Breaking Barriers: How Sexual Stigma Impacts Women's Health Care Seeking Behavior Through the Lens of Sexual Health Literacy

Breaking Barriers: How Sexual Stigma Impacts Women's Health Care Seeking Behavior Through the Lens of Sexual Health Literacy | 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 Breaking Barriers: How Sexual Stigma Impacts Women's Health Care Seeking Behavior Through the Lens of Sexual Health Literacy Elif Zahide Çelebi, Merve Murat Mehmed Ali This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8982002/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: This study aimed to examine the mediating role of sexual health literacy in the relationship between perceived stigma regarding sexual/reproductive health and readiness to seek sexual/reproductive health services among young women aged 18–24 living in Istanbul. Methods This quantitative, cross-sectional, and correlational study was conducted between June and November 2025 with 425 young women living in Istanbul using an online snowball sampling method. Data were collected using a Personal Information Form, the Sexual and Reproductive Health Stigmatization Scale in Young Women (SRHSSYW), the Sexual Health Literacy Scale (SHLS), and the Sexual and Reproductive Health Service Seeking Scale (SRHSS). Relationships were tested using Pearson correlations; mediation analyses were performed using a regression-based approach with the Hayes PROCESS Macro (Model 4; bootstrap = 5000). Results The mean age of the participants was 22.16 ± 1.77. Stigma negatively predicted sexual health literacy (B = − 1.688, SE=.155, p<.001; R²=.219), and sexual health literacy positively predicted service-seeking tendency (B=.234, SE=.021, p<.001). The overall effect of stigma on service-seeking tendency was significant (c = -0.793, SE = 0.076, p < .001). When the mediating variable was controlled, the direct effect decreased but remained significant (c′ = -0.398, SE = 0.076, p < .001). The indirect effect was significant (ab =- .395, BootSE = .053; 95% BootGA [− .498, − .295]), and the results indicated partial mediation. Conclusion The findings show that as stigma increases, sexual health literacy and service-seeking tendencies decrease; as sexual health literacy increases, service-seeking tendencies increase; and sexual health literacy plays a partial mediating role in the stigma-service-seeking relationship. sexual/reproductive health stigma sexual health literacy service-seeking attitudes mediation analysis Figures Figure 1 Figure 2 Introduction Stigma is a multi-component social process that begins with labeling a specific characteristic as “undesirable” and is produced within power relations through dynamics of stereotyping, segregation, loss of status, and discrimination ( 1 ). It is stated that stigma distorts individuals' social identities and devalues ​​them ( 2 ). Stigma is experienced more intensely, especially in cases of mental illness, obesity, disability, and HIV/AIDS. In societies like Turkey, where patriarchal structures are dominant, women are more exposed to stigma, particularly in the context of sexual and reproductive health, and female sexuality is severely restricted ( 3 , 4 ). In the field of sexual and reproductive health, stigma can increase the fear of “shame/labeling” in young women aged 8–24 regarding issues such as sexual activity, pregnancy, contraception, and the use of sexual and reproductive health services, thus affecting their health-related decisions and support-seeking behaviors. Tools for measuring sexual and reproductive health stigma emphasize the importance of considering dimensions such as internalized stigma, experienced/actualized stigma, and societal attitudes together ( 5 , 6 ). Stigma towards sexual behavior leads not only to social exclusion but also to serious individual and societal problems such as shame, violence, and mental health disorders ( 6 ). This double standard forces women to live their sexuality within the boundaries set by society and increases social control ( 7 ). In this context, stigma can prevent women from accessing reproductive health and counseling services, increasing the risk of miscarriage and maternal deaths. It can also lead to delays in the diagnosis and treatment of sexually transmitted diseases, resulting in secondary infertility cases ( 8 ). It has been found that young people are reluctant to access healthcare services due to stigma ( 9 , 10 ). Social norms, individual reservations, and barriers to the healthcare system all play a role in young people's use of sexual and reproductive health services ( 11 , 12 ). It is stated that negative attitudes of healthcare professionals affect young women's access to sexual and reproductive health services ( 9 , 10 , 13 ). Therefore, it is essential to prevent individuals from being denied access to healthcare services due to fear of exclusion and discrimination stemming from stigma ( 2 ). Sexual stigma plays a significant role in shaping women's healthcare-seeking behavior and sexual health literacy ( 14 ). In societies where sexuality cannot be openly discussed due to social, cultural, and religious beliefs, individuals hesitate to seek help from healthcare institutions and instead turn to unreliable online resources. It has been reported that experiences of microaggression and repression in online environments can shape women's help-seeking processes when seeking sexual and reproductive health care ( 15 ). This situation increases information pollution and misinformation, thus multiplying health risks. At this point, sexual health literacy emerges as a critical component that determines young women's capacity to access, understand, and evaluate accurate information, select reliable sources, and obtain appropriate services. Sexual health literacy is the sum of knowledge, beliefs, attitudes, motivations, and skills necessary for an individual to access, comprehend, critically evaluate, and apply information in decisions related to sexual health ( 16 ). Since this capacity may weaken in conditions of high stigma, sexual health literacy is expected to function as a mechanism explaining the relationship between stigma and the readiness/inclination to seek sexual and reproductive health services. This study aims to examine the mediating role of sexual health literacy in the relationship between sexual/reproductive health stigma and readiness to seek sexual/reproductive health services among young women aged 18–24 living in Istanbul. In this study, the following hypotheses were tested: H1: As sexual/reproductive health stigma scores increase, sexual health literacy scores decrease. H2: As sexual health literacy scores increase, readiness to seek sexual/reproductive health services increases. H3: Sexual health literacy mediates the relationship between stigma and readiness to seek services. The model to be tested for the hypotheses formulated is presented in Fig. 1 : METHOD Research Design: The research used a quantitative, cross-sectional, correlational design. The relationships between variables and the mediation model were tested using a regression-based approach. Research Location and Time: The research was conducted with young women (aged 18-24) living in Istanbul between June and November 2025. Research Population and Sample: The research population consists of women residing in Istanbul according to the 2023 Turkish Statistical Institute data (total female population of Istanbul: 7,881,140) (17). The research sample was calculated to consist of at least 385 women using the sample calculation formula (95% confidence interval, 5% margin of error) for a known population. The sample was created online using the snowball sampling method, a non-probability sampling method, and consisted of 425 young women. Inclusion and Exclusion Criteria: Inclusion criteria: (i) being female between the ages of 18 and 24, (ii) residing in Istanbul, (iii) voluntarily completing the online form, and (iv) answering all form and scale items thoroughly. Exclusion criteria: (i) incomplete answers to form/scale items, (ii) being outside the defined age range. Data Collection Tools: Personal Information Form: A 12-item form assessing participants' sociodemographic and individual sexual characteristics was developed by the researchers based on a literature review. Sexual and Reproductive Health Stigmatization Scale in Young Women (SRHSSYW): Developed by colleagues in 2018 to determine stigma related to sexual and reproductive health in women aged 15–24 (5). The Turkish validity and reliability of the scale were established by Bayrakçeken in 2018. The scale consists of 20 items and three sub-dimensions: External stigma (items 1–6), Unrealistic stigmatizing attitudes (items 7–10, 14–16, 19–20), and Internal stigma (items 11–13, 17–18). The lowest possible score on the scale is “0”, and the highest is “20”. The items are scored as “0=Disagree, 0=Neutral, 1=Agree”. As the score on the scale increases, the stigmatizing attitude increases. In a study examining Turkish validity and reliability, Cronbach's alpha was 0.83 (18). In this study, the Cronbach's alpha coefficient was 