Needs for a gender‐based perimarital couples’ counselling services in Iran

Abstract Aim To assess needs for a gender‐sensitive perimarital counselling services in Iran. Design A descriptive cross‐sectional study. Methods This was a study on all 236 premarital counselling providers in 37 health centres in Shiraz‐Iran. The tools for data collection included the following: (a) a demographic information questionnaire and; (b) a valid and reliable Needs Assessment questionnaire for Gender‐Sensitive Perimarital Counseling Services (GSPCS) in 3 sections of needs for process, structure and policy making of the perimarital counselling services. Data were analysed using SPSS 21. Results All health providers with average working experience of 8.63 (SD 5.35) years participated in the study. Results demonstrated highest scores for needs related to facilities as the structure of the services (90.09 SD 13.70 per cent) and community empowerment (89.50 SD 16.67 per cent) as the necessary policy for the gender‐sensitive services. We concluded that providing gender‐sensitive perimarital counselling healthcare services needs to reform the process, structure and policies of the services.

AIDS prevention and contraceptive use which are from important issues in marital life. Therefore, perimarital health counselling services are important as these help couples to initiate a healthy sexual relations and life (Ramazani et al., 2013). Besides, perimarital counselling about incorrect gender norms improves couples' understanding and relations from beginning of their marital life. (WHO, 2010).
Perimarital counselling in primary healthcare services needs high attention in middle-eastern countries as they are facing with polarization of their culture into traditional and modern cultures about sexual behaviours (Women, 2019). While some people choose premarital sexual activity, some others consider even talking about sex as a taboo (Ussher et al., 2017). Hymen examination as the "Virginity testing" is still important for traditional Iranian families because they think intact hymen means no sexual relationship before marriage , while this custom results in non-vaginal sexual relationships such as anal and oral relationship and hymenoplasty before marriage (Robatjazi et al., 2016a(Robatjazi et al., , 2016b. Studies in Iran show majority of couples consider sexual and reproductive health affaires as a feminine issue and reproductive health system such as perinatal services are mostly defined and provided for women not men (Eskandari et al., 2017;Simbar et al., 2010). In a study by United Nation Population Fund (UNFPA), patriarchy, early marriage and son preference are the most effective barriers of women's equality and equity in Asia especially in Middle East countries (UNFPA, 2005).

Besides, talking about sex with adolescents is a taboo in many
Muslim countries (UNFPA, 2005) and therefore youth may not be prepared to protect themselves against STIs/HIV/AIDS and unwanted pregnancy until marriage (Banaei et al., 2019) and even after marriage . Besides, information about prevalence of STIs among non-married youth in Islamic countries including Iran, where non-marital sex and homosexuality are prohibited by religion and culture, is notably limited. Some of the STIs preventive strategies that are advocated and used in non-Islamic countries are not acceptable in Islamic countries. For instance, the concept of "Safe Sex" to prevent STIin non-Islamic countries basically promotes the use of condoms for non-marital sexual relations, considered in Islamic countries a way of promoting out of marriage sex which is absolutely prohibited in Islam (Madani, 2006). Therefore, the effective cultural factors and the gender-based discriminations in any community should be known before any interventional programmes to promote family and marital health (Jacob, 2017). Otherwise, to plan an effective reproductive health educational programme, extensive anthropological and sociological needs assessments are necessary to know about gender roles and stereotypes in a sexual and marital life in the family and social framework and their specific physiological needs (Faludi & Rada, 2019).
Premarital counselling is integrated in PHC services in the recent decades in Iran. It began with educating couples about preventing unplanned pregnancy and STIs/AIDS prevention. Its certification is a requirement for conventional marriage (Khalesi et al., 2016;Mehrolhassani et al., 2018). This service was criticized because of inappropriate time, duration and content, for instance, the service were provided when couples are involved with heavy task related to their marriage ceremony . Now, the educational content develops to provide sexual health and couples' communication skills (Dabiri et al., 2019).
However, in our knowledge there is no study to understand gender-based needs of couples for perimarital counselling. Therefore, this study aims to assess needs for a gender-sensitive perimarital counselling services based on the perspectives of experienced providers of perimarital counselling with a valid and reliable questionnaire.

| Design
This was a descriptive cross-sectional study in Shiraz-Iran 2018.

| Participants
All 236 providers of couples' premarital counselling, with at least 2 years work experience including physicians, midwives and health educators from all 37 health centres in Shiraz-Iran, participated in the study. The sample size was calculated using a pilot study to calculate sample size based on the following formula:

| Tools for data collection
Two questionnaires were used including (a) a demographic information questionnaire and (b) a valid and reliable questionnaire to assess needs of Gender-Sensitive Perimarital Counseling services (GSPCS) (Rahmanian et al., 2014). This was a self-completed questionnaire (e) needs for management (4 items); (f) needs for intersectional cooperation (4 items); (g) needs for supportive policies (6 items); and (h) needs for community empowerment (3 items).
Each item of the questionnaire was scored by a 3-point rating scale from "not necessary," "somewhat necessary" to "completely necessary" which scores from 0 to 2. The scores of items were summed up for each sub scale and total scale and then converted to per cent (0-100).
GSPCS was developed by authors of the present study through a qualitative study by content analysis approach and an extensive literature review (inductive-deductive method for the tool development) in Persian language. Then Content validity index and content validity ratio of the GSPCS were calculated 0.99 and 0.95, respectively. Reliability of GSPCS is also confirmed by alpha Cronbach 0.96 for internal consistency and intra-cluster correlation coefficient 0.804 of test retest for stability. Data were analysed using SPSS 21.

