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   Table of Contents      
Year : 2017  |  Volume : 22  |  Issue : 4  |  Page : 303-307

Changing beliefs and behaviors related to sexually transmitted diseases in vulnerable women: A qualitative study

1 Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Social Sciences, Isfahan University, Isfahan, Iran
3 Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
4 Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
5 Department of Islamic Studies, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication14-Aug-2017

Correspondence Address:
Farzin Khorvash
Nosocomial Infection Research Center, Medical School, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnmr.IJNMR_117_16

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Background: The first step in health education is awareness of the people and their acceptance to change their behavior. Therefore, the aim of this study was to investigate the effects of empowerment program towards the concept of self-care and prevention of sexually transmitted diseases (STDs) in women at risk of STDs. Materials and Methods: The present study was conducted as a qualitative approach (step of action and observation of an action) by using conventional content analysis method. An empowerment program regarding STDs (Action) was performed among 32 (with convenient sample) drug user women with addicted husbands referring to the counseling center for vulnerable women (drop in enter) in Isfahan in 2015. The knowledge of quiddity, transmission, and prevention of STDs, as well as some items of life skills such as self-awareness, interpersonal communication, and assertive behavior were taught in an educational program. Teaching methods were lectures, group, and individual training and role play. The impact of the program on modified belief and behavior change regarding STDs was evaluated with structured interviews. Results: Analysis of the obtained results yielded three categories. The categories were awareness of STD, believing in being at risk, and decision and change. Conclusions: Promoting self-care and prevention through education programs based on action research can make a significant reduction in the incidence of problems and cause a behavior change in women with the disease or those at risk for STDs.

Keywords: High-risk sex, qualitative research, sexually transmitted diseases, unprotected sex, vulnerable population

How to cite this article:
Boroumandfar Z, Kianpour M, Zargham A, Abdoli S, Tayeri K, Salehi M, Momeni G, Khorvash F. Changing beliefs and behaviors related to sexually transmitted diseases in vulnerable women: A qualitative study. Iranian J Nursing Midwifery Res 2017;22:303-7

How to cite this URL:
Boroumandfar Z, Kianpour M, Zargham A, Abdoli S, Tayeri K, Salehi M, Momeni G, Khorvash F. Changing beliefs and behaviors related to sexually transmitted diseases in vulnerable women: A qualitative study. Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2022 Jul 6];22:303-7. Available from: https://www.ijnmrjournal.net/text.asp?2017/22/4/303/212980

  Introduction Top

Sexually transmitted diseases (STD) are transmitted through sexual activities and close contact (vaginal, rectal, and oral) with their sexual partners.[1] The most common STDs are human immunodeficiency virus (HIV) (26%), chlamydia (10–25%), gonorrhea (3–18%), Trichomonas (8–16%), herpes (2–12%), and syphilis (0–3%).[2] Goya (2006) reported prevalence of STD as 11.3%.[3] Vulnerable women are among the main groups at risk of STDs. One of these groups is addicted women or those with an addicted husband.[4] Illegal sexual contacts are common among injection addicts, and use of condoms is rarely seen among addiction women.[5],[6] Women with high risk behaviors and those who are exposed to and involved in STDs suffer from complications such as pelvic inflammatory diseases, infertility, ectopic pregnancy, genital organ cancer, as well as its negative outcomes, unplanned pregnancy, trauma, violence, and transmission of infectious diseases, especially hepatitis and acquired immunodeficiency diseases (AIDS).[7] Approximately 82% of vulnerable women follow their sexual partners' requests under any circumstances.[8] Therefore, regarding unprotected sexual behaviors and drug abuse, high prevalence of STDs, and lack of necessary information regarding health care and STD[4] the first step in health education is giving the individuals an awareness training and achieving an acceptance for behavior change.[9] One of the needs among women with behaviors leading to STDs is empowerment of self-care. Better control on their protective behavior can be promoted through women's empowerment. Their empowerment is a prerequisite for improvement of prenatal health.[10] The number of studies reporting strategies to empower this group of women according to sociocultural and religion conditions of Iran is low.[11] On the other hand, a deep understanding and recognition of the effective factors on such behaviors, beliefs, and women's experiences regarding STDs is essential to develop protective behaviors in high-risk group.[12] Action research with social and educational empowerment goals can obviate such an issues.[13],[14] Centreb (2002) showed that those who attended an action research were empowered regarding recognition and analysis of the problems.[15] Goto (2008) reported that action research is applicable in the prevention of HIV in the educational field, empowerment, and research.[16] Therefore, this study aimed at action in the form of an awareness empowerment program, belief modification, and behavior change concerning STD among women.

