Background: Complaints about sexuality is more common among women in comparison to men. Designing effective interventions in this field requires the identification of predictive factors. This study aims to predict the sexual satisfaction of women based on the components of knowledge and attitude.
Methods: In a cross-sectional descriptive study, 480 women who had been referred to Hamedan health centers were selected by two-stage cluster sampling; they completed Hadson sexual satisfaction questionnaires as well as SKAS knowledge and attitude questionnaire. In addition to descriptive analysis, the Pearson correlation coefficient was used to analyze the relationships between variables and finally, linear regression was used to determine the relationship between variables by eliminating confounding factors.
Results: The findings of the analysis revealed a positive and direct correlation between the variables of sexual satisfaction and sexual attitude. There was a positive and significant relationship between sexual satisfaction and sexual knowledge (r=0.442, P=0.000) and sexual satisfaction and sexual attitude (r=0.506, P=0.000); i.e. increase in knowledge and attitude about sexual issues are associated with enhancement of sexual satisfaction. The predicted sexual satisfaction of married women was predominantly attributed to sexual attitude.
Conclusion: The results of our analysis showed that women's knowledge and attitudes can predict their sexual satisfaction. Therefore, increasing sexual knowledge and improving the attitude of women should bring about greater sexual satisfaction for women. By designing and implementing effective educational interventions and counseling aimed at promoting women's sexual knowledge and improving false beliefs, effective steps can be taken to preserve and enhance the sexual health of women and, consequently, couples.
According to the definition presented by the World Health Organization (WHO), sexual satisfaction implies a harmony between mind, body, and soul that can lead to rationalism, improved society, and developed personality. Accordingly, the International Conference on Population and Development in Cairo (1999) considers it a right for all humans to achieve the highest standard of information and sexual health. Sexual satisfaction, which is a multidimensional concept that includes emotional aspects and physiological aspects of sex Mofid et al., 2014 , is one of the important factors affecting the quality of life and the sense of well-being. Family stability and durability of marital life depend on the satisfaction of sexual relationships Abdoly and Pourmousavi, 2013 Talayizadeh and Bakhtiyarpour, 2016 . Researchers have shown that dissatisfaction with sex can lead to deep-seated problems in couples, hatred, abuse, jealousy, rivalry, feelings of low self-esteem, feelings of humiliation, and increased divorce rates Parsa et al., 2017 Soleimani et al., 2015 . Sexual satisfaction in marital relationships is one of the key factors in assessing a person's quality of life, in general, and the quality and continuity of the marital relationship, in particular del Mar SÃ¡nchez-Fuentes et al., 2014 . It is closely associated with marital-related structures such as communication MacNeil and Byers, 2009 and the satisfaction of communication between couples.
Indeed, sexual satisfaction can serve as one of the most important factors of marital instability and predictors for future divorce Nasiri and Mousavi, 2015 . The results of a study, entitled â€˜Investigating the relationship between sexual dissatisfaction and intimacy in Iranâ€™, showed that 67% of divorces occur due to sexual problems Movahed and Azizi, 2011 . Sexual satisfaction varies among men and women, with complaints of sexual dissatisfaction more common among women compared to men Abdoly and Pourmousavi, 2013 Ramezani et al., 2012 . Presumably, the relative lack of sexual satisfaction of women, in comparison with men, may be attributed to factors such as late onset of sexual activity, conservative attitudes about sex, lack of importance about sexual issues in life, lack of sexual expression, and use of restricted sexual techniques Rahmani et al., 2010 . While sexual activity is an important part of the life of women, it is estimated that 60-80% of women have various forms of sexual dysfunction that directly or indirectly affects many aspects of their lives Bahrami et al., 2007 , as women with sexual dysfunction develop symptoms of instability, low self-confidence, anxiety, restricted self-control, and feelings of guilt Nasiri and Mousavi, 2015 .
The existence of socio-cultural barriers, such as taboos, makes it difficult to accurately estimate the prevalence of sexual disorders, but it seems that the prevalence of these disorders in women is very high. The racial, ethnic, cultural and social differences prevail over the differences in the extent of sexual disturbances posed between countries Safarinejad, 2006 . Studies in Iran have reported significant levels of female sexual dysfunction. According to studies by Bahrami et al., only 39.6% of women were fully satisfied with their sex life Bahrami et al., 2012 . Based on study results of Fallah et al., about 89% of married women struggle with sexual dysfunction in Qazvin. In another study, 93.1% of women and 80.6% of men suffered from at least one sexual disorder Yekeh and Goudarzi, 2009 . Ranjbaran et al. showed in a meta-analysis study (2015) that the overall prevalence of female sexual dysfunctions in Iran was 43.9%. Dissatisfaction exists despite physical, mental and emotional well-being, healthy family life, and happiness among women Hamadiyan et al., 2016 Jaafarpour et al., 2013 .