| Procedure of the study
Two hundred and thirty-six counselling providers with at least two years' experience in premarital counselling from all 37 health centres in Shiraz agreed to participate completed the questionnaires. The questionnaires were self-completion forms. The questionnaires were completed by responders anonymously. The responders were ensured about the confidentiality of their personal information, by providing explanation about anonymous responses and keeping and using information just for the study's objectives. All participants contributed to the research after giving the informed consent. All 236 counselling providers accept to complete the paper questionnaires, and all completed the questionnaires completely and so no drops were happened. The questionnaires were collected, and the data were analysed.

| Data analysis
Data were analysed using SPSS 21 and descriptive analytical methods such as calculating frequency and percentage and sorting results for prioritizing of the needs.

| Ethics
The study was approved by the Ethical committee of Shahid Beheshti University of Medical Sciences. All participants of the study gave a written consent for their participation in the study.

| RE SULTS
Two hundred and thirty-six premarital counselling provides with average age of 32.90 (SD 6.48) years and with working experience duration of 8.63 (SD 5.35) years participated in the study. Majority of the counselling providers were female and midwife. Table 1 shows the participants' demographic characteristics. Results demonstrated highest needs for facilities and community empowerment. Table 2 shows mean and standards deviation of 8 dimensions in 3 sections of perimarital counselling services. Table 3 shows high priorities (items with highest scores) in each dimension of premarital counselling services.

| D ISCUSS I ON
This was the first study to assess needs for providing a gender-based perimarital counselling service in Iran. Findings of present study showed the highest priorities for reforms in the structure especially facilities of the pre-marriage services, and policy making by community empowerment through providing opportunities for the education before choosing a spouse at the community level. services provide a good opportunity to increase couples' knowledge about sexual health and rights but it is not responder to their postmarriage problems, questions and needs such as about their reproductive system (Bostani Bostani Khalesi et al., 2015). In a study in eight countries, Hardy et al. found that an empowering environment that includes specialized health services for young women and men and support services can reduce sexual abuse, violence, sexual dissatisfaction and communication problems (Hardee et al., 1999). Therefore, providing services in appropriate time and place for men are essential (Simbar et al., 2010). Although establishment of such services is considered to improve men's reproductive health, it is very costly and inoperative. Successful experiences demonstrated that changing clinics' working hours in the afternoon and holidays, hiring male personnel and creating the right physical environment for men is possible to improve these services in the existing system (Simbar et al., 2011;Simbar et al., 2010).

Sections Dimensions
Mean ± SD (score 0-100)  Schools are from the best centres where sexual health can be promote among young people (Bahrami et al., 2013;Shahhosseini et al., 2016).
In the section of supportive policies, the needs for "Planning a STIs risk assessment programme in counselling process " and "Planning for individuals' education on negotiation skills for sexual health" took the highest scores from the point of view of the participants. In the cultures that men and women suffer from sexually transmitted diseases that leads to violence, isolation and social stigmatization for women, a risk assessment system should be designed for overcoming the barriers of detected high-risk behaviours and using experience of other countries (Khalesi et al., 2016;Lichtenstein, 2003;Medley et al., 2004). A review also showed that health plans that consider couples as the target group were far more successful than programmes that define each male and female as a target group (Tokhi et al., 2018). Also, interventions can have better results if consider people's reproductive health rights (Population Council, 2005).

| Limitations of the study
The taboo for discussing about sexual and gender issues was the main limitation of this study, which was partially controlled by keeping confidentiality of the names of individuals, explaining about goals and intimate encounters with the participants.
Healthcare providers who recruited as the participants of the present study live in our traditional society and they may follow the same myth and traditions of the community. However, they receive a comprehensive sexual education in academic courses but gender-based effective factors on couples' health during marital life are not considered in the courses. Besides, it is shown that talking about sex topic is hard for counselling, especially when providing sexual counselling for clients of opposite sex is necessary (Pourmohsen et al., 2018). It seems the healthcare providers beliefs should also be corrected first of all.

| Implications
World Health Organization emphasizes on improving quality of reproductive health services including premarital counselling services by providing gender-sensitive services. Improving quality of services in all 3 dimensions of healthcare services including structure, procedure and outcome is essential. The present study assessed the needs for providing a gender-sensitive premarital care services in all 3 dimensions using a standard questionnaire and showed the gaps and needs of the system to reform. The process of the present study and its needs assessment tool can be applicable in similar services for needs assessment and showing the gaps of the system which needs intervention and reform for providing quality gender-sensitive services. The research shows gender-based educational planning are necessary to integrate in present programmes to improve quality of perimarital care and counselling programmes. Therefore, further research is suggested to find other culturally gender-based barriers and facilitators to improve quality of care in other aspects of sexual reproductive health such as in the area of family planning and adolescents health.

ACK N OWLED G EM ENT
We appreciate Deputy of research of Shahid Beheshti University of medical sciences for financial support.

CO N FLI C T S O F I NTE R E S T
The authors declare they have no conflict of interest.

AUTH O R CO NTR I B UTI O N S
All authors: substantial contribution to and agreement on the final version of the manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.