Development and Psychometric Properties of the Sexual Health Scale for Middle-Aged Married Women
(SHIMA): a Mixed Methods Study
Sedigheh Moghasemi1, Masoumeh Simbar2, Fazlollah Ahmadi3, Ali Montazeri4,5, Hamid Sharif Nia6, Giti Ozgoli2*
Purpose: This study aimed to develop and psychometrically validate the Sexual Health Scale for Middle-Aged
sexually active women (SHIMA).
Methods: This study was a sequential exploratory study consisting of two phases. In phase one, we interviewed 19
middle-aged women and reviewed the existing instruments to generate an item pool. Then, a panel of experts (n =
16) examined the items. In the second phase, the psychometric properties of the scale were assessed. For content
and face validity, a panel of experts (n = 8) and a group of middle-aged women (n = 10) reviewed the items. For
construct validity, a cross-sectional study was carried out on a sample of 427 married women. Finally, SHIMA’s
reliability was assessed.
Results: In the first phase, the sexual health concept was explored, and a provisional scale including 60 items was
generated. Next, 21 items were removed based on content and face validity. Accordingly, the results obtained from
the exploratory factor analysis (EFA) indicated acceptable loading for 34 items tapping into six factors that jointly
explained 48.67% of the total variance observed. The internal consistency evaluation revealed that Cronbach’s
alpha and McDonald’s omega were greater than 0.7, and the average inter-item correlation was greater than 0.4,
except for one factor that showed borderline results. Test-retest reliability over a 2-weeks interval was 0.90, indi-
cating its high stability.
Conclusion: The SHIMA is a reliable and valid scale for measuring sexual health in middle-aged married women.
It can be used as a sexual health screening scale by healthcare professionals and for research purposes.
Keywords: Surveys and Questionnaires; middle aged; sexual health; psychometrics
INTRODUCTION
According to the World Health Organization (WHO), “sexual health is a state of physical, emo-
tional, mental and social well-being in relation to sex-
uality” that is important not only during reproductive
years but also during lifetime(1). However, sexual health
is an issue beyond the absence of disease or dysfunc-
tion(2) such that a holistic approach to sexual health is
recommended by international societies such as WHO
and the International Society for the Study of Women’s
Sexual Health (ISSWSH)(3).
Female sexual problems and dysfunctions are usually
due to the interaction of best identified and resolved
factors using the biopsychosocial model. Female sexual
function is influenced by some psychosocial, relational,
and contextual factors. Therefore, addressing these var-
iables in therapy can help improve sexual functioning
1Counseling and Reproductive Health Research Centre, School of Nursing and Midwifery, Golestan University
of Medical Sciences, Gorgan, Iran.
2Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health,
School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.
4Health Metrics Research Center, Iranian Institutes for Health Sciences Research, ACECR, Tehran, Iran.
5Faculty of Humanity Sciences, University of Science & Culture, Tehran, Iran.
6Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical
Sciences, Sari, Iran.
*Correspondence: Midwifery and Reproductive Health Research Center, Department of Midwifery and
Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences
, Tehran, Iran. Mobile: (98)9123223453 . Email: g.ozgoli@gmail.com.
Received December 2021 & Accepted June 2022
in women. Ultimately, a comprehensive biopsychoso-
cial assessment and treatment plan will provide women
with the most holistic method to ameliorate their sex-
ual health difficulties(3). In this respect, the result of a
survey showed that biopsychosocial management of
Female Sexual Dysfunction (FSD) was associated with
patient-perceived benefits, satisfaction, and value(4).
The sexual health of women beyond reproductive years
has long been considered taboo. This attitude has re-
sulted in the sexual life of middle-aged women do not
receive enough attention and have to conceal their sex-
ual desire(5).
The mentioned issues make it difficult for middle-aged
women to receive their desired health services, despite
their particular sexual health needs. For instance, health
workers in sexual health do not have the required com-
petencies to meet the care needs of middle-aged women
such that they concentrate on meeting their biomedical
Urology Journal/Vol 19 No. 5/ Sep[tember-October 2022/ pp. 398-405. [DOI:10.22037/uj.v19i.7154]
ANDROLOGY
needs(6). Hence, this important health component is ig-
nored by middle-aged women and health care provid-
ers, and issues such as sexual health are not prioritized
in preventive health care(7).