0.77. Sexual Health Literacy Scale (SHLS): Developed by Üstgörül (2022) to assess individuals' sexual health literacy, the SHL is a 17-item, five-point Likert-type scale. The scale exhibits a two-factor structure, focusing on sexual knowledge and sexual attitudes. In the development study, the Cronbach's alpha coefficients were 0.91 for the sexual knowledge factor, 0.87 for the sexual attitude factor, and 0.88 for the total scale (19). In this study, Cronbach's alpha was 0.91. Sexual and Reproductive Health Service Seeking Scale (SRHSS): Developed by Özdal and Demiralp to determine young adults' knowledge and attitudes towards SHR, the barriers to accessing services, and to evaluate young adults' attitudes and needs towards receiving SHR services, the scale has undergone validity and reliability studies in Turkish and English. The Service Seeking Needs Scale consists of 23 items divided into four sub-dimensions: Individual Considerations in Service Seeking (11 items), Individual Attitudes in Service Seeking (6 items), Need for Training in Service Seeking (4 items), and Need for Institutional Support in Service Seeking (2 items). The Service Seeking Needs Scale uses a 3-point Likert scale: 2 points for “Correct, agree”, 0 points for “Incorrect, disagree”, and 1 point for “I don’t know”. The lowest possible total score is 0, and the highest is 46. Lower scores indicate that young adults feel they need to receive services related to Service Seeking. In comparison, higher scores indicate that young adults are ready to receive services related to Service Seeking. The Cronbach's alpha coefficient of the scale ranges from 0.95 to 0.98 for the sub-dimensions and is 0.90 for the total scale (20). In this study, Cronbach's alpha was 0.87. Data Collection Method: Research data were collected using a Personal Information Form, the Sexual and Reproductive Health Stigma Scale for Young Women, the Sexual Health Literacy Scale, and the Sexual and Reproductive Health Service Seeking Scale. Before data collection, participants were given an Informed Consent Form outlining the purpose of the research and were asked to provide their consent. After ethical committee approval, to reach the determined sample size, the survey form was distributed to women living in Istanbul via social media (WhatsApp, Instagram, Twitter, etc.) using the snowball sampling method, and only participants who received the questionnaire link could access it. Data Evaluation: Statistical analysis of the data was performed using IBM SPSS Statistics (version 29.0) and Andrew F. Hayes' PROCESS Macro (v4.2) add-on. Sociodemographic variables were summarized as number (n) and percentage (%); mean ± standard deviation and minimum-maximum values were reported for scale scores. The scales' reliability was evaluated using Cronbach's alpha. Linear relationships between variables were examined using Pearson correlation analysis (two-way), and correlation coefficients and significance levels were reported. Within the scope of the study's null hypothesis, the mediating role of sexual health literacy (M) on the effect of sexual/reproductive health stigma (X) on service-seeking intention (Y) was tested using PROCESS. In the mediation analysis, the significance of the indirect effect was evaluated using a 95% confidence interval based on a 5000 bootstrap sample; the absence of a 0 value in the confidence interval was taken as evidence of significance. Total effect, direct effect, and indirect effect coefficients, as well as regression model summaries, were reported for the models. In statistical analyses, the significance level was accepted as p<.05 (two-sided). Ethical Aspects: Ethical approval was obtained from the non-interventional human research ethics committee of a foundation university to conduct the research (Decision No: 2024-40161-141, Date: 31.05.2024). Before data collection began, each participant in the study was directed to the Informed Consent Form page and provided consent. The research was conducted in accordance with the Helsinki Declaration. Electronic permissions for the use of data collection instruments were obtained. Results The age distribution of the participants ranged from 18 to 24, with an average age of 22.16±1.77. The highest percentage was in the 24-year-old age group (n=135, 31.8%). Regarding education level, the vast majority of participants held associate's or bachelor's degrees (n=373, 87.8%). 85.2% of the participants reported being unemployed (n=362). Regarding income, 49.6% of the participants stated that their income equaled their expenses (n=211). Regarding relationship status, 58.8% of participants were single (n=250), and 39.1% were in a romantic relationship (n=166). 18.6% of the participants stated that they were sexually active (n=79) (Table 1). When the descriptive features of the scales were examined in Table 2, it was seen that the mean score of the participants on the Stigma Scale for Sexual and Reproductive Health in Young Women was 6.37±3.64 and the scores varied between 0 and 20. The mean score for the Sexual Health Literacy Scale was 62.57±13.13 and the score range was determined as 17–85. The mean score on the Sexual and Reproductive Health Service Seeking Scale was 40.38±6.39, with a range of 0 to 46. According to the results of the Pearson correlation analysis in Table 3, there is a moderate, negative and statistically significant relationship between the level of sexual and reproductive health stigma and sexual health literacy in young women (r=−.439, p<.001). Similarly, a negative and significant relationship was found between the level of stigmatization and the tendency to seek sexual and reproductive health services (r=−.386, p<.001). On the other hand, a moderate-to-high positive and significant relationship was found between sexual health literacy and service-seeking tendency (r=.528, p<.001). These findings show that literacy and service seeking scores tend to be lower as the stigma score increases; service seeking scores tend to be higher as literacy scores increase. The regression model, which was established to examine the effect of sexual and reproductive health stigma level on sexual health literacy, was found to be statistically significant, F(1,423)=118.764, p<.001, and the model explained 21.9% of the variance in sexual health literacy (R²=.219). The stigma score significantly and negatively predicted sexual health literacy (B = -1.688, SE = .155, t = -10.898, p < .001; 95% CI [−1.992, −1.384]). Accordingly, as stigma increases, the sexual health literacy score decreases significantly (Table 4). The regression model testing the effect of stigma and sexual health literacy on the propensity to seek sexual and reproductive health services together was significant, F(2,422)=131,520, p<.001, and the model explained 38.4% of the variance in the propensity to seek sexual and reproductive health services (R²=.384). When included together in the model, sexual health literacy predicted a positive tendency to seek services (B = .234, SE = .021, t = 11.108, p < .001; 95% CI [.193, .275]). The direct effect of stigma on service seeking remained negative even after controlling for the mediator variable (B =- .398, SE = .076, t = -5.241, p < .001; 95% CI [−.547, −.249]). These findings show that as literacy increases, the tendency to seek services increases, while stigma decreases the search for services (Table 4). The mediation model is presented in Figure 2, and the corresponding statistical estimates are reported in Table 5. The total effect of stigma on service seeking was negative and significant (B =- .793, SE = .076, t = -10.407, p < .001; 95% CI [−.942, −.643]). When the mediator variable was added to the model, the direct effect decreased but remained significant (B =- .398, SE = .076, t = -5.241, p < .001). The indirect effect calculated by the Bootstrap method was significant (B_ind=−0.395, BootSE=0.053; 95% BootGA [−0.498, −0.295]). The fact that the confidence interval did not include zero suggests that sexual health literacy statistically mediates the relationship between stigma and service seeking. The direct effect remains significant, suggesting that the findings are in line with the partial mediation model. Discussion In this study, the mediating role of sexual health literacy in the relationship between perceived stigma about sexual/reproductive health and the tendency (readiness) of sexual/reproductive health services was investigated in young women aged 18-24 living in Istanbul. The research results suggest that we can explain the relationship between stigma and service-seeking processes not only through lack of knowledge, but also through psychosocial and structural mechanisms. It is seen that there is a negative, moderately significant relationship between the level of sexual and reproductive health stigma and the tendency to seek health care (r=-.386). While this result supports the restrictive effect of stigma on individuals' healthcare decisions, it is also consistent with findings indicating that fear of judgment, privacy concerns, embarrassment, and stigmatization complicate the application