facial expressions, tone of voice, and other pertinent observations throughout the interview process. Interviews continued until participants had exhausted their insights. If necessary, particularly in cases of participant fatigue or data saturation, the interviews were conducted in subsequent sessions with the same individual. To ensure the confidentiality of the interview data, the recorded files were securely stored in an encrypted format by the corresponding author (F.H.). Once all interviews were completed, the recordings were transcribed into Persian promptly by the first author and converted into a Word document. Data analysis and initial coding of each interview were completed prior to commencing the next interview using MAXQDA version 22. Data Analysis: For data analysis, this study employed the directed content analysis method, guided by the definition and conceptual model proposed by Martin (2017) [ 10 ]. This model was selected because it offers a comprehensive and holistic understanding of sexual health literacy, integrating broad perspectives such as Nutbeam's three-dimensional model (2000), the inclusive concept outlined by Sørensen et al. (2012), and the definitions provided by Jones and Norton (2007) and McMichael and Gifford (2010) [ 1 , 3 , 23 , 28 ]. Furthermore, given the researcher's and research team's interest in examining the social and cultural contexts of the study population, we found this definition particularly relevant to our research topic. While the model encompasses various dimensions, including sexual health information, personal skills, and context, this paper specifically focuses on the dimension of "contexts and environments." This focus aligns with the research's aim to investigate the social and cultural factors that influence sexual and reproductive health literacy. During the data analysis process, each interview transcript was read multiple times to achieve a comprehensive understanding of its content. The interviews were subsequently imported into MAXQDA software, where open coding was conducted within relevant semantic units. Open codes were continuously compared and categorized based on conceptual similarities, initially resulting in seven categories, which were then consolidated into three main categories. Ultimately, themes related to the social and cultural structures of sexual and reproductive health literacy emerged, encompassing subthemes derived from the aforementioned categories (see Table 1 ). The research team reviewed and evaluated the data analysis process in several sessions to ensure consensus on the accuracy of the findings. Data management and analysis were conducted using MAXQDA version 22. Trustworthiness and rigor To evaluate the validity of the findings from this study, we applied the five criteria proposed by Johnson (2017): credibility, confirmability, dependability, transferability, and authenticity [ 28 ]. Credibility was established through the researcher's prolonged engagement with the data, which involved extensive review and continuous reflection on the codes and categories. The research team held multiple meetings to reach a consensus on the findings, and a colleague reviewed the interviews to provide an external perspective. Additionally, we conducted participant reviews by providing transcribed interviews in Word format to three participants, allowing them to assess the accuracy of the transcriptions. To enhance dependability, we ensured that the research process was transparent, allowing readers to follow the progression from data collection to the development of subcategories, categories, and themes. The integrity of the research process—including interviewing, coding, and the extraction of categories and themes—was confirmed by the research team. Furthermore, the dependability of the data was assessed by three external experts in sexual and reproductive health, who were proficient in qualitative research. They oversaw the data analysis process and provided valuable feedback. Confirmability was achieved through the documentation of all stages of the research process, along with confirmation from both participants and research team members regarding the findings. For transferability, we selected participants with maximum diversity in terms of age, education, number of children, and socio-economic status, thereby enhancing the applicability of the findings to broader contexts. Lastly, the authenticity of the findings was ensured by purposively sampling participants based on established inclusion criteria. Ethical Considerations: All ethical considerations regarding anonymity, confidentiality, and informed consent were strictly followed during the fieldwork process. Informed consent was obtained from all participants before their involvement in the study. Additionally, explicit consent was obtained from each participant for the use of voice recording during the interviews. At any stage of the interview, participants were fully free to withdraw from the interview, and their participation was entirely voluntary. The data was stored in appropriately identified files and will be destroyed after the completion of the research. This study is part of a mixed-methods doctoral dissertation on reproductive health, conducted in accordance with the Helsinki Declaration guidelines and approved by the Ethics Committee (Ethical code: IR.MODARES.REC.1402.266) at Tarbiat Modares University, Tehran, Iran. All authors have confirmed their consent for the publication of this work. Findings The data analysis led to the identification of the theme " Social-Cultural Contexts of Sexual and Reproductive Health Literacy ," which includes three main categories: "Customs and Traditions," "Social and Cultural Beliefs," and "Economic Conditions," along with eight subcategories. The categories and subcategories are presented in Table 2 . Table 2 Theme, Categories, and Sub-categories of Social-Cultural Contexts of Sexual and Reproductive Health Literacy in Married Women Theme Categories Sub-categories Social-Cultural Contexts of Sexual and Reproductive Health Literacy (105 open codes) Customs and Traditions (26 codes) Wedding Ceremonies and the Importance of Virginity (16 codes) Female Circumcision and Gendering (6 codes) Mourning Ceremonies and the Restriction of Sexual Relations between Spouses (4 codes) Social and Cultural Norms and Beliefs (59 codes) Gender Cultural Beliefs (12 codes) Cultural Beliefs on Sexuality (27 codes) Social Contexts (20 codes) Economic Conditions (22 codes) Economic Limitations Affecting Access (18 codes) Lack of Priority for Sexual Health Topics in Economic Poverty (4 codes) The first category: Customs and Traditions : Customs and traditions are identified as the first concept in the social-cultural context that plays a role in shaping sexual and reproductive health literacy among women. These customs not only confine women's behaviors to specific frameworks, but also limit their choices by creating guilt and social pressure. In this context, sexual and reproductive health literacy can serve as a tool for critiquing these beliefs and enhancing women's decision-making power. This enables them to assess their needs based on personal understanding and analysis, rather than solely on imposed social beliefs. These experiences demonstrate how culture and social expectations influence self-control, attitudes, and decision-making abilities. At the same time, more informed women can challenge these norms and contribute to their change. Subcategories under this category include: marriage ceremonies and the importance of virginity, female genital mutilation (FGM) practices, and mourning ceremonies that limit sexual relations between spouses. Marriage Ceremonies and the Importance of Virginity Based on participants' experiences in this study, one of the traditional customs commonly practiced in the studied community to prove virginity and the absence of sexual relations before marriage is obtaining a virginity certificate. These experiences show how traditional customs, by imposing social pressures, affect women's decision-making ability and autonomy, which are key elements of sexual and reproductive health literacy. Participants reported feeling bad about the pressure from their families, particularly their mothers, to obtain a virginity certificate and criticized these customs, calling them harsh and meaningless. The insistence of mothers was often driven by fear of societal gossip and adherence to traditional norms. "I remember my mother insisted we go get the virginity certificate before the wedding. I was so embarrassed. If it wasn't for the pressure, I wouldn't have gone. I was confident about myself, but my mother said it was the custom, and we needed it so there wouldn't be rumors later. So, I reluctantly agreed." (p10, 40 years old, two children). These customs strongly influence young women’s ability to resist these norms. Many women emphasized the role of awareness and knowledge in ignoring these customs. "Obtaining the virginity certificate is a tradition in my area, especially in my father's family. But neither I nor my husband were willing to do it. Fortunately, my family, especially my mother, supported me. Individual awareness and family support in rejecting these baseless customs are very important." (p14, 29 years old, no children). Female Genital Mutilation The custom of female circumcision is a cultural tradition in the study community that impacts women's health and self-esteem. Based on participants' experiences, while this practice has diminished compared to the past, it still continues in some Kurdish regions. This tradition is passed down from generation to generation without awareness of its consequences. Some participants criticized less educated mothers for continuing this practice, believing that women, with awareness of their individual rights and health, would make more informed decisions about their own and their children’s bodies. Misconceptions also exist about the role of circumcision in improving the appearance of women’s external genital. "In our family, my grandmother insisted that every girl born should be circumcised. I don't know what the reason was. When I asked my mother about myself, she had nothing to say. She just said, 'Your grandmother said it improves the beauty of the female genital organ.'" (p1, 39 years old, two children). Based on some participants' experiences in this study, difficulties in achieving sexual pleasure and dissatisfaction in sexual relations due to circumcision were reported. Given the awareness of the consequences of female circumcision, these women criticized the practice as harmful and unnecessary. "I was circumcised because it was the custom back then. I feel like I take longer to reach sexual pleasure and often don't feel satisfied. I believe this affects pleasure, but my sexual desire is natural because the brain controls it. But in general, I completely disagree with this custom as I’ve researched and found no benefits; in fact, it causes problems." (p13, 41 years old, one child). Mourning Ceremonies and Limitations on Sexual Relations Between Spouses One of the traditional customs discussed by participants was the prohibition of sexual relations during mourning periods. Some women, with a critical view, considered this custom unfounded and even harmful to mental health. One participant, reflecting on her personal experience, concluded that mourning and sexual relations are two independent matters. These views demonstrate that as women gain more awareness, they gain greater power to critique traditional beliefs and make decisions in line with their personal and psychological needs. "Most people say that after the death of a loved one, sexual relations should be avoided for 40 days. After my brother passed away, I was in a very bad emotional state. Since I had heard that there shouldn’t be sexual relations until the 40th day, I avoided it. But later I realized that this issue had nothing to do with mourning. When I was with my husband, I felt more at peace. I think this belief is just a custom that can add more emotional pressure rather than help with mourning." (p8, 35 years old, two children). In contrast, some participants continued to follow this custom without questioning its consequences due to deep cultural and societal influence. "When someone close passes away, it’s customary not to have sex until the 40th day. When my father passed away, I really thought that if I slept with my husband, it would mean I was indifferent to my father’s death, which caused me to distance myself from him. Since I believed this was a custom, I followed it." (p16, 44 years old, two children). Second Category: Socio_cultural norms and Beliefs : This category addresses the socio_cultural norms and beliefs that impact women’s sexual and reproductive health literacy. The social-cultural context provides a framework for socio_cultural beliefs, which dictate societal expectations for sexual behaviors. These norms often prescribe what is considered acceptable or unacceptable in relation to sexual health. Based on the experiences of participants in this study, social and cultural beliefs can influence individuals' thinking about sexual and reproductive matters, discussions about these topics, and even their decisions in three ways: gender beliefs, beliefs about sexual relations, and social environments. Gender Beliefs Gender beliefs in the studied community emphasize concepts such as gender discrimination, gender double standards, male superiority over women, the need for women to comply with their husbands to maintain the family, and the importance of having sons. From the narratives and testimonies of women, it is clear how much pressure women still face from their husbands and extended families to bear male children, with social stigmas surrounding the birth of daughters. "The result of marriage and sexual relations is having children and becoming parents. Thank God my first child was a boy, so I wasn't stressed about the next one. Having a son is very important to my husband, and his family also prefers it. My sister-in-law, who has three daughters, is constantly being criticized." (p2, 36 years old, two children). Regarding the need for women to comply with their husbands' wishes in marital relations, one