By increasing the life expectancy(8), women spend at
least a third of their lives in middle age and beyond.
Therefore, it is necessary to reform the concept of
sexual health as a part of public health and women’s
health in middle age and beyond. On another side, using
questionnaires is one element of the basic Structured
Approach to screen and diagnosing a sexual problem(3).
Recently, a more holistic approach has been developed
to measure sexual health. The female sexual well-being
scale (FSWB scale) assessing sexual well-being rath-
er than sexual dysfunction in women without medical/
psychosocial conditions is an example(9). Collected
data from such tools play an essential role in determin-
ing individual sexual health, health service planning,
and policy-making(10).
As sexual health have different meaning based on the
socio-cultural context(11), its definition varies in differ-
ent age groups(7). Hence, it is necessary to assess female
sexual health based on their understanding of sexu-
al health from a more holistic viewpoint. The present
study aimed to investigate the Sexual Health of Iranian
Married Middle-Aged Women (SHIMA) through the
development and psychometric validation of a sexu-
al health scale in sexually functional women in their
midlife.
MATERIALS AND METHODS
The present exploratory sequential mixed method
study was conducted in Gorgan, Iran. It is a joint re-
search between Shahid Beheshti University of Medical
Sciences and Golestan University of Medical Scienc-
es with the ethical codes of IR.SBMU.PHARMACY.
REC.1399.175 and IR.GOUMS.REC.1397.146, re-
spectively.
Following the descriptions of the Waltz model(12), the
present study included two phases: a) scale develop-
ment and b) Psychometric evaluation. A summary of
the two phases is presented in Fig. 1.
Phase one: scale development
I: Qualitative study: Using a conceptual framework to
systematically guide the measurement process increas-
es the likelihood of identifying and illustrating the con-
cepts and variables universally salient to health care
practice(12). Thus, the conceptual model of sexual health
was explored using qualitative content analysis. To this
end, between May and November 2015, 19 middle-aged
women aged 40-65 years were interviewed. The main
research question was “how do middle-aged women
perceive the notion and dimensions of sexual health?”
Purposive sampling with maximum diversity in terms
of age, education, and economic status was performed
on women under the coverage of comprehensive health
centers affiliated with Golestan University of Med-
ical Sciences (Table 1). Data were collected through
semi-structured in-depth interviews conducted by the
main researcher (S. M). Women interested in talking
about their marital and sexual experiences were invit-
ed with the assistance of trusted health professionals to
participate in the study. Each interview lasted about 60
minutes on average. All interviews were audio-record-
ed.
Before each interview, the participants were informed
about their rights in the study and signed written con-
sent. The interviews were carried out in a private and
calm place.
Because talking about sexuality in Iranian culture
is very hard and embarrassing, especially with mid-
dle-aged and elderly people, after warm-up, interviews
began with the open-end, general, and the well-known
question of “please talk about your marital relation-
ship”. Then, the interview continued by considering
the points mentioned by the interviewee, which were
related to their sexuality. The principal questions raised
through the interviews included “when do you feel
healthy sexually?” and “when have you felt healthy/
unhealthy sexually? Explain it”.
Moreover, we verified the trustworthiness and accu-
racy of data and promoted the validity of results by
rewording or summarizing the participants’ responses.
Except in one case, one interview session was held for
all participants.
Data collection and data analysis were conducted si-
multaneously. Data were collected until data saturation
was achieved. Next, data analysis was performed based
on the systematic approach proposed by Graneheim and
Lundman(13).