  Materials and Methods Top

This is a part of an extensive participative action research conducted through content analysis method. This article reports the stage of action and observation (evaluation). Action was conducted among 32 addicted women with addicted husbands who were selected through convenient sampling and included women referring to a drop-in-center specified for women in Isfahan during March–May 2015, Iran. Inclusion criteria were age over 18 years and providing an informed consent to attend the study. Exclusion criterion was any existence of diagnosed physical or mental diseases; addicted women who were candidates for receiving methadone; sex workers without or with addiction requiring methadone; and those with an addicted or jailed husband voluntarily refer to these centers either directly or by drop-in-center. Researcher referred to this center, and after explanation of the research goals and gaining clients' trust, selected 32 clients who met the inclusion criterion through convenient sampling. Then, an outline of the educational program was explained to the participants. Empowerment program was conducted in the form of eight 90-minute sessions (including a 10-minute reception) for three 10–11-member groups. Next, group education, picture projection, and role play concerning STDs as well as some life skills items were conducted (self-awareness, communication skills, interpersonal communication, and saying NO method). In the last session, participants were taken to vulnerable women occupation centers to visit from 8:00 AM till 15:00 PM. This visit was conducted to encourage the participants to make money for their life expenses, which was their main problem. Research goals follow up was conducted for 6 months. After the end of the action (in the last session), participants received a time schedule of researcher's attendance in the center. As three groups attended the research, three days of the week were assigned for participants' follow up and face-to-face visits with the researcher. In these personal and face-to-face visits, participants' beliefs, behaviors and barriers and their facilitators were discussed. At times, participants asked questions concerning sexual and psychological issues as well as the problems they had with their husbands or sexual partners. Then, these issues were discussed. If needed, the participants were also referred to a gynecologist or counselor out of the center with coordination of the head of the center. Sometimes, they needed consult provision of their life costs or finding a job, for which the researcher tried to guide and refer them to relevant centers because of her familiarity with such centers (associations, job agencies for vulnerable women) she had make during the study. Some participants required the researcher to talk personally to their husbands at the gate of the center concerning high-risk behaviors, especially sexual behaviors and their association with their addiction, and the researcher did that. During 6 months, participants asked for three more sessions, two on the skill of daring and its practice and one on further explanation of herpes and genital warts. The method of action and wait is common in action research, and in fact, it is a reflection from participants to the research trend. Then, stage of observation (evaluation) was conducted by 20–30-minute structured interviews. Interviews started with grand tour questions such as “What information concerning STD did you attain?” “What preventive and self care ways against the disease did you start?” Further questions continued based on participants' described experiences. It should be noted that the participants missing more than one educational sessions or those who did not attend any stage of observation were left out of the study (n = 3). Qualitative content analysis was adopted to analyze the data. Rigor of the data in qualitative research such as confirmability, reliability, and transferability were respected via participants' review, immediate transcriptions of the data, and research team indications.[19] This study received approval from vice-chancellery for research in Isfahan University of Medical Sciences.

Ethical considerations

Ethical considerations such as attaining written informed consent from the participants before attending the study and recording interviews, data confidentiality and participants' right to leave the study whenever they liked were all respected. This study has ethics committee code 192090 from vice-chancellery for research in Isfahan University of Medical Sciences.

