|Year : 2017 | Volume
| Issue : 3 | Page : 180-185
Sex education of married women based on theory of planned behavior
Zeinab Jalambadani1, Gholamreza Garmarodi1, Mahmood Tavousi2
1 Department of Health Education and Promotion, Faculty of Health, Tehran University of Medical Sciences, Tehran, Iran
2 Health Education & Promotion Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran
|Date of Web Publication||13-Jul-2017|
Department of Health Education and Promotion, Faculty of Health, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background: More than half of the sexual problems which cause life destruction and marital relationships are due to insufficient knowledge or false beliefs about sexual relationships. Theory of planned behavior (TPB) is one of the important theories that explain the main process of adopting health behaviors. This study investigates sex education based on TPB in married women visitors to Mashhad health-care centers in Iran. Materials and Methods: In this quasi-experimental study, 80 women visiting health centers of Mashhad city were studied, selected from 5 health centers by random-cluster method. Methods and data collection tool were the questionnaire which completed through the interview. The validity and reliability of this questionnaire were determined through face and content validity and through Cronbach's alpha and test-retest, respectively. Statistical Analysis Used: Data were analyzed using statistical SPSS (22) software, Spearman's correlation coefficient tests, and linear regression analysis. Results: In linear regression analysis, it was determined that attitudes, subjective norms, and perceived behavioral control (PBC) predict 0.45 overall of total variance of sexual function intention, which among these variables, the effect of subjective norms was more than the other ones (P value < 0.05). After educational intervention, the average rates of knowledge, attitude, PBC, and intention to sexual function in sex education group were increased meaningfully (P value < 0.05); these changes were not meaningful in control group. There was also no statistically meaningful difference in subjective norms between two groups after intervention. Conclusion: According to findings, it is proposed that TPB be used to improve sex education.
Keywords: Sex education, sexual function, theory of planned behavior
|How to cite this article:|
Jalambadani Z, Garmarodi G, Tavousi M. Sex education of married women based on theory of planned behavior. CHRISMED J Health Res 2017;4:180-5
|How to cite this URL:|
Jalambadani Z, Garmarodi G, Tavousi M. Sex education of married women based on theory of planned behavior. CHRISMED J Health Res [serial online] 2017 [cited 2018 Jul 22];4:180-5. Available from: http://www.cjhr.org/text.asp?2017/4/3/180/210489
| Introduction|| |
Sexual instinct is one of the most important human needs causing generation survival and reproduction, and researchers have accepted it as the foundation of family formation and considered its satisfaction to be significant and essential. The researches show that sexual inadequacies are closely associated with social problems such as crimes, sexual assaults, mental illnesses, and divorce. Furthermore, being nervous, the incidence of lower abdominal and back pains, inability to concentrate, and even inability to do daily affairs are the other consequences of failure to satisfy the sexual instinct. However, desirable sexual function is the factor to strengthen family and the foundation to obtain and stabilize a consistent culture. Possibly, even couples having sexual inadequacies and they themselves are unaware of its effect on marital life problems and its role in building poor communication, low self-confidence, and depression in themselves and their spouses. In the studies, the most common sexual disorders in women were reported sexual desire disorder (22%–63.3%), sexual arousal disorder (31.6%–43%), orgasmic disorder (34.5%–45.8%), and sexual pain disorder (12.8%–36.8%).,, The cited statistics are the reasons for the importance of attention to sexual health since sexual instinct is one of the inherent human needs as Maslow has put it into the categories of physical or basic survival needs. Regarding intercourse can be also said that although happy married life is only somewhat related to intercourse, this relationship may be one of the most significant reasons of happiness or lack of that in marital life. Because if this relationship not to be satisfactory, it will result in deprivation and failure feeling, the lack of safety feeling, jeopardizing mental health, and finally family disintegration. Therefore, sex education programs include issues that have been considered to raise awareness and reduce sexual problems at all social levels. To develop sexual health education program, it is essential to pay attention to particular aspects of culture, religion, laws, norms, and prevailing values in the society and families. Media, the appropriate message and the appropriate message transmitter, is also very important to success of every educational program. Theory of planned behavior (TPB) was made by Ajzen and Fishbein in 1980. This theory is considered the intention of doing a behavior as the main cause for doing that. Intention is also influenced by the attitude toward behavior, abstract norms toward that, and individual's sense of control over it (in terms of its ease or difficulty). The behavioral intention of an individual is the most significant determinant of that behavior. The individual's behavioral intention depends on his/her attitude toward abstract behaviors and norms related to that behavior., The review of prior studies indicates that there has never been study yet on sex education based on the TPB of women in Iran. Thus, the current research has been carried out with the aim of applying sex education based on the TPB of women visiting health-care centers of Mashhad city.
