Social health and sexual self-care in women: exploring the role of social cohesion, acceptance, and participation

Abstract

Background

Sexual self-care represents a critical dimension of a health-oriented lifestyle and is essential for promoting women’s sexual health. This study aimed to examine the association between social health and sexual self-care among women visiting comprehensive health service centers affiliated with Mashhad University of Medical Sciences.

Methods

In this descriptive-analytical study, 312 women were selected via multistage cluster sampling. Data were collected using Keyes et al.’s (2004) Social Well-being Questionnaire and Yazdani et al.’s (2023) Sexual Self-Care Questionnaire, followed by correlation analyses in SPSS-27.

Results

No significant correlation was observed between the overall scores of social health and sexual self-care (P = 0.77). However, specific dimensions of social health exhibited significant associations with sexual self-care: Social Actualization correlated positively with cancer and unwanted pregnancy prevention (P < 0.05), Social Cohesion with prevention of sexually transmitted infections (STIs) (P < 0.05), Social Acceptance with STI prevention (P < 0.01), and Social Participation with cancer prevention (P < 0.01).

Conclusion

The findings underscore the influence of distinct social health dimensions on women’s sexual self-care, particularly in mitigating risks related to cancer, STIs, and unintended pregnancy. These insights offer a foundation for integrated public health strategies and advocate for policy initiatives that incorporate social and health dimensions into sexual health promotion programs.

Introduction

In the 21 st century, health is universally recognized as a multidimensional construct and a fundamental human right, encompassing physical, mental, social, spiritual, and sexual well-being [1–3]. Women’s health, in particular, holds dual significance: it is vital not only for individual autonomy but also for sustaining family and community health. Despite global commitments to gender equality—such as the 1994 International Conference on Population and Development (Cairo) and the 1995 Beijing Platform for Action—women continue to face systemic barriers to health equity [4]. Compared to men, women experience disproportionate exposure to health risks, including limited access to sexual and reproductive healthcare, socio-cultural stigmatization, and economic disparities, all of which contribute to preventable morbidity and mortality [5].

Sexual health, a cornerstone of public health, transcends individual well-being to influence marital, familial, and societal stability [6]. Yet, it remains one of the most undertreated and culturally contested dimensions of health. Evidence highlights the interplay between socio-economic status and sexual health outcomes: Alizadeh et al. linked household poverty to poorer sexual function in women [7], while Darooneh et al. identified social support and economic stability as key predictors of sexual health [8]. Despite its centrality, sexual health—especially for women—remains marginalized in policy and practice, often due to restrictive gender norms and limited agency over bodily autonomy [9].

The World Health Organization (WHO) defines self-care as “the ability of individuals, families, and communities to promote health, prevent disease, and cope with illness with or without formal healthcare support” [9]. In other words, self-care refers to activities that are tailored to individual needs to maintain and improve health, including maintaining and promoting sexual health [10]. For women, sexual self-care—encompassing prevention of sexually transmitted infections (STIs), unintended pregnancies, prevention of women’s cancers, and promotion of sexual health is a critical yet underexplored domain [11]. Barriers such as sociocultural taboos, lack of education, and restricted decision-making power often hinder women’s ability to practice self-care [12]. When achieved, however, it enhances quality of life, reduces healthcare burdens, and strengthens health systems [13].The socio-cultural landscape in Iran presents distinct challenges in facilitating open discourse on women’s sexual self-care. Sexual and reproductive health services in Iran’s are actually designed for married women. For instance, cervical cancer screenings like Pap tests are institutionally administered post-marriage, reflecting Sharia-based prohibitions against premarital intimacy. In another example, sexually transmitted disease prevention is taught with a focus on religiously approved methods (e.g., premarital counseling).