process, especially in highly confidential services such as sexually transmitted infections, contraception, and counselling (21). Therefore, the results obtained are in line with the literature, which emphasizes that reducing stigma and discrimination in sexual and reproductive health care is a public health priority (22, 23). A negative relationship between stigma against sexual and reproductive health and sexual health literacy (r=-.439) and regression findings (R²=.219) suggest that stigmatization anxiety may suppress access to information, health communication, and help-seeking processes. This suggests that social pressure and stigmatization anxiety may be associated with sabotaging the individual's access to information. It is emphasized that health-related stigma can suppress access to information, health communication, and service use at the individual, interpersonal, and structural levels (24, 25, 26). The findings of the study and the results of the literature are consistent with the knowledge that stigma is one of the main determinants of suppression of sexual health literacy in societies with strong cultural norms. On the other hand, the strong positive relationship between sexual health literacy and the tendency to seek health care (r=.528), and the mediation model findings, support the conclusion that literacy is one of the most important predictors of service-seeking encouragement. In a study conducted to determine the sexual health literacy levels and sexual and reproductive health service seeking levels of young people in Turkey, to reveal the factors affecting these levels, and to determine the relationship between sexual health literacy and the tendency to seek sexual and reproductive health services, it was determined that the probability of benefiting from sexual and reproductive health services increased as the level of sexual health literacy increased (27). Our findings suggest that higher literacy scores are associated with a propensity to seek services, and this may be related to the capacity to cope with the psychological burden and act more effectively in the health system. The partial mediating role of sexual health literacy in the mediating analysis between stigma and the tendency to seek health care reveals the originality of the study. According to the results of the Bootstrap analysis, the indirect effect was significant (ab =- .395; 95% BootGA [-.498, -.295]), indicating that stigmatization is partly related to literacy in the tendency to seek health services. This indicates that interventions to increase literacy can buffer the negative impact of stigma. However, the fact that the direct effect remained significant (c ′ =- .398) indicates that the findings are consistent with the partial mediation model. This picture is not only about increasing individual literacy; it also suggests that structural arrangements such as privacy assurance, the reduction of exclusionary and judgmental attitudes, and youth-friendly service delivery may be necessary (22, 27, 28). Limitations and Strengths In this study, data were collected based on self-reports. Participants may tend to be socially likable in subjects where social taboos such as sexual activity and stigmatization are intense; This may have led to different reporting of actual attitudes and experiences. Due to the study's cross-sectional design, the relationships between variables cannot be interpreted causally; mediation findings should be evaluated at the statistical level. In addition, the online snowball sampling method can create selection bias and limit the generalizability of the findings. The fact that the sample consists largely of associate/undergraduate-level participants may limit the generalizability of the findings to young women with lower levels of education or living in rural areas. The strength of the study is that it not only delineates the relationship between sexual/reproductive health stigma and the propensity to seek health care but also quantitatively reveals the possible mechanism by testing the mediating role of sexual health literacy. In addition, the sample size is sufficient, and the scales used demonstrate acceptable internal consistency, supporting the reliability of the findings. This study found that the level of stigma related to sexual/reproductive health in young women aged 18-24 living in Istanbul was negative, with the tendency to seek sexual health/reproductive health services; sexual health literacy is positively related to the tendency to seek services, and sexual health literacy plays a partial mediating role in this relationship. The findings indicate that to strengthen access to services, it may be necessary not only to increase the level of knowledge, but also to reduce barriers such as judgment anxiety and privacy concerns that feed stigma. In this direction; (i) strengthening youth-friendly and safe service areas in health institutions where young women can receive services without judgment and where privacy is guaranteed, (ii) integrating sexual health literacy into training programs to include the dimensions of patient rights, coping with stigma and communication skills in addition to biological knowledge, and (iii) stigmatization-free, scientific and accessible digital health platforms, taking into account the information seeking practices of young people. It is recommended to be supported. Implications and Contributions This study is an important contribution to the body of literature on sexual and reproductive health because it provides an empirical test of the partial mediating effect of sexual health literacy on the association between sexual/reproductive health stigma and the willingness of young women to seek health services. By examining the process by which this association occurs, the current study extends beyond the simple documentation of the stigma effect and provides insight into the manner in which the experience of stigma, via reduced health literacy, dampens the willingness to seek health services. At the same time, the current findings point to the buffering effect of sexual health literacy as an important consideration for the development of interventions that not only include biomedical content but also include skills training that addresses the experience of stigma, the ability to navigate the health system, and the exercise of patient rights. At the same time, the direct effect of stigma suggests the need to develop service models that are sensitive to the experience of stigma and that promote a sense of confidentiality and non-judgmental attitudes within the health system. Declarations Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Elif Zahide Çelebi] and [Merve Murat Mehmed Ali]. The first draft of the manuscript was written by [Elif Zahide Çelebi] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Availability of data and material: Not applicable. Code availability: Not applicable. References Link, B. G. & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385 Dağlı, E., & Reyhan, F. A. (2024). Stigma in women's sexual health and reproductive health: The example of midwifery students. Mersin University Faculty of Medicine Lokman Hekim Journal of History of Medicine and Folkloric Medicine, 14(1), 141-149. Başar, F. (2017). 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PLOS Global Public Health, 2(6), e0000582. https://doi.org/10.1371/journal.pgph.0000582 Tables Table 1: Sociodemographic Characteristics (N: 425) Age n % 18 19 4.5 19 22 5.2 20 38 8.9 21 66 15.5 22 63 14.8 23 82 19.3 24 135 31.8 Education Status Primary Education 8 1.9 High School 27 6.3 Associate-Undergraduate 373 87.8 Graduate 17 4.0 Employment Status Yes 63 14.8 No 362 85.2 Income Status Income Less Than Expenditure 102 24.0 Income Equals Expenditure 211 49.6 Income More Than Expenditure 112 26.4 Relationship Status No relationship 250 58.8 Romantic Relationship 166 39.1 Married 9 2.1 Sexual Activity Status Yes 79 18.6 No 346 81.4 Table 2: Descriptive Characteristics of Scales Scales Mean (SD) Min Max Cronbach Alfa Sexual and Reproductive Health Stigmatization Scale in Young Women 6.37 (3.64) 0 20 0.773 Sexual Health Literacy Scale 62.57 (13.13) 17 85 0.918 Sexual and Reproductive Health Service Seeking Scale 40.38 (6.39) 9 46 0.874 Table 3: Pearson Correlations Between Sexual and Reproductive Health Stigmatization Scale in Young Women, Sexual Health Literacy, and Sexual and Reproductive Health Service Seeking in Young Women (N=425) Sexual and Reproductive Health Stigmatization Scale in Young Women Sexual Health Literacy Scale Sexual and Reproductive Health Service Seeking Scale Sexual and Reproductive Health Stigmatization Scale in Young Women r 1.000 p - Sexual Health Literacy Scale r -.439 ** 1.000 p < .001 - Sexual and Reproductive Health Service Seeking Scale r -.386 ** .528 ** 1.000 p < .001 < .001 - **. Correlation is significant at the 0.01 level (2-tailed). Table 4: PROCESS Model 4 Mediation Analysis Regression Results (n=425) Predictor B SE t p 95% GA Alt 95% GA Üst Constant 73.342 1.137 64.495 <.001 71.107 75.577 Sexual and Reproductive Health Stigmatization Scale in Young Women -1.688 0.155 -10.898 <.001 -1.992 -1.384 Model summary: R² = .219 , F(1,423)=118.764, p<.001, MSE=135.017 Predictor B SE t p 95% GA Alt 95% GA Üst Constant 28.283 1.621 17.448 <.001 25.097 31.470 Sexual and Reproductive Health Stigmatization Scale in Young Women -0.398 0.076 -5.241 <.001 -0.547 -0.249 Sexual Health Literacy Scale 0.234 0.021 11.108 <.001 0.193 0.275 Model summary: R² = .384 , F(2,422)=131.520, p<.001, MSE=25.325 Table 5: Total, Direct and Indirect Effects (Bootstrap=5000) Effect B SE / BootSE t p 95% GA Alt 95% GA Üst Total impact (c): Sexual and Reproductive Health Stigmatization Scale in Young Women→ Sexual and Reproductive Health Service Seeking Scale -0.793 0.076 -10.407 <.001 -0.942 -0.643 Direct effect (c′): Sexual and Reproductive Health Stigmatization Scale in Young Women→ Sexual and Reproductive Health Service Seeking Scale (M control) -0.398 0.076 -5.241 <.001 -0.547 -0.249 Indirect effect (a*b): Sexual and Reproductive Health Stigmatization Scale in Young Women → Sexual Health Literacy Scale→ Sexual and Reproductive Health Service Seeking Scale -0.395 0.053 — — -0.498 -0.295 Additional Declarations No competing interests reported. 