Priorities for a gender‐sensitive sexually transmitted infections and human immunodeficiency virus (STIs/HIV) services: An exploratory mixed methods study

Abstract Background and Aim Providing gender‐sensitive health services is emphasized by the World Health Organization. This study aimed to assess and prioritize the needs for the gender‐sensitive sexually transmitted infections/human immunodeficiency viruses (STIs/HIV) prevention services by a valid and reliable questionnaire. Methods This was an exploratory mixed methods sequential study in Shiraz Iran 2019. The first phase was a qualitative study on 37 providers and managers of the services who were recruited using the purposive and then snowball sampling method. In the second phase, following the content analysis of the qualitative data and a review of related literature, a questionnaire was developed and its psychometric properties were evaluated. Then, in the third phase, the questionnaire was used to assess and prioritize the needs through a quantitative descriptive cross‐sectional study on all 290 providers of STI/HIV prevention services affiliated with Shiraz University of Medical Sciences. Results The finding of the qualitative phase showed gender‐sensitive STI/HIV prevention services should provide gender‐sensitive care and education by the trained personnel and manages with appropriate facilities and equipment. Providing these services also requires supportive policies, intersectoral cooperation, and community capacitation. In the second phase, a questionnaire was developed with 63 items. Assessment of psychometric properties of the questionnaire demonstrated the scale content validity index and ratio (S‐CVI = 0.98 and S‐CVR = 0.87, respectively), as well as the reliability of the questionnaire (internal consistency = 0.972 and intracluster correlation coefficient = 0.910). Results of the third descriptive phase of the study demonstrated the highest priorities for gender‐sensitive education (92.01 ± 11.76%) and care services (92.11 ± 12.04%), respectively. Conclusions To improve the quality of the services, a gender‐based education and care process, as well as a gender‐sensitive structure, including gender‐sensitive personnel, facilities, and management are necessary. Recognizing and meeting the needs for gender‐sensitive services will improve the quality of the services.

they do not seek ways to protect themselves in the event of a partner's STIs infection. 7 Also, male gender roles may predispose them to STIs. Early initiation of sexual relationships and having multiple sex partners increase male risk of STIs. 8,9 Furthermore, men would not usually seek counseling and treatment services for STIs/ HIV and acquired immunodeficiency syndrome (AIDS) because of a myth that "seeking care is a sign of weakness" and it is not masculine behavior in their gender norms. 5,10 Therefore, providing genderbased counseling and care services seems to be necessary for STIs/ HIV care services.
Gender is a fundamental factor that shapes health systems and outcomes. 11 Gender norms are among the most important effective factors on STIs/HIV incidence and care services. 12 Hence recognizing the behaviors arising from gender norms affecting STIs/HIV prevention behaviors and services seems to be necessary.
Nowadays, providing gender-sensitive health services is emphasized by the World Health Organization. 13,14 Gendersensitive health services mean that health authorities have the knowledge and are able to perceive existing gender differences and to integrate these into their decision-making and actions. 15 Therefore, gender-based special needs in any community and culture should be known and considered in providing STIs/HIV prevention services. 16 The needs assessment requires a valid and reliable tool. Therefore, developing valid and reliable questionnaires to assess the real needs for providing gender-sensitive services helps health care managers to improve the quality of the services. 17 To our knowledge either there are limited studies to assess needs for gender-based reproductive health services 17,18 or no tool to assess needs for providing STIs/HIV prevention services.
There are very few studies on the gender-based special needs for STI/HIV prevention services. Lichtenstein et al. 19 showed men's concern about stigmatization as the main barrier for seeking STI prevention and treatment services. Garcia et al. 20 stated that stigma causes many people to avoid seeking STI-related services because of experiences, such as discrimination, indifference, and overt hostility in the health care setting. They mentioned to a world-wide barrier to a full range of reproductive health services such as restricted access to STI testing, criminalization of sexual behaviors associated with STI transmission, for example, commercial sex work or same-sex sexual relationships. A study in Nigeria demonstrated that a greater proportion of males than of females had sought treatment for their STIs (64% vs. 48%).
Females had lower odds than males of having sought STI treatment (odds ratio: 0.6). 21 Rahmanian et al. 22 in Iran used a valid and reliable questionnaire to assess the needs of gender-sensitive adolescents reproductive health services (ANQ-GSARHS), indicating the priorities for providing gender-sensitive services for adolescents, such as providing contraceptives for female adolescents, educating female adolescents about STIs, counseling male adolescents about confronting with peer pressure, employment of trained male providers for male adolescents' reproductive health services, and improving knowledge of providers about adolescents' reproductive health. However, to our knowledge, there is no study to understand the gender-based needs of STIs/HIV prevention services. Besides, very few tools are available to assess gender sensitivity in STIa services, 23 male participation in perinatal care services, 24 and reproductive health services. 25 The most comprehensive questionnaire to assess gender sensitivity in reproductive health services is available at the level of staff and facilities. 26 Therefore, considering the daily incidence of more than 1 million (STIs) cases worldwide 27 ; 26.4 million cases of four curable STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and Trichomonas vaginalis) in the Eastern Mediterranean region 28 ; and respecting to 59,531 estimated number of people with HIV in Iran in 2021 29 and also growing spread of STIs and HIV in Iran, 30 as well as the importance of gender-specific needs assessment in STIs/HIV health services with a valid and reliable tool, this exploratory mixed sequential study aimed to assess and prioritize the needs of gendersensitive STIs/HIV prevention services, by a valid and reliable questionnaire.