Sexual satisfaction in women is affected by several factors that are referred to as social factors; these include age, marital status, income level, and emotional-personality factors (e.g. self-confidence, sexual guilt, empathy, positive family attitudes, etc.) Asgari et al., 2011 Bahrami et al., 2016 Besharat and Rafiezadeh, 2016 Tavakol et al., 2011 . The duration of marriage and the age interval of couples are two other demographic factors Shahhosseini et al., 2014 . Meanwhile, Sepens has emphasized the great impact of the lack of knowledge on the sexual abusiveness of women Salim and Fatehizade, 2012 . Scholars have also found that increasing women's information about sex leads to a change in their attitudes toward sexual activity Sasanpour et al., 2016 . Researchers have shown that many of the inappropriate sexual activities of couples is derived from lack of sexual knowledge, sexual skills, and/or communication skills De Graaf et al., 2015 Yoo et al., 2014 .
Sexual knowledge is a collection of information and refers to the knowledge and awareness of the individual about sex and sexuality (including physiological aspects, reproduction, performance, and individual sexual behavior). Lack of sexual knowledge is associated with an increase in vulnerability, which creates a context for the emergence of sexual disorders Salim and Fatehizade, 2012 . On the other hand, people have different opinions and attitudes about a wide range of issues, such as normal or abusive sexual activity, sexual role, or sexual activity. Indeed, sexual orientation is, in fact, a positive or negative perspective in the pursuit of sexual orientation/events. Researchers believe that knowledge and attitudes are related to different aspects of behavior, performance, sexual satisfaction and sex Soltani et al., 2017 .
Considering the importance of the family in the Iranian community and the importance of sexual satisfaction and its impact on family empowerment, it is essential to determine the predictors of sexual satisfaction in women. By doing so, effective interventions can be developed to strengthen the foundation of the family. The purpose of this study was to predict the sexual satisfaction of women, referred to Hamedan health centers, based on knowledge and gender components.
Materials - Methods
The present cross-sectional study was conducted on 480 women referred to health centers in Hamedan, Iran. Two-step cluster sampling method was used to separate participating subjects. Among the 21 health centers in the city, 10 centers were selected as clusters (50% cluster). The 48 married women who were eligible subjects, according to inclusion criteria, were randomly selected from each center. After obtaining informed consents and assuring the confidentiality of the collected information, demographic characteristics were obtained. The subjects completed the Hudson's sexual satisfaction questionnaire as well as SKAS knowledge and attitude questionnaire.
The collected data were analyzed by statistics software SPSS (version 18) via descriptive-analytical statistical tests and chi-squared test. Moreover, P<0.05 was considered as the significance level. In addition to descriptive analysis, the Pearson correlation coefficient was used to analyze the relationships between variables and, lastly, the linear regression test was used to determine the net effect of the relationship between variables by eliminating the confounding factors. At this stage, the variables were entered into the final model, which had a P-value <0.2 in the single-variable test. Of note, the research plan was accepted by Hamadan University of Medical Sciences in Iran.
Data collection tools
Hudson's sexual satisfaction questionnaire
The Hudson's sexual satisfaction questionnaire was created by Hudson, Harrison and Kruskappa in 1981 to assess the levels of marital satisfaction. The scale has 25 questions in a 7 Likert scale that includes 0-6 points; the score of the questionnaire ranges from 0-150. As a cut-off point, the score of 75 and above reflects good sexual satisfaction of the individual with his/her partner.
SKAS knowledge and attitude questionnaire
This questionnaire was created by Farajnia, Hosseinian, Shahidi and Sadeqi in 2015 as a combination of Snell's Sex Orientation Inventory (1990), Besharatâ€™s Sexual Knowledge and Sex Questionnaire (2005), Hoover's Sexual Knowledge Questionnaire (1992), and Khoshabi and Valaeiâ€™s Sexual Attitude (2000). The scale of this questionnaire has 20 items categorized into two distinct clusters of sexual knowledge and sexual attitude. Likertâ€™s 5-scale rating was used to determine the value of the items: 5 points for â€˜completely agreeâ€™, 4 points for â€˜agreeâ€™, 3 points for â€˜somewhat agreeâ€™, 2 points for â€˜disagreeâ€™, and 1 point for â€˜completely disagreeâ€™. Also, the range of scores of this questionnaire varies from 20-100, with higher scores reflecting greater knowledge and attitude of the subject. In the present study, in addition to the component-specific code, a total score for each subject was calculated and the cut-off point was considered to be 60 for the total score.