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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-8982002","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608501890,"identity":"5c6e9868-5f7a-4427-84b1-1e1744036fe0","order_by":0,"name":"Elif Zahide Çelebi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIie2QsWrDMBCGdQiU5ahWGad9BoWsJX4WE8iULVNooRIC+xUK7XNorjGkrxBIhzh5gWQIJFN7Dlm6WOkWqL5BOsT/cadjLBK5RXpgdnT1mQK7pgLvggoH+9omSXG6LURYYXBRmFDtQ1CRnFt7fH5EmbpifpiO+oLxZrPsUBIH1qjFBJP3qljd+zENJobDaYeiayjXA1OjXubFKvGcFBRpl5LV1CU335iRMkv8S1jRtDFTmQ/UKi9g7+uwoqiLNYsxqq/KpeA/UfDAX2RZNrSx0YN8K5v9yT9lsueabZfyC47n89p4Cxz/ko5EIpF/ww9vu0S6E0ilPwAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Bilgi University","correspondingAuthor":true,"prefix":"","firstName":"Elif","middleName":"Zahide","lastName":"Çelebi","suffix":""},{"id":608501891,"identity":"8aac34bb-ec9b-4962-a6e8-fb068a7ec412","order_by":1,"name":"Merve Murat Mehmed Ali","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"Murat Mehmed","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2026-02-26 23:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8982002/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8982002/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105282514,"identity":"a45440d1-09bc-4860-8610-4a20454f8dbd","added_by":"auto","created_at":"2026-03-24 10:28:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105531,"visible":true,"origin":"","legend":"\u003cp\u003eResearch Model\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8982002/v1/81557314170da14bf1ef6e86.png"},{"id":105564514,"identity":"63216b06-79bc-4dc8-b3f8-06452b2e58f9","added_by":"auto","created_at":"2026-03-27 12:49:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":129467,"visible":true,"origin":"","legend":"\u003cp\u003eMediation Model\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8982002/v1/4f8b0d338644108261a4179c.png"},{"id":105569415,"identity":"339655bb-a04d-46bb-9db9-4e386d0b99a1","added_by":"auto","created_at":"2026-03-27 13:12:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1136362,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8982002/v1/4183add8-b335-4dc4-8232-e51b1d89b8e1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Breaking Barriers: How Sexual Stigma Impacts Women's Health Care Seeking Behavior Through the Lens of Sexual Health Literacy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStigma is a multi-component social process that begins with labeling a specific characteristic as \u0026ldquo;undesirable\u0026rdquo; and is produced within power relations through dynamics of stereotyping, segregation, loss of status, and discrimination (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is stated that stigma distorts individuals' social identities and devalues ​​them (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Stigma is experienced more intensely, especially in cases of mental illness, obesity, disability, and HIV/AIDS. In societies like Turkey, where patriarchal structures are dominant, women are more exposed to stigma, particularly in the context of sexual and reproductive health, and female sexuality is severely restricted (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In the field of sexual and reproductive health, stigma can increase the fear of \u0026ldquo;shame/labeling\u0026rdquo; in young women aged 8\u0026ndash;24 regarding issues such as sexual activity, pregnancy, contraception, and the use of sexual and reproductive health services, thus affecting their health-related decisions and support-seeking behaviors. Tools for measuring sexual and reproductive health stigma emphasize the importance of considering dimensions such as internalized stigma, experienced/actualized stigma, and societal attitudes together (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Stigma towards sexual behavior leads not only to social exclusion but also to serious individual and societal problems such as shame, violence, and mental health disorders (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This double standard forces women to live their sexuality within the boundaries set by society and increases social control (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In this context, stigma can prevent women from accessing reproductive health and counseling services, increasing the risk of miscarriage and maternal deaths. It can also lead to delays in the diagnosis and treatment of sexually transmitted diseases, resulting in secondary infertility cases (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It has been found that young people are reluctant to access healthcare services due to stigma (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSocial norms, individual reservations, and barriers to the healthcare system all play a role in young people's use of sexual and reproductive health services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). It is stated that negative attitudes of healthcare professionals affect young women's access to sexual and reproductive health services (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore, it is essential to prevent individuals from being denied access to healthcare services due to fear of exclusion and discrimination stemming from stigma (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSexual stigma plays a significant role in shaping women's healthcare-seeking behavior and sexual health literacy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In societies where sexuality cannot be openly discussed due to social, cultural, and religious beliefs, individuals hesitate to seek help from healthcare institutions and instead turn to unreliable online resources. It has been reported that experiences of microaggression and repression in online environments can shape women's help-seeking processes when seeking sexual and reproductive health care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This situation increases information pollution and misinformation, thus multiplying health risks. At this point, sexual health literacy emerges as a critical component that determines young women's capacity to access, understand, and evaluate accurate information, select reliable sources, and obtain appropriate services. Sexual health literacy is the sum of knowledge, beliefs, attitudes, motivations, and skills necessary for an individual to access, comprehend, critically evaluate, and apply information in decisions related to sexual health (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Since this capacity may weaken in conditions of high stigma, sexual health literacy is expected to function as a mechanism explaining the relationship between stigma and the readiness/inclination to seek sexual and reproductive health services. This study aims to examine the mediating role of sexual health literacy in the relationship between sexual/reproductive health stigma and readiness to seek sexual/reproductive health services among young women aged 18\u0026ndash;24 living in Istanbul.\u003c/p\u003e \u003cp\u003eIn this study, the following hypotheses were tested:\u003c/p\u003e \u003cp\u003eH1: As sexual/reproductive health stigma scores increase, sexual health literacy scores decrease.\u003c/p\u003e \u003cp\u003eH2: As sexual health literacy scores increase, readiness to seek sexual/reproductive health services increases.\u003c/p\u003e \u003cp\u003eH3: Sexual health literacy mediates the relationship between stigma and readiness to seek services.