| Materials and Methods|| |
In this quasi-experimental study, the married women visiting health centers of Mashhad in 2015 were investigated. The sample was included 80 women visiting Mashhad health centers which were selected from 5 health centers by cluster-random sampling method. The selection criteria included age between 18- and 49 years old, visiting research-related health-care centers to receive family planning services, marital status, living with spouse currently, having a tendency to participate in the study, not being pregnant, being Iranian, the absence of certain circumstances which hinder them from their common intercourse. All of the participants provided informed consent to be involved in the study.
The data collection tools of multiple-choice questionnaire included demographic data (13 questions), awareness (21 questions), dimensions of the TPB including attitude (12 questions), subjective norms (8 questions), perceived behavioral control (PBC) (6 questions), behavioral intention (3 questions), and sexual function (19 questions).
It included 21 questions about sexual function. The questions of this part were as four multiple-choice and true and false ones. The scores of 1 and 0 were assigned to true and false responses, respectively; for instance, one of the four multiple-choice questions was such as “which part of the women genital is more sensitive to sexual stimulation than others?” Furthermore, a sample of true and false questions is as follows: “If appropriate stimulation be done, are women able to experience multiple orgasms during an intercourse?” The items had high external consistency (r = 0.93).
This scale had 12 items, indirect attitude assessed (1) behavioral beliefs by six 5-point items ranging from “disagree strongly” to “agree strongly” (−2–+2) and (2) outcome evaluations by six 5-point items ranging from “not at all” to “very much” (+1–+5). Once multiplied together, possible indirect subjective norm scores ranged from −8 to +40, the items had high internal consistency (Cronbach's α = 0.85).
This scale had 8 items, indirect subjective norm assessed (1) normative beliefs by four 5-point items ranging from “disagree strongly” to “agree strongly” (−2–+2) and (2) motivation to comply by four 5-point items ranging from “not at all” to “very much” (+1–+5). Once multiplied together, possible indirect subjective norm scores ranged from –8 to +40, the items had high internal consistency (Cronbach's α = 0.80).
Perceived behavioral control
This scale had 6 items, indirect PBC assessed control beliefs and their perceived power of the behavior by three 5-point items ranging from “disagree strongly” to “agree strongly” (−2–+2) and three 5-point items ranging from “not at all” to “very much” (+1–+5). Once multiplied together, possible indirect subjective norm scores ranged from −6 to +30. The items had moderate internal consistency (Cronbach's α = 0.79).
This scale had 3 items, intention was measured as the sum of three 5-point items (+1–+5) that assessed intention to have the sexual function in the future (e.g., “I intend to always orgasm during vaginal sex with my partner during the next months” from “not at all” to “very much”). The items had moderate internal consistency (Cronbach's α = 0.70).
This scale had 19 items, index of sexual functioning for women (Rosen R, Brown C, et al., 2000) is a 19-item self-report inventory that measures current levels of sexual functioning and satisfaction in women. The items had high external consistency (r = 0.93).
In the first step (before providing education), the questionnaire was completed by participants; participants were divided into two groups of sex education and control randomly. Then, educational intervention was conducted during four training sessions of 75 min each, based on the analysis of the results obtained from the first step for experimental group. In the first session, the group individuals discussed and exchanged the experiences of their friends and familiar individuals with themselves. Discussion and exchange of ideas were directed within 75 min by the educator to determine positive opinions and attitudes of individuals so that it can indirectly provide positive motivation for them to talk about their sexual affairs with spouse, to make new attitudes, and to change negative attitude toward intercourse. In the second session, sexual identity, steps, and process of sexual function were explained by displaying training slides and to be tried to make more motivation for marital relationship, based on being necessary for intercourse, with emphasis on satisfactory one, and were followed by 30 min discussion with women on hardness and easiness of intercourse; also, common beliefs and misconceptions about sexual relationship were discussed within 75 min so that the intensity of these misconception would be reduced and the ground be prepared for attitude and belief change. The third and fourth sessions took 75 min. Indirect training was provided using one booklet and two education leaflets. There was no educational intervention in control group. Then again, after 1 month follow-up, the questionnaires were completed by two groups of sex education and control.
