Knowledge, Attitude and Self-efficacy towards Providing Sexual Counselling among Students Doing the Master of Counseling in Midwifery Program in Iran

Introduction

Sexual health, one of the most important aspects of family and society health, greatly impacts human life and is directly related to individuals and society's mental health and quality of life (1) The World Health Organization (WHO) emphasizes incorporating sexual health in the primary care system, and its neglect has been cited as the root of many health-related problems worldwide (2).

One of the essential rights of individuals is to pay attention and respect to their sexual world, and health care providers should evaluate sexual issues, relevant prevention, and effective treatment to provide comprehensive and complete care (3, 4). Sexual education and counseling improve couples' emotional relationships and reduce marital conflicts (5). Masters & Johnson showed that sexual dysfunction is caused by a lack of knowledge of the sexual health system (6), and sexual education can effectively improve sexual health and enhance women's quality of sexual life (7).

Although most healthcare providers believe it is necessary to talk about sexual issues with their clients, they do it the least frequently and often feel unable to do so (4). There are also no adequate skills or self-efficacy to evaluate, diagnose and treat sexual problems (8). Midwifery students do not feel comfortable when counseling lesbians or sex workers despite having a positive attitude towards sexual counseling (4). A study in Iran showed that although midwifery students had a good attitude toward discussing couples' sexual relationships, the average students' clinical skills score was very low (9).

There are many reasons why sexual counseling is not performed in the clinic or is not of the required quality (10). Individual factors, such as marital status (11), age and degree of religiosity of the counselor (12), and organizational/structural factors such as time constraints, high workload, and cultural issues are the reasons. One of the critical roles of midwives is education and counseling in the field of sexual and reproductive health (13) and providing health services for women and families in the clinic requires knowledge and skills. Clinical competence to provide safe, legal, independent, and successful sexual health services for women and families is vital (14). A midwife is regarded as a person beside women during critical periods, including puberty, marriage, pregnancy, childbirth, and menopause, and is trusted by them (15). Midwives should allow clients to talk freely about their sexual issues in the first level of contact with the client by creating a safe environment. Therefore, they must acquire the necessary training and skills in the field of sexual education according to cultural, religious and social conditions (16).

In the recent years, the program of MSC in Counseling in Midwifery has been launched in Iran, and students in this major are expected, as stated in their job description, to facilitate sexual health by focusing on counseling skills and, promoting their empowerment, providing access to counseling services. Therefore, the present study aimed to measure knowledge, attitude and self-efficacy towards providing sexual counseling among students doing the master of Counseling in Midwifery program in Iran.

Materials and Methods

This cross-sectional study was conducted in 2021. The Ethics Committee of Alborz University of Medical Sciences approved this study under code of Abzums.Rec.1399.107.IR. Inclusion criteria included: being a student in Counseling in Midwifery program, studying at any university across the country, membership in an online social network for students, and willingness to participate in the study. The exclusion criterion included: participants who did not complete more than 10% of the questionnaire. Using Morgan's table, the sample size was determined based on Cochran's formula. Of about 250 community members, 148 students should have entered the study. The attrition rate was considered 15 percent, and the total sample size was 170. Sampling was conducted using convenience sampling on members of the online social network of students doing the master of Counseling in Midwifery after providing their informed consent.

The objectives of study were explained after coordination with the group admins, and according to the pre-defined inclusion and exclusion criteria, the research participation notification was sent. Questionnaires were provided to the participants using the online survey platform "PorsLine" and were collected similarly. First, the research aim was explained in an audio file to the participants in the online group of Counseling in Midwifery students, and then the questionnaire link was provided. Sampling lasted three months. Authentication was done in a self-declarative manner, and they were asked to answer the submitted questionnaire honestly. They were also assured about the confidentiality of their information.

Demographic characteristics: The first part consisted of 9 questions about students' personal and educational information, including age, marital status, level of interest in the field of study, semester, clinical experience, completing of postgraduate courses, and being religious. The students scored based on a 3-point Likert scale rating from devoted to religion to not religious. Then, they were classified into three categories; devoted to religion, somewhat religious, and not religious.