participant, who was a religious studies student, explained: "My husband doesn’t like makeup, even when we’re alone. So, I respect that because I don’t want to argue. After all, he’s the man. My mother says a woman should obey her husband." (p4, 21 years old, one child). Some perceptions highlight the significant role of cultural gender beliefs in shaping attitudes and decisions regarding reproductive health. The belief in male superiority and the easier upbringing of boys can impact women's awareness, preventing them from gaining essential knowledge about sexual and reproductive health. For example, the emphasis on preserving daughters' honor while boys are perceived as less likely to bring shame is rooted in gender double standards in sexual matters within society. "In our Kurdish culture, boys and men generally have a higher status than girls and women. Most of the time, men are right. Even when I talk to my husband about pregnancy and having children, he insists the first child must be a boy. He believes raising a daughter is harder, but a son will always support his father and won't bring shame if he makes a mistake." (p17, 18 years old, no children). Cultural Beliefs on Sexuality: Misconceptions about sexuality impact women's sexual and reproductive health literacy. When women view sexual intercourse as a duty to satisfy their husbands or refrain from expressing their desires and problems due to taboos, these beliefs result in both women and men lacking a proper understanding of each other’s sexual rights, needs, and health. Consequently, they may not seek information in this regard. It appears that meeting men's sexual needs in a relationship takes precedence over the emotional and sexual needs of women, with men not being educated about this and making no effort to ensure a satisfying sexual relationship for their wives. "Now, even though it's been a few months since we got married, my opinion doesn't matter to him, and he doesn't respect me. For example, whenever he wants, we have to have sex, and he never listens when I say I don't feel like it or am not in the mood. I just endure it until it's over." (p17, 18 years old, no children) On the other hand, coercion in sexual relations due to cultural and traditional beliefs can lead to challenges that women face when seeking sexual information, especially under the pressure of social expectations and the opinions of elders. A participant pointed out that elders view sexual relations as a duty rather than a positive, mutually enjoyable experience. These pressures, combined with the lack of access to accurate information, can lead to feelings of guilt and obligation, making women feel enslaved in sexual relations where their needs and desires are ignored. Women's lack of awareness of female orgasm in sexual relations contributed to their sexual beliefs. "At the beginning of my marriage, I didn't really know what orgasm was. I enjoyed sex but didn't know what it felt like. I only continued because I'd heard older people say that sex is a must, and if a woman refuses, her husband will become cold. So, I did it out of obligation, but it felt horrible, like I was a slave." (p1, 39 years old, two children) In some participants, talking about sexual issues was taboo, rooted in strict parental upbringing. Cultural taboos and social norms impact how people interact with sexual and reproductive health topics from childhood. The prohibition of discussing such issues and being scolded for natural curiosity can lead to shame and uncertainty when seeking information and communicating between spouses. "I really don't like to discuss or exchange information about this subject in a group. We have to accept that our culture has always viewed talking and asking about these issues as shameful since childhood. I remember whenever I asked my mom about sexual issues or even menstruation, I'd get scolded for asking such questions." (p12, 27 years old, two children) Having extensive knowledge about sexual topics may even lead to stigmatization by a partner, as they might associate such knowledge with more sexual experience. Therefore, people might present themselves as inexperienced in sexual matters to avoid appearing promiscuous. "I've read a lot about how to improve sex, but out of fear that my husband will think I learned these things or moves somewhere else or find my behavior shameless, I stay silent." (p5, 40 years old, one child) Social Contexts: The experiences of participants show that individuals face serious obstacles in accessing accurate sexual and reproductive health information within social structures and contexts. The lack of formal, needs-based education, the absence of specialized staff at health centers, and the lack of private spaces for asking sexual health questions have had multiple consequences on women's sexual and reproductive health literacy. Without appropriate education that aligns with different life stages (adolescence, young adulthood, and middle age), participants have had to learn through trial and error, which not only causes issues in marital relationships but also leads to the ignorance of mothers who are unable to pass on correct information to their children. One participant mentioned: "I only go to the health center for my kids' care, like height and weight checks and vaccinations. It’s free, but I don't trust it for serious or private matters like sexual health. The staff here don't know much about sexual issues. One time, I asked about positions for intimacy, and they told me to go to a specialist; they said they would know better." (p12, 27 years old, two children) Additionally, media, which can play a significant role in raising awareness, does not provide enough programs on these sensitive topics. This lack of coverage has meant that sexual topics remain surrounded by negative judgments and misconceptions, while issues like women’s health and pregnancy are covered better. This neglect of sexual education, besides negatively impacting health literacy, can create grounds for sexual and reproductive health issues in women. The need for education was emphasized by the women. One participant said: "I’ve never seen a TV program about sexual issues. There are programs about pregnancy or various diseases, but not about sex. They invite gynecologists or even midwives, but nothing about sex. If there were, it would be great." (p15, 26 years old, one child) Third category: Economic Conditions : Some participants, especially those facing economic hardship, expressed that meeting basic life needs took priority, and thus spending money on sexual and reproductive health information and counseling was considered a luxury, less of a priority. Financial constraints shifted their focus from sexual and reproductive health to basic survival concerns. "When you don't even have money to buy bread for your kids, who has time to think about learning about sexual matters? For us, we have to think first about feeding our kids. Everything else comes second." (p2, 36 years old, two children) For others, economic conditions profoundly affected choices related to sexual and reproductive health, particularly with the young generation citing poor economic conditions as leading to decreased willingness to have children and, in some cases, delaying pregnancy. Conversely, some women noted that due to the costs of contraception methods and their non-provision for free by public centers, they had no choice but to use natural methods, despite being aware of their lack of accuracy and fearing unintended pregnancies. "My husband is a worker; some days he works, some days he doesn't, and we are renters. Our financial situation isn't good. Health centers don't give us free pills or contraception anymore. We have to rely on natural methods, even though I've heard it's not accurate. We have to be very careful because if I get pregnant unexpectedly, with our situation, I really don't know what I’d do." (p16, 44 years old, two children). Discussion According to established definitions of health literacy and sexual health literacy in the academic literature, the importance of considering broader social contexts and the necessity of focusing on structural and socio-cultural influences on health literacy have been particularly emphasized [ 3 , 4 , 28 ]. This study explores and examines the complex social and cultural contexts that impact married women's sexual and reproductive health literacy. The theme of "socio-cultural context of sexual and reproductive health literacy" consists of three main categories: "customs and traditions," "social and cultural norms and beliefs," and "economic conditions." The findings indicate that social, cultural, and economic factors function as fundamental infrastructures, playing a crucial role in either shaping or hindering the development of sexual and reproductive health literacy (Fig. 1 ). Regarding customs and traditions, this study found that marriage-related customs, the importance of proving virginity, female genital mutilation (FGM) and its role in women's sexuality and sexual desire, and customs limiting marital sexual relations during mourning periods significantly impact women's acquisition and application of sexual and reproductive health literacy. Previous studies have also demonstrated the link between health literacy and cultural contexts. Specifically, prior research has shown that low health literacy is associated with stigma related to mental illnesses and fatalistic beliefs about disease prevention [ 3 , 29 ]. Additionally, another study found that cultural and religious norms, emphasizing modesty and chastity, hinder open discussions about sexual and reproductive health, thereby restricting access to essential sexual and reproductive health information and services [ 30 ]. A common custom in the studied society is the mandatory virginity examination and certification, which is presented to the groom’s family. Women experience this as part of a social and cultural process meant to prove and uphold their "chastity" and "worthiness" before marriage. In Iran, as a religious society, a woman’s virginity is regarded as an honor, and preserving it is considered valuable and necessary for girls. Any harm to a girl’s virginity before marriage can be perceived as a major catastrophe for her and her family, carrying severe consequences [ 31 ]. This issue highlights that the social and familial pressures related to the custom of virginity can negatively affect women's ability to make independent decisions about their bodies and sexual health. This is directly linked to sexual and reproductive health literacy, as one of its key aspects is the ability to understand, evaluate, and make informed decisions regarding sexual and reproductive issues. When cultural norms compel women to conform to specific traditions, this capacity is severely restricted. A systematic review (2024) identified recurring themes across multiple studies, including parental and societal expectations regarding "sexual purity” before marriage through abstinence, limited parent-child communication about sexual matters, and gender norms restricting young women’s sexual and reproductive decision-making [ 16 ]. Our findings indicate that this experience is context-dependent, as some individuals perceive it as a positive and necessary practice for preserving family honor. Another tradition examined in this study is female genital mutilation (FGM). Although the prevalence of FGM has declined in contemporary Iranian society, it continues to be practiced in certain regions [ 32 ]. Participants who had either undergone FGM themselves or knew others who had experienced it strongly criticized the practice, viewing it as detrimental to women's sexual and reproductive health. Women who had undergone FGM stated that low awareness, weak decision-making power among senior family members (especially mothers), and adherence to traditional customs led to the continuation of this practice. Traditional values constitute a crucial part of the cultural environment and meaning-making systems. These values are passed down from one generation to the next and, through socialization processes, may unconsciously become embedded in individual beliefs and values [ 33 ]. Enhancing sexual and reproductive health literacy, particularly among mothers, can serve as a strong barrier against the intergenerational transmission of harmful practices such as FGM. It appears that the ability to analyze and evaluate scientific information, combined with personal experience, has helped contemporary mothers critically assess this tradition and recognize its harmful impact on sexual health. This finding suggests that sexual and reproductive health literacy not only improves individual knowledge but also fosters critical reassessment of traditional beliefs and more informed decision-making. Participants who had experienced FGM explicitly stated that they would not subject their own daughters to the same practice. Factors such as religion, tradition, family elders' control over women's chastity, and aesthetic considerations were cited by participants as reasons for the continuation of this custom. In line with these findings, a study by Rabeipour and colleagues in Iran (2022) demonstrated that inappropriate social and cultural norms, along with religious attitudes, contributed to the perpetuation and prevalence of FGM, while improvements in health knowledge and awareness led to a decline in the practice among newer generations [ 32 ]. Given the negative consequences of FGM, cultural advancements must begin through education and awareness. By educating individuals and increasing public awareness about this issue, positive changes can be reinforced, ultimately contributing to the effective resolution of this problem [ 34 ]. Socio_cultural norms and beliefs, as hidden forces, play a significant role in shaping attitudes and behaviors related to sexual and reproductive health. These beliefs not only establish specific mental frameworks for the acceptance or rejection of sexual behaviors but also profoundly influence an individual’s understanding of their sexual and reproductive needs. Findings from this study indicated that the taboo or sensitivity surrounding sexual topics leads individuals to refrain from seeking knowledge and education