After collecting data, the questionnaires were encoded and data entered into the computer, and the analysis was carried out by SPSS 22 software, Spearman's correlation coefficient tests, and linear regression analysis. Descriptive statistics including mean and deviation frequency were used to describe demographic information of research samples. Independent samples t-test, Mann–Whitney U-test, and Chi-square test were used for homogeneous test. The correlation coefficient of Pearson and Spearman and linear regression were used to determine correlation between TPB variables and to determine the predictive power TPB variables, respectively. The level of significance of P < 0.05 was considered for all tests.
| Results|| |
The study results have been expressed in three sections including demographic variables, predictor of intention of having intercourse, and constructs of the TPB before and after training, in the groups of sex education and control.
Before training in two groups of test and control, Mann–Whitney U-test did not show any statistically meaningful difference in terms of age, marriage age [Table 1], marriage duration, the number of children, income status, and the oldest and youngest child [Table 2].
|Table 1: Mean age and marriage age in sex education and control groups before of education|
Click here to view
|Table 2: Median duration of marriage, the number of children, income status, and the age of the oldest and youngest child, in two groups of sex education and control before training|
Click here to view
The majority of sex education and control group has university (42.5%) and high school (37.5%) degree, respectively, and the education level of husband in sex education and control group has been high school degree (50%) and university degree (40%), respectively. The job of majority of research units in both groups was homemaker (70%). The husband's job in sex education and control group was freelance (52.5%). The income of the majority of research units (90%) was enough. The majority of research units (66.3%), in terms of housing status, had their personal home.
Predictor of having intercourse intention
[Table 3] displays the Spearman's correlation coefficient among TPB variables, intention, attitude, subjective norm, and PBC. As shown, all the components of the TPB correlated significantly with behavioral intention. Subjective norm (r = 0.465, P < 0.01) was significantly and strongly correlated followed by the PBC (r = 0.31, P < 0.01) and attitude (r = 0.292, P < 0.01). Since they correlated positively an increase in the value of one, TPB component was accompanied by an increased intention to sexual function. However, knowledge did not correlate significantly with any of the TPB component. [Table 4] shows there was the highest correlation between subjective norms and intention of having intercourse among attitude variables, subjective norms, and PBC; according to the results of linear regression analysis, attitude variables, subjective norms, and PBC predicted 0.45 overall of variance of having sex intention that the effect of subjective norms among these variables was more than other variables. The comparison among the average of studied variables in group of education and control, before and after intervention [Table 5].
|Table 3: Correlations among the components theory of planned behavior, knowledge, intention, attitude, subjective norms, perceived behavioral control, and sexual function|
Click here to view
|Table 4: Linear regression of intention on knowledge, attitude, subjective norms, and perceived behavioral control|
Click here to view
|Table 5: The comparison among the average of studied variables in group of education and control, before and after intervention|
Click here to view
| Discussion|| |
This study was carried out as a semi-experimental one using TPB and education intervention based on variables of this theory, with the general aim of determining the effect of sex education based on TPB over sexual function of women visiting health-care centers of Mashhad city. The results show that all attitude variables, subjective norms, and PBC can explain the intention of having sex which subjective norms had the greatest power of predictor among these variables. The results of the study are consistent with the following studies.,,
The results of current study are not consistent with the study of Tavousi et al. In the study of Tavousi et al., there has been a weaker relationship between subjective norms with behavioral intention and behavior than relationship of other constructs. The usages of self-efficacy construct rather than the construct of PBC can be considered the reason behind the difference between the results of mentioned study with this study, which regarding the issue of drug abuse, it had a more influence than other constructs with behavioral intention. There has been no developed sex education for none of the age groups in Iran, and thus, the knowledge level of different people groups about sexual health, scientific, and authentic issues related to sexual affairs is not high enough. Furthermore, the findings of before intervention of this study show the same issue. The results of the current study show that the score of awareness after intervention in sex education group had a meaningful difference than the score of that before intervention. In other words, the planned educational intervention in this research has caused the increase of knowledge of sex education group.