II: Then, concept maps and primary items for each
theme were provided to generate an item pool. Simul-
taneously, similar tools and related documents were
Variable n = 19
Age (years) 40-49 11
50-59 5
60-65 3
Educational level Lower than diploma 5
Diploma 8
Bachelor degree or higher 6
Occupation Housewife 12
Working 7
Religion (Islam) Shia’ 16
Sunni 3
Menopausal state Premenopausal 12
Postmenopausal 7
Marital status Divorced 3
Married 16
Table 1. Demographic characteristics of participants in the qualitative study
Construct Number of the generated items Number of the items extracted from the literature review
Sexual health care 19 1
Holistic/multi-dimensional sexual preparation 22 -
Quality of sexual relationship 42 4*
Partner sexual incompetency 11 -
Compatibility and resolving sexual problems conflicts 22 -
Conservative socio-cultural norms 42 -
Total 159
Table 2. The number of items in each construct of sexual health in the item pool of SHIMA
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The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
Vol 19 No 5 September-October 2022 399
Unclassified 238
searched using a literature review via electronic data-
bases in Persian (Scientific Information Database (SID),
IranMedex) and English (ProQuest, PubMed, Science
Direct, and Scopus) languages. Finally, the initial item
pool included 158 items generated by the research team
and 1 item extracted from the study conducted by Lotfi
et al.(14). In addition, 4 items were modified according
to the FSWB scale proposed by Rosen(9); see Table 2.
The provisional 159 items scale was reviewed by an
expert panel (n = 16), including scholars in sexual re-
productive health, nurses and sex therapists. The output
of this revision was the initial item reduction, and as
a result, 99 items were removed. The items were re-
moved mostly because of the similarity and repetition
of the items. For example, we merged the following
three questions “I feel like I am a means to satisfy my
husband’s sexual needs”, “I am worth sexually to my
husband”, and “I am satisfied as being a woman in sex”
into the following question: “I feel valuable during sex
with my wife”.
Phase two: Psychometric evaluation
I. Content validity
The content validity of the study scale was performed
both qualitatively and quantitatively. Eight experts
(psychology, sexual and reproductive health, nurse, and
community medicine) were invited to evaluate the scale.
For qualitative content validity, experts commented on
Vol 19 No 2 March-April 2022 153
Characteristics n = 407
Age, years
Mean (±SD) 46.38 (± 5.46)
Range 40-63
Education, N (%)
<High school graduate 103(± 25.3)
High school graduate 138 (± 33.9)
Some college 48 (± 11.8)
College graduate 103 (± 25.3)
>college 14 (± 3.4)
Missing 1 (± 0.2)
Job Status, N (%)
Employee 154 (± 27.8)
Unemployed 253 (± 62.2)
Duration of marriage, years
Mean (SD) 22.6 (±8.6)
Range 1-47
Menstrual status, N (%)
Premenopause 296 (±72.7)
Postmenopaus 106 (±26.0)
missing 5 (±1.2)
Table 3. Demographic characteristics of participants in the
cross-sectional study
The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
Table 4. The results obtained from the exploratory factor analysis for the SHIMA
Andrology 400
Items Factor loading h2 Variance λ
Q12: My partner can satisfy my sexual expectations. 0.831 0.646 14.08 4.928
Q5: In general, I have a good sexual relationship with my partner. 0.820 0.738
Q9: After the intercourse is over, my partner kisses or hugs me 0.762 0.513
Q6: Before having sex, I am mentally ready 0.757 0.647
Q11: I can satisfy my partner’s sexual desires. 0.698 0.566
Q8: In a sexual relationship, my partner does enough touch and foreplay. 0.680 0.504
Q10: My partner and I talk about our sexual desires and reach an agreement. 0.635 0.575
Q7: We have sex in a safe and private place. 0.633 0.361
Q28: My partner cares about my sexual satisfaction. 0.568 0.605
Q29: My partner is satisfied with the quality of our sex. 0.466 0.617
Q27: I get relaxed after sex. 0.345 0.582
Q20: My partner and I respect each other. 0.960 0.720 12.31 4.311
Q19: My partner and I are close to each other. 0.878 0.700
Q18: I am satisfied with my marriage. 0.876 0.744
Q21: My partner has accepted me and he pays attention to me. 0.831 0.667
Q22: I have good memories of sexual relationships with my partner in the past. 0.675 0.545
Q23; I feel valued during the sexual relationship with my spouse. 0.600 0.627
Q24; I have the willingness to have sex with my partner. 0.588 0.534
Q34: I am satisfied with my breasts’ appearance. 0.855 0.670 7.42 2.599
Q35: I am satisfied with the appearance and function of my genitals 0.844 0.728 .