| Design of the study
This was a mixed-method exploratory sequential qualitativequantitative study. The exploratory sequential study is used when the researcher is interested in following up qualitative findings with quantitative analysis. This two-phase approach is particularly useful for a researcher interested in developing a new instrument or treatment protocol. 31 Therefore, the first phase of the present study was a qualitative study to produce codes and themes. These codes were used for the concept definition and item generation of the questionnaire. In the second phase, the questionnaire's psychometric properties were assessed. Thereafter, in the third phase, the questionnaire was used for a descriptive cross-sectional study to assess and prioritize the needs for gender-sensitive STIs/HIV prevention services. 31 Therefore, the method section is presented in these three abovementioned phases, (1) qualitative phase, (2) tool development phase, and (3) quantitative phase.
2.2 | Phase 1: The qualitative phase of the study

| Design
This phase of the study was a qualitative study with a content analysis approach. The codes extracted from the qualitative phase were used for item generation for the questionnaire. For developing the questionnaire, the steps described by Waltz et al. 32 were used. Respecting the first step for the questionnaire development, the qualitative phase was performed to explain needs for gender-sensitive STIs/HIV prevention services and the extracted codes were used for the items generation.

| Study settings
The research interviews were conducted in primary health care centers, voluntary counseling and testing services, and hospitals af-

| Participants
Participants were STIs/HIV care providers and managers or policymakers.

| Eligibility criteria
The inclusion criteria for participation were at least 2 years of working experience as a provider, manager, or policymaker of STIs/HIV prevention services.

| Sampling method
The participants were selected using the purposive and snowball sampling method. Recruitment continued until data saturation was reached.

| Outcome measures
Explaining the need for gender-sensitive STII/HIV prevention services.

| Tool for data collection
Data were collected using in-depth interviews using a semistructured questionnaire. The guide questions for the interview were: "How do you perceive the concept of gender-sensitive STIs/HIV prevention services"; "what is your perception about the gender roles that may affect sexual health"; and "what is necessary for a gendersensitive STIs/HIV services?" and "how these services could be provided?" A demographic questionnaire was also used for data collection.

| Study procedure
Data were collected using a deep face-to-face individual interview by using the semi-structured interviews and continued until data saturation; that is, when no new code of data was added to the study.
The interviews were conducted by the second author Dr. Rahmanian, who is an assistant professor in the Department of Midwifery and Reproductive Health at SUMS. After being introduced to the interviewer, the participants were informed about the goals of the study and promised the confidentiality of their personal information. Also, field notes were made during and after the interview. The interviews were performed after two pilot interviews. The average duration of interviews was about 60-90 min. All interviews were audiotaped, transcribed verbatim, and analyzed consecutively.