Sexual counseling knowledge: The sexual counseling knowledge questionnaire included 19 items based on Sung et al. studies (17-19). This questionnaire was scored based on a 4-point Likert scale ranging from no knowledge (score 1) to good knowledge (score 4). The test scores ranged from 19 to 76, and a higher score indicated better therapist knowledge. The questions were self-reported about physiology, anatomy, psychosexual development, sexual response cycle, puberty, sexual dysfunction, and other areas of sexual health. The validity of the questionnaire was assessed qualitatively and quantitatively by Content Validity Ratio (CVR), and Content Validity Index (CVI) based on the opinions of nine faculty members of midwifery and reproductive health experienced in sexuality education and counseling. Cronbach's alpha internal consistency method was used to assess the reliability of the questionnaires. CVI and CVR values ​​were calculated at 0.95 and 0.85, respectively. Cronbach's alpha coefficient was detected at 0.907.

Attitudes toward sexual counseling: The third part of the questionnaire assessed students' attitudes toward sexual counseling. This part was taken from the Sexuality Attitude and Beliefs Survey (Reynolds & Magnan, 2005) (20). However, several questions were extracted from the study by Oren et al. (2018) (4) and the literature review on attitudes toward sexual health counseling among sexual counseling providers. This questionnaire consisted of 19 items and was designed as a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1). The possible score range was 19 to 95. The low score showed a more negative attitude towards sexual counseling. Students' views were evaluated in three areas: student comfort in providing sexual counseling, the views of midwifery students about their professional role in approaching clients' sexual issues, and willingness to provide information about sexuality to clients. CVI and CVR values ​​were 0.90 and 0.82, respectively, and Cronbach's alpha internal consistency coefficient was also calculated to be 0.816.

Sexual counseling self-efficacy: Sexual counseling self-efficacy included 28 items on students' feelings of competence and weakness in various aspects of sexual health counseling based on a literature review. Sexual health self-efficacy in this study indicated Counseling in Midwifery students' judgments about their ability to perform sexual health care and provide support and information to clients. The questions of this questionnaire focused on three areas: students' self-confidence to communicate about sexual issues, support and information and self-management, self-promotion, and timely referral if necessary (18). These items were scored based on a five-point Likert scale, ranging from strongly agree (5) to strongly disagree (1). CVI and CVR values ​​were equal to 0.92 and 0.85, respectively, and Cronbach's alpha internal consistency coefficient was obtained at 0.964.

Data were analyzed using descriptive statistics, t-test, ANOVA, and Pearson correlation in SPSS ver.25. A P-value less than 0.05 was considered the significance level. To clarify, the mean scores and SD of each questionnaire were also presented based on percent, which means the percentage of the total score for each of the questionnaires.

Results

One hundred seventy students of MSc in Counseling in Midwifery completed and sent the questionnaire. About 15 percent were incomplete, and more than ten percent were excluded from the study. The individual and educational characteristics of the participants are presented in Table 1. The mean + SD of participants' age was 33.75 +8.13 years. The age range of the participants was 21-57 years. Approximately 70% of the participants were married. The highest knowledge scores were related to the "sexual response cycle" and " reproductive counseling ". While the lowest score was related to "treatment of sexual assault victims "and "counseling models (such as PLISSI, BETTER, ...)". M ± SD of the total raw score of knowledge (19-76) was obtained 56.15± 9.12, and M ± SD percentage of the total score was 74.67 ± 12.

The highest attitude score was related to "talking about sexual issues is essential for clients' health" and "sexual education and counseling make couples' intercourse more satisfying and the family relationships warmer." While the lowest scores were related to "Sexual counseling with men is easy for me" and "Most clients are not interested in sexual issues". M ± SD of the total raw score of attitude was obtained at 76.73± 8.54, and M ± SD percentage of the total score was 80.76 ± 8.98.