  Results Top

Results showed that participants' mean age was 36 (5) years, 6 participants were illiterate (18.75%), 14 had primary school education (43.75%), and 12 had under high school diploma and high school diploma (37.44%). Sixteen participants had a history of addiction (50%), 12 were under treatment with methadone (37.50%), and 13 had an addicted husband (40.62%). Data were analyzed in three themes and six sub-themes as “awareness of STD,” “believing in being at risk,” “decision and change (individuals' will for change and attaining the ability of self-protection) [Table 1].
Table 1: Themes and sub-themes concerning awareness, believing, and change when faced with STDs

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Awareness of sexually transmitted diseases

Participants stated that they became aware of the nature of the disease and reported that as “Informing about the disease” and “knowing about the disease.”

Informing about the disease

They believed that it was a prerequisite for understanding about the risk of the disease. Participants stated:

“I even knew nothing about STD names. I learned that having sex with several partners in a day makes many problems. One may be involved in herpes, blisters, gonorrhea, and warts even if with a condom.”

Knowing about the disease

Most of the participants believed that they became aware of their health and STD. A participant stated:

“This course made me aware of many thing. Let's say I got alerted about STD. I thought those were just for women and I did not care about my husband's sex with others. Now, I never think of having sex with my addicted husband who always has several sexual partners.”

Believing in being at risk

Participants gradually believed that they could have a correct understanding of the disease. They emphasized on “understand the importance of disease” and “believing in importance of health.”

Emphasized on disease

They believed remarked that as a motive to become aware of the disease. A participant with regard to understanding the importance of disease stated:

“Many things got cleared for me in these classes. I remember that my husband had a genital wound, I did not know it might be due to having sex. I was shocked as he gave me the herpes through prostitutes, and I was at risk because I had to as a wife.”

Believing in importance of health

Another participant with regard to understanding the importance of health stated:

“My husband irregularly used a condom from his addiction on, and I did not care. The examples you gave me and the slides of sexual infections you showed me made me determined to insist him on having sex with condom.”

Decision for change

Participants believed that they attained the ability to decide on their self-protection against the disease. They indicated to concepts as “individuals' will for change,” “attaining the ability of self protection” (through appropriate communication skills, dialogue and saying NO), and “believing in application of condom and using that.”

Individuals' will for change

Participants stated that they could make a decision for a change against STDs when they themselves wanted. A participant stated:

“My husband was addicted and indifferent to me. I had a boyfriend till 4-5 months ago when classes started. He was addicted and single. I was afraid of having STD. I myself started the relationship and I had to cut it. I hope God will forgive me.”

Attaining the ability of self-protection

Some participants reported that they tried to convince their spouses or sexual partners with their firm behavior, clarity, and honesty instead of conflicts and arguments. Participants stated that they understood the concept of saying no and had no fear of that anymore. They felt that they attained independency through saying no, had better self-worth, and protected themselves. They indicated to “firm behavior toward their spouse or sexual partner for self-protection,” “communication skills and husbands' acceptance of a condom,” and “feeling free and avoidance made by saying no method.”

A participant with regard to firm behavior and convincing the spouse stated:

“From the time I attended the classes, I lost many of my customers as I never accept their previous requests anymore. They gossip that I am useless as I insist in having sex with a condom, and I don't follow their requests such as rectal or oral sex, especially with no condom. If you follow their demands, they admire you and say she is the best, but if you firmly say no, they say she is useless, she is a condom girl, she is a plastic girl. Anyhow, I am not to harm myself anymore.”

A participant with regard to communication skill and acceptance of condom by husband stated:

“The prevention methods and the diseases should be taught to the men too. After these classes, I explained to him and even took him a condom. I explained it was good for his and my health and recommended him to have sex with others with a condom. I leave it somewhere and say I do not mind seeing you take it. He accepted so as not to be blamed and shouted at anymore.”

A participant with regard to saying no skill stated:

“I did not know what saying NO was. I felt it. No brought me feelings of confidence, independency, getting rid of chains. I can think about myself. Therefore, saying No is the best protection against this disease, even when one is deprived from drugs.”