| Data rigor and trustworthiness
To assess the trustworthiness of data, four criteria of Lincoln and Guba's 33 were used, including credibility, dependability, confirmability, and transferability. To increase credibility, adequate time was allocated to data collection and frequent reviewing of the data. In addition, integration of data collection methods, that is, individual interviews and observations increased the credibility of the data. The participants (the service providers) were observed at the STIs/HIV prevention services and field notes were taken. Field notes are a qualitative approach, most often used in ethnography. Field notes are written observations recorded during or immediately following SIMBAR ET AL. | 3 of 15 participant observations in the field and are considered critical to understanding phenomena encountered in the field. 34 Some codes extracted from interviews were reviewed by four participants, including two managers and also two service providers, who had not participated in the study to ensure that the results accurately depicted the participants' experiences and perceptions. To confirm the dependability of the data, code-recode and external checking were used. To assess the confirmability of the data, the researchers abandoned all their assumptions and thoughts and carefully documented all the research steps, and allowed external auditors to investigate all the steps. To ensure transferability and comprehensiveness, a clear explanation of the methods of collecting and analyzing the data was presented along with examples of the statements made by the participants.

| Data analysis
The data were analyzed by using MAXQUDA10 and a conventional content analysis based on the criteria proposed by Graneheim and Lundman. 35 After transcribing, the recorded interviews, the transcripts were carefully reviewed by the researcher two to three times to achieve an accurate understanding of the interview contents. The text was divided into meaning units, meaning units were condensed while preserving the meaning and labeled with codes. Similar codes were then categorized into subcategories, and the subcategories were classified into a category based on common properties. The latent content of the similar categories was eventually formulated as a theme.

| Ethical considerations
Before conducting the interviews, the researcher briefed the participants on the objectives of the study and assured them that their responses will be confidential. Informed written and verbal consent was also obtained from the participants for participating in the study and recording the interviews.

| Phase 2: The questionnaire development and assessment of the psychometric properties
The method of this phase of the study is described in two parts: (1) the questionnaire development and (2) the assessment of psychometric properties of the questionnaire. The qualitative phase was performed using the conventional content analysis method to explain the concept and dimensions of gendersensitive STI/HIV prevention services. The primary pool of items and subscales of the questionnaire were respectively generated from codes and categories extracted from the data analysis of the qualitative phase.
A few items were also added to the pool after a literature review.
The literature review: To ensure that the items and construct definition aligns with relevant prior research and to identify existing survey scales or items that might be used, an extensive literature review was conducted.
Search strategy: The preferred reporting items for systematic reviews 36 was used to identify and articulate the needs for the STIs/HIV services.
We used appropriate operators, such as AND and OR, and a combination of search strategies for each database. We conducted a comprehensive search using the keywords "STI," "HIV," "AIDS," "prevention," "Care," "Service," "Gender," and "questionnaire" in Scopus, PubMed, Science Direct, Google Scholar, SID, World Health Organization, International Confederation of Planned Parenthood, United Nation Population fund websites, and Magiran databases.
Eligibility criteria: The inclusion criteria were Persian or English sources, the articles published between 1990 and 2019 in the abovementioned databases.
Some appropriate items were recognized in the review and added to the primary pool of items. In this way, the initial questionnaire was prepared for evaluating the psychometric properties.

| Psychometric properties of the questionnaire
The questionnaire was assessed regarding its validity and reliability as below: Validity of the questionnaire: Face validity and content validity as the theoretical and representational validity of the questionnaire was evaluated by qualitative and quantitative methods. The validity of a questionnaire can be established using a panel of experts that explore theoretical constructs. This form of validity exploits how well the idea of a theoretical construct is represented in an operational measure. This is called translational or representational validity. 37 Face validity: For qualitative face validity assessment, 15 providers of STIs/HIV prevention services were asked about the items' difficulty, irrelevancy, and ambiguity. 32 Next, for quantitative face validity assessment, they were asked to specify the importance of the items on a 5-point scale. Then the impact scores were calculated using the following formula: "impact score = importance × frequency." Afterward, the impact score of each item was calculated and evaluated by the cut-off point of >1.5. 38,39 So, the items with the impact score ≥1.5 was considered appropriate.
Content validity: For qualitative content validity assessment, 10 experts in reproductive health, midwifery, and nursing were asked to provide feedback on the questionnaire regarding grammar, appropriate word use, and appropriate placement of phrases. Then, for quantitative content validity assessment, the content validity ratio (CVR) and content validity index (CVI) were measured. 40 Content validity ratio: To ensure the selection of the most important items, CVR was calculated for each item. The experts signified their opinions by assigning each item scores of 1-3, which correspond to "not necessary," "useful but not essential," and "essential," respectively. The scores were then calculated using the following formula: where Ne is the number of experts indicating an item as "essential" and N is the total number of experts. The accepted value was determined based on Lawshe's table and the number of experts. 41 The opinions of the 10 experts were referred to in evaluating the CVR with 0.62 regarded as acceptable. 41