Q31: I am satisfied with my partner’s penis erection (penile stiffness) during the sex. 0.619 0.603
Q33: I am satisfied with my face and appearance. 0.589 0.505
Q30: I am satisfied with my partner’s ejaculation time (releasing the semen from the penis) 0.504 0.563
during the sex.
Q25: I am satisfied with the degree of moisture and wetness of my genitalia during the sex. 0.330 0.424
Q4: If needed, I would easily ask my sexual questions from experts in counseling and/or 0.935 0.837 6.23 2.185
health centers.
Q3: If needed, I would go to a counseling or health center to solve my sexual problem. 0.804 0.714
Q2: If needed, I have access to counseling and/or health centers to solve my sexual problem. 0.685 0.484
Q1: If I have any sexual problem, I will try to solve it. 0.437 0.536
Q17: I take the initiative to have sex with my spouse 0.646 0.443 3.15 1.103
Q14: I feel very sexual, like when I was younger. 0.594 0.471
Q16: I try to have a romantic relationship with my partner. 0.577 0.540
Q37: I worry about urinary control (urinary incontinence) during sex. 0.833 0.690 4.766 1.668
Q36: I am worried that my partner does not find me sexually attractive. 0.705 0.602
Q38: I am worried that having sex too often damages my health. 0.691 0.456
couple sexual interaction
Factors
couple relationship quality
Satisfaction w
ith sex
organs’appearance
and function
A
ccess to sexual
health services
sexual agency
sexual concerns
h2: Item communality, λ: Eigenvalue
whether appropriate words and structure for each item
were used, whether items were placed in a fair domain,
and whether appropriate scoring was assigned. Eight
experts calculated the Content Validity Index (CVI)
and Content Validity Ratio (CVR) for content validity
analysis. Items with CVI > 0.75 were retained. As the
number of experts was less than 10, CVI for each item
(I-CVI) was calculated by modified Kappa (K*). I-CVI
> 0.74 and Summative CVI (S-CVI) average ≥ 0.9 were
considered appropriate(15).
II. Face validity
Face validity was evaluated both qualitatively and
quantitatively. First, 10 married middle-aged women
stated their viewpoints about the difficulty, relevance,
and ambiguity of each item. Second, items’ impact
score was calculated, and items with an impact score
higher than 1.5 were retained.
III. Construct validity
The construct validity of the scale was determined using
factor analysis. Since the scale has 39 items, an aver-
age of 6 samples per item (360 people) was considered
appropriate(18). Finally, the sample size was calculated
to be 424 people, considering the dropout rate of 15%.
The samples were selected through stratified random
sampling with appropriate allocation from the electron-
ic files available in the Centers for Integrated Health-
care Services of Gorgan (NAB system). For this pur-
pose, in the order of the list, the eligible individuals
were invited to complete the scale. Inclusion criteria
in this study were marriage, age 40-65 years, fluency
in Persian, and at least high school education. On the
other hand, the exclusion criteria were having diseases
such as uncontrolled diabetes or hypertension, psychia-
try (e.g., depression and anxiety under treatment) prob-
lems, based on self-reporting, incomplete filling of the
questionnaire by not answering more than 5% of the
questions.
Data collection tools included: 1) a written consent
form, 2) a demographic characteristics form, and 3) the
39-item SHIMA.
Data was analyzed to estimate scale validity and relia-
bility. The procedure for construct validity analysis is
as follows:
a. Structural validity was evaluated using estimation of
maximum likelihood exploratory factor analysis (EFA)
with Promax rotation. Items with a factor loading equal
to or greater than 0.4 were included in the scale.