\u003c/p\u003e \u003cp\u003eThe model to be tested for the hypotheses formulated is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"METHOD","content":"\u003cp\u003e\u003cstrong\u003eResearch Design:\u0026nbsp;\u003c/strong\u003eThe research used a quantitative, cross-sectional, correlational design. The relationships between variables and the mediation model were tested using a regression-based approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Location and Time:\u0026nbsp;\u003c/strong\u003eThe research was conducted with young women (aged 18-24) living in Istanbul between June and November 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Population and Sample:\u0026nbsp;\u003c/strong\u003eThe research population consists of women residing in Istanbul according to the 2023 Turkish Statistical Institute data (total female population of Istanbul: 7,881,140) (17). The research sample was calculated to consist of at least 385 women using the sample calculation formula (95% confidence interval, 5% margin of error) for a known population. The sample was created online using the snowball sampling method, a non-probability sampling method, and consisted of 425 young women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion and Exclusion Criteria:\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(i) being female between the ages of 18 and 24, (ii) residing in Istanbul, (iii) voluntarily completing the online form, and (iv) answering all form and scale items thoroughly. Exclusion criteria: (i) incomplete answers to form/scale items, (ii) being outside the defined age range.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Tools:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal Information Form:\u0026nbsp;\u003c/strong\u003eA 12-item form assessing participants\u0026apos; sociodemographic and individual sexual characteristics was developed by the researchers based on a literature review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Stigmatization Scale in Young Women (SRHSSYW):\u0026nbsp;\u003c/strong\u003eDeveloped by colleagues in 2018 to determine stigma related to sexual and reproductive health in women aged 15\u0026ndash;24 (5). The Turkish validity and reliability of the scale were established by Bayrak\u0026ccedil;eken in 2018. The scale consists of 20 items and three sub-dimensions: External stigma (items 1\u0026ndash;6), Unrealistic stigmatizing attitudes (items 7\u0026ndash;10, 14\u0026ndash;16, 19\u0026ndash;20), and Internal stigma (items 11\u0026ndash;13, 17\u0026ndash;18). The lowest possible score on the scale is \u0026ldquo;0\u0026rdquo;, and the highest is \u0026ldquo;20\u0026rdquo;. The items are scored as \u0026ldquo;0=Disagree, 0=Neutral, 1=Agree\u0026rdquo;. As the score on the scale increases, the stigmatizing attitude increases. In a study examining Turkish validity and reliability, Cronbach\u0026apos;s alpha was 0.83 (18). In this study, the Cronbach\u0026apos;s alpha coefficient was 0.77.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual Health Literacy Scale (SHLS):\u003c/strong\u003e Developed by \u0026Uuml;stg\u0026ouml;r\u0026uuml;l (2022) to assess individuals\u0026apos; sexual health literacy, the SHL is a 17-item, five-point Likert-type scale. The scale exhibits a two-factor structure, focusing on sexual knowledge and sexual attitudes. In the development study, the Cronbach\u0026apos;s alpha coefficients were 0.91 for the sexual knowledge factor, 0.87 for the sexual attitude factor, and 0.88 for the total scale (19). In this study, Cronbach\u0026apos;s alpha was 0.91.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Service Seeking Scale (SRHSS):\u0026nbsp;\u003c/strong\u003eDeveloped by \u0026Ouml;zdal and Demiralp to determine young adults\u0026apos; knowledge and attitudes towards SHR, the barriers to accessing services, and to evaluate young adults\u0026apos; attitudes and needs towards receiving SHR services, the scale has undergone validity and reliability studies in Turkish and English. The Service Seeking Needs Scale consists of 23 items divided into four sub-dimensions: Individual Considerations in Service Seeking (11 items), Individual Attitudes in Service Seeking (6 items), Need for Training in Service Seeking (4 items), and Need for Institutional Support in Service Seeking (2 items). The Service Seeking Needs Scale uses a 3-point Likert scale: 2 points for \u0026ldquo;Correct, agree\u0026rdquo;, 0 points for \u0026ldquo;Incorrect, disagree\u0026rdquo;, and 1 point for \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;. The lowest possible total score is 0, and the highest is 46. Lower scores indicate that young adults feel they need to receive services related to Service Seeking.\u003cbr\u003e\u0026nbsp;In comparison, higher scores indicate that young adults are ready to receive services related to Service Seeking. The Cronbach\u0026apos;s alpha coefficient of the scale ranges from 0.95 to 0.98 for the sub-dimensions and is 0.90 for the total scale (20). In this study, Cronbach\u0026apos;s alpha was 0.87.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Method:\u0026nbsp;\u003c/strong\u003eResearch data were collected using a Personal Information Form, the Sexual and Reproductive Health Stigma Scale for Young Women, the Sexual Health Literacy Scale, and the Sexual and Reproductive Health Service Seeking Scale. Before data collection, participants were given an Informed Consent Form outlining the purpose of the research and were asked to provide their consent. After ethical committee approval, to reach the determined sample size, the survey form was distributed to women living in Istanbul via social media (WhatsApp, Instagram, Twitter, etc.) using the snowball sampling method, and only participants who received the questionnaire link could access it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Evaluation:\u0026nbsp;\u003c/strong\u003eStatistical analysis of the data was performed using IBM SPSS Statistics (version 29.0) and Andrew F. Hayes\u0026apos; PROCESS Macro (v4.2) add-on. Sociodemographic variables were summarized as number (n) and percentage (%); mean \u0026plusmn; standard deviation and minimum-maximum values were reported for scale scores. The scales\u0026apos; reliability was evaluated using Cronbach\u0026apos;s alpha.\u003c/p\u003e\n\u003cp\u003eLinear relationships between variables were examined using Pearson correlation analysis (two-way), and correlation coefficients and significance levels were reported. Within the scope of the study\u0026apos;s null hypothesis, the mediating role of sexual health literacy (M) on the effect of sexual/reproductive health stigma (X) on service-seeking intention (Y) was tested using PROCESS. In the mediation analysis, the significance of the indirect effect was evaluated using a 95% confidence interval based on a 5000 bootstrap sample; the absence of a 0 value in the confidence interval was taken as evidence of significance. Total effect, direct effect, and indirect effect coefficients, as well as regression model summaries, were reported for the models. In statistical analyses, the significance level was accepted as p\u0026lt;.05 (two-sided).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Aspects:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from the non-interventional human research ethics committee of a foundation university to conduct the research (Decision No: 2024-40161-141, Date: 31.05.2024). Before data collection began, each participant in the study was directed to the Informed Consent Form page and provided consent. The research was conducted in accordance with the Helsinki Declaration. Electronic permissions for the use of data collection instruments were obtained.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe age distribution of the participants ranged from 18 to 24, with an average age of 22.16\u0026plusmn;1.77. The highest percentage was in the 24-year-old age group (n=135, 31.8%). Regarding education level, the vast majority of participants held associate\u0026apos;s or bachelor\u0026apos;s degrees (n=373, 87.8%). 85.2% of the participants reported being unemployed (n=362). Regarding income, 49.6% of the participants stated that their income equaled their expenses (n=211). Regarding relationship status, 58.8% of participants were single (n=250), and 39.1% were in a romantic relationship (n=166). 18.6% of the participants stated that they were sexually active (n=79) (Table 1).\u003c/p\u003e\n\u003cp\u003eWhen the descriptive features of the scales were examined in Table 2, it was seen that the mean score of the participants on the Stigma Scale for Sexual and Reproductive Health in Young Women was 6.37\u0026plusmn;3.64 and the scores varied between 0 and 20. The mean score for the Sexual Health Literacy Scale was 62.57\u0026plusmn;13.13 and the score range was determined as 17\u0026ndash;85. The mean score on the Sexual and Reproductive Health Service Seeking Scale was 40.38\u0026plusmn;6.39, with a range of 0 to 46.\u003c/p\u003e\n\u003cp\u003eAccording to the results of the Pearson correlation analysis in Table 3, there is a moderate, negative and statistically significant relationship between the level of sexual and reproductive health stigma and sexual health literacy in young women (r=\u0026minus;.439, p\u0026lt;.001). Similarly, a negative and significant relationship was found between the level of stigmatization and the tendency to seek sexual and reproductive health services (r=\u0026minus;.386, p\u0026lt;.001). On the other hand, a moderate-to-high positive and significant relationship was found between sexual health literacy and service-seeking tendency (r=.528, p\u0026lt;.001). These findings show that literacy and service seeking scores tend to be lower as the stigma score increases; service seeking scores tend to be higher as literacy scores increase.