Content validity index: This index was calculated based on Waltz and
Bausell's 40 criteria to ensure that the items of the questionnaire are appropriately designed to measure content. The expert evaluation was focused on relevance, clarity, and simplicity and was expressed using a 4-point Likert scale (scores 1-4, respectively).
The CVI score of each item was computed as the number of experts giving a rating of 3 or 4 to the relevancy, clarity, and simplicity of each item, divided by the total number of experts. Based on this index, an entire statement was initially measured in terms of relevance, after which its acceptability was determined according to the following criteria: CVI > 0.79, the item is relevant, between 0.70 and 0.79, the item needs revisions, and if the value is below 0.70 the item is eliminated. 42 Scale-level content validity index (S-CVI) and scale-level content validity ratio (S-CVR) were also computed by calculating the mean of CVI and CVR values. S-CVI 0.9% were considered as the acceptable validity index of the questionnaire. 42 Reliability of the questionnaire: To assess the reliability of the questionnaire, the internal consistency, as well as the stability of the questionnaire, was measured.
Internal consistency: Cronbach's coefficient α was calculated to examine the internal consistency of the subscales and the entire instrument. Values above 0.79 are considered acceptable in a descriptive study. 43 Stability: The stability was also assessed by the test-retest method and through the completion of the questionnaires by 15 care providers within a 2-week interval. Intraclass correlation coefficient (ICC) was also calculated to assess the stability of the questionnaire. If the ICC is above 0.7, the stability was considered appropriate. 44 Describing the questionnaire and the scoring system: The final version of the questionnaire was a valid and reliable questionnaire that was used to measure needs for gender-sensitive STIs/HIV prevention services with three-level scales from "not at all" to "completely" important, which were scored from 0 to 2. The total score and the scores for the subscales of the questionnaire were calculated and converted to 0-100. High scores show more important needs for the gender-sensitive STIs/HIV prevention services.

| Outcome measures
CVI, CVR, α Cronbach's, ICC of the questionnaire were the outcome measures in this phase of the study.
2.4 | Phase 3: The quantitative phase of the study "needs assessment for a gender-sensitive STIs/HIV prevention services"

| Design of the study
This was a descriptive cross-sectional study in Shiraz-Iran 2019.

| Subjects of the study
All 290 providers of STIs/HIV prevention service providers participated in the study.

| Inclusion criteria
The eligibility criteria for participation were at least 2 years of work experience in reproductive health care services, including STIs/HIV prevention care and counseling.

| The setting of the study
All 37 health centers affiliated with SUMS and nine hospitals in Shiraz-Iran.

| Sampling
All 290 STIs/HIV prevention care providers. So, the subjects of the study were recruited using the survey convenience method of sampling.

| Tool for data collection
The tools for data collection were (1) Figure 1 shows the procedure of the study.  Table 1).

| Ethical considerations
The extracted concept for gender-sensitive STIs/HIV prevention services was: "the services with the appropriate structure, including gender-sensitive personnel, facilities, and management as well as the appropriate process, including gender-sensitive care and education.
To achieve gender-sensitive services, appropriate policies, the collaboration of different systems, and community empowerment are necessary for development and promotion of gendersensitive" (Figure 2).

| Phase 3:
The quantitative phase of the study "assessment needs for gender-sensitive STIs/HIV prevention services" Two hundred ninety health providers participated in the study, with an average age of 33.48 ± 6.53 years (mean ± SD) and a working  Results of the quantitative descriptive phase demonstrated the highest priorities for the gender-sensitive process (including care and educational dimensions) and then gender-sensitive structure. The finding showed the highest priorities for the gender-sensitive educational (92.01 ± 11.76%) and care services (92.11 ± 12.04%), respectively. Table 3 shows mean scores of all eight dimensions of the services and Table 4 demonstrates two priorities for the eight dimensions of the services.