With regard to the self-efficacy questionnaire items, the highest scores were related to "I easily talk about sexual issues with a female client" and "I offer sexual counseling to maintain adolescent sexual and reproductive health considering physiological changes during puberty." While the lowest scores were related to "I can easily talk about sexual issues with a male client" and "I present and implement a treatment plan for premature ejaculation". M ± SD of the total raw score of self-efficacy was obtained 114± 23, and M ± SD percentage of the total score was 81 ± 16.

  The relationship between knowledge, attitude, and self-efficacy has been assessed, and results showed a significant relationship between knowledge and attitude (r=0.307), and self-efficacy (r=0.433) (p=0.001).

Pearson’s coefficient for the relationship between attitude and self-efficacy of sexual counseling was 0.411 (p=0.001).

The relationship between demographic variables and students' knowledge, attitude, and self-efficacy in providing sexual counseling is shown in Table 2.

The results of the t-test showed a significantly lower mean knowledge score in the less than the 40-year-old group. There was no significant relationship between knowledge, attitude, and self-efficacy scores with marital status, level of interest in the field of study, semester, and degree of religion (P> 0.05).

Students with clinical experience had significantly higher knowledge (p= 0.041) and self-efficacy scores (p = 0.03). Also, the attitude score of participants who passed the complementary course was significantly different from that of those who did not pass such courses (p = 0.05).

Discussion

The present study revealed that students' knowledge, attitude, and self-efficacy were at an acceptable level. There have been few studies in Iran on midwifery students' knowledge, attitude, and self-efficacy, even in undergraduate education. Despite a positive attitude toward sexual counseling, students had poor sexual counseling skills (8). However, there has been no study on the empowerment status of students with MSC in Counseling in Midwifery in Iran. In general, sexuality is often one of the most difficult topics to be discussed in conservative societies and mainly in Muslim countries (21). In countries with similar cultural status, such as Turkey, sex educators are conservative (4) and can undermine the quality of education and service since sexual issues are not a priority in the health system. The results of the current study, like a study by Sung et al. (2015) conducted on the nursing students, showed a positive relationship between the knowledge, attitude, and self-efficacy scores with the provision of sexual counseling (18).

The relationship between demographic variables and students' knowledge, attitude, and self-efficacy showed a significant positive relationship between the therapist's age, clinical experiences, and passing complementary courses and questionnaire scores. Still, there was no significant relationship between marital status, semester, level of interest in religion, degree of religiosity, and the main variables. Regarding the individual items of the instrument used in the present study, the lowest score belonged to the treatment of sexual assault victims and the use of counseling models (such as PLISSIT and BETTER, etc.) in the knowledge questionnaire. Students seem to visit a few clients with sexual assault, and there is very little data in this area. Students with MSC in Counseling in Midwifery should become familiar with counseling skills and techniques in the abovementioned fields.

 Counseling in Midwifery students also expressed discomfort and poor self-efficacy when providing sexual counseling to men. Midwives need to understand their feelings, beliefs, and attitudes about sexuality. Stayton (2015) emphasized that the Sexual Attitude Restructuring (SAR) model can help the professionals to reassess their attitudes about sexuality, lower anxiety, and reinforce knowledge and skill-building in sexual counseling in a learning environment (22).

Counselors’ sexual education and training experience, supervision experience discussing sexuality, sexual attitudes, years of practice, and age were all associated with both counselors’ sexual comfort and willingness to discuss sexual issues with couples (23). Midwives are well educated in genital anatomy and physiology, the essential domain of sexual health and counseling (24). Since the value system of individuals is one of the most important factors affecting their attitudes and feelings of comfort, it is possible that the social, cultural, and religious conditions of society and lack of clinical experience have led to this result. The counselor's positive sexual attitude towards sexual counseling can provide clients with a safe and non-judgmental environment (22). Turkish midwifery students do not feel comfortable when offering sexual counseling to lesbians and sex workers (4). Over the past decade, the attitude of health workers towards sexuality and the treatment of people who are members of the lesbian, gay, bisexual, and transgender (LGBT) communities has changed positively (25).