Crucially, self-care behaviors do not occur in isolation; they are shaped by broader social ecosystems, including trust, cohesion, and collective participation [14].Social health, reflecting an individual’s capacity to engage meaningfully in society, is a key determinant of overall well-being [15]. Its dimensions—social cohesion, acceptance, participation, and actualization—enable individuals to build resilient networks, adapt to stressors, and access health-promoting resources [16].

women, with higher social health levels had greater life satisfaction [17] and adopted more health-promoting behaviors, as demonstrated by Abbaszadeh et al., who tied social trust and group participation to improved self-care practices [18]. Yet, the specific mechanisms linking social health to sexual self-care remain poorly understood, particularly in low- and middle-income contexts where gender inequities persist [19].

Although WHO has advocated for self-care integration into sexual and reproductive health (SRH) programs for decades [20], implementation lags, and research on women’s sexual self-care is scarce. No prior studies have explicitly examined how social health dimensions—such as cohesion, acceptance, and participation—influence sexual self-care behaviors, particularly in conservative settings like Iran. This study addresses this gap by investigating the relationship between social health and sexual self-care among women attending comprehensive health centers in Mashhad, Iran. By elucidating these connections, our findings aim to inform holistic interventions that leverage social capital to improve women’s sexual health outcomes.

Research hypotheses

Main hypothesis

“There is a significant positive relationship between dimensions of social health (participation, acceptance, and social cohesion) and sexual self-care in women.”

Methods

Study design and setting

This cross-sectional, correlational study was conducted in Mashhad, Iran—the second-most populous city in the country and a major cultural and religious hub. Mashhad is characterized by its diverse socioeconomic demographics and conservative societal norms, which influence women’s health-seeking behaviors. The study population consisted of women visiting comprehensive health service centers affiliated with Mashhad University of Medical Sciences (MUMS), a leading institution in public health research and services in northeastern Iran.

In this study, after obtaining ethical approval and the necessary official permissions, the researchers approached eligible women at the selected comprehensive health service centers in coordination with the center administrators. The study objectives were clearly explained to the participants, and written informed consent was obtained. The questionnaires were administered in person in a private and secure environment and were completed through self-reporting. A trained researcher was present to clarify any questions the participants might have without influencing their responses. Confidentiality of all participant information was strictly maintained throughout the study.

Sampling strategy and participants

A multistage cluster random sampling approach was employed to ensure representativeness (shape 1).

The sample size was determined using G*Power 3.1, assuming a small effect size (r = 0.20), α = 0.05, and power (1-β) = 0.99, yielding a minimum requirement of 262 participants. Accounting for a 20% attrition rate, the final sample size was set at 314 women. Quota sampling was applied within each center, and participants were recruited via convenience sampling (Fig 1).

Fig. 1.

Sampling flow diagram (Source: Authors' own illustrations)

Inclusion criteria included

Eligible participants were:

• - Aged 15–45 years.

• - Married and cohabiting with their spouse.

• - Non-pregnant and non-lactating.

• - Without a diagnosis of breast or uterine cancer.

Exclusion criteria included:

• - Unwillingness to continue participation.

• - Incomplete questionnaire responses.

Data collection instruments

1- Sexual Self-Care Questionnaire (Yazdani et al., 2023), a 40-item tool assessing four domains:

• - STD and genital infection prevention (14 items; score range: 14–70).

• - Cancer prevention (7 items; score range: 7–35).

• - Unwanted pregnancy prevention (6 items; score range: 6–30).

• - Sexual health promotion (13 items; score range: 13–65).

Responses were recorded on a 5-point Likert scale (1 = Strongly disagree to 5 = Strongly agree), with a total score range of 40–200.Validity and reliability (Cronbach’s alpha = 0.94) were confirmed in Yazdani’s study. The Cronbach’s alpha value in the present study was) α = 0.83(.sample items for each of the subscales of the questionnaire is given below.

Subscale	Sample Item
STI Prevention	“I use protection (e.g., condoms) during sexual intercourse.”
Cancer Prevention	“I perform regular breast self-examinations.”
Unwanted Pregnancy Prevention	“I discuss contraceptive methods with my partner.”
Sexual Health Promotion	“I seek medical advice when experiencing unusual genital symptoms.”