\u003c/p\u003e\n\u003cp\u003eThe regression model, which was established to examine the effect of sexual and reproductive health stigma level on sexual health literacy, was found to be statistically significant, F(1,423)=118.764, p\u0026lt;.001, and the model explained 21.9% of the variance in sexual health literacy (R\u0026sup2;=.219). The stigma score significantly and negatively predicted sexual health literacy (B = -1.688, SE = .155, t = -10.898, p \u0026lt; .001; 95% CI [\u0026minus;1.992, \u0026minus;1.384]). Accordingly, as stigma increases, the sexual health literacy score decreases significantly (Table 4).\u003c/p\u003e\n\u003cp\u003eThe regression model testing the effect of stigma and sexual health literacy on the propensity to seek sexual and reproductive health services together was significant, F(2,422)=131,520, p\u0026lt;.001, and the model explained 38.4% of the variance in the propensity to seek sexual and reproductive health services (R\u0026sup2;=.384). When included together in the model, sexual health literacy predicted a positive tendency to seek services (B = .234, SE = .021, t = 11.108, p \u0026lt; .001; 95% CI [.193, .275]). The direct effect of stigma on service seeking remained negative even after controlling for the mediator variable (B =- .398, SE = .076, t = -5.241, p \u0026lt; .001; 95% CI [\u0026minus;.547, \u0026minus;.249]). These findings show that as literacy increases, the tendency to seek services increases, while stigma decreases the search for services (Table 4).\u003c/p\u003e\n\u003cp\u003eThe mediation model is presented in Figure 2, and the corresponding statistical estimates are reported in Table 5. The total effect of stigma on service seeking was negative and significant (B =- .793, SE = .076, t = -10.407, p \u0026lt; .001; 95% CI [\u0026minus;.942, \u0026minus;.643]). When the mediator variable was added to the model, the direct effect decreased but remained significant (B =- .398, SE = .076, t = -5.241, p \u0026lt; .001). The indirect effect calculated by the Bootstrap method was significant (B_ind=\u0026minus;0.395, BootSE=0.053; 95% BootGA [\u0026minus;0.498, \u0026minus;0.295]). The fact that the confidence interval did not include zero suggests that sexual health literacy statistically mediates the relationship between stigma and service seeking. The direct effect remains significant, suggesting that the findings are in line with the partial mediation model.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the mediating role of sexual health literacy in the relationship between perceived stigma about sexual/reproductive health and the tendency (readiness) of sexual/reproductive health services was investigated in young women aged 18-24 living in Istanbul. The research results suggest that we can explain the relationship between stigma and service-seeking processes not only through lack of knowledge, but also through psychosocial and structural mechanisms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is seen that there is a negative, moderately significant relationship between the level of sexual and reproductive health stigma and the tendency to seek health care (r=-.386). While this result supports the restrictive effect of stigma on individuals\u0026apos; healthcare decisions, it is also consistent with findings indicating that fear of judgment, privacy concerns, embarrassment, and stigmatization complicate the application process, especially in highly confidential services such as sexually transmitted infections, contraception, and counselling (21). Therefore, the results obtained are in line with the literature, which emphasizes that reducing stigma and discrimination in sexual and reproductive health care is a public health priority (22, 23).\u003c/p\u003e\n\u003cp\u003eA \u0026nbsp; negative relationship between stigma against sexual and reproductive health and sexual health literacy (r=-.439) and regression findings (R\u0026sup2;=.219) suggest that stigmatization anxiety may suppress access to information, health communication, and help-seeking processes. This suggests that social pressure and stigmatization anxiety may be associated with sabotaging the individual\u0026apos;s access to information. It is emphasized that health-related stigma can suppress access to information, health communication, and service use at the individual, interpersonal, and structural levels (24, 25, 26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings of the study and the results of the literature are consistent with the knowledge that stigma is one of the main determinants of suppression of sexual health literacy in societies with strong cultural norms. On the other hand, the strong positive relationship between sexual health literacy and the tendency to seek health care (r=.528), and the mediation model findings, support the conclusion that literacy is one of the most important predictors of service-seeking encouragement. In a study conducted to determine the sexual health literacy levels and sexual and reproductive health service seeking levels of young people in Turkey, to reveal the factors affecting these levels, and to determine the relationship between sexual health literacy and the tendency to seek sexual and reproductive health services, it was determined that the probability of benefiting from sexual and reproductive health services increased as the level of sexual health literacy increased (27). Our findings suggest that higher literacy scores are associated with a propensity to seek services, and this may be related to the capacity to cope with the psychological burden and act more effectively in the health system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe partial mediating role of sexual health literacy in the mediating analysis between stigma and the tendency to seek health care reveals the originality of the study. According to the results of the Bootstrap analysis, the indirect effect was significant (ab =- .395; 95% BootGA [-.498, -.295]), indicating that stigmatization is partly related to literacy in the tendency to seek health services. This indicates that interventions to increase literacy can buffer the negative impact of stigma. However, the fact that the direct effect remained significant (c \u0026prime; =- .398) indicates that the findings are consistent with the partial mediation model. This picture is not only about increasing individual literacy; it also suggests that structural arrangements such as privacy assurance, the reduction of exclusionary and judgmental attitudes, and youth-friendly service delivery may be necessary (22, 27, 28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Strengths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, data were collected based on self-reports. Participants may tend to be socially likable in subjects where social taboos such as sexual activity and stigmatization are intense; This may have led to different reporting of actual attitudes and experiences. Due to the study\u0026apos;s cross-sectional design, the relationships between variables cannot be interpreted causally; mediation findings should be evaluated at the statistical level. In addition, the online snowball sampling method can create selection bias and limit the generalizability of the findings. The fact that the sample consists largely of associate/undergraduate-level participants may limit the generalizability of the findings to young women with lower levels of education or living in rural areas. The strength of the study is that it not only delineates the relationship between sexual/reproductive health stigma and the propensity to seek health care but also quantitatively reveals the possible mechanism by testing the mediating role of sexual health literacy. In addition, the sample size is sufficient, and the scales used demonstrate acceptable internal consistency, supporting the reliability of the findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study found that the level of stigma related to sexual/reproductive health in young women aged 18-24 living in Istanbul was negative, with the tendency to seek sexual health/reproductive health services; sexual health literacy is positively related to the tendency to seek services, and sexual health literacy plays a partial mediating role in this relationship. The findings indicate that to strengthen access to services, it may be necessary not only to increase the level of knowledge, but also to reduce barriers such as judgment anxiety and privacy concerns that feed stigma.