in these areas. A study conducted in Myanmar found that most participating students reported that cultural taboos hinder open discussions about sexual issues and premarital relationships among young people, potentially leading to low awareness and understanding. These taboos prevent students from engaging in open discussions about sexual health with sources such as parents and healthcare providers [ 35 ]. By fostering open dialogue and collaboration, community engagement can help reduce the stigma associated with sexual and reproductive health (SRH) and promote a supportive environment for discussing these issues [ 36 , 37 ]. Additionally, the findings of the present study revealed that gendered beliefs regarding male superiority and a preference for male offspring persist as part of cultural and social beliefs in the 21st century, particularly among Kurdish communities. This issue not only pressures women to fulfill the expectations of their husbands and families but also imposes social pressures to have male children as a symbol of high social value, severely limiting women's autonomy in reproductive decision-making. Consistent with our findings, a study by Meherali (2024) demonstrated that prioritizing the needs of husbands and families over individual needs in women can lead to the neglect of their personal sexual and reproductive health needs [ 38 ]. Traditional cultural beliefs within families and broader social contexts continue to shape attitudes and beliefs related to SRH, creating barriers to accessing information and services [ 22 ]. Male control over women is a recurring theme in SRH literature [ 39 ]. Our research findings confirm this notion, as participants' experiences illustrate concepts such as prioritizing male sexual needs over female needs and sexual coercion driven by fear of abandonment by a spouse. These aspects clearly reflect the potential negative impacts of traditional cultural attitudes and gender role norms on autonomy in SRH-related decision-making, as highlighted in previous research [ 40 – 42 ]. Participants in this study identified several structural and social factors, including the lack of culturally and individually tailored formal sexual education, the absence of private spaces, the lack of specialized personnel in public healthcare centers, and the absence of educational media programs on sexual matters, all of which, based on their experiences, hinder access to accurate and comprehensive sexual and reproductive health information. Consistent with our findings, the absence of safe educational and cultural content has been highlighted in previous studies as a barrier to accessing sexual health information [ 22 , 28 , 43 ]. Regarding the lack of privacy in healthcare centers, privacy limitations for patients are recognized as a barrier to accessing SRH information and services. In fact, feelings of embarrassment and discomfort in discussing personal SRH issues in a public setting, coupled with fear of judgment from healthcare providers and peers, may prevent young people from seeking essential information and services or expressing their SRH needs [ 30 , 44 ]. Addressing these barriers requires the establishment of private spaces in healthcare centers that ensure confidentiality, along with the implementation of comprehensive sexual education programs tailored to individuals' ages and needs. Low SRH literacy can contribute to intergenerational unawareness and reliance on trial-and-error learning, ultimately increasing risky behaviors and marital issues. In addition to social and cultural factors, economic conditions were identified in this study as another underlying factor influencing SRH literacy, consistent with previous studies [ 16 , 21 , 45 , 46 ]. In the present study, women facing economic hardships did not prioritize acquiring information related to SRH. A systematic review conducted in Iran similarly demonstrated that favorable economic conditions are among the positive predictors of adequate SRH literacy [ 46 ]. Participants reported that financial constraints, even when they possessed adequate health literacy, posed challenges in accessing and utilizing SRH information and services. Supporting this finding, a study showed that financial barriers could restrict individuals' autonomy and decision-making abilities in sexual and reproductive health [ 47 ]. Furthermore, in the current economic climate of Iran, where pronatalist policies and limited access to free contraceptive methods prevail, economic difficulties directly influence reproductive decisions, including childbearing. Many families delay this crucial decision due to concerns about affording living costs and raising children. For older women in their reproductive years facing economic hardships, these conditions pose serious challenges, increasing the risk of unintended and high-risk pregnancies. This issue not only affects women’s physical and health conditions but also imposes a greater financial burden on low-income families due to the rising costs associated with pregnancy and childbirth. Economic stability may facilitate access to educational and healthcare resources, whereas women from lower socioeconomic backgrounds may have limited access to SRH information and services, contributing to knowledge gaps [ 48 ]. Consequently, low health literacy can lead to an increase in complications such as unplanned pregnancies, abortions, high-risk pregnancies, and, ultimately, maternal mortality [ 49 ]. These findings align with the Cultural Care Theory (CCT), which underscores the importance of understanding how cultural values, beliefs, and behaviors, as well as structural and social factors such as religion, economic status, family relationships, policy, education, and technology, influence individuals' attitudes, knowledge, behaviors, and skills [ 50 ]. Strengths and Limitations This qualitative study comprehensively demonstrated how social and cultural contexts influence the sexual and reproductive health literacy of women of reproductive age in a region of Iran, highlighting the challenges associated with these factors. The findings revealed that these contexts, particularly cultural taboos and social norms, create significant barriers to accessing accurate information, receiving appropriate education, and improving sexual and reproductive health. Furthermore, the results of this study underscore the necessity of designing and implementing educational interventions for sexual and reproductive health literacy that take into account social and cultural norms. Such interventions can ultimately contribute to the enhancement of sexual and reproductive health within this group. Educational efforts aimed at correcting inaccurate normative beliefs are among the recommendations of this study. The data for this study were collected through semi-structured in-depth interviews. This approach facilitated a detailed understanding of the social and cultural influences at play. However, the nature of these conversations may have led some participants to express views influenced by cultural norms. To ensure data richness, data collection continued until saturation was achieved, thereby enhancing the credibility of the findings. This study also has certain limitations. As a qualitative study conducted with a limited sample of women residing in Sanandaj, the findings may not be generalizable to other regions of Iran or to different ethnic and cultural groups. Due to the qualitative nature of the research and the restricted number of participants, the results should be interpreted with caution in terms of their broader applicability. Future research is recommended to examine more diverse groups across various cultural and geographical contexts to enhance the generalizability of the findings. Conclusion Overall, this study highlights that social, cultural, and economic context shape individuals' beliefs, norms, behaviors, and access to information regarding sexual and reproductive health. These socio-cultural contexts play a determining role in shaping individuals' levels of sexual and reproductive health literacy by creating either constraints or opportunities. Cultural norms, taboos, and economic limitations can act as barriers to raising awareness and accessing services. Therefore, the development of educational programs and reproductive and sexual health policies must consider these socio-cultural contexts to address and reform certain misconceptions and social taboos. This, in turn, can contribute to improving reproductive and sexual health, particularly among women. The findings of this study can serve as a valuable foundation for the development of educational programs and policies related to sexual and reproductive health in societies with similar demographic and socio-cultural characteristics. Declarations Acknowledgments We extend our gratitude to all the women of reproductive age who participated in the interviews, as well as to the health care staff of selected clinics who assisted the research team throughout this research project. Authors’ Contributions All authors contributed to the conceptualization and design of the study. HF drafted the initial manuscript. FKF carefully read and contributed to the main draft and edited several times. All other authors reviewed and provided feedback on the final draft and finally approved the final version of the manuscript. Funding No funding was received for this research. Data Availability Transcribed versions of the data used in this study, excluding the recorded audio files of the participants, are available upon reasonable request from the corresponding author. This study is part of a PhD thesis focused on reproductive health at Tarbiat Modares University and has received approval from the Ethics Committee of Tarbiat Modares University, Tehran, Iran (Ethic Code: IR.MODARES.REC.1402.266). Informed consent was obtained from all participants, and the study was conducted in accordance with the principles outlined in the Helsinki Declaration, following established ethical guidelines and regulations. Consent for Publication All authors have reviewed and approved the manuscript. Conflict of Interest The authors declare that there are no conflicts of interest. Author Details 1 Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. 2 Family Research Institute, Shahid Beheshti University, Shahid Shahriari Square, Evin, Tehran 1983969411, Iran. 3 Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. 4 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. 5 Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran. 6 Faculty of Humanity Sciences, University of Science and Culture, Tehran, Iran. References Nutbeam DJS. .s. and medicine. Evol concept health Lit. 2008;67(12):2072–8. Rootman I, Gordon-El-Bihbety DJO. 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J Adolesc Health. 2012;50(3 Suppl):S12–7. Hassannezhad K et al. The comparison of sexual function in types I and II of female genital mutilation. 2024. 24(1): p. 31. Kyu HA et al. Cultural taboos and low sexual and reproductive health literacy among university students in Magway city, Myanmar. 2024: pp. 1–15. Mukherjee A et al. Perception and practices of menstruation restrictions among urban adolescent girls and women in Nepal: a cross-sectional survey. 2020. 17: pp. 1–10. Kpodo L et al. Socio-cultural factors associated with knowledge, attitudes and menstrual hygiene practices among Junior High School adolescent girls in the Kpando district of Ghana: A mixed method study. 2022. 17(10): p. e0275583. Meherali S et al. Between cultures and traditions: a qualitative investigation of sexual and reproductive health experiences of immigrant adolescents in Canada. 2024: pp. 1–17. Hussein J, Ferguson L. Eliminating stigma and discrimination in sexual and reproductive health care: a public health imperative. Sex Reprod Health Matters. 2019;27(3):1–5. Rawson HA, Liamputtong P. Culture and sex education: the acquisition of sexual knowledge for a group of Vietnamese Australian young women. Ethn Health. 2010;15(4):343–64. Rogers C, Earnest J. A Cross-Generational Study of Contraception and Reproductive Health Among Sudanese and Eritrean Women in Brisbane, Australia. Health Care Women Int. 2014;35(3):334–56. Lirios A, et al. Sexual and reproductive health literacy of culturally and linguistically diverse young people in Australia: a systematic review. Cult Health Sex. 2024;26(6):790–807. Botfield JR et al. Learning about sex and relationships among migrant and refugee young people in Sydney, Australia:‘I never got the talk about the birds and the bees’. 2018. 18(6): pp. 705–20. Sidamo NB, et al. Socio-Ecological Analysis of Barriers to Access and Utilization of Adolescent Sexual and Reproductive Health Services in Sub-Saharan Africa: A Qualitative Systematic Review. Open Access J Contracept. 2023;14:103–18. Shahrahmani H et al. Sexual health literacy and its related factors among couples: A population-based study in Iran. 2023. 18(11): p. e0293279. Hamzehgardeshi Z, et al. Factors Associated with Sexual and Reproductive Health Literacy: A Scoping Review %J. J health Res community. 2022;8(3):96–110. VandeVusse A, et al. Cost-related barriers to sexual and reproductive health care: Results from a longitudinal qualitative study in Arizona. SSM - Qualitative Res Health. 2023;4:100360. Prémusz V, et al. Socio-Economic and Health Literacy Inequalities as Determinants of Women's Knowledge about Their Reproductive System: A Cross-Sectional Study. Epidemiologia (Basel). 2024;5(4):627–42. Ghavami B, et al. 