The sexual knowledge and awareness of couples is followed by pleasure and improvement of marital and emotional relationship between them. If couples have a better understanding about this important dimension of relationship, they will be able to change their communication methods and to improve them and to take an appropriate solution against the incidence of marital conflicts and problems. The ignorance and the lack of sexual knowledge and gaining inaccurate information about intercourse will result in increasing sexual conflicts and problems of couples. The issue of education's impact on increasing knowledge is consistent with studies of Kaviani et al., Safarinejad et al., Rahimi et al., and McMullen and Rosen.,,, The attitude score after intervention in sex education group had a meaningful difference compared with that of attitude before intervention, which this score was not meaningful in control group. As it can be seen, although measured attitude status in this study has been on the average, the rate of attitude change after intervention had a meaningful difference compared to that of rate before intervention. It seems that positive attitude by itself is not enough to have proper sexual function, and the awareness level affects this issue as well. For instance, the intervention group had a positive attitude toward enjoyment of sexual pleasure but was not aware of manner and quality of that. Taking this issue into consideration that the attitude of studied individuals in intervention group had a meaningful difference before and after training, but this difference that has not been observed in control group indicates that educational intervention has caused this difference in intervention group. The current study was not consistent with study of Ahmadi et al. The case of increasing attitude score of experimental group has stated that the average variable score of the attitude of experimental group after intervention had not a meaningful difference with control group. The reason can be considered as less involvement of studied group in learning process, less self-originating in spouses, and use of inactive learning methods in the study of Ahmadi et al.
The obtained results from the average variable subjective norms in sex education group had no meaningful difference compare to before intervention. Therefore, it may be required to be spent more time justifying and training sexual function to increase the score of subjective norms, or it may be required subjective norms such as their spouses who are important for studied group to be entered into training sessions as well.
In marital life, there are beliefs that are true and there is no evidence to support them. These strongly held beliefs create expectations that prevent spouses from achieving their goals and put their sexual health in danger and become the main reason behind many conflicts, especially between spouses, as dysfunctional beliefs., Addis and Bernard stated in the study that subjective norms had the most correlation with the intention of taking HIV test. This inconsistent results can be linked to time issue since intervention, in the case of time, has been carried out in more amount of time than that of this study. The results of the current study indicate that the score of PBC after intervention in sex education group had a meaningful difference compared to that of score before intervention, which this score was not meaningful in control group. In the current study, PBC and the feeling of having the will and control over doing the behavior are important factors to start having a sexual function in sex education group and increase of that followed by intervention is indicated the effect of education on rising PBC. The results of the study are consistent with the study of Omer and Haidar.
| Conclusion|| |
The results of the current study indicate that the score of behavioral intention after intervention in sex education group had a meaningful difference compare to that of score before intervention, which this score has not been meaningful in control group. Hence, sex education has caused the increase of the behavioral intention in experimental group. According to this, whenever women acquire enough knowledge along with positive attitude toward sexual function, and on the other hand, if women feel that environmental factors (facilities and barriers) are in their own willpower, they will be full of intention about sexual function, and if intention express properly, they will have the better sexual function have stated that there is a correlation between attitude and behavioral intention and subjective norms and the intentions of safe sexual behavior as well., The score of sexual function after intervention in sex education group had a meaningful difference compared to that of score before intervention in the same group, which this score has not been meaningful in control group. In the received trainings in educational intervention that were carried out in this thesis, it was tried to learn women how they can use their own information tools and refuse behaviors that they do not like or be considered.
The authors are thankful for supporting the study by Tehran University of Medical Sciences, Tehran, Iran. Our gratitude and thanks is also extended to all managers' experts and students.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abdel-Tawab N, Roter D. The relevance of client-centered communication to family planning settings in developing countries: Lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68.
Bayrami R, Sattarzadeh N, Koochaksariie FR, Pezeshki MZ. Sexual dysfunction in couples and its related factors during pregnancy. J Reprod Infertil 2008;9:271-82.
Cayan S, Akbay E, Bozlu M, Canpolat B, Acar D, Ulusoy E. The prevalence of female sexual dysfunction and potential risk factors that may impair sexual function in Turkish women. Urol Int 2004;72:52-7.
Ponholzer A, Roehlich M, Racz U, Temml C, Madersbacher S. Female sexual dysfunction in a healthy Austrian cohort: Prevalence and risk factors. Eur Urol 2005;47:366-74.