2- Keyes’ Social Well-being Questionnaire (2004), a 20-item instrument evaluating five dimensions: Social Integration, Social Acceptance, Social Participation, Social Actualization, Social Cohesion. Responses were also measured on a 5-point Likert scale. The scale’s validity and reliability were confirmed by Ahrari (2013). The Cronbach’s alpha value in the present study was (α = 0.80(.sample items for each of the subscales of the questionnaire is given below.

Subscale	Sample Item
Social Integration	“I feel like a valued member of my community.”
Social Acceptance	“I believe most people are trustworthy.”
Social Cohesion	“My community collaborates well to address problems.”
Social Actualization	Society is progressing toward better conditions for all people.”
Social Participation	“I actively contribute to social groups or events in my neighborhood.”

Data analysis

Statistical analyses were performed using SPSS-27. Descriptive statistics (mean, standard deviation) summarized participant characteristics, to examine the predictive role of social health dimensions on sexual self-care, multiple regression analysis was conducted. while Pearson’s correlation assessed relationships between social health dimensions and sexual self-care. A p-value < 0.05 was considered statistically significant.

Ethical considerations

The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences (Code: IR.MUMS.FHMPM.REC.1403.187). Participants provided informed consent, and confidentiality was maintained throughout data collection and analysis.

Results

This cross-sectional study included 314 women recruited from comprehensive health centers in Mashhad, Iran. The mean age of participants was 34.56 ± 6.07 years, while their spouses averaged 38.43 ± 6.19 years. The mean marital duration was 11.56 ± 5.78 years, reflecting a stable, long-term partnership demographic.

Educational attainment was relatively high: 58.3% (n = 183) of women and 45% (n = 141) of their spouses held bachelor’s degrees. A majority of participants and their partners (51.7%, n = 162) were employed, and 50% (n = 157) described their household income as “sufficient.” (See Table 1 for full descriptive statistics).

Table 1.

Frequency distribution of demographic characteristics

	Variable	Frequency	Percent
Woman’s job	HouseWife	106	33.8
	Worker	40	12.7
	Employee	146	46.5
	Frelancer	22	7
Man’s job	Worker	18	5.6
	Employee	155	49.3
	Frelancer	141	45.1
Female education	Elementary	22	7
	Secondary	102	32.4
	Bachelor’s degree	164	52.1
	MA, MSc	26	8.5
	Phd	0	0
Male education	Elementary	31	9.9
	Secondary	102	32.4
	Bachelor’s degree	128	40.8
	MA, MSc	53	16.9
	Phd	0	0
Income level	Less than adequate	49	15.5
	Adequate	234	74.6
	more than adequate	31	9.9

The Pearson correlation test was employed to assess associations between social health and sexual self-care. Prior to analysis, the Kolmogorov-Smirnov test (P > 0.05 for all variables) confirmed normal distribution, validating parametric assumptions (Table 2).

Table 2.

Descriptive indices of the study variables

Variable	Mean	Standard deviation	Kolmogorov-Smirnov test
			z p- value
Actualization	13.63	1.69	0.118	0.361
Integration	10.04	1.80	0.118	0.370
Cohesion	11.29	2.30	0.103	0.178
Acceptance	15.75	2.44	0.116	0.460
Participation	13.71	3.61	0.122	0.330
Social health	66.96	5.71	0.089	0.910
Prevention of sexually transmitted diseases	52.31	10.34	0.085	0.086
Cancer prevention	23.55	9.48	0.043	0.054
Unwanted pregnancy	16.86	4.69	0.280	0.290
Health promotion	49.28	9.50	0.490	0.500
Sexual self-care	142.01	25.97	0.200	0.332

Table 3 shows the results of Pearson correlation coefficients. Overall social health showed a significant positive correlation with cancer prevention (P < 0.05). Social acceptance was positively associated with total sexual self-care (P < 0.05). However, no significant link emerged between total social health and total sexual self-care (P = 0.77).

Table 3.