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Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2025 Read the published version in Reproductive Health → Version 1 posted Editorial decision: Revision requested 30 Jun, 2025 Reviews received at journal 19 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviews received at journal 16 May, 2025 Reviews received at journal 13 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers invited by journal 13 May, 2025 Editor assigned by journal 17 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 15 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6234753","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456085840,"identity":"b4bdbe6c-c427-4efd-a241-a9a27f7691e3","order_by":0,"name":"hosna faridi","email":"","orcid":"","institution":"Tarbiat Modares University","correspondingAuthor":false,"prefix":"","firstName":"hosna","middleName":"","lastName":"faridi","suffix":""},{"id":456085842,"identity":"c0f21323-46eb-44b9-9ec0-73c9c31ccc32","order_by":1,"name":"farideh khalajabadi farahani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBAC9gY2NgaGAgZmBgkGBomECoYEiLgBbi08B0BaDGBazpCghQGshbENpgUP4GFgS3vww8COnX9288MbD+fV5RkcYH74gaHgHj4txw17DJKZJe4cM7ZI3Ha42OAAm7EEg0ExTi32DOxtEjwGzMwMNxLMJBK3HUjccIDBDOhU3A7kAWqR/GNQzyx/I/2bROKcOqAW9m8EtLAdk+YxOMxscCMHaEsDM1ALDyFb2NKkZQyOMxveOVNskXDscLHkYZ5iiQT8Wswk31RUJ8vdbt9480dNXR7f8faNHz78wa2FQf4BmEpGiDADMR4NcGBHhJpRMApGwSgYqQAA/q5MoTIKivYAAAAASUVORK5CYII=","orcid":"","institution":"Shahid Beheshti University","correspondingAuthor":true,"prefix":"","firstName":"farideh","middleName":"khalajabadi","lastName":"farahani","suffix":""},{"id":456085844,"identity":"0867cf58-8a8e-4d07-b279-a138ffe99cd8","order_by":2,"name":"minoor Lamyian","email":"","orcid":"","institution":"Tarbiat Modares University","correspondingAuthor":false,"prefix":"","firstName":"minoor","middleName":"","lastName":"Lamyian","suffix":""},{"id":456085846,"identity":"e2e5ef8a-4677-44f2-8c17-2a6022e95714","order_by":3,"name":"fazlollah ahmadi","email":"","orcid":"","institution":"Tarbiat Modares University","correspondingAuthor":false,"prefix":"","firstName":"fazlollah","middleName":"","lastName":"ahmadi","suffix":""},{"id":456085848,"identity":"320ecf44-36fd-4a23-a609-b45b51b10a02","order_by":4,"name":"ali montazeri","email":"","orcid":"","institution":"University of Science and Culture","correspondingAuthor":false,"prefix":"","firstName":"ali","middleName":"","lastName":"montazeri","suffix":""}],"badges":[],"createdAt":"2025-03-15 21:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6234753/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6234753/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12978-025-02155-2","type":"published","date":"2025-10-17T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82887464,"identity":"c4bb556e-6e15-467f-b282-e8b7f29e9fd2","added_by":"auto","created_at":"2025-05-16 11:56:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":321989,"visible":true,"origin":"","legend":"\u003cp\u003eSocio-cultural Context of sexual and reproductive health literacy among women\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6234753/v1/0ef46cb85d29b8a5ec37ddd8.jpeg"},{"id":93956000,"identity":"32da8faf-2906-41d1-8147-8b73b32d480a","added_by":"auto","created_at":"2025-10-20 16:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1189636,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6234753/v1/b2573da3-fceb-4d05-8a8e-b28f8ada459c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Socio-Cultural Contexts of Women's Sexual and Reproductive Health Literacy in Iran: A Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth literacy is an overarching concept, meaning it is not limited to individual health capabilities but also considers the role of healthcare systems and the surrounding environment. Health literacy is shaped by a range of individual, social, structural, and cultural factors, contextual and historical factors, different health services[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and emerging technologies[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003ePromoting sexual and reproductive health literacy among women of reproductive age is of great importance, especially since these women play multiple roles as wives and mothers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Health literacy is a dynamic concept with various dimensions. One of these dimensions is sexual and reproductive health literacy. Enhancing sexual and reproductive health literacy is a key strategy for improving women's reproductive health and well-being [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sexual and reproductive health literacy plays a critical role in empowering women to make informed decisions regarding sexual and reproductive health. This concept is not merely limited to their awareness of sexual relationships, menstrual cycles, or contraception methods, but extends to skills and abilities that enable individuals to search for, understand, evaluate, and ultimately apply related information [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Increasing sexual and reproductive health literacy can significantly contribute to reducing negative outcomes such as sexually transmitted infections, unintended pregnancies, and maternal mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual and reproductive health literacy is influenced by various factors, including cultural beliefs, personal attitudes, access to information, and social norms. Regarding the multifaceted nature of sexual health literacy, Martin (2017) has provided a definition which considers sexual health literacy as a combination of knowledge, beliefs, attitudes, motivations, and skills that help individuals access, understand, evaluate, and apply sexual health information in social, sexual, online, and healthcare contexts. This helps individuals make decisions and judgments about sexual health, public health, relationships, and well-being[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This concept goes beyond basic knowledge of sexual facts and includes the ability to manage sexual relationships and healthcare, engage in discussions and persuasion in cases of sexual coercion, use protective strategies, and address moral stigmas related to sexually transmitted infections, sexual identities, and social norms of sexual behavior [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].Women require accurate information in all areas of sexual and reproductive health, making it essential to offer interventions that meet these needs and help improve sexual health literacy (SHL) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In support of this, the World Health Organization (2023) has emphasized the role of education and health literacy in reducing the risks associated with unintended pregnancies and sexually transmitted infections [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual and reproductive health (SRH) is a fundamental component of overall well-being, while discussions on sexual and reproductive health are often veiled under cultural and social taboos [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite progress in global health education, sexual and reproductive topics remain overshadowed by misinformation and stigmatization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For example, in many parts of the world, menstruation is still considered a topic that should not be publicly discussed, leading to a phenomenon known as \"menstrual poverty\" and poor menstrual health management [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Cultural taboos surrounding premarital sexual relationships among youth in Asian countries such as Bangladesh, India, and Pakistan significantly hinder open discussions about sexual health between young people, their parents, teachers, and healthcare providers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIdentifying the socio-cultural contexts surrounding sexual and reproductive health (SRH) and access to related care is crucial [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The context and surrounding environment of individuals should be considered in the comprehensive conceptualization of sexual and reproductive health literacy, as contextual factors can complicate individual decision-making processes in choosing healthy sexual behaviors and may have a greater impact than a lack of awareness or insufficient motivation. In other words, to better understand sexual health literacy in any given socio-cultural context, attention must be paid to the specific social, cultural, and economic context [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research has identified various factors associated with sexual health literacy, including demographic, cultural-social, and medical-reproductive factors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Among these factors, the socio-cultural contexts of individuals' lives, particularly the widespread feelings of shame and embarrassment around discussing sexual issues, have been a significant focus in previous studies. The stigma surrounding sexual topics often acts as a barrier to individuals seeking sexual health information and prevents open discussions about sexual matters and access to specialists and medical services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A review study conducted in Australia clearly highlights the importance of socio-cultural context in promoting sexual health literacy and ensuring equitable access to sexual and reproductive health (SRH) information and services. This study emphasizes the need for theory-based strategies and policies that specifically address the social, cultural, and structural factors affecting youth from diverse cultural and linguistic backgrounds [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA qualitative study conducted to elucidate the challenges surrounding sexual health in Iran identified five predominant themes: (1) the taboo surrounding sexual issues and a general public unawareness; (2) the prevalence of unconventional sexual behaviors and their associated social harms; (3) stigma and discrimination; (4) a lack of political commitment; and (5) the absence of statistical indicators coupled with the underutilization of existing resources [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Addressing these challenges necessitates a comprehensive understanding of the socio-cultural norms that influence sexual health and sexual health literacy. Enhancing sexual health literacy through targeted interventions could significantly improve overall sexual health outcomes in the region [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo promote and achieve sexual health literacy and equitable access to SRH information and care that are culturally appropriate and meet local needs, conscious strategies and policies are needed that consider social, cultural, and structural components. Specifically, issues such as using appropriate language and refraining from verbal communication on topics related to sexual and reproductive literacy are crucial [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The socio-cultural contexts in which individuals are situated and the expectations placed on them play a significant role in shaping their access to and experiences with sexual health. Sexual health literacy must include awareness and critical analysis of social and cultural beliefs, attitudes, and behaviors that may negatively impact autonomy and decision-making and limit opportunities for safe sexual behaviors and decision-making [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Results from a qualitative study in Northern Ireland showed that formal sexual education based on traditional gender norms led to participants' inadequate awareness of sexual issues [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In other words, sexual health literacy goes beyond medical and biological understanding and involves critical and interactive awareness of the discourses and social and cultural structures that influence sexual aspects. This perspective helps integrate sexual knowledge with purposeful decision-making, effective communication, and empowering individuals to control their sexual experiences [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite previous studies on sexual health literacy, research that deeply explores women's interpretations of the socio-cultural contexts that may shape their sexual and reproductive health literacy is rare. The critical interpretive theoretical approach, which examines how women view traditional and cultural contexts related to sexual and reproductive health outcomes, is considered in this study. The aim of this research is to explore the socio-cultural contexts in which women's sexual and reproductive health literacy is formed in Iran.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Design:\u003c/h2\u003e\n \u003cp\u003eA qualitative methodology was selected to align with the aim of this study, which is to explore the social, cultural, and economic contexts of sexual and reproductive health literacy among married women of reproductive age. The research setting for this study is healthcare centers affiliated with the Kurdistan University of Medical Sciences in the western region of Iran. In this study, directed content analysis was employed. This deductive approach, introduced by Hsieh and Shannon (2005), is used to validate or develop an existing conceptual framework or theory [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this method, initial coding is based on a theoretical framework or findings from similar studies. The selected theory helps the researcher predict related concepts and their relationships, upon which operational definitions for each code are developed [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eParticipants:\u003c/h3\u003e\n\u003cp\u003eThe research population consisted of women of reproductive age who were selected through purposive sampling with maximum diversity (in terms of age, education level, place of residence, and economic status). Sampling was conducted from 17 comprehensive health centers in the city of Sanandaj, with a focus on four health centers that had a high volume of visitors. These centers are located in different areas of the city with varying social and economic levels (north, center, west, and a center in the suburbs of the city ). The inclusion criteria for the study were as follows: married, Iranian women aged 18\u0026ndash;45 years, who self-reported having no underlying health conditions, spoke either Kurdish or Persian, and were willing to participate in the study. The participants\u0026apos; ages ranged from 18 to 45 years, with an average age of 33.7 years. In total, 22 women were contacted for interviews, and three of them declined due to lack of interest. Interviews with two women were also terminated at the request of their mothers or companions. Ultimately, 17 interviews were conducted with women of reproductive age, each lasting an average of 42 minutes (ranging from 29 to 55 minutes) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Characteristics of Study Participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDemographic Characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;29 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u0026ndash;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eDuration of Marriage (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eNumber of Children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 or more children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary and Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGovernment Job\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eHousehold Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u0026ndash;19\u0026nbsp;million Toman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;30\u0026nbsp;million Toman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 30\u0026nbsp;million Toman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAt the time of the study, 1\u0026nbsp;million Toman was approximately equal to 17\u003c/p\u003e\n\u003cp\u003eUSD.Therefore, the income categories of 10\u0026ndash;19\u0026nbsp;million Toman, 20\u0026ndash;30\u003c/p\u003e\n\u003cp\u003emillion Toman, and more than 30\u0026nbsp;million Toman correspond to around\u003c/p\u003e\n\u003cp\u003e170\u0026ndash;323 USD, 340\u0026ndash;510 USD, and more than 510 USD, respectively.