Next, we conducted maximum likelihood CFA to val-
idate the factorial structure extracted from EFA. The
model fit was assessed through a number of fit indices,
such as Chi-square (χ2) test, Chi-square(χ2) /degree of
freedom(df) ratio < 4, goodness-of-fit index (GFI)> .9,
Factors AVE MSV CR MaxR (H) Alpha (95% CI) AIC Omega
Couple sexual interaction 0.504 0.676 0.917 0.922 0.918 (0.906 to 0.930) 0.508 0.920
Couple relationship quality 0.586 0.527 0.909 0.918 0.910 (0.896 to 0.923) 0.592 0.912
Couple sexual function 0.492 0.676 0.853 0.857 0.857 (0.835 to 0.878) 0.510 0.864
Access to sexual health services 0.570 0.332 0.840 0.857 0.827 (0.798 to 0.853) 0.540 0.832
Sexual agency 0.426 0.537 0.688 0.699 0.690 (0.633 to 0.738) 0.427 0.692
Sexual concerns 0.581 0.012 0.804 0.834 0.799 (0.762 to 0.830) 0.571 0.804
Table 5. The indices of the convergent, divergent validity, and internal consistency of SHIMA
AVE: Average Variance Extracted; MSV: Maximum Shared Squared Variance; CR: Composite Reliability; MaxR (H): Maximum Reli-
ability, Alpha: Cronbach’s alpha; AIC; Average inter-item Correlation; Omega: McDonald’s omega coefficient.
comparative fit index (CFI)> .9, normed fit index (NFI)
> .9, relative Fit Index (RFI) >.9, incremental fit index
(IFI) > .9, and TuckerLewis index (TLI) > .9, standard-
ized root mean square residual (SRMR) < .09, and root
mean square error of approximation (RMSEA) < .08(16).
b. Convergent and divergent validity: The convergent
and divergent validity was estimated using Fornell and
Larcker approach (1981) by measuring Average Var-
iance Extracted (AVE), Maximum Shared Squared
Variance (MSV), and Composite Reliability (CR). An
AVE < 0.5 and CR > AVE reflects suitable convergent
validity and MSV > AVE confirms divergent validity.
c. Reliability: The internal consistency was assessed
via calculating Cronbach’s alpha, McDonald’s omega,
and Average inter-item Correlation (AIC). Cronbach’s
alpha and McDonald’s omega values of more than 0.7
and the minimum AIC values of 0.2-0.4 were consid-
ered satisfactory. Ten middle-aged women completed
SHIMA twice for two weeks, and stability was assessed
using test-retest analysis (Intraclass correlation coeffi-
cient-ICC)(16). In addition, absolute reliability was ex-
amined by the standard error of measurement (SEM),
which was calculated according to the following formu-
la: SEM = SD Pooled√(1-ICC).
RESULTS
Findings from phase one
Table 1 shows the demographic characteristic of the
participants. Qualitative data analysis resulted in 1624
condensed codes, 166 codes, 46 sub-categories, 15
categories, and 6 themes. The emerged themes were
‘quality of sexual relationship’, ‘sexual health care’,
‘holistic/multi-dimensional sexual preparation’, ‘part-
ner sexual incompetency’, ‘conservative socio-cultural
norms’, and ‘compatibility and resolving sexual prob-
lems conflicts’.
Finally, based on the themes extracted from the experi-
ences of middle-aged women participating in the pres-
ent study, the conceptual framework of middle-aged
women’s sexual health was extracted as follows:
“Sexual health is a dynamic and multi-dimensional
concept perceived through general health, sexual rights,
and a satisfactory sexual response. The realization of
this concept is affected by how to take care of sexual
health, the cohabitation context, the sexual satisfaction
of the spouse, and how to adapt and resolve conflicts
in sexual matters. Conservative socio-cultural patterns
are the contextual factors shaping the sexual attitudes
and behaviors of middle-aged women. The product of
women’s sexual health is family stability”.
Accordingly, the provisional 60-items scale was devel-
oped, and its psychometrics was assessed in phase two.
The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
Vol 19 No 5 September-October 2022 401
Findings from phase two
I. Content validity
CVR and CVI were calculated for quantitative content
validity assessment. In this step, 21 items were elim-
inated. Finally, the SCVI/Ave for the remaining 39
items was 0.95.
II. Face validity:
In the qualitative face validity, some minor wording
changes were made according to the women’s sug-
gestions. The results revealed that all the items had an
impact score ≥ 1.5. These items were important in the
target group.