Goshtasebi A, Vahdaninia M, Rahimi Foroushani A, MohammadiA. Reproductive correlates of female sexual dysfunctions in Kohgiluyeh and Boyer-Ahmad Province: A population-based study. J Payesh 2008;7:67-73.
Toorzani ZM, Zahraei RH, Ehsanpour S, Nasiri M, Shahidi S, Soleimani B. A study on the relationship of sexual satisfaction and common contraceptive methods employed by the couples. Iran J Nurs Midwifery Res 2010;15:115-9.
Vandermassen G. Sexual selection: A tale of male bias and feminist denial. Eur J Womens Stud 2004;11:9-26.
Enjezab B, Farajzadegan Z, Taleghani F, Aflatoonian A. Internal motivations and barriers effective on the healthy lifestyle of middle-aged women: A qualitative approach. Iran J Nurs Midwifery Res 2012;17:390-8.
Armitage CJ. Can the theory of planned behavior predict the maintenance of physical activity? Health Psychol 2005;24:235-45.
Tolma EL, Reininger BM, Evans A, Ureda J. Examining the theory of planned behavior and the construct of self-efficacy to predict mammography intention. Health Educ Behav 2006;33:233-51.
Mausbach BT, Semple SJ, Strathdee SA, Patterson TL. Predictors of safer sex intentions and protected sex among heterosexual HIV-negative methamphetamine users: An expanded model of the Theory of Planned Behavior. AIDS Care 2009;21:17-24.
Omer S, Haidar J. Applicability of the theory of planned behavior in predicting intended use of Voluntary HIV Counseling and Testing services among teachers of Harari Region, Ethiopia. Ethiop J Health Dev 2010;24:96-102.
Asare M, Sharma M. Using the theory of planned behavior to predict safer sexual behavior by Ghanaian immigrants in a large Midwestern U.S. city. Int Q Community Health Educ 2010;30:321-35.
Tavousi M, Hidarnia AR, Montazeri A, Taremia F, Hajizadeh E, Ghofranipour F. Modification of reasoned action theory and comparison with the original version by path analysis for substance abuse prevention among adolescents. Med J Hormozgan 2009;14:45-54.
Kaviani M, Rahnavard T, Azima S, Emamghoreishi M, Asadi N, Sayadi M. The effect of education on sexual health of women with hypoactive sexual desire disorder: A randomized controlled trial. Int J Community Based Nurs Midwifery 2014;2:94-102.
Safarinejad MR, Kolahi AA, Hosseini L. The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous women and their husbands. J Sex Med 2009;6:1645-67.
Rahimi E, Shafiabady A, Yonesy F. The effect of sexual cognitive-behavioral therapy on females' sexual knowledge, sexual attitude, and sexual self-confidence. A case study in Shiraz, Iran. Armaghan Danesh 2009;14:103-11.
McMullen S, Rosen RC. Self-administered masturbation training in the treatment of primary orgasmic dysfunction. J Consult Clin Psychol 1979;47:912-8.
Ahmadi TS, Taghdisi M, Nakhaei N, Balali F. Effect of educational intervention based on the theory of planned behaviour on the physical activities of Kerman health center's staff (2008). J Babol Univ Med Sci 2010;12:62-9.
Addis J, Bernard ME. Marital adjustment and irrational beliefs. J Ration Emot Cogn Behav Ther 2002;20:3-13.
Epstein N. Cognitive marital therapy. J Ration Emot Cogn Behav Ther 1986;4:68-81.
Mirkuzie AH, Sisay MM, Moland KM, Astrøm AN. Applying the theory of planned behaviour to explain HIV testing in antenatal settings in Addis Ababa – A cohort study. BMC Health Serv Res 2011;11:196.
Rye BJ, Fisher WA, Fisher JD. The theory of planned behavior and safer sex behaviors of gay men. AIDS Behav 2001;5:307-17.
Villarruel AM, Jemmott JB 3rd
, Jemmott LS, Ronis DL. Predictors of sexual intercourse and condom use intentions among Spanish-dominant Latino youth: A test of the planned behavior theory. Nurs Res 2004;53:172-81.
Hoyer J, Uhmann S, Rambow J, Jacobi F. Reduction of sexual dysfunction: By-product of cognitive-behavioural therapy for psychological disorders? Sex Relatsh Ther 2009;24:64-73.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]