\u0026quot;\u003c/p\u003e\n\u003ch3\u003eData Collection Method:\u003c/h3\u003e\n\u003cp\u003eData collection for this study was conducted from April 20, 2024, to November 16, 2024. The data collection method involved semi-structured in-depth interviews. The first author (HF) attended comprehensive health service centers in the cities of Kurdistan province. Information regarding women who met the eligibility criteria for the study was obtained from the midwives or health workers who had the participant\u0026rsquo;s details. Subsequently, the researcher introduced herself and explained the research objectives during a phone call with the individuals. Upon agreement, the time and location of the interview were scheduled.\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted individually, in a private setting, within health centers approved by the participants, after obtaining informed consent. The interviews were recorded using a voice recorder with the participants\u0026apos; permission. At the beginning of the interviews, introductory questions were asked to help the researcher become familiar with the participants and create a friendly atmosphere. The interview process was then guided by targeted questions based on the theoretical framework of the study [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. A developmental approach was also employed during the interviews, meaning that, in addition to confirming pre-defined concepts, sufficient space was provided for the identification of new dimensions and expansion of findings related to sexual and reproductive health literacy. For example, participants were asked: \u0026quot;Based on your experience, what information does sexual and reproductive health literacy include? What are the contextual factors that contribute to acquiring sexual and reproductive health literacy? Are there specific beliefs or traditions regarding sexual and reproductive health in your family or community? How do these beliefs affect women\u0026apos;s behavior or decisions?\u0026quot; After each participant\u0026rsquo;s response, probing questions were asked to deepen and broaden the answers. These included: \u0026quot;Can you explain this further? What does that mean? ... Like what?\u0026quot; The interview guide questions were developed based on the research team\u0026rsquo;s opinions.\u003c/p\u003e\n\u003cp\u003eAt the conclusion of each interview, participants were invited to share any additional thoughts they might have. Following expressions of gratitude, the researcher discussed the potential need for follow-up interviews or further questions. In addition to voice recordings, the researcher took detailed notes using pen and paper to document participants\u0026apos; emotions, facial expressions, tone of voice, and other pertinent observations throughout the interview process. Interviews continued until participants had exhausted their insights. If necessary, particularly in cases of participant fatigue or data saturation, the interviews were conducted in subsequent sessions with the same individual. To ensure the confidentiality of the interview data, the recorded files were securely stored in an encrypted format by the corresponding author (F.H.). Once all interviews were completed, the recordings were transcribed into Persian promptly by the first author and converted into a Word document. Data analysis and initial coding of each interview were completed prior to commencing the next interview using MAXQDA version 22.\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis:\u003c/h2\u003e\n \u003cp\u003eFor data analysis, this study employed the directed content analysis method, guided by the definition and conceptual model proposed by Martin (2017) [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. This model was selected because it offers a comprehensive and holistic understanding of sexual health literacy, integrating broad perspectives such as Nutbeam\u0026apos;s three-dimensional model (2000), the inclusive concept outlined by S\u0026oslash;rensen et al. (2012), and the definitions provided by Jones and Norton (2007) and McMichael and Gifford (2010) [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, given the researcher\u0026apos;s and research team\u0026apos;s interest in examining the social and cultural contexts of the study population, we found this definition particularly relevant to our research topic.\u003c/p\u003e\n \u003cp\u003eWhile the model encompasses various dimensions, including sexual health information, personal skills, and context, this paper specifically focuses on the dimension of \u0026quot;contexts and environments.\u0026quot; This focus aligns with the research\u0026apos;s aim to investigate the social and cultural factors that influence sexual and reproductive health literacy.\u003c/p\u003e\n \u003cp\u003eDuring the data analysis process, each interview transcript was read multiple times to achieve a comprehensive understanding of its content. The interviews were subsequently imported into MAXQDA software, where open coding was conducted within relevant semantic units. Open codes were continuously compared and categorized based on conceptual similarities, initially resulting in seven categories, which were then consolidated into three main categories. Ultimately, themes related to the social and cultural structures of sexual and reproductive health literacy emerged, encompassing subthemes derived from the aforementioned categories (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe research team reviewed and evaluated the data analysis process in several sessions to ensure consensus on the accuracy of the findings. Data management and analysis were conducted using MAXQDA version 22.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTrustworthiness and rigor\u003c/h3\u003e\n\u003cp\u003eTo evaluate the validity of the findings from this study, we applied the five criteria proposed by Johnson (2017): credibility, confirmability, dependability, transferability, and authenticity [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCredibility was established through the researcher\u0026apos;s prolonged engagement with the data, which involved extensive review and continuous reflection on the codes and categories. The research team held multiple meetings to reach a consensus on the findings, and a colleague reviewed the interviews to provide an external perspective. Additionally, we conducted participant reviews by providing transcribed interviews in Word format to three participants, allowing them to assess the accuracy of the transcriptions.\u003c/p\u003e\n\u003cp\u003eTo enhance dependability, we ensured that the research process was transparent, allowing readers to follow the progression from data collection to the development of subcategories, categories, and themes. The integrity of the research process\u0026mdash;including interviewing, coding, and the extraction of categories and themes\u0026mdash;was confirmed by the research team. Furthermore, the dependability of the data was assessed by three external experts in sexual and reproductive health, who were proficient in qualitative research. They oversaw the data analysis process and provided valuable feedback.\u003c/p\u003e\n\u003cp\u003eConfirmability was achieved through the documentation of all stages of the research process, along with confirmation from both participants and research team members regarding the findings. For transferability, we selected participants with maximum diversity in terms of age, education, number of children, and socio-economic status, thereby enhancing the applicability of the findings to broader contexts. Lastly, the authenticity of the findings was ensured by purposively sampling participants based on established inclusion criteria.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical Considerations:\u003c/h2\u003e\n \u003cp\u003eAll ethical considerations regarding anonymity, confidentiality, and informed consent were strictly followed during the fieldwork process. Informed consent was obtained from all participants before their involvement in the study. Additionally, explicit consent was obtained from each participant for the use of voice recording during the interviews. At any stage of the interview, participants were fully free to withdraw from the interview, and their participation was entirely voluntary. The data was stored in appropriately identified files and will be destroyed after the completion of the research. This study is part of a mixed-methods doctoral dissertation on reproductive health, conducted in accordance with the Helsinki Declaration guidelines and approved by the Ethics Committee (Ethical code: IR.MODARES.REC.1402.266) at Tarbiat Modares University, Tehran, Iran. All authors have confirmed their consent for the publication of this work.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eThe data analysis led to the identification of the theme \u0026quot;\u003cstrong\u003eSocial-Cultural Contexts of Sexual and Reproductive Health Literacy\u003c/strong\u003e,\u0026quot; which includes three main categories: \u0026quot;Customs and Traditions,\u0026quot; \u0026quot;Social and Cultural Beliefs,\u0026quot; and \u0026quot;Economic Conditions,\u0026quot; along with eight subcategories. The categories and subcategories are presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTheme, Categories, and Sub-categories of Social-Cultural Contexts of Sexual and Reproductive Health Literacy in Married Women\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSub-categories\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial-Cultural Contexts of Sexual and Reproductive Health Literacy\u003c/strong\u003e (105 open codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCustoms and Traditions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(26 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWedding Ceremonies and the Importance of Virginity (16 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale Circumcision and Gendering (6 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMourning Ceremonies and the Restriction of Sexual Relations between Spouses (4 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial and Cultural Norms and Beliefs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(59 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender Cultural Beliefs (12 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCultural Beliefs on Sexuality (27 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial Contexts (20 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEconomic Conditions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(22 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEconomic Limitations Affecting Access (18 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of Priority for Sexual Health Topics in Economic Poverty (4 codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe first category: \u003cstrong\u003eCustoms and Traditions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eCustoms and traditions are identified as the first concept in the social-cultural context that plays a role in shaping sexual and reproductive health literacy among women. These customs not only confine women\u0026apos;s behaviors to specific frameworks, but also limit their choices by creating guilt and social pressure. In this context, sexual and reproductive health literacy can serve as a tool for critiquing these beliefs and enhancing women\u0026apos;s decision-making power. This enables them to assess their needs based on personal understanding and analysis, rather than solely on imposed social beliefs. These experiences demonstrate how culture and social expectations influence self-control, attitudes, and decision-making abilities. At the same time, more informed women can challenge these norms and contribute to their change. Subcategories under this category include: marriage ceremonies and the importance of virginity, female genital mutilation (FGM) practices, and mourning ceremonies that limit sexual relations between spouses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarriage Ceremonies and the Importance of Virginity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on participants\u0026apos; experiences in this study, one of the traditional customs commonly practiced in the studied community to prove virginity and the absence of sexual relations before marriage is obtaining a virginity certificate. These experiences show how traditional customs, by imposing social pressures, affect women\u0026apos;s decision-making ability and autonomy, which are key elements of sexual and reproductive health literacy. Participants reported feeling bad about the pressure from their families, particularly their mothers, to obtain a virginity certificate and criticized these customs, calling them harsh and meaningless. The insistence of mothers was often driven by fear of societal gossip and adherence to traditional norms.