Being Single as a Social Barrier to Access Reproductive Healthcare Services by Iranian Girls

Background: Iranian single women are deprived of reproductive healthcare services, though the provision of such services to the public has increased. This study aimed to explore the experiences of Iranian single women on their access to reproductive health services. Methods: A qualitative design using a conventional content analysis method was used. Semi-structured interviews were held with 17 single women and nine health providers chosen using the purposive sampling method. Results: Data analysis resulted in the development of three categories: ‘family’s attitudes and performance about single women’s reproductive healthcare,’ ‘socio-cultural factors influencing reproductive healthcare,’ and ‘cultural factors influencing being a single woman.’ Conclusion: Cultural and contextual factors affect being a single woman in every society. Therefore, healthcare providers need to identify such factors during the designing of strategies for improving the facilitation of access to reproductive healthcare services.


Implications for policy makers •
Despite the development and widespread utilization of reproductive healthcare services in Iran, single women have a limited access to these services. • To increase the utilization of reproductive healthcare services by single women, contextual factors should be considered and incorporated into healthcare programs. • Appropriate interventions are required for the modification of individual, interpersonal, and socio-cultural issues that hinder single women' access to reproductive healthcare services. • Limited health literary, the family's poor attitudes and functions, socio-cultural issues and being a member of a specific social group are barriers to access reproductive healthcare services by Iranian single women.

Introduction
The utilization of healthcare services is influenced by healthcare policies, people's educational level, gender, sociocultural factors, patterns of disease severity, income level, and access to the services. [1][2][3] According to the studies conducted on the utilization of healthcare services, socio-cultural factors are the key determinants of individuals' willingness to utilize healthcare services. 4 A vast range of socio-cultural factors influences the utilization of healthcare that corresponds to each country's culture and context. Therefore, different approaches are required to improve access to reproductive and sexual healthcare by social groups with different demographic characteristics. 5 Social norms can also marginalize some subgroups such as single women and hinders their access to healthcare services. 6 Although the number of single women and women in the reproductive age is increasing over the world, 7 being single in adult age is considered against the social norm in different societies. It is believed that social norms and negative social attributes affect single women' lives and their general and reproductive health status. 8,9 Background in Iran Many efforts have been made in Iran to provide an equitable distribution of primary healthcare facilities to people. There is also an emphasis on the provision of comprehensive healthcare services to Iranian citizens. 10 In recent years, supplementary healthcare programs such as the Iranian women's health, Iranian men's health and older people's health have covered various age and gender groups. Reproductive healthcare services as the key element of general healthcare have been added recently to the above-mentioned programs. [11][12][13] In addition to the public healthcare services provided by the Iranian government, the private sector also plays an important role in the provision of reproductive healthcare services to the general population. 14 The improvement of access to and facilities of reproductive healthcare services have increased the utilization of these services by the Iranian society. Nevertheless, single women have been ignored due to the specification of reproductive healthcare services to married women. Furthermore, despite the need to conducting studies on women with different socio-demographic characteristics, 15 most Iranian studies have focused on married women and adolescent females as their samples and therefore, have missed the reproductive healthcare issues of single women. Therefore, this study aimed to explore the experiences of Iranian single women on their access to reproductive healthcare services. Similar to other part of the world, the celibacy of Iranian girls especially in big cities has been increased in recent decades 16 due to a higher educational level, women's employment and urbanization. 17 With an average age of 25 years at the verge of marriage, 16 Isfahan city has a high rank among other cities in terms of the number of single women who are at the verge of marriage. 18 About 30% of young adults live alone and it has been said that single women' inclination to live alone in big cities has increased comparing to the past. 19 However, living alone has not been yet accepted as a norm in the Iranian society. 20 Single women live for more years with their families and are expected to behave under the family's laws. A large percentage of families allows their girls to have sufficient freedom to go to the college, be employed and have free movements in the society. On the other hand, some girls face with various restrictions imposed by their families due to the social norm of getting married at young ages. It is noted that problems associated with financial independence and autonomy are the concerns of many Iranian single women. 21

Methods
A qualitative design using a conventional content analysis method was used.