  Discussion Top

With regard to STDs, this qualitative study yielded three themes of awareness of the disease, believing in being at risk, and decision and change. Results showed that the participants achieved information about transition routes, signs, and some common treatments of STD;in the other words, became aware of STDs. Niknami reported that AIDS prevention educational program was effective for the improvement of addicted husbands' awareness. He stated that one of the basic factors in a prevention program success concerning AIDS is quality education and informatics.[17] Mobey (2013) indicated that primary prevention includes giving information and deep education to control and prevent STDs.[18] Another finding was that participants' beliefs about STDs were stronger, and they became more aware of the disease. Maglajlic (2006), in an action research, reported that participants' attitude changed to a deep understanding from puberty transition and use of contraception methods.[19] Ghafari (2003) also reported the effect of an educational program on individuals' self-care attitude and ability with regard to safe sexual behaviors.[20] In fact, if individuals feel they are at risk of a disease, they manifest preventive behavior.[21] In the present study, researcher was empathetic towards the participants and had a deep interaction with them (for approximately 7 months), and encouraged them to modify their belief regarding preventive behavior and self-care against STD. Their first step toward deciding on self-care was their own decision for a change in behaviors leading to STD. In fact, when individuals understand a benefit or a threat, the possibility of healthy behavior manifestation is empowered, and they either do that or prevent it.[22] In the present study, the participants themselves had to understand the necessity of the high risk sexual behavior change, resulting from the understanding of the importance of the issue. Results showed that participants understood interpersonal communication and dialogue skills, and the skill of saying no after attending the educational program. They peacefully discussed about the behaviors leading to STD with their spouse, and if not helpful, either firmly prevented high-risk sexual relation or convinced their spouse to use a condom. Several studies indicated the role of communication skills education in solving couples' marital conflicts and an increase in their satisfaction.[22] Participants needed daring behavior to protect them against STDs, and most of them attained and applied such a skill. Nichols (2010) showed that logical and detailed discussions were effective on high risk suggestions refusal,[23] which is in line with the present study regarding the skill of saying no and the increase in this skill after education.[24] Therefore, it seems that high risk sexual behavior and STD can be prevented through proper and constant life skills training.[25]

The present study was conducted among vulnerable women who were exposed to STDs in Isfahan, Iran. Although the sociocultural status of these women is similar to other vulnerable women in other areas in Iran, results of a qualitative research are inevitably not capable of generalization, which is among the limitations of the present study.

  Conclusion Top

Our findings revealed theoretical and practical applications of the administrated program. At the theoretical level, the program focuses on determining the role of addicted women's empowerment with emphasis on awareness of STDs and familiarization with communication and dialogue skills with a variety of educational channels. At the practical level, it helps suggesting proper interventions such as education with interaction, empathy, support, and a motive to understand the women at risk of STD to prevent high risk behaviors, resulting from addiction, and avoiding such behaviors.


Researcher acknowledges all personnel and clients of Mehr Women Counseling Center, Social Security office under coverage of well-being organization for their kind cooperation. This article is a part of an action research approved by vice-chancellery for research in Isfahan University of Medical Sciences (no 192090).

Financial support and sponsorship

The present article was partially derived from a PhD thesis (ethics code number 192090), Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