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I remember my mother insisted we go get the virginity certificate before the wedding. I was so embarrassed. If it wasn\u0026apos;t for the pressure, I wouldn\u0026apos;t have gone. I was confident about myself, but my mother said it was the custom, and we needed it so there wouldn\u0026apos;t be rumors later. So, I reluctantly agreed.\u0026quot;\u003c/em\u003e (p10, 40 years old, two children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThese customs strongly influence young women\u0026rsquo;s ability to resist these norms. Many women emphasized the role of awareness and knowledge in ignoring these customs.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Obtaining the virginity certificate is a tradition in my area, especially in my father\u0026apos;s family. But neither I nor my husband were willing to do it. Fortunately, my family, especially my mother, supported me. Individual awareness and family support in rejecting these baseless customs are very important.\u0026quot;\u003c/em\u003e (p14, 29 years old, no children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eFemale Genital Mutilation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe custom of female circumcision is a cultural tradition in the study community that impacts women\u0026apos;s health and self-esteem. Based on participants\u0026apos; experiences, while this practice has diminished compared to the past, it still continues in some Kurdish regions. This tradition is passed down from generation to generation without awareness of its consequences. Some participants criticized less educated mothers for continuing this practice, believing that women, with awareness of their individual rights and health, would make more informed decisions about their own and their children\u0026rsquo;s bodies. Misconceptions also exist about the role of circumcision in improving the appearance of women\u0026rsquo;s external genital.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In our family, my grandmother insisted that every girl born should be circumcised. I don\u0026apos;t know what the reason was. When I asked my mother about myself, she had nothing to say. She just said, \u0026apos;Your grandmother said it improves the beauty of the female genital organ.\u0026apos;\u0026quot;\u003c/em\u003e (p1, 39 years old, two children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eBased on some participants\u0026apos; experiences in this study, difficulties in achieving sexual pleasure and dissatisfaction in sexual relations due to circumcision were reported. Given the awareness of the consequences of female circumcision, these women criticized the practice as harmful and unnecessary.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I was circumcised because it was the custom back then. I feel like I take longer to reach sexual pleasure and often don\u0026apos;t feel satisfied. I believe this affects pleasure, but my sexual desire is natural because the brain controls it. But in general, I completely disagree with this custom as I\u0026rsquo;ve researched and found no benefits; in fact, it causes problems.\u0026quot;\u003c/em\u003e (p13, 41 years old, one child).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eMourning Ceremonies and Limitations on Sexual Relations Between Spouses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the traditional customs discussed by participants was the prohibition of sexual relations during mourning periods. Some women, with a critical view, considered this custom unfounded and even harmful to mental health. One participant, reflecting on her personal experience, concluded that mourning and sexual relations are two independent matters. These views demonstrate that as women gain more awareness, they gain greater power to critique traditional beliefs and make decisions in line with their personal and psychological needs.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Most people say that after the death of a loved one, sexual relations should be avoided for 40 days. After my brother passed away, I was in a very bad emotional state. Since I had heard that there shouldn\u0026rsquo;t be sexual relations until the 40th day, I avoided it. But later I realized that this issue had nothing to do with mourning. When I was with my husband, I felt more at peace. I think this belief is just a custom that can add more emotional pressure rather than help with mourning.\u0026quot;\u003c/em\u003e (p8, 35 years old, two children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIn contrast, some participants continued to follow this custom without questioning its consequences due to deep cultural and societal influence.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;When someone close passes away, it\u0026rsquo;s customary not to have sex until the 40th day. When my father passed away, I really thought that if I slept with my husband, it would mean I was indifferent to my father\u0026rsquo;s death, which caused me to distance myself from him. Since I believed this was a custom, I followed it.\u0026quot;\u003c/em\u003e (p16, 44 years old, two children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSecond Category: \u003cstrong\u003eSocio_cultural norms and Beliefs\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis category addresses the socio_cultural norms and beliefs that impact women\u0026rsquo;s sexual and reproductive health literacy. The social-cultural context provides a framework for socio_cultural beliefs, which dictate societal expectations for sexual behaviors. These norms often prescribe what is considered acceptable or unacceptable in relation to sexual health. Based on the experiences of participants in this study, social and cultural beliefs can influence individuals\u0026apos; thinking about sexual and reproductive matters, discussions about these topics, and even their decisions in three ways: gender beliefs, beliefs about sexual relations, and social environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGender Beliefs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender beliefs in the studied community emphasize concepts such as gender discrimination, gender double standards, male superiority over women, the need for women to comply with their husbands to maintain the family, and the importance of having sons. From the narratives and testimonies of women, it is clear how much pressure women still face from their husbands and extended families to bear male children, with social stigmas surrounding the birth of daughters.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The result of marriage and sexual relations is having children and becoming parents. Thank God my first child was a boy, so I wasn\u0026apos;t stressed about the next one. Having a son is very important to my husband, and his family also prefers it. My sister-in-law, who has three daughters, is constantly being criticized.\u0026quot;\u003c/em\u003e (p2, 36 years old, two children).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eRegarding the need for women to comply with their husbands\u0026apos; wishes in marital relations, one participant, who was a religious studies student, explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My husband doesn\u0026rsquo;t like makeup, even when we\u0026rsquo;re alone. So, I respect that because I don\u0026rsquo;t want to argue. After all, he\u0026rsquo;s the man. My mother says a woman should obey her husband.\u0026quot;\u003c/em\u003e (p4, 21 years old, one child).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSome perceptions highlight the significant role of cultural gender beliefs in shaping attitudes and decisions regarding reproductive health. The belief in male superiority and the easier upbringing of boys can impact women\u0026apos;s awareness, preventing them from gaining essential knowledge about sexual and reproductive health. For example, the emphasis on preserving daughters\u0026apos; honor while boys are perceived as less likely to bring shame is rooted in gender double standards in sexual matters within society.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In our Kurdish culture, boys and men generally have a higher status than girls and women. Most of the time, men are right. Even when I talk to my husband about pregnancy and having children, he insists the first child must be a boy. He believes raising a daughter is harder, but a son will always support his father and won\u0026apos;t bring shame if he makes a mistake.\u0026quot;\u003c/em\u003e (p17, 18 years old, no children).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eCultural Beliefs on Sexuality:\u003c/h3\u003e\n\u003cp\u003eMisconceptions about sexuality impact women\u0026apos;s sexual and reproductive health literacy. When women view sexual intercourse as a duty to satisfy their husbands or refrain from expressing their desires and problems due to taboos, these beliefs result in both women and men lacking a proper understanding of each other\u0026rsquo;s sexual rights, needs, and health. Consequently, they may not seek information in this regard. It appears that meeting men\u0026apos;s sexual needs in a relationship takes precedence over the emotional and sexual needs of women, with men not being educated about this and making no effort to ensure a satisfying sexual relationship for their wives.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Now, even though it\u0026apos;s been a few months since we got married, my opinion doesn\u0026apos;t matter to him, and he doesn\u0026apos;t respect me. For example, whenever he wants, we have to have sex, and he never listens when I say I don\u0026apos;t feel like it or am not in the mood. I just endure it until it\u0026apos;s over.\u0026quot; (p17, 18 years old, no children)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eOn the other hand, coercion in sexual relations due to cultural and traditional beliefs can lead to challenges that women face when seeking sexual information, especially under the pressure of social expectations and the opinions of elders. A participant pointed out that elders view sexual relations as a duty rather than a positive, mutually enjoyable experience. These pressures, combined with the lack of access to accurate information, can lead to feelings of guilt and obligation, making women feel enslaved in sexual relations where their needs and desires are ignored. Women\u0026apos;s lack of awareness of female orgasm in sexual relations contributed to their sexual beliefs.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;At the beginning of my marriage, I didn\u0026apos;t really know what orgasm was. I enjoyed sex but didn\u0026apos;t know what it felt like. I only continued because I\u0026apos;d heard older people say that sex is a must, and if a woman refuses, her husband will become cold. So, I did it out of obligation, but it felt horrible, like I was a slave.\u0026quot; (p1, 39 years old, two children)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIn some participants, talking about sexual issues was taboo, rooted in strict parental upbringing. Cultural taboos and social norms impact how people interact with sexual and reproductive health topics from childhood. The prohibition of discussing such issues and being scolded for natural curiosity can lead to shame and uncertainty when seeking information and communicating between spouses.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I really don\u0026apos;t like to discuss or exchange information about this subject in a group. We have to accept that our culture has always viewed talking and asking about these issues as shameful since childhood. I remember whenever I asked my mom about sexual issues or even menstruation, I\u0026apos;d get scolded for asking such questions.\u0026quot; (p12, 27 years old, two children)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eHaving extensive knowledge about sexual topics may even lead to stigmatization by a partner, as they might associate such knowledge with more sexual experience. Therefore, people might present themselves as inexperienced in sexual matters to avoid appearing promiscuous.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;ve read a lot about how to improve sex, but out of fear that my husband will think I learned these things or moves somewhere else or find my behavior shameless, I stay silent.\u0026quot; (p5, 40 years old, one child)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSocial Contexts:\u003c/h2\u003e\n \u003cp\u003eThe experiences of participants show that individuals face serious obstacles in accessing accurate sexual and reproductive health information within social structures and contexts. The lack of formal, needs-based education, the absence of specialized staff at health centers, and the lack of private spaces for asking sexual health questions have had multiple consequences on women\u0026apos;s sexual and reproductive health literacy. Without appropriate education that aligns with different life stages (adolescence, young adulthood, and middle age), participants have had to learn through trial and error, which not only causes issues in marital relationships but also leads to the ignorance of mothers who are unable to pass on correct information to their children. One participant mentioned:\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I only go to the health center for my kids\u0026apos; care, like height and weight checks and vaccinations. It\u0026rsquo;s free, but I don\u0026apos;t trust it for serious or private matters like sexual health. The staff here don\u0026apos;t know much about sexual issues. One time, I asked about positions for intimacy, and they told me to go to a specialist; they said they would know better.