Research Participants
Participants were consisted of seventeen single women aged between 25 and 60 years old who were the inhabitants of Isfahan city, Iran. Also, nine reproductive healthcare providers working in the public and private sectors were recruited. The participants were chosen using purposive sampling. The inclusion criteria for the selection of the single women were: age between 25 and 60 years and having no history of legal marriage. The exclusion criteria were the participants' unwillingness to participate in this study. The inclusion criterion for the selection of healthcare providers were having at least 6 months experience of work as reproductive healthcare providers.
To recruit the participants, one of the authors referred to healthcare centers and requested to be provided with the contact information of those families who had a single women as a family member and also met the abovementioned inclusion criteria. The probable samples were contacted and informed of this study's purpose and method. Those participants who accepted to take part in this study determined the convenient time and place for holding interviews.

Data Collection
Face to face semi-structured interviews were held in the participants' work places, healthcare centers, and educational centers. The focuses of the interviews' questions were: What do you do, when you encounter any issue related to reproductive health? and What factors facilitate or hinder you to access and utilize reproductive healthcare services? On average, the interviews lasted between 15 and 65 minutes.

Data Analysis
The method of conventional content analysis suggested by Graneheim and Lundman 22 was use to analyze data. According to this method, researchers created codes and categories to answer the study's question. The following steps were taken to analyze data: • Each interview was recorded and transcribed verbatim and read several time to get the sense of whole; • Meaning units, condensed meaning units, and codes were developed; and • Through the process of reduction of data, categories and subcategories were developed from the codes. 22 Rigor To ensure of this study's rigor, credibility, dependability, transferability, and confirmability were considered. 23 Conducting in-depth interviews at various times and places convenient to the participants, choosing the participants with the consideration of maximum variation and verifying the extracted codes by the participants were in line with ensuring credibility. Also, a couple of healthcare researchers who were familiar with qualitative data analysis approaches were asked to check the analysis process that led to the improvement of this study's dependability. To assess transferability, a couple of single women was provided with a brief report of data analysis and transcriptions and was asked to confirm that the study's results were transferable to their own context. The process of data coding and analysis were checked and verified by peer reviewers to ensure of the data analysis' confirmability.

Results
In total, 17 single women and nine reproductive healthcare providers consisted of seven midwives and two gynecologists participated in this study. Most single women were between 30 and 40 years old, were employed and had an academic degree education ( Table 1). Most of the reproductive healthcare providers were older than 30 years old and had a bachelor degree in midwifery. Three categories were developed during the data analysis: 'family's attitudes and performance about single women's reproductive healthcare, ' 'socio-cultural factors influencing reproductive healthcare, ' and 'cultural factors influencing being a single woman. ' Each category was consisted of a couple of subcategories described as follows ( Table 2).
Family's Attitudes and Performance About Single Women's Reproductive Healthcare This category was consisted of two subcategories: 'Influence of the family on the formation of girls' attitudes toward reproductive health-related issues, ' and "Mothers' ability in the surveillance of their daughters' reproductive health. " Individuals' attitudes influence their behaviors in reproductive healthcare and families were considered important contributors to the formation of girls' attitudes about healthy behaviors.

Influence of the Family on the Formation of Girls' Attitudes About Reproductive Health-Related Issues
The participants stated that public attitudes about reproductive healthcare influenced their decisions to access and utilize reproductive healthcare services. If single women would be taught to consider their reproductive healthcare status as a component of their general health, and would deal with it similar to physiological healthcare, they decided to refer to reproductive healthcare centers without being shameful for dealing with it.  Socio-Cultural Factors Influencing Reproductive Healthcare This category was consisted of two subcategories: 'public prejudgment toward reproductive health-related issues' and 'silence and sham when faced with reproductive health-related issues. ' The participants described the notion of reproductive health-related issues as a taboo and the problem of girls' silence and shame in disclosing reproductive health-related issues. The utilization of reproductive healthcare services was under the intensive effectuality of the socio-cultural environment, in which the family was a constitutive component. Therefore, the single women faced many challenges when they needed to use reproductive healthcare services.

Public Prejudgment Toward Reproductive Health-Related Issues
The participants indicated that making reproductive healthrelated issues as taboo was ingrained upon the girls' psyche from childhood. This uncomfortable feeling in women was gradually internalized and negatively affected the utilization of reproductive healthcare services.

