How Do Iranian Men Perceive Their Sexual and Reproductive Health Situation? A Qualitative Content Analysis

INTRODUCTION

Men’s sexual and reproductive health (SRH) is one of the major components of their general health. ¹ Despite the effective role of men in promoting their SRH, they have been often neglected for cultural and social causes, and there is limited evidence in this context. ² By the mid-1990s, in most countries, policies on SRH such as family planning, sexually transmitted infections, and sexual health focused on women to promote their health through increased awareness on the issues. ³

Studies conducted on the SRH needs of men show that, despite efforts to improve male reproductive health, they lack adequate knowledge of their reproductive health. ^{4 , 5} Iran has a female-oriented reproductive health system, in which men often have limited awareness of their SRH needs and responsibilities. ⁶ In such a situation, marginalizing and neglecting men’s health needs would make it impossible for them to achieve SRH goals. ⁷

Men’s involvement is considered an important strategy to promote SRH for men and women. ⁸ In developing countries, the critical roles of men in the reproductive health field can be outlined with three approaches including emphasis on unmet needs of men for their SRH, ability to emotionally support women to improve access to health services, and an effective role of men for positive changes. ³ Men are often known as a leader in the community because they are mostly the head of the household and have a crucial role in policymaking. Many gender roles that place women second to men, thereby influencing people’s beliefs, attitudes, and practices, not only endanger women’s health, but also the health of their male counterparts. ⁹ Hence, it is essential that health services provide the necessary support to enhance the SRH knowledge of men. ¹⁰

Men’s reproductive and sexual behavior perception is a cornerstone in their SRH. ¹¹ There is limited understanding of how men view their ability to promote SRH in families. We don’t know to what extent they perceive their responsibilities and roles to achieve a desirable situation. ¹² There are different levels of accessibility of reproductive health-related behaviors among men in terms of their attitude and perception toward SRH matters that could influence service utility. ¹³

Despite the importance of men’s viewpoints towards sexual and reproductive issues and their needed services to promote the family’s reproductive health, there is no accurate information about the perception of men, particularly Iranian men, of the SRH situation and its related services. Hence, this qualitative study aimed to investigate male perceptions of their SRH situations.

MATERIALS AND METHODS

A qualitative study was conducted on data acquired through semi-structured interviews with 19 adult males selected from the population of health centers in the province of Alborz, Iran, from May 2016 to April 2017. According to qualitative research, access centers for these individuals can be diverse. Individuals were selected purposefully, with many variations in age, education, occupation, income, and marital status; individual interviews were continued until saturation. Inclusion criteria were male population with Iranian nationality and age between 18 to 59 years, experience in sexual relationships, and lack of a known severe mental illness. Participants who were unwilling to continue participating in this research were excluded from the study. One of the health care providers selected qualified male participants to be recruited; then, the researcher invited these individuals to participate in interviews after explaining the objectives of the study. In addition, some participants included were selected from parks and clubs because of maximum variation in sampling and hearing the statements and quots of the participants who were not under the coverage of health centers. The interviewer was a male physician of the research team (the second author) and an expert in qualitative methods. Interviews were done in a private place in a health center in Karaj with a mean duration of 45 minutes.

A conventional content analysis approach was used to analyze the data based on Graneheim and Lundman. This method has five stages: manifest and latent content, unit of analysis, meaning unit, condensation, reduction, content area, code, category, and theme. Analysis was carried out simultaneously with data gathering. As an inductive qualitative data analysis strategy, this method combines “inductive category coding with a comparison of the social incidents observed and coded”. ¹⁴ The interviews were recorded on tapes; then, the recorded interviews were subsequently transcribed verbatim and read several times to reach an overall understanding of each participant’s perspective on SRH. First, each participant’s interview was analyzed, and then the next interview was conducted. All texts were divided into meaning units (each containing several words, sentences, and phrases) related to our study aim; the meaning units were condensed into open coding. Next, our data was organized, and the condensed meaning units were abstracted with codes. Finally, the codes were arranged into subcategories and categories based on assessing their similarities and differences. ¹⁵ OneNote software version 2016 was used to classify the codes and continue the data analysis.

To evaluate the rigor and confirm the trustworthiness of the qualitative data, we used Lincoln and Guba’s ¹⁶ criteria, including credibility, dependability, transferability, and confirmability. In this study, member checking, an important step in protecting against researcher bias, provided the five randomly selected men with the opportunity to either agree or disagree with the interpretations extracted from the interviews; they were given a full transcript of the coded interviews with a summary of the emergent themes to assess whether the codes matched their viewpoints. The participants confirmed and documented their agreement with the concepts that had been developed by researchers.