\u0026quot; (p12, 27 years old, two children)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eAdditionally, media, which can play a significant role in raising awareness, does not provide enough programs on these sensitive topics. This lack of coverage has meant that sexual topics remain surrounded by negative judgments and misconceptions, while issues like women\u0026rsquo;s health and pregnancy are covered better. This neglect of sexual education, besides negatively impacting health literacy, can create grounds for sexual and reproductive health issues in women. The need for education was emphasized by the women. One participant said:\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026rsquo;ve never seen a TV program about sexual issues. There are programs about pregnancy or various diseases, but not about sex. They invite gynecologists or even midwives, but nothing about sex. If there were, it would be great.\u0026quot; (p15, 26 years old, one child)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThird category: \u003cstrong\u003eEconomic Conditions\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eSome participants, especially those facing economic hardship, expressed that meeting basic life needs took priority, and thus spending money on sexual and reproductive health information and counseling was considered a luxury, less of a priority. Financial constraints shifted their focus from sexual and reproductive health to basic survival concerns.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;When you don\u0026apos;t even have money to buy bread for your kids, who has time to think about learning about sexual matters? For us, we have to think first about feeding our kids. Everything else comes second.\u0026quot; (p2, 36 years old, two children)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eFor others, economic conditions profoundly affected choices related to sexual and reproductive health, particularly with the young generation citing poor economic conditions as leading to decreased willingness to have children and, in some cases, delaying pregnancy. Conversely, some women noted that due to the costs of contraception methods and their non-provision for free by public centers, they had no choice but to use natural methods, despite being aware of their lack of accuracy and fearing unintended pregnancies.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My husband is a worker; some days he works, some days he doesn\u0026apos;t, and we are renters. Our financial situation isn\u0026apos;t good. Health centers don\u0026apos;t give us free pills or contraception anymore. We have to rely on natural methods, even though I\u0026apos;ve heard it\u0026apos;s not accurate. We have to be very careful because if I get pregnant unexpectedly, with our situation, I really don\u0026apos;t know what I\u0026rsquo;d do.\u0026quot; (p16, 44 years old, two children).\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccording to established definitions of health literacy and sexual health literacy in the academic literature, the importance of considering broader social contexts and the necessity of focusing on structural and socio-cultural influences on health literacy have been particularly emphasized [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This study explores and examines the complex social and cultural contexts that impact married women's sexual and reproductive health literacy.\u003c/p\u003e \u003cp\u003eThe theme of \"socio-cultural context of sexual and reproductive health literacy\" consists of three main categories: \"customs and traditions,\" \"social and cultural norms and beliefs,\" and \"economic conditions.\" The findings indicate that social, cultural, and economic factors function as fundamental infrastructures, playing a crucial role in either shaping or hindering the development of sexual and reproductive health literacy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding customs and traditions, this study found that marriage-related customs, the importance of proving virginity, female genital mutilation (FGM) and its role in women's sexuality and sexual desire, and customs limiting marital sexual relations during mourning periods significantly impact women's acquisition and application of sexual and reproductive health literacy. Previous studies have also demonstrated the link between health literacy and cultural contexts. Specifically, prior research has shown that low health literacy is associated with stigma related to mental illnesses and fatalistic beliefs about disease prevention [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, another study found that cultural and religious norms, emphasizing modesty and chastity, hinder open discussions about sexual and reproductive health, thereby restricting access to essential sexual and reproductive health information and services [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA common custom in the studied society is the mandatory virginity examination and certification, which is presented to the groom\u0026rsquo;s family. Women experience this as part of a social and cultural process meant to prove and uphold their \"chastity\" and \"worthiness\" before marriage. In Iran, as a religious society, a woman\u0026rsquo;s virginity is regarded as an honor, and preserving it is considered valuable and necessary for girls. Any harm to a girl\u0026rsquo;s virginity before marriage can be perceived as a major catastrophe for her and her family, carrying severe consequences [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This issue highlights that the social and familial pressures related to the custom of virginity can negatively affect women's ability to make independent decisions about their bodies and sexual health. This is directly linked to sexual and reproductive health literacy, as one of its key aspects is the ability to understand, evaluate, and make informed decisions regarding sexual and reproductive issues. When cultural norms compel women to conform to specific traditions, this capacity is severely restricted. A systematic review (2024) identified recurring themes across multiple studies, including parental and societal expectations regarding \"sexual purity\u0026rdquo; before marriage through abstinence, limited parent-child communication about sexual matters, and gender norms restricting young women\u0026rsquo;s sexual and reproductive decision-making [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our findings indicate that this experience is context-dependent, as some individuals perceive it as a positive and necessary practice for preserving family honor.\u003c/p\u003e \u003cp\u003eAnother tradition examined in this study is female genital mutilation (FGM). Although the prevalence of FGM has declined in contemporary Iranian society, it continues to be practiced in certain regions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Participants who had either undergone FGM themselves or knew others who had experienced it strongly criticized the practice, viewing it as detrimental to women's sexual and reproductive health. Women who had undergone FGM stated that low awareness, weak decision-making power among senior family members (especially mothers), and adherence to traditional customs led to the continuation of this practice. Traditional values constitute a crucial part of the cultural environment and meaning-making systems. These values are passed down from one generation to the next and, through socialization processes, may unconsciously become embedded in individual beliefs and values [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnhancing sexual and reproductive health literacy, particularly among mothers, can serve as a strong barrier against the intergenerational transmission of harmful practices such as FGM. It appears that the ability to analyze and evaluate scientific information, combined with personal experience, has helped contemporary mothers critically assess this tradition and recognize its harmful impact on sexual health. This finding suggests that sexual and reproductive health literacy not only improves individual knowledge but also fosters critical reassessment of traditional beliefs and more informed decision-making. Participants who had experienced FGM explicitly stated that they would not subject their own daughters to the same practice.\u003c/p\u003e \u003cp\u003eFactors such as religion, tradition, family elders' control over women's chastity, and aesthetic considerations were cited by participants as reasons for the continuation of this custom. In line with these findings, a study by Rabeipour and colleagues in Iran (2022) demonstrated that inappropriate social and cultural norms, along with religious attitudes, contributed to the perpetuation and prevalence of FGM, while improvements in health knowledge and awareness led to a decline in the practice among newer generations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Given the negative consequences of FGM, cultural advancements must begin through education and awareness. By educating individuals and increasing public awareness about this issue, positive changes can be reinforced, ultimately contributing to the effective resolution of this problem [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSocio_cultural norms and beliefs, as hidden forces, play a significant role in shaping attitudes and behaviors related to sexual and reproductive health. These beliefs not only establish specific mental frameworks for the acceptance or rejection of sexual behaviors but also profoundly influence an individual\u0026rsquo;s understanding of their sexual and reproductive needs. Findings from this study indicated that the taboo or sensitivity surrounding sexual topics leads individuals to refrain from seeking knowledge and education in these areas. A study conducted in Myanmar found that most participating students reported that cultural taboos hinder open discussions about sexual issues and premarital relationships among young people, potentially leading to low awareness and understanding. These taboos prevent students from engaging in open discussions about sexual health with sources such as parents and healthcare providers [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. By fostering open dialogue and collaboration, community engagement can help reduce the stigma associated with sexual and reproductive health (SRH) and promote a supportive environment for discussing these issues [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, the findings of the present study revealed that gendered beliefs regarding male superiority and a preference for male offspring persist as part of cultural and social beliefs in the 21st century, particularly among Kurdish communities. This issue not only pressures women to fulfill the expectations of their husbands and families but also imposes social pressures to have male children as a symbol of high social value, severely limiting women's autonomy in reproductive decision-making. Consistent with our findings, a study by Meherali (2024) demonstrated that prioritizing the needs of husbands and families over individual needs in women can lead to the neglect of their personal sexual and reproductive health needs [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Traditional cultural beliefs within families and broader social contexts continue to shape attitudes and beliefs related to SRH, creating barriers to accessing information and services [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Male control over women is a recurring theme in SRH literature [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Our research findings confirm this notion, as participants' experiences illustrate concepts such as prioritizing male sexual needs over female needs and sexual coercion driven by fear of abandonment by a spouse. These aspects clearly reflect the potential negative impacts of traditional cultural attitudes and gender role norms on autonomy in SRH-related decision-making, as highlighted in previous research [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants in this study identified several structural and social factors, including the lack of culturally and individually tailored formal sexual education, the absence of private spaces, the lack of specialized personnel in public healthcare centers, and the absence of educational media programs on sexual matters, all of which, based on their experiences, hinder access to accurate and comprehensive sexual and reproductive health information. Consistent with our findings, the absence of safe educational and cultural content has been highlighted in previous studies as a barrier to accessing sexual health information [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Regarding the lack of privacy in healthcare centers, privacy limitations for patients are recognized as a barrier to accessing SRH information and services. In fact, feelings of embarrassment and discomfort in discussing personal SRH issues in a public setting, coupled with fear of judgment from healthcare providers and peers, may prevent young people from seeking essential information and services or expressing their SRH needs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Addressing these barriers requires the establishment of private spaces in healthcare centers that ensure confidentiality, along with the implementation of comprehensive sexual education programs tailored to individuals' ages and needs. Low SRH literacy can contribute to intergenerational unawareness and reliance on trial-and-error learning, ultimately increasing risky behaviors and marital issues.