  References Top

UNAIDS Reference Group on Estimates, Modelling, and Projections: Working Group on Measuring Concurrent Sexual Partnerships HIV: Consensus indicators are needed for concurrency. Lancet 2010;375:621-22.  Back to cited text no. 1
Kaningham H, Lono S, Beloom R. Pregnancy and childbirth Williams. Translated by: Ghazi Jahani B, Ghotbi R. 23rd ed. Golban Publications; 2010.  Back to cited text no. 2
Gouya M, Nabai S. Prevalence of Some Sexually Transmitted Infections in a Family Planning Service. RJMS 2007;14:143-52.  Back to cited text no. 3
Centers for disease control and prevention. Tracking the hidden epidemics. United States; 2000.cdc, Administration and Control of AIDS and STDs. Protocol counseling centers for vulnerable women.2010. www.cdc.gov.  Back to cited text no. 4
Razzaghi E. Profiles of risk: A qualitative study of injecting drug users in Tehran, Iran. Harm Reduction J 2006;3:12.  Back to cited text no. 5
Ostovar M, Nassiriziba F, Taavoni S, Haghani H. Knowledge and Attitudes of Women Towards sexually. Transmitted diseases and AIDS. J Nurs Midwifery 2007;19:47-54.  Back to cited text no. 6
Clementi LH. Addiction and substance misuse. Medicine Publishing 2008;36:422-9.  Back to cited text no. 7
Kolahi A, Sayarifard A, Rastegarpour A, Sohrabi M, Abdi AR, Nabavi M. Performance vulnerable and at-risk women to prevent HIV. Qom Univ Med Sci J 2011;6:58-64.  Back to cited text no. 8
Laloei A, Kashanizadeh N, Teimori M, Saeedi Y. The knowledge of women's health and educational needs of the rest of the hospital in the case of AIDS in 2007. Med Sci J Islamic Azad Univ Mashhad 2007;3:143-50.  Back to cited text no. 9
ICPD: International, Xairo, 1994. Available at WHO. AIDS epidemic update.; 2002:URL: http://www.who.int  Back to cited text no. 10
Ulin PR, Rabinson ET, Tolley EE. Qualitative methods in public health: A field guide for applied research. 1st ed. San Francisco: Jossey-Bass; 2005.  Back to cited text no. 11
Pettifor A, Macphail C, Corneli A, Sibeko J, Kamanga G, Rosenberg N. Continued high risk sexual behavior following diagnosis with acute HIV Infection in South Africa and Malawi: Implications for prevention. AIDS Behav 2010;15:1243-50.  Back to cited text no. 12
Atashzadeh Shourideh F, Hassani P. Action research: A way to improving quality nursing practice. Nurs Res 2011;6:48-58.  Back to cited text no. 13
Lofman P, Pelkonen M, Pietila AM. Ethical issues in participatory action research. Scand J Caring Sci 2004;18:333-40.  Back to cited text no. 14
Centreb T, Mabalac R, Allend K. Participatory action research on HIV/AIDS through a popular theatre approach in Tanzania. Eval Prog Plan 2002;25:333-9.  Back to cited text no. 15
Goto K, Tiffany J, Pelto G, Pelletier D. Use of Q methodology to analyze divergent perspectives on participatory action research as a strategy for HIV/AIDS prevention among Caribbean youth. Aids Educ Prev 2008;20:301-11. available from: https://doi.org/10.1521/aeap.2008.20.4.301.  Back to cited text no. 16
Niknami SH, Hatami A. The Effect of Health Educational Program on Preventing AIDS in Self-reported Addicts' Wives. J Kermanshah Univ Med Sci 2008;20:301-11.  Back to cited text no. 17
Mayaud P, Mobey D. Approaches to the control of STDs in developing countries: Old problems and modern challenges. Group.bmj.com on December 30, 2013 - Published by sti.bmj.com.  Back to cited text no. 18
Maglajlic R, Tiffany J. Participatory Action Research with Youth in Bosnia and Herzegovina. Med J Aust 2007;186:513-8.  Back to cited text no. 19
Ghaffari M, Jamali RS, Rakhshandeh S, Eslami AA. Effect of educational program on HIV/AIDS-related knowledge, attitude, and behavioral intentions of male high school's students in Bavanat (Fars province): An interventional research]. J Health Field 2013;1:6-12.  Back to cited text no. 20
Dehghanei S, Ghasemi H, Safari S, Ebraheimi AK, Etemadi O. The effectiveness of motivational interviewing group meetings on improving self-esteem and self-efficacy Addicted Women. Quart J Res Addict 2013;7:145-58.  Back to cited text no. 21
Joaning H. The long term effects of the couple communication program. J Marital Fam Ther 2009;8:463-8.  Back to cited text no. 22
Nichols TR, Birnel S, Graber JA, Brooks-Gunn J, Botvin GJ. Refusal skills ability: An examination of adolescent perceptions of effectiveness. J Prim Prev 2010;31:127-37.  Back to cited text no. 23
Hargie O, Saunders C. Social skills in interpersonal communication. Translated by Firozbakht M, Beigi KH. Tehran: Roshd Publications; 1390.  Back to cited text no. 24
Yarmohammadi Vasel M, Narenjiha H, Rafiey H. Developing and Validation of Life Skills Inventory for Substance Abusers. Soc Welfare Quart 2011;39:151-76.  Back to cited text no. 25


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