| DISCUSSION
This is the first mixed exploratory study to explain the concept and dimensions of gender-sensitive STIs/HIV/AIDS prevention services and then the needs and priorities for providing these services.
Gender-sensitive STI/HIV prevention services were defined as: "the services with the appropriate structure, including gendersensitive personnel, facilities, and management, as well as the appropriate process, including gender-sensitive care and education.
To achieve gender-sensitive services, appropriate policies, the

T A B L E 3 Needs for gender-sensitive STIs/HIV prevention services based on their priorities
Sections Dimensions Mean ± SD (score 0-100) Mean ± SD (score 0-100)  Trained male personnel about counseling, diagnosis, and treatment of men's STIs Results showed three priorities for educational procedures, including "women's education about self-protection" and "Sexual health education based on the men's and women's special needs" and The results demonstrated "supportive policies" as the priority of the services. Two items showed the highest scores, including "Making spouses aware about STIs, for improving family health" and "Planning for abstinence promotion and the risk reduction policy." It is demonstrated that spouses' awareness about STIs prevention, their treatment, and preventing from recurrent infections is important. 56 In many countries spouses' counseling is compulsory in health services and counseling is performed in STI cases. 57 It seems a comprehensive sexual health education including a risk reduction program should be considered as a supportive policy for our community. Planning of skill-based educational interventions that enhance behavioral and preventive beliefs and promote abstinence would reduce the risk of STIs. 58 Findings also showed two priorities for the intersectional cooperation for supporting the gender-sensitive services, including "Academic research about sexual behavior in different communities" and "Determining common sexual medications in the private sector, effective on preventing or spreading of STIs." Extensive research was demonstrated as an essential base for an evidence-based intervention for promoting sexual health. 59 Since there are some limitations in public sectors for providing services to high-risk individuals, information about taking these medications is low. It is revealed that a minority of youth are involved in premarital relationships. 60 Homosexuality is also forbidden and there is no information about the frequency of AIDS among these high-risk groups. 61

| Limitation
The taboo of talking about sexual issues was a limitation that was controlled by an explanation about the confidentiality of the information by providing a nameless questionnaire. Also, we did not mention the needs of individuals with gender dysphoria, as we believe they have vast special needs. Besides, since homosexuality in Iran is against the law and sharia, researching this area requires a different research design. We recommend further research focusing on sexual orientation/behavior and the needs for providing the services based on the specific needs of individuals with opposite sexual orientation and behavior. It should be noted that people with dysphonia have permission for surgery and gender reassignment. 77 Since the aim of the present study was to explain and determine the needs of the system to provide gender-sensitive STI/HIV prevention services, we develop and use GSPS questionnaire with theoretical validity (content and face validity). We suggest factor analysis for empirical construct and criterion validity as well as theoretical validity assessment in future studies that aim at tool development.

| CONCLUSION
This was the first mixed exploratory study to assess needs for gender-sensitive STIs/HIV prevention services. With a theoretical valid and reliable tool (GSPS with S-CVI = 0.98; S-CVR = 0.87; α Cronbach = 0.91 stability; ICC = 0.910). It was demonstrated that providing STIs/HIV prevention services requires reforms to achieve a gender-appropriate educational and care process, as well as a gendersensitive structure, including gender-sensitive personnel, facilities, and management. These dimensions need advocacy by supportive policies and intersectional cooperation, as well as equipping the community for promoting gender-sensitive STIs/HIV prevention services. Certainly, providing these comprehensive and efficient services improves the quality of the STIs/HIV prevention services. In this article, the need and priorities for making the gender-sensitive STIs/HIV prevention services were explained. A valid and reliable questionnaire to assess these needs was developed and introduced.
The paper made evidence-based suggestions for managers and policymakers to improve the quality of the services by providing gendersensitive services.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The corresponding author Soheila Nazarpour confirms that he had full access to all of the data in the study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.