\u003c/p\u003e \u003cp\u003eIn addition to social and cultural factors, economic conditions were identified in this study as another underlying factor influencing SRH literacy, consistent with previous studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In the present study, women facing economic hardships did not prioritize acquiring information related to SRH. A systematic review conducted in Iran similarly demonstrated that favorable economic conditions are among the positive predictors of adequate SRH literacy [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Participants reported that financial constraints, even when they possessed adequate health literacy, posed challenges in accessing and utilizing SRH information and services. Supporting this finding, a study showed that financial barriers could restrict individuals' autonomy and decision-making abilities in sexual and reproductive health [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Furthermore, in the current economic climate of Iran, where pronatalist policies and limited access to free contraceptive methods prevail, economic difficulties directly influence reproductive decisions, including childbearing. Many families delay this crucial decision due to concerns about affording living costs and raising children. For older women in their reproductive years facing economic hardships, these conditions pose serious challenges, increasing the risk of unintended and high-risk pregnancies. This issue not only affects women\u0026rsquo;s physical and health conditions but also imposes a greater financial burden on low-income families due to the rising costs associated with pregnancy and childbirth. Economic stability may facilitate access to educational and healthcare resources, whereas women from lower socioeconomic backgrounds may have limited access to SRH information and services, contributing to knowledge gaps [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Consequently, low health literacy can lead to an increase in complications such as unplanned pregnancies, abortions, high-risk pregnancies, and, ultimately, maternal mortality [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings align with the Cultural Care Theory (CCT), which underscores the importance of understanding how cultural values, beliefs, and behaviors, as well as structural and social factors such as religion, economic status, family relationships, policy, education, and technology, influence individuals' attitudes, knowledge, behaviors, and skills [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis qualitative study comprehensively demonstrated how social and cultural contexts influence the sexual and reproductive health literacy of women of reproductive age in a region of Iran, highlighting the challenges associated with these factors. The findings revealed that these contexts, particularly cultural taboos and social norms, create significant barriers to accessing accurate information, receiving appropriate education, and improving sexual and reproductive health. Furthermore, the results of this study underscore the necessity of designing and implementing educational interventions for sexual and reproductive health literacy that take into account social and cultural norms. Such interventions can ultimately contribute to the enhancement of sexual and reproductive health within this group. Educational efforts aimed at correcting inaccurate normative beliefs are among the recommendations of this study.\u003c/p\u003e \u003cp\u003eThe data for this study were collected through semi-structured in-depth interviews. This approach facilitated a detailed understanding of the social and cultural influences at play. However, the nature of these conversations may have led some participants to express views influenced by cultural norms. To ensure data richness, data collection continued until saturation was achieved, thereby enhancing the credibility of the findings.\u003c/p\u003e \u003cp\u003eThis study also has certain limitations. As a qualitative study conducted with a limited sample of women residing in Sanandaj, the findings may not be generalizable to other regions of Iran or to different ethnic and cultural groups. Due to the qualitative nature of the research and the restricted number of participants, the results should be interpreted with caution in terms of their broader applicability. Future research is recommended to examine more diverse groups across various cultural and geographical contexts to enhance the generalizability of the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, this study highlights that social, cultural, and economic context shape individuals' beliefs, norms, behaviors, and access to information regarding sexual and reproductive health. These socio-cultural contexts play a determining role in shaping individuals' levels of sexual and reproductive health literacy by creating either constraints or opportunities. Cultural norms, taboos, and economic limitations can act as barriers to raising awareness and accessing services. Therefore, the development of educational programs and reproductive and sexual health policies must consider these socio-cultural contexts to address and reform certain misconceptions and social taboos. This, in turn, can contribute to improving reproductive and sexual health, particularly among women. The findings of this study can serve as a valuable foundation for the development of educational programs and policies related to sexual and reproductive health in societies with similar demographic and socio-cultural characteristics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We extend our gratitude to all the women of reproductive age who participated in the interviews, as well as to the health care staff of selected clinics who assisted the research team throughout this research project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors contributed to the conceptualization and design of the study. HF drafted the initial manuscript. FKF carefully read and contributed to the main draft and edited several times. All other authors reviewed and provided feedback on the final draft and finally approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No funding was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Transcribed versions of the data used in this study, excluding the recorded audio files of the participants, are available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThis study is part of a PhD thesis focused on reproductive health at Tarbiat Modares University and has received approval from the Ethics Committee of Tarbiat Modares University, Tehran, Iran (Ethic Code: IR.MODARES.REC.1402.266). Informed consent was obtained from all participants, and the study was conducted in accordance with the principles outlined in the Helsinki Declaration, following established ethical guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors have reviewed and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Family Research Institute, Shahid Beheshti University, Shahid Shahriari Square, Evin, Tehran 1983969411, Iran.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUniversity, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003e Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e Faculty of Humanity Sciences, University of Science and Culture, Tehran, Iran.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNutbeam DJS. .s. and medicine. 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Glob J Health Sci. 2015;8(7):152\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabeipour S, Ahmadi Z. \u003cem\u003eSURVEY OF KNOWLEDGE AND ATTITUDE OF PREGNANT WOMEN REFERRING TO THE DELIVERY WARD OF IMAM KHOMEINI HOSPITAL IN PIRANSHAHR REGARDING CIRCUMCISION IN 2020: A CROSS-SECTIONAL STUDY %J Nursing and Midwifery Journal.\u003c/em\u003e 2022. 19(12): pp. 953\u0026ndash;963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao E, et al. How does traditional Confucian culture influence adolescents' sexual behavior in three Asian cities? J Adolesc Health. 2012;50(3 Suppl):S12\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassannezhad K et al. 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Socio-cultural factors associated with knowledge, attitudes and menstrual hygiene practices among Junior High School adolescent girls in the Kpando district of Ghana: A mixed method study. 2022. 17(10): p. e0275583.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeherali S et al. \u003cem\u003eBetween cultures and traditions: a qualitative investigation of sexual and reproductive health experiences of immigrant adolescents in Canada.\u003c/em\u003e 2024: pp. 1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussein J, Ferguson L. Eliminating stigma and discrimination in sexual and reproductive health care: a public health imperative. Sex Reprod Health Matters. 2019;27(3):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawson HA, Liamputtong P. Culture and sex education: the acquisition of sexual knowledge for a group of Vietnamese Australian young women. 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Socio-Ecological Analysis of Barriers to Access and Utilization of Adolescent Sexual and Reproductive Health Services in Sub-Saharan Africa: A Qualitative Systematic Review. Open Access J Contracept. 2023;14:103\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahrahmani H et al. \u003cem\u003eSexual health literacy and its related factors among couples: A population-based study in Iran.\u003c/em\u003e 2023. 18(11): p. e0293279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamzehgardeshi Z, et al. Factors Associated with Sexual and Reproductive Health Literacy: A Scoping Review %J. J health Res community. 2022;8(3):96\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandeVusse A, et al. Cost-related barriers to sexual and reproductive health care: Results from a longitudinal qualitative study in Arizona. SSM - Qualitative Res Health. 2023;4:100360.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePr\u0026eacute;musz V, et al. Socio-Economic and Health Literacy Inequalities as Determinants of Women's Knowledge about Their Reproductive System: A Cross-Sectional Study. Epidemiologia (Basel). 2024;5(4):627\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhavami B, et al. Relatsh between reproductive health Lit Compon healthy fertility women reproductive age. 2024;13(1):105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcFarland MR, Wehbe-Alamah HB. Leininger's Theory of Culture Care Diversity and Universality: An Overview With a Historical Retrospective and a View Toward the Future. J Transcult Nurs. 2019;30(6):540\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health literacy, sexual and reproductive health literacy, socio-cultural factors, Iranian women, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-6234753/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6234753/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Objective:\u003c/strong\u003e This study aimed to explore the socio-cultural contexts of women's sexual and reproductive health literacy in Kurdistan, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In-depth semi-structured interviews were conducted with 17 women aged 18 to 45 who visited selected clinics in Sanandaj, Kurdistan, Iran. Participants were recruited through purposive sampling between April 20 and November 16, 2024. The qualitative data were analyzed using directed qualitative content analysis based on the model proposed by Hsieh \u0026amp; Shannon (2005) and processed using MAXQDA software, version 22.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e The socio-cultural context of women's sexual and reproductive health literacy was extracted into three main categories: customs and traditions, socio-cultural norms and beliefs, and economic conditions. Customs and traditions, including marriage-related customs, the importance of virginity, female genital mutilation, gender roles, and sexual relations restrictions during mourning periods, influence sexual and reproductive health literacy by shaping traditional norms, imposing behavioral constraints, and enforcing social obligations. Socio-cultural norms and beliefs, including gender beliefs, perceptions of sexual behavior, and social contexts, play a role in shaping individuals' perspectives on sexual and reproductive topics, their willingness to discuss these issues and their behaviors. Lastly, economic conditions and financial constraints significantly impact access to sexual and reproductive health information, health literacy, utilization of services, and choices related to women's sexual and reproductive health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Designing educational programs and developing sexual and reproductive health policies with consideration of socio-cultural contexts can help reduce cultural taboos, enhance the effectiveness of interventions, and improve sexual and reproductive health in society.\u003c/p\u003e","manuscriptTitle":"The Socio-Cultural Contexts of Women's Sexual and Reproductive Health Literacy in Iran: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 11:56:33","doi":"10.21203/rs.3.rs-6234753/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-30T07:01:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T14:38:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165368771880969825291993698039714829755","date":"2025-05-18T13:19:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334932339210251777349746308377332462284","date":"2025-05-18T06:58:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-16T14:36:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-13T16:02:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228342773518208472238986553815879953021","date":"2025-05-13T10:01:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118218808051032049803665336044072952884","date":"2025-05-13T09:39:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31149017502649846349235818073719372554","date":"2025-05-13T07:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-13T06:46:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-18T00:37:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-18T00:34:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Reproductive Health","date":"2025-03-15T21:13:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bb589ceb-9603-42c9-bed6-fc7d47001595","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:01:49+00:00","versionOfRecord":{"articleIdentity":"rs-6234753","link":"https://doi.org/10.1186/s12978-025-02155-2","journal":{"identity":"reproductive-health","isVorOnly":false,"title":"Reproductive Health"},"publishedOn":"2025-10-17 15:57:37","publishedOnDateReadable":"October 17th, 2025"},"versionCreatedAt":"2025-05-16 11:56:33","video":"","vorDoi":"10.1186/s12978-025-02155-2","vorDoiUrl":"https://doi.org/10.1186/s12978-025-02155-2","workflowStages":[]},"version":"v1","identity":"rs-6234753","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6234753","identity":"rs-6234753","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}