Results of pearson correlation coefficients

Variable	1	2	3	4	5	6	7	8	9	10	11
Actualization	1
Integration	0.022	1
Cohesion	0.148	0.048	1
Acceptance	0.283**	0.154	0.067	1
Participation	0.210**	0.248**	0.390**	0.271**	1
Social health	0.571**	0.514**	0.110	0.651**	0.703**	1
Prevention of sexually transmitted diseases	−0.079	0.188*	0.062	−0.245**	0.124	0.042	1
Cancer prevention	0.167*	0.043	0.020	0.061	0.254**	0.185*	0.405**	1
Unwanted pregnancy	0.175*	0.061	0.041	0.117	0.054	0.037	0.252**	0.549**	1
Health promotion	0.027	0.048	0.049	0.076	0.090	0.007	0.363**	0.569**	0.505**	1
Sexual self-care	0.068	0.088	0.254**	0.171*	−0.190*	0.031	0.731**	0.822**	0.662**	0.802**	1

p < 0.05*

p < 0.01**

Subscale-Specific Correlations:

Notably, distinct dimensions of social health predicted targeted aspects of sexual self-care: Social actualization correlated with cancer prevention (P < 0.05) and unwanted pregnancy prevention (P < 0.05). Social cohesion and social acceptance were linked to STD prevention (P < 0.05 and P < 0.01, respectively). Social participation aligned with cancer prevention (P < 0.01).

Regression

Tables 4 and 5 shows the results of “analysis of variance” and it’s related “coefficients”.

Table 4.

Analysis of variance table

Model		Sum of Squares	Df	Mean Square	F	Sig.
	Regression	8433.001	13	2811.000	26.615	.000b
	Residual	54391.809	310	424.936
	Total	62824.811	314

Table 5.

Coefficients table

Model	Unstandardized Coefficients		Standardized Coefficients	T	Sig.
	B	Std. Error	Beta
(Constant)	41.497	29.803		1.392	0.166
Female’s age	− 0.195	0.667	− 0.049	− 0.292	0.771
Male’s age	0.496	0.719	0.129	0.690	0.491
Duration of cohabitation	− 0.143	0.551	− 0.035	− 0.260	0.795
Female education	11.021	2.916	0.384	3.780	0.000
Male education	−1.863	2.584	− 0.073	− 0.721	0.472
Woman’s job	2.139	2.156	0.087	0.992	0.323
Man’s job	5.992	3.160	0.164	1.896	0.060
Income	−2.453	3.782	− 0.063	− 0.648	0.518
Cohesion	0.780	1.379	0.053	0.566	0.572
Acceptance	3.595	0.982	0.324	3.662	0.000
Participation	−1.920	0.795	− 0.228	−2.416	0.017
Actualization	− 0.412	0.706	− 0.048	− 0.584	0.560
Integration	0.657	1.186	0.048	0.554	0.581

The results of the table show that at least one independent variable has a significant effect on the dependent variable (p = 0.000).

According to the table, coefficients Female education, Acceptance and Participation are statistically significant and should be included in the model.

Discussion

This study explored the relationship between social health and sexual self-care among women in Mashhad, Iran. While overall social health did not significantly correlate with total sexual self-care, key sub-dimensions of social health (social cohesion, acceptance, participation, and actualization) were significantly associated with specific aspects of sexual self-care, including STD prevention, cancer prevention, and unwanted pregnancy prevention.

Social cohesion and acceptance in STD prevention

Social acceptance and social cohesion, as two core components of social health, facilitate sexual self-care by establishing normative, supportive, and educational frameworks. In societies where these characteristics are more evident, individuals are motivated to adhere to principles of sexual health (such as fidelity, STD prevention, and respect for relational boundaries) not merely due to fear of ostracism, but because of their sense of belonging and mutual responsibility. The positive correlation between social cohesion and STD prevention supports Keyes’ (1998) model, which posits that individuals embedded in cohesive communities are more likely to engage in health-protective behaviors due to shared norms and mutual accountability [21]. Similarly, social acceptance was linked to better STD prevention, consistent with Tajfel’s Social Identity Theory [22], which suggests that a sense of belonging and societal acceptance encourages individuals to adopt health-promoting norms and behaviors [23]. This aligns with Aghayari Hir et al. (2020), who emphasized that sexual health in women is shaped by interpersonal and societal contexts rather than individual factors alone [24].