III. Construct validity
a. Exploratory factor analysis (EFA): All 424 mid-
dle-aged women completed the questionnaire. Of these
participants, 17 women were excluded due to incom-
plete responses to the questionnaire. Thus, the data ob-
tained from 407 participants were analyzed for construct
validity. The characteristics of the study participants
are presented in Table 3. In EFA, the KMO test value
The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
Andrology 402
Figure 1. The flowchart of SHIMA scale development process
was 0.943 and Bartlett’s test value was 7843.55 (P <
0.001). Thirty-four items and six factors were extract-
ed and named as couple sexual interaction (11 items),
couple relationship quality (7 items), satisfaction with
sex organs appearance and function (6 items), access to
sexual health service (4 items), sexual agency (3 items),
and sexual concerns (3 items). The six factors explained
48.67% of the total variance (Table 4). Figure 2 pre-
sents the final factor analysis model for SHIMA.
b. The results (Table 5) revealed that all factors had
acceptable convergent and divergent validity.
c. Reliability: For five factors, internal consistency eval-
uation revealed that Cronbach’s alpha and McDonald’s
omega were greater than 0.7, and the average inter-item
correlation was greater than 0.4. Finally, the composite
and maximum reliability (H) were acceptable except
for one factor (Table 5). Test-retest reliability over a
2-week period was 0.90.
DISCUSSION
This study showed that sexual health is a multi-dimen-
sional concept for middle-aged married women, and
the SHIMA had acceptable psychometric properties to
measure sexual health in this population.
The SHIMA represents the multidimensionality of the
sexual health concept and assesses it in the dimensions
beyond sexual satisfaction or sexual function. Accord-
ing to the definition of sexual health(1), in addition to
the physical aspect, SHIMA encompasses psycho-so-
cio-emotional dimensions. In other words, it indicates
sexual health in a bio-psycho-social model. As the
quality of a relationship affects women’s sexual health
in different ways(17,18), “couple sexual interaction” and
“couple relationship quality” are the most powerful
predictive factors of this concept. These two factors
encompass 26.39% from 48.67% of the total variance
of SHIMA, respectively. In this regard, based on the
theory of systems, an individual’s situation in a couple
affects the whole system (both members of a couple).
Therefore, partners’ competency and life skills can help
a couple have a happier relationship(19). However, there
is not any similar domain in Female Sexual Function
Index (FSFI)(20), which is a widely-used measure in
women’s sexuality studies.
“Interpersonal domain” and “cognitive-emotional”
domains in FSWB imply the importance of couple in-
teractions in women’s sexual health in a similar way(9).
Therefore, these items should be considered in sexual
health promotion intervention programs.
The third factor is “satisfaction with sex organs ap-
pearance and function”. Normal sexual function is as-
sessed based on the sexual response cycle, which is a
combination of mind and body responses(21). As body
image affects all aspects of female sexual function(22),
the items of the third facto are related to the body and
sexual self-image. In recent years, several studies have
reported the association between body image and fe-
male sexual function(22-24). A multi-center study in Iran
showed that sexual dysfunction is more prevalent in
married women who feel they are not attractive to their
partners (OR: 1.9)(25).
The scale used in this study had an item about the sat-
isfaction about lubrication during sex. This question
assessed the most objective part of female sexual re-
sponse. Limited lubrication is related to vaginal dryness
and dyspareunia especially after cessation of the men-
Figure 2. The final factor analysis model for SHIMA
The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
Vol 19 No 5 September-October 2022 403
strual cycles in menopausal women. Also, Kennedy
et al. in a systematic review found that lubricants can
be an important part of improving sexual health and
well-being(26).
In the third factor, not only female sexual function but
also a spouse’s sexual function is assessed from the
women’s viewpoint. In sexual dysfunction assessment,
it is strongly recommended to evaluate sex partner-re-
lated factors regularly(18,21).