The present study showed acceptable knowledge scores, and a more positive attitude towards sexual counseling was seen in participants with high knowledge levels. Song & Lin (2013) found that the relationship between knowledge and attitude may be because sexual health education can help students increase their knowledge and discover their values and feelings while providing sexual counseling to the clients.

To improve the functional self-efficacy of health care providers, individuals need to have the adequate technical knowledge and relevant professional skills to meet the clients' needs (26). The present study showed the highest correlation coefficient between knowledge and self-efficacy. To provide effective sexual counseling, the counselor must have the necessary self-efficacy. The more empowerment and competence, the more effort and interest the counselor will have when counseling (18).

Some personal factors may influence sexual education competency (11). There was no significant relationship between knowledge, attitude, and self-efficacy scores with marital status, level of interest in the field of study, semester, and degree of religion in this study. But, students over 40 had significantly higher knowledge scores in this study. Age over 40 helps to encounter more about sexual matters and gain more sexual self-confidence to provide counseling (23).

There was no significant relationship between the scores of students' knowledge, attitude, and self-efficacy and their semester. This finding was unexpected; because we expected the students’ knowledge, attitude, and self-efficacy will be enhanced, as the semester progressed. This point may be better understood by considering the variety of midwifery students’ experiences in different grades. Some students have more knowledge, attitude, and competency due to personal interest and study.

 The present study reported a positive and significant relationship between the mean score of knowledge and self-efficacy with clinical experiences. Having clinical work experience in this field is important. Cupit (2010) also found that the more clinical experiences therapists had, the more likely they were more eager to start talking about sexual issues with clients with more competency (23). Concerns about sexuality among sex counseling providers can be alleviated by employing highly qualified, experienced supervisors. Besides, studies have shown that the most effective and important factor that improves self-efficacy is previous positive experiences (27). Consistent with other studies, the present study showed a significant positive relationship between postgraduate education courses about clinical sexuality and therapists' attitude when providing sexual health care (28). However, only about 33.5% of the participants stated that they had completed postgraduate courses on sexuality.

The present study demonstrated no significant relationship between the degree of religiosity and knowledge, attitude, and self-efficacy of sexual counseling. Cupit et al. (2010) also found no significant relationship between the degree of religiosity and the level of comfort and the beginning of the discussion about sexuality (23). Inconsistent with the preset study, West et al. (2012) found a correlation between the degree of religiosity and a negative attitude toward counseling. They believe that health professionals and patients are cultural beings with beliefs and attitudes formed based on family traditions, social development, and exposure to new experiences (28).

This study was the first to evaluate the competency of the Counseling in Midwifery postgraduate students from its inception and can be used for educational policies and curriculum revisions. Poor response rate is one of the challenges of online research. Attempts were made to overcome this problem by communicating correctly with the participants and motivating them. The data collection instrument was a questionnaire, and it can be stated that the use of the questionnaire has limitations, including that people may not reflect the facts about themselves and their beliefs for various reasons. Due to the self-administered questionnaire-based data gathering in this study, it is suggested that research would be designed to assess the sexual counseling knowledge of the students by concrete methods such as multiple-choice exams instead of self-declaration.

Conclusion

Despite the relatively optimal mean knowledge, attitude, and self-efficacy scores in the field of sexual counseling, there are still weaknesses that need to be improved by designing and revising the relevant lesson plan in the theoretical and clinical sections. We can bridge the gap between a will and a way to provide clinical sexual counseling by increasing knowledge, attitude, and self-efficacy to hold complementary courses. Considering the sensitivity of sexual issues to society and family health and the fact that the sexual world of the local clients is not a place for trial and error, therapists need to gain clinical experience under the supervision of educators before graduation. Students need to effectively communicate with male clients and victims of rape and sexual counseling techniques. Hence, it is suggested that a standard educational setting with a proper environment will be established to improve the quality of sexual counseling provided by midwifery students.

Acknowledgements

This article results from a Master's degree in Midwifery from Alborz University of Medical Sciences. The authors would like to express their sincere gratitude to the students with MSC in Counseling in Midwifery in universities across Iran for devoting their precious time to participating in the present research.

Conflicts of interest

Authors declared no conflicts of interest.