The present study is the first study to design and assess the psychometric properties an instrument for measuring sexual and reproductive health literacy in women with infertility. The initial instrument was designed based on data from a qualitative study of infertile women, expert opinions, and extensive literature review on health literacy. The designed instrument includes a range of questions to assess reproductive health literacy and sexual health literacy. The results showed that the SRH-Life is a valid instrument for measuring sexual and reproductive health literacy among women with infertility. Also, the multidimensional structure of the designed questionnaire is one of its strengths. The questionnaire consists of 35 questions and is developed in 4 dimensions, including reproductive health information, infertility and treatment information, sexual health information, and sexual- reproductive functional literacy, which are completed as self-administrating. Because most participants completed the questionnaire within 15 minutes, the questionnaire could be easily used for screening. One of the strengths of this instrument is that by removing the dimension of "Infertility and Treatment Information" consisting of 9 items and removing an item related to infertility (Question 29) related to the dimension of functional literacy, it can be used as an instrument to measure sexual- reproductive health literacy in women of reproductive ages (consisting of 25 questions).
Measuring health literacy is essential to prevent of the dangers of limited literacy by awareness and or designing specific interventions to increase it [25]. Since the introduction of health literacy, researchers have developed a variety of tools for measuring health literacy, the most widely used of which are the rapid estimate of adult literacy in medicine (REALM)6 test of functional health literacy in adults (TOFHLA)7, and the newest vital sign (NVS)8[26]. Most health literacy studies examine general health literacy and do not focus on specific areas [27].
Women's sexual- reproductive health literacy is a new topic and although many studies have identified health literacy in women's reproductive health as important [28], few studies have been conducted in this area. In this regard, Masoumi et al. (2019) designed an instrument for measuring the sexual health literacy of Iranian adults (men and women over the age of 18) that included 40 questions in 4 dimensions including access (7 items), reading and comprehension (18 items), evaluation and analysis (5 items), information usage (10 items) and literature review was used to design the initial items of the instrument [29]. Sexual health literacy for adults (SHELA) questionnaire, like most health literacy instruments, including health literacy assessment instruments in Iranian adolescents [30], health literacy instruments for married immigrant women in South Korea [31] and health literacy instruments for women with breast cancer [32] were designed based on the dimensions of health literacy. Dimensions of access, understanding, evaluation and judgment, decision-making and behavior are the main foundations of health literacy in definitions [33]. In the present instrument, the domain of functional sexual- reproductive literacy consisting of 10 items examines women's ability to access and search, understand and evaluate, evaluate and use the information of sexual- reproductive health.
The questions of the present instrument were extracted from a qualitative study based on in-depth interviews, during the factor analysis, the dimensions of reproductive health information, infertility and treatment information and sexual health information were obtained, which can examine the knowledge and the most important information needs of reproductive and sexual in women with infertility. Compared to other studies, the factor analysis structure in the present instrument has a more diverse range and due to the presence of more than 3 items in each factor, it has a more stable and reliable structure [34]. The ability of the instrument present in examining the various dimensions of reproductive and sexual health literacy, including relevant knowledge and information, is one of the strengths of this instrument. In this regard, the Maternal Health Literacy Assessment Instrument designed by Dia et al. (2014) and the McCatherine et al. (2011) Prenatal Health Literacy Instrument evaluate the health knowledge dimension and information related to maternal health [35, 36].
Sorensen et al. (2016) provided a conceptual framework for health literacy consisting of 12 dimensions in which knowledge was introduced as the first dimension of health literacy [37]. Also, Edwards et al. (2012) proposed 5 steps in the designed model of Health Literacy Road, the first step of which was health knowledge, so that a person's basic knowledge of health and health concerns is formed through reading, interacting with health professionals or health care providers, discussing with friends and family, and providing health information from the media, and the individual can increase health knowledge in the later stages by developing health literacy skills and practices, including information seeking, comprehension, etc., and ultimately lead to conscious decision-making and appropriate action [38].
Health literacy is the individual, cognitive, and social skills that determine a person's ability to access, understand, and use information to maintain and promote desired health and improve knowledge and understanding of health components and change attitudes and motivations related to health behavior and improve self-efficacy in relation to certain tasks [39]. Therefore, by recognizing the dimensions of sexual- reproductive health in women through a special and comprehensive instrument, health care providers and specialists can provide the required information in accordance with the facilities and understanding of women. As a result of better interaction with health care providers, women's participation in the decision-making process of treatment and self-care methods will lead to optimal treatment outcomes and the promotion of women's sexual and reproductive health.
Limitations:
To measure how valid of instrument, it is necessary to compare the results of measurements with other recognized instruments. Therefore, it is recommended that concurrent or criterion validity of the instrument be investigated in future studies. Also, the instrument was tested in one location using a cross-sectional approach and stability (test-retest analysis) was examined in a separate sample.