It is worthy to mention that as sex and sexual desire are
considered undesirable for women in the most conserv-
ative cultures and communities, such as Iran, especially
in the post-reproductive years, thus questioning straight
about sexuality may be seemed unfair or accompanied
by feelings of shame. So some items which are related
to sexual desire such as Q 17 (I have the willingness to
have sex with my partner) and Q 24 (I take the initiative
for having sex with my spouse) were loaded in the “sex-
ual agency” and “couple relationship quality” domain,
respectively.
The fourth factor is “access to sexual health service”,
which encompasses three factors, namely physical,
financial, and information(27). In this respect, the pro-
vision of free-of-charge Primary Health Care (PHC)
in most countries, such as Iran, facilitates access to
health care services physically and financially. Never-
theless, there are some limitations in providing health
information, especially on a difficult topic such as
sexuality(28). Sexual health care services are restricted
to providing contraception methods and reproductive
cancer screening for reproductive-aged and married
women and prevention of STDs in high-risk groups (6,
29). Therefore, sexual health generally is neglected for
men and women beyond reproductive age or marriage.
This approach can result in unmet sexual health needs
in different groups and communities. Access to sexual
health services, as an important factor in an individual’s
sexual health, can help both individuals and HCPs plan
appropriate interventions based on a need assessment or
situation analysis.
The fifth factor is “sexual agency”. It refers to people’s
ability to act on their sexual needs, desires, and wishes.
Starting sex and attempting to make love imply wom-
en’s tendency to break common limiting beliefs and
norms to meet their sexual needs and wishes. Women
with a high negotiation ability about the sexual agency
have more sexual desire and better sexual well-being(30).
The sixth factor is sexual concerns. This dimension,
which has three items, is very important because, de-
spite various changes in sexual life in midlife and be-
yond, there are substantial barriers to seeking help for
sexual health problems and concerns. Hence, only a few
middle-aged people with sexual problems seek care(31).
In this regard, Pakgohar et al. showed that 27.2% of
menopausal women with urinary incontinence seek
medical attention(32). It is assumed that the “sexual con-
cern” dimension can be an appropriate trigger for wom-
en to speak about their sexual health problems with
healthcare providers (HCPs).
Sexual health is a multi-dimensional and dynamic is-
sue(22). Therefore, researchers and HCPs should focus
on women’s sexual health from a multi-dimensional
or bio-psycho-social perspective instead of focusing
solely on sexual function as a physical problem. This
approach could result in an individual’s well-being and
quality of life. In other words, considering genitalia
The Sexual Health Scale for Middle-Aged Married women (SHIMA)-Moghasemi et al.
response to sexual function, sexual health cannot be
outlined without incorporating individuals’ satisfaction
with physical, emotional, and social experiences(33).
The SHIMA is a multi-dimensional and context-based
scale developed using a more holistic approach to
women’s sexual health. Thus, it assesses not only phys-
ical but also intrapersonal (sexual concerns and sexu-
al agency), interpersonal (couple relationship quality,
couple sexual interaction, and couple sexual function),
and the social/community (access to sexual health ser-
vice) measures of sexual health from a bio-psycho-so-
cial perspective. Overall, it is assumed that SHIMA can
provide a better sexual health profile of women in re-
search and clinic than the female sexual function ques-
tionnaires.
This study had some limitations. Although this scale
was designed specifically for middle-aged married
women, there are few specific items for this age group.
This pattern may indicate that being in midlife solely
is not an important factor in women’s sexual health. In
other words, psychosocial factors are more important
than physical and age-related changes, including hor-
monal alteration. Therefore, it is recommended to apply
this scale to other populations such as reproductive-age
women, women with special conditions (e.g., chronic
diseases), and intervention studies to confirm its va-
lidity and reliability in other populations. Moreover,
conducting the same study on unmarried women could
give insight into the meaning and importance of sexual
health in these women.
CONCLUSIONS
The Sexual Health scale for Middle-aged women (SHI-
MA) is a validated and reliable scale for measuring sex-
ual health in this population that can be used as a sexual
health-screening tool. Also, the data acquired by the
scale could be useful for designing appropriate inter-
ventions to improve women’s sexual health, especially
in their midlife.
CONFLICT OF INTEREST
The authors report no conflict of interest.
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