Issues Related to the Preservation of Girls' Virginity
The participants expressed that single women' virginity was important in the girls' singlehood period and could become a barrier to the efficient utilization of reproductive healthcare services by them. The fear of damaging their virginity during physical examination in healthcare centers created a strong sense of anxiety when they accessed healthcare services. A 35-year-old single participant said: "I do my best not to refer to any healthcare center, since I always think that during physical examination, my virginity may be damaged. " It is worth mentioning that because of being afraid of the legal consequences of damaging girls' virginity, even healthcare staff faced challenges for providing reproductive healthcare services to such referents. They tried to refer the single women to other centers. A midwife stated: "Sometimes single women do not inform us of their marital status, and they want to put the blame of damaging their virginity on healthcare staff. Such girls use legal authorities to press charges. We are scared in distasteful circumstances and do not feel comfortable to provide healthcare services to single women. " Healthcare staff had insufficient knowledge about issues affecting the virginity of single women. Under such circumstances, healthcare staff were incapable of administrating usual and appropriate examinations and therefore, utilized higher technologies with lower availability levels and higher costs, which could be regarded as barriers to the utilization of reproductive healthcare services.

Discussion
The results of this study showed that barriers and facilitators affecting the single women's access to reproductive healthcare services were consisted of family's attitudes and performance about single women's reproductive healthcare issues, sociocultural factors influencing reproductive healthcare and cultural factors influencing being a single woman. Reproductive health-related issues are considered taboos in some cultures. 24,25 This study reported shame and silence when the single women and healthcare staffs faced reproductive healthcare issues at personal, family, and social levels. 26 Families were shameful of providing their girls with essential information regarding sexual and reproduction issues. Nevertheless, those families that overcomed the existing cultural barriers, a true and efficient attitude about single women's reproductive health status emerged and mothers played their supportive roles. The results of this study indicated that being single brought a limitation to the single women' autonomy and was a barrier to access reproductive healthcare services. The relationship between girls' autonomy and the utilization of healthcare services is reported by antecedent studies. 27,28 A low level of reproductive health literacy and unawareness of available services were other barriers to access reproductive healthcare services stated by the participants. 29,30 The common fear in the single women and healthcare providers were the damage to the girls' virginity during clinical examinations in healthcare settings. Other studies reported that avoiding sexual relationships and the maintenance of virginity were considered moral values for girls in the Iranian society. 25,31 In addition, according to the Iranian law, those healthcare providers that damage single women' virginity are published legally and financially, even if it is accidental and happens during medical checkups. 32 Because of technical limitations in administrating routine examinations, the healthcare staffs referred single women to other healthcare centers. Socio-cultural sensitivities around sexual and reproductive healthcare are higher for vulnerable groups of the society including single women. 14,33 For instance, if a girl is diagnosed with a reproductive system disease, she is accused of having an illegal sexual relationship by the society. Such a prejudice leads to the stigmatization of single women. 34 Various studies indicate that stigmatization anxiety against diseases such as AIDS, reproductive system infections and psychological disorders are barriers to receiving healthcare services. 1,35,36 Therefore, ensuring of the confidentiality of single women' referral to reproductive healthcare services plays a key role in efficient utilization of healthcare services. 37,38 Limitations The generalization of the findings of this study should be done with caution due to qualitative approach and sample size. This limitation was tried to be reduced through the selection of the participants with maximum variations in demographic characteristics in terms of age, educational level, employment and socio-economic status.

Conclusion
Socio-cultural context influences Iranian single women' behaviors in relation to the access and utilization of reproductive healthcare services. Therefore, healthcare providers need to identify such factors during the designation of strategies for improving the facilitation of access to reproductive healthcare services.

Ethical issues
The research protocol was approved by the research committee affiliated with Isfahan University of Medical Sciences, Isfahan, Iran (No. 392478). The researcher introduced herself to the participants, explained the study's aim, anonymous identity of their participants and possibility of withdrawal from the study at any time without being penalized. Also, the permission to taperecord the interviews was obtained from them. Finally, of those who agreed to participate in this study written informed consents were obtained.