The mean age of the women in the study was 28.9Â±5.4 years; the mean age of the last child was 3.04Â±3.8 years, and the mean number of the individuals was 3.3Â±0.88 ( Table 1 ). The highest and lowest mean of sexual satisfaction were found to be related to differences in sexual attitude ( Table 2 ). In order to investigate the relationship between sexual satisfaction and sexual knowledge and attitude, the Pearsonâ€™s correlation coefficient was used; there was a positive and meaningful relationship between sexual satisfaction and sexual knowledge (r=0.442, P=0.000) and sexual satisfaction and attitude (r=0.506, P=0.000).
Demographic profile of participants
Mean of sexual satisfaction, sexual knowledge and sexual attitude of women
With increasing knowledge and attitude, sexual satisfaction also increases ( Table 3 ). In fact, sexual knowledge (P=0.000, B=0.355) and sexual orientation (P=0.000, B=0.875) can positively predict the sexual satisfaction of married women ( Table 4 ). According to the obtained beta, the highest share of predicted sexual satisfaction in married women was associated with sexual attitude.
Correlation between components of sexual satisfaction with sexual knowledge and sexual attitude
Sexual satisfaction regression with variables of sexual knowledge and sexual attitudes
Sexual satisfaction plays an important role in the prevention of high-risk sexual behaviors, serious mental illness, and social delinquency Hajivosough et al., 2012 . The lack of sexual satisfaction in women is reported more often than in men. Female sexual dissatisfaction affects the mood of women and has a significant relationship with depression and other psychiatric disorders Peleg-Sagy and Shahar, 2013 . Poor knowledge, false beliefs, and cultural taboos associated with sexual activity of women are among the main factors in this regard Ramezani et al., 2012 .
The results of the present study showed that there is a positive and significant correlation between sexual knowledge and attitudes of women in terms of sexual satisfaction. Indeed, the two components of knowledge and attitudes could predict sexual satisfaction of married women; those women with a higher level of sexual knowledge and more positive attitude toward sexual activity are inclined to experience more pleasure. Moreover, the lack of sexual knowledge leads to an increase in conflicts and sexual harm of couples while efficient sexual knowledge increases the likelihood of finding a logical solution to marital problems Soltani et al., 2017 . In fact, couples are required to have a comprehensive knowledge of sexual tendencies of their partners in order to have a healthy and happy life.
In addition, greater sexual knowledge and a positive attitude have implications for enhancing/increasing sexual behaviors, regularity of sex, coping abilities (to deal with sexual dysfunctions), and awareness of the needs of the spouse Hajivosough et al., 2012 Peleg-Sagy and Shahar, 2013 , all of which can lead to the sexual satisfaction of couples. In our analysis, sexual attitude was the most powerful predictor of sexual satisfaction in married women.
One of the strongest factors affecting sexual satisfaction was mental health. Mental health refers to the thoughts and overall well-being of the individual with respect to their life and specific components (e.g. sex, interpersonal communication, physicals status, and mental status) Althof and Needle, 2013 Shahhosseini et al., 2014 Syme et al., 2013 . Inefficient sexual beliefs can lead to the development of sexual maladministration; researchers have investigated the difference between sexual beliefs of women and men in two sexually disadvantaged and sexually-abusive groups, and they found that both sexually abusive women and men with non-conventional tendencies are more dangerous in comparison to those whose sexual tendencies follow mainstream strategies. People who have a positive attitude towards sexuality will experience sex without feelings of guilt.
Positive versus negative outlooks on sex have different effects on one's sexual response. Negative factors, which can generate negative attitudes about sex, can be derived from misconceptions or misinterpretations during sexual situations. Positive factors (e.g. enjoyment of experience, desire, arousal, and orgasm) play important roles as input stimuli which produce positive sexual opinions. Of course, it must be acknowledged that oneâ€™s sexual attitude which affects the body of beliefs about sex and oneâ€™s sexual behavior is deeply rooted in the cultural beliefs as well as previous experiences of the individual Rezakhaniha B, 2016 . Therefore, knowledge of cultural taboos, traditional beliefs, and falsely perceived beliefs of each society, particularly from the viewpoint of women in those societies, can raise the level of knowledge of sex among couples. In women, especially, interventions to promote sexual health can be quite effective. In fact, the increase of sexual knowledge is a consequence of improving the attitude of women. The limitation of the present study was the reluctance of some people in the study community to participate in the study.
The present study showed that women's knowledge and attitudes can predict sexual satisfaction. Increasing knowledge and improving the attitude of women increases the sexual satisfaction of women. Therefore, designing and implementing effective educational interventions, as well as offering counseling aimed at promoting women's sex knowledge, can improve false beliefs. Thus, effective steps can be taken to preserve and enhance the sexual health of women and, consequently, couples.
WHO: World Health Organization
All authors equally contributed to the design of the research, wrote the manuscript, and approved the manuscript for publication.
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