Social participation and cancer prevention

The significant association between social participation and cancer prevention can be explained through social capital theory [25]. Active community engagement enhances access to health information [26] and reinforces self-efficacy in health management [27]. Studies suggest that women with stronger social networks are more likely to undergo cancer screenings [28] and adopt preventive behaviors due to peer influence and resource sharing [29]. While social capital and social health are related concepts, they differ in scope: social health, as used in this study, reflects the individual’s subjective perception of their social environment and engagement, while social capital refers more broadly to the structural and relational resources embedded within social networks. Referencing social capital theory here helps interpret behavioral mechanisms underlying observed associations without conflating it with the core construct of social health.

The significant association between social participation and cancer prevention can be explained through health psychology theories. Participation enhances access to health information [29], builds self-efficacy in managing health [27], and reduces stress [30]—all of which contribute to better preventive behaviors. These findings are aligned with Tavakol et al. (2011), who found that social participation helps protect physical health and immune system functioning, reducing the risk of cancer [31].

Social actualization and empowerment in sexual health

Social actualization—reflecting optimism about societal progress—correlated with cancer prevention and unwanted pregnancy prevention, resonating with empowerment theories [27]. Women who perceive agency in their social roles are more likely to exercise control over their reproductive and sexual health [30]. This is supported by findings that employed women exhibit higher self-care behaviors [31] and reduced unintended pregnancies [32].

Individuals who believe they can influence life outcomes and who perceive societal progress are more likely to engage in self-care behaviors [32, 33]. This aligns with empowerment theories, such as Kabeer’s model, which emphasizes the importance of social and economic resources for women’s control over their health and bodies [34]. The Self-Determination Theory by Deci and Ryan also suggests that perceived competence and autonomy—which are strengthened by Social Actualization—are linked to health-promoting behaviors [35]. The other findings of this study revealed that among demographic variables (age, occupation, women’s education), only education had a significant association with sexual self-care. In this regard, various studies can be mentioned that indicate the relationship between women’s employment and the reduction of unwanted pregnancy, as well as the relationship between women’s employment and greater self-care [36, 37]. Ghazinejad et al. (2017) reported in their study that women’s employment in appropriate working conditions leads to the promotion of their social health by strengthening self-fulfillment, increasing empowerment, and improving social performance [36].

Sexual health-promoting behaviors—particularly multidimensional sexual self-care—are socially constructed and sustained through interpersonal and broader societal relational frameworks [38]. These findings align with existing theoretical frameworks and empirical research, such as the Hartley and Barnett framework. These theories suggest that the addition of social roles to women’s traditional roles is beneficial and can enhance their health [39, 40]. Similarly, Putnam’s social capital theory—emphasizing the importance of social networks and mutual trust—can help explain the observed relationships [25].

The findings can be theoretically explained through positive role-enhancement models in societies such as Iran, discussions surrounding sexual issues are considered taboo due to prevailing cultural norms and societal values. As a result, open and comfortable expression on such topics—particularly in social and cultural contexts—is often limited or discouraged. Furthermore, religious beliefs, along with related legal and ethical considerations, can significantly influence both individual sexual experiences and the broader societal understanding of sexuality. Therefore, the study results indicate that key dimensions of social health - cohesion, participation, and acceptance - significantly influence women’s sexual self-care behaviors. Accordingly, we recommend the following practical interventions for Sexual Self-Care Promotion:

Community-based interventions

Train respected female community leaders (e.g., teachers, midwives) to deliver stigma-free STI education in group settings (e.g., women’s health circles).