\u003c/p\u003e\n\u003cp\u003eIn this direction; (i) strengthening youth-friendly and safe service areas in health institutions where young women can receive services without judgment and where privacy is guaranteed, (ii) integrating sexual health literacy into training programs to include the dimensions of patient rights, coping with stigma and communication skills in addition to biological knowledge, and (iii) stigmatization-free, scientific and accessible digital health platforms, taking into account the information seeking practices of young people. It is recommended to be supported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is an important contribution to the body of literature on sexual and reproductive health because it provides an empirical test of the partial mediating effect of sexual health literacy on the association between sexual/reproductive health stigma and the willingness of young women to seek health services. By examining the process by which this association occurs, the current study extends beyond the simple documentation of the stigma effect and provides insight into the manner in which the experience of stigma, via reduced health literacy, dampens the willingness to seek health services. At the same time, the current findings point to the buffering effect of sexual health literacy as an important consideration for the development of interventions that not only include biomedical content but also include skills training that addresses the experience of stigma, the ability to navigate the health system, and the exercise of patient rights. At the same time, the direct effect of stigma suggests the need to develop service models that are sensitive to the experience of stigma and that promote a sense of confidentiality and non-judgmental attitudes within the health system.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Elif Zahide \u0026Ccedil;elebi] and [Merve Murat Mehmed Ali]. The first draft of the manuscript was written by [Elif Zahide \u0026Ccedil;elebi] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCode availability:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLink, B. G. \u0026amp; Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363\u0026ndash;385\u003c/li\u003e\n\u003cli\u003eDağlı, E., \u0026amp; Reyhan, F. A. (2024). Stigma in women\u0026apos;s sexual health and reproductive health: The example of midwifery students. Mersin University Faculty of Medicine Lokman Hekim Journal of History of Medicine and Folkloric Medicine, 14(1), 141-149.\u003c/li\u003e\n\u003cli\u003eBaşar, F. (2017). Social gender inequality: its effect on women\u0026rsquo;s health. Acıbadem University Journal of Health Sciences, (3), 131-137. \u003c/li\u003e\n\u003cli\u003ePolat, F., \u0026amp; Şenol, D. K. (2022). Examining the correlation between sexual and reproductive health stigmatization level and gender perception: a case of a university in Turkey-a descriptive cross-sectional study. Sao Paulo Medical Journal, 141, 146-153.\u003c/li\u003e\n\u003cli\u003eHall, K. S., Manu, A., Morhe, E., Harris, L. H., Loll, D., Ela, E., ... \u0026amp; Dalton, V. K. (2018a). Development and validation of a scale to measure adolescent sexual and reproductive health stigma: results from young women in Ghana. The Journal of Sex Research, 55(1), 60-72.\u003c/li\u003e\n\u003cli\u003eHall, K. S., Morhe, E., Manu, A., Harris, L. H., Ela, E., Loll, D., Kolenic, G., Dozier, J. L., Challa, S., Zochowski, M. K., Boakye, A., Adanu, R., \u0026amp; Dalton, V. K. (2018b). Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana. PloS One, 13(4), e0195163. https://doi.org/10.1371/journal.pone.0195163\u003c/li\u003e\n\u003cli\u003eKalav, A. (2012). Namus and gender. Mediterranean Journal of Humanities, 2(2), 151-163. \u003c/li\u003e\n\u003cli\u003eHindin, M. J., Christiansen, C. S., \u0026amp; Ferguson, B. J. (2013). Setting research priorities for adolescent sexual and reproductive health in low-and middle-income countries. Bulletin of the World Health Organization, 91, 10-18.\u003c/li\u003e\n\u003cli\u003eNmadu, A. G., Mohammed, S., \u0026amp; Usman, N. O. (2020a). Barriers to adolescents\u0026apos; access and utilisation of reproductive health services in a community in north-western Nigeria: A qualitative exploratory study in primary care. African Journal of Primary Health Care \u0026amp; Family Medicine, 12(1), e1\u0026ndash;e5. https://doi.org/10.4102/phcfm.v12i1.2307\u003c/li\u003e\n\u003cli\u003eCharlton, B. M., Hatzenbuehler, M. L., Jun, H. J., Sarda, V., Gordon, A. R., Raifman, J. R., \u0026amp; Austin, S. B. (2019). Structural stigma and sexual orientation‐related reproductive health disparities in a longitudinal cohort study of female adolescents. Journal of Adolescence, 74(1), 183-187.\u003c/li\u003e\n\u003cli\u003eNmadu, A. G., Mohamed, S., \u0026amp; Usman, N. O. (2020b). Adolescents\u0026rsquo; utilization of reproductive health services in Kaduna, Nigeria: the role of stigma. Vulnerable Children and Youth Studies, 15(3), 246-256. \u003c/li\u003e\n\u003cli\u003eTilahun, M., Mengistie, B., Egata, G., \u0026amp; Reda, A. A. (2012). Health workers\u0026apos; attitudes toward sexual and reproductive health services for unmarried adolescents in Ethiopia. Reproductive Health, 9, 19. https://doi.org/10.1186/1742-4755-9-19\u003c/li\u003e\n\u003cli\u003eBoamah, E. A., Asante, K. P., Mahama, E., Manu, G., Ayipah, E. K., Adeniji, E., \u0026amp; Owusu-Agyei, S. (2014). Use of contraceptives among adolescents in Kintampo, Ghana: a cross-sectional study. Open Access Journal of Contraception, 7-15. \u003c/li\u003e\n\u003cli\u003ePratt, M. C., Jeffcoat, S., Hill, S. V., Gill, E., Elopre, L., Simpson, T., ... \u0026amp; Matthews, L. T. (2022). \u0026ldquo;We feel like everybody\u0026apos;s going to judge us\u0026rdquo;: black adolescent girls\u0026rsquo; and young women\u0026apos;s perspectives on barriers to and opportunities for ımproving sexual health care, ıncluding prep, in the Southern US. Journal of the International Association of Providers of AIDS Care, 21, 23259582221107327.\u003c/li\u003e\n\u003cli\u003eRyu, H., \u0026amp; Pratt, W. (2025). Reducing the stigma of sexual and reproductive health care through supportive and protected online communities. AMIA ... Annual Symposium proceedings. AMIA Symposium, 2024, 970\u0026ndash;979.\u003c/li\u003e\n\u003cli\u003eShahrahmani, H., Kariman, N., Keshavarz, Z., Ahmadi, A., \u0026amp; Nasiri, M. (2023). Sexual health literacy and its related factors among couples: A population-based study in Iran. Plos One, 18(11), e0293279. \u003c/li\u003e\n\u003cli\u003eTurkish Statistical Institute. (2023). Address Based Population Registration System Results, 2022. \u003cu\u003ehttps://data.tuik.gov.tr/Bulten/Index?p=Adrese-Dayali-Nufus-Kayit-Sistemi-Sonuclari-2023-49684#:~:text=T%C3%BCrkiye\u0026apos;de%20ikamet%20eden%20n%C3%BCfus,9\u0026apos;unu%20ise%20kad%C4%B1nlar%20olu%C5%9Fturdu\u003c/u\u003e. \u003c/li\u003e\n\u003cli\u003eBayrak\u0026ccedil;eken, E. (2018). Validity and reliability of the Sexual and Reproductive Health Stigma Scale in Young Women. Atat\u0026uuml;rk University Institute of Health Sciences. Obstetrics, Women\u0026apos;s Health and Diseases Nursing Master\u0026apos;s Thesis. Erzurum.\u003c/li\u003e\n\u003cli\u003e\u0026Uuml;stg\u0026ouml;r\u0026uuml;l, S. (2022). Development of the Sexual Health Literacy Scale: a validity and reliability study. Ankara Journal of Health Sciences, 11(2), 164-176.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zdal, D., \u0026amp; Demiralp, M. (2024). Sexual and Reproductive Health Service Seeking Scale (SRHSSS): development, validity, and reliability. BMC Public Health, 24(1), 359.\u003c/li\u003e\n\u003cli\u003eWeerasinghe, M., Hewageegana, N. R., Varshney, K., Romero, L., \u0026amp; Fisher, J. (2025). Sexual and reproductive health information and service needs of adolescents and young adults: A systematic review. BMC Public Health, 25, 24324. https://doi.org/10.1186/s12889-025-24324-5\u003c/li\u003e\n\u003cli\u003eHussein, J., \u0026amp; Ferguson, L. (2019). Eliminating stigma and discrimination in sexual and reproductive health care: A public health imperative. Sexual and Reproductive Health Matters, 27(3), 1\u0026ndash;5. https://doi.org/10.1080/26410397.2019.1697103\u003c/li\u003e\n\u003cli\u003eMohammadi, F., Kohan, S., Mostafavi, F., \u0026amp; Gholami, A. (2016). The stigma of reproductive health services utilization by unmarried women. Iranian Red Crescent Medical Journal, 18(3), e24231. https://doi.org/10.5812/ircmj.24231\u003c/li\u003e\n\u003cli\u003eStangl, A. L., Earnshaw, V. A., Logie, C. H., et al. (2019). The health stigma and discrimination framework. BMC Medicine, 17, 31. https://doi.org/10.1186/s12916-019-1271-3\u003c/li\u003e\n\u003cli\u003eYıldız, M., Yıldırım, M. S., \u0026amp; Okyar, G. (2020). Determination of sexual and reproductive health stigmatization levels of young women. Anatolian Journal of Family Medicine, 3(3), 254\u0026ndash;259. https://doi.org/10.5505/anatoljfm.2020.36349\u003c/li\u003e\n\u003cli\u003eBalkan, B., \u0026amp; Bal\u0026ccedil;ık \u0026Ccedil;olak, M. (2025). Sexual and reproductive health problem in young people: Stigma. Sel\u0026ccedil;uk Sağlık Dergisi, 6(1), 59\u0026ndash;76. https://doi.org/10.70813/ssd.1415596\u003c/li\u003e\n\u003cli\u003eCelik, N., \u0026amp; Yesildere Saglam, H. (2026). Sexual health literacy and sexual and reproductive health service-seeking among young people in T\u0026uuml;rkiye: Levels and determinants. BMC Public Health. https://doi.org/10.1186/s12889-025-26130-5\u003c/li\u003e\n\u003cli\u003eBohren, M. A., Vazquez Corona, M., Odiase, O. J., Wilson, A. N., Sudhinaraset, M., Diamond-Smith, N., Berryman, J., Tun\u0026ccedil;alp, \u0026Ouml;., \u0026amp; Afulani, P. A. (2022). Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review. PLOS Global Public Health, 2(6), e0000582. https://doi.org/10.1371/journal.pgph.0000582\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eSociodemographic Characteristics (N: 425)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePrimary Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eHigh School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eAssociate-Undergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e87.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eGraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIncome Less Than Expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIncome Equals Expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIncome More Than Expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eNo relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e58.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eRomantic Relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e39.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Activity Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 200px;\"\u003e\n \u003cp\u003e81.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eDescriptive Characteristics of Scales\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScales\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach Alfa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eSexual and Reproductive Health Stigmatization Scale in Young Women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e6.37 (3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.773\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eSexual Health Literacy Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e62.57 (13.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eSexual and Reproductive Health Service Seeking Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e40.38 (6.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.874\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003ePearson Correlations Between Sexual and Reproductive Health Stigmatization Scale in Young Women, Sexual Health Literacy, and Sexual and Reproductive Health Service Seeking in Young Women (N=425)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Stigmatization Scale in Young Women\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Health Literacy Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Service Seeking Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Stigmatization Scale in Young Women\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Health Literacy Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e-.439\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual and Reproductive Health Service Seeking Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e-.386\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.528\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 122px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 605px;\"\u003e\n \u003cp\u003e**. Correlation is significant at the 0.01 level (2-tailed).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003ePROCESS Model 4 Mediation Analysis Regression Results (n=425)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA Alt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA \u0026Uuml;st\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSexual and Reproductive Health Stigmatization Scale in Young Women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-1.688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-10.898\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-1.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-1.384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 610px;\"\u003e\n \u003cp\u003eModel summary: \u003cstrong\u003eR\u0026sup2; = .219\u003c/strong\u003e, F(1,423)=118.764, p\u0026lt;.001, MSE=135.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA Alt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA \u0026Uuml;st\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSexual and Reproductive Health Stigmatization Scale in Young Women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-5.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSexual Health Literacy Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 610px;\"\u003e\n \u003cp\u003eModel summary: \u003cstrong\u003eR\u0026sup2; = .384\u003c/strong\u003e, F(2,422)=131.520, p\u0026lt;.001, MSE=25.325\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u0026nbsp;\u003c/strong\u003eTotal, Direct and Indirect Effects (Bootstrap=5000)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE / BootSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA Alt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% GA \u0026Uuml;st\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal impact (c):\u003c/strong\u003e Sexual and Reproductive Health Stigmatization Scale in Young Women\u0026rarr; Sexual and Reproductive Health Service Seeking Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e-10.407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.643\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirect effect (c\u0026prime;):\u003c/strong\u003e Sexual and Reproductive Health Stigmatization Scale in Young Women\u0026rarr; Sexual and Reproductive Health Service Seeking Scale (M control)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e-5.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndirect effect (a*b):\u003c/strong\u003e Sexual and Reproductive Health Stigmatization Scale in Young Women \u0026rarr; Sexual Health Literacy Scale\u0026rarr; Sexual and Reproductive Health Service Seeking Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sexual/reproductive health, stigma, sexual health literacy, service-seeking attitudes, mediation analysis","lastPublishedDoi":"10.21203/rs.3.rs-8982002/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8982002/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThis study aimed to examine the mediating role of sexual health literacy in the relationship between perceived stigma regarding sexual/reproductive health and readiness to seek sexual/reproductive health services among young women aged 18\u0026ndash;24 living in Istanbul.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis quantitative, cross-sectional, and correlational study was conducted between June and November 2025 with 425 young women living in Istanbul using an online snowball sampling method. Data were collected using a Personal Information Form, the Sexual and Reproductive Health Stigmatization Scale in Young Women (SRHSSYW), the Sexual Health Literacy Scale (SHLS), and the Sexual and Reproductive Health Service Seeking Scale (SRHSS). Relationships were tested using Pearson correlations; mediation analyses were performed using a regression-based approach with the Hayes PROCESS Macro (Model 4; bootstrap\u0026thinsp;=\u0026thinsp;5000).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of the participants was 22.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77. Stigma negatively predicted sexual health literacy (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.688, SE=.155, p\u0026lt;.001; R\u0026sup2;=.219), and sexual health literacy positively predicted service-seeking tendency (B=.234, SE=.021, p\u0026lt;.001). The overall effect of stigma on service-seeking tendency was significant (c = -0.793, SE\u0026thinsp;=\u0026thinsp;0.076, p \u0026lt; .001). When the mediating variable was controlled, the direct effect decreased but remained significant (c\u0026prime; = -0.398, SE\u0026thinsp;=\u0026thinsp;0.076, p \u0026lt; .001). The indirect effect was significant (ab =- .395, BootSE = .053; 95% BootGA [\u0026minus;\u0026thinsp;.498, \u0026minus;\u0026thinsp;.295]), and the results indicated partial mediation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings show that as stigma increases, sexual health literacy and service-seeking tendencies decrease; as sexual health literacy increases, service-seeking tendencies increase; and sexual health literacy plays a partial mediating role in the stigma-service-seeking relationship.\u003c/p\u003e","manuscriptTitle":"Breaking Barriers: How Sexual Stigma Impacts Women's Health Care Seeking Behavior Through the Lens of Sexual Health Literacy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 10:28:18","doi":"10.21203/rs.3.rs-8982002/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56a2e01f-755a-4110-b78f-ff80575d5d2c","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-24T10:28:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 10:28:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8982002","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8982002","identity":"rs-8982002","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}