- Couples’ Workshops: Facilitate spousal dialogues about joint responsibility for STI prevention, leveraging cohesive family/community networks to normalize discussions. - -Mosque Partnerships: Collaborate with religious leaders to integrate Sexual Self-Care Programs into community activities, emphasizing shared moral responsibility for health.

Development of educational podcasts/short videos on domestic platforms

Partnership with female religious leaders to: - Deliver sermons linking self-care to Islamic values of wellness.

• Provider Training Programs: Mandatory sensitivity training for clinicians on:

• Non-judgmental sexual history taking

• Trauma-informed care approaches

• Cultural competency in conservative contexts

• Certification programs for sexual health counselors at primary care centers

Strengths and limitations

The key strengths and methodological limitations of this study are presented separately in the following sentences:

Strengths

Culturally contextualized insights

This study addresses a critical gap in sexual health research by examining social health dimensions in Iran, a conservative setting where such topics are often stigmatized. The findings provide valuable insights for designing culturally sensitive interventions.

Robust sampling strategy

The use of multistage cluster sampling across diverse health centers in Mashhad enhances the representativeness of the sample, strengthening the generalizability of results to urban women in similar socio-religious contexts.

Validated instruments

The study employs psychometrically validated tools (Keyes' Social Well-being Questionnaire and Yazdani’s Sexual Self-Care Questionnaire), adapted and tested for reliability in the target population (Cronbach’s α = 0.80–0.94), ensuring measurement accuracy.

Multidimensional analysis

By dissecting social health into distinct dimensions (e.g., cohesion, acceptance), the study reveals nuanced associations with specific self-care behaviors (e.g., STI prevention), offering actionable levers for targeted public health programs.

Policy-relevant recommendations

The practical interventions proposed—such as community-based education and provider training—are grounded in empirical data and align with WHO’s call for integrating social determinants into sexual health initiatives.

Limitations

Cross-sectional design

The study’s design precludes causal inferences. Longitudinal research is needed to establish temporal relationships between social health and sexual self-care behaviors.

Sampling constraints

Participants were recruited from health centers affiliated with a university, potentially excluding marginalized groups (e.g., rural populations, unmarried women) due to cultural and institutional barriers. Future studies should expand recruitment to non-clinical settings.

Self-report bias

Social desirability bias may have influenced responses, particularly for sensitive topics like sexual health. Triangulation with qualitative methods (e.g., interviews) could mitigate this limitation.

Instrument applicability

While the Keyes scale was validated in Persian, its Western origins may not fully capture culturally specific facets of social health in Iran. Developing indigenous tools could improve conceptual alignment.

Unmeasured confounders

Key variables (e.g., reproductive history, religiosity) were not assessed, which might influence sexual self-care. Future work should incorporate these factors to refine predictive models.

Conclusion

Women’s sexual self-care is intricately linked to contextual social factors, particularly acceptance and participation. While holistic social health may not directly predict sexual self-care, targeted social empowerment initiatives—such as strengthening community networks and fostering inclusive health policies could enhance women’s engagement in preventive behaviors. These findings underscore the need for multilevel interventions that integrate social determinants into sexual health promotion strategies, aligning with global efforts to achieve gender-equitable health outcomes.

Authors' contributions

Study conception and design: J.M and M.ED, Data collection: M.ED, Data analysis: SV.J, Results interpretation: J.M, SS.T, M.ED and SV.J, writing the initial manuscript: J.M and M.ED, Critical revision of the manuscript for important intellectual content: : J.M, SS.T, M.ED and SV.J.

Funding

This research did not receive any specific funding.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.FHMPM.REC.1403.187) reviewed and approved this study. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committees, as well as the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants received oral and written information about the study. All participants gave their written informed consent to participate. Participants were also free to withdraw during the study at any moment during the process. Lastly, confidentiality and privacy were observed in the study.

Consent for publication

Not applicable. This manuscript does not contain any individual person’s data or identifiable information requiring consent for publication.

Competing interests

The authors declare no competing interests.