Debriefing, another step towards confirming trustworthiness, was established by sharing the data and ongoing analysis with two senior experts in qualitative research; during the analysis, the research team worked together, participating in meetings to discuss emergent codes and themes and any revisions, if necessary. Dependability and confirmability were accomplished using an audit trail. To ensure data accuracy, the researchers kept decision trails to document the decisions that were made over the course of the study. Moreover, independent coding was done by two authors, and the concordance was calculated to be highly acceptable at 90%.

Ethical Considerations

This research project was approved by the ethics committee of the Research Institute for Endocrine Sciences (IR.SBMU.RIES.REC.1394.67). Written informed consent to participate and permit the tape recording of interviews was obtained from all participants, who were assured that audio files would be kept confidential in a safe place. All participants were free to withdraw from the study at any time.

RESULTS

In this study, 19 interviews were conducted with 19 adult males aged 18 -50 years (mean age 33.4±9.2 years). The participants were representative of a local population with a good diversity of various demographic characteristics. Table 1 shows the demographic characteristics of the study participants.

Of 1877 extracted codes, after excluding duplicate codes, a total of 97 main codes remained. These codes were classified into 23 subcategories, which subsequently merged into nine categories. Finally, three main concepts emerged using the conventional content analysis as follows:

1) Perceived SRH Needs, including “need to increase men’s awareness about SRH”, “need to have an accessibility to SRH services”, and “need to have a high-quality sexual relationship”; 2) perceived SRH responsibilities, including “health-seeking behaviors”, “sexual skills”, “childbearing responsibilities” and “ethical commitment”, and 3) Men’ perception of the trends of social and cultural norms, including “changing SRH priorities” and “changing marital prototype” (Table 2).

1. Perceived SRH Needs

One of the themes that emerged from the men’s viewpoint was perceived SRH needs. The concept of needs had three categories: awareness, access to SRH services, and high-quality sexual relationship.

1.1. Need to Increase Men’s Awareness about SRH

The study participants believed that awareness about male genital tract symptoms; timely diagnosis methods; prevention of diseases, cancers, and sexually transmitted infections (STIs); human immunodeficiency syndrome (HIV); infertility; and sexual issues were important factors for adopting SRH behaviors. Subcategories of awareness included sexual issues, STIs/HIV/acquired immunodeficiency syndrome (AIDS), and male genital system functions.

1.1.1. Awareness about Sexual Issues

Men believed that if they had higher awareness about sexual issues, their sexual health would improve.

“If I had enough sex awareness, I would prefer my wife to be prepared for enjoyable experiences during sex. I wish I had more knowledge about sexual issues”. (P6)

Moreover, there were major misconceptions about the signs of diseases and sexual and reproductive disorders in men. An interviewee considered occasional and spontaneous ejaculation at bedtime as a disorder; he thought that masturbating was a factor in inducing body weakness and even a source of unemployment and dismissal from a job.

“I think that erection during sleep is not normal, and masturbation leads to my weakness, frailty, anger, and even loss of my job”. (P8)

1.1.2. Awareness about STIs/HIV/AIDS

Many of the participants were confused about the transmission route of HIV/AIDS and other STIs. One participant stated:

“As far as I know, AIDS is transmitted through dirty work. I think that I do not get AIDS by once sex, but I’m not sure. I wish I knew what to do”. (P8)

1.1.3. Awareness about the Male Genital System Functions Related to Reproduction and Its Problems

Males’ information on male genital cancers and infertility was inadequate. They believed that they needed more information to be more alert about the abnormality of their genital tract.

“I do not really have any information about male genital disorders. I just know that the testis is a fertility organ in men. Nobody gives us comprehensive information about the genital system and its diseases.” (P19)

1.2. Need to Have Accessibility to SHR Services

Most men did not know where to refer if they needed specialized services on SRH issues. Access to SRH services had two subcategories, including SRH service delivery centers and a supportive environment.

1.2.1. Accessibility to SRH Service Delivery Centers

Most men expressed their personal experiences to highlight their difficulties with access to the services required in the prevention and treatment of infections, sexual problems, and infertility. Even educated participants in medical fields believed that they needed to learn more about accessible SRH services.

“I think that sexuality is a real need. Men often have inadequate information on where sexual health services are located. Although I am a Master of Sciences in Health, I do not have enough information about sexual issues. Therefore, special centers should be considered to provide health services for men”. (P1)

1.2.2. Accessibility to a Supportive Environment

Some participants suggested that creating a safe and supportive environment to meet men’s sexual needs was vital in prevention of sexual chaos in society, mainly due to the current conditions of society, in which marriage requirements are not met, while the age of marriage has increased.

“There are many sexual stimulations in the community, and it is too hard for a young man to have self-control. You know? Men and women should get married in due time, but they need to earn an adequate income. For a good income, you need to have a job. So, our community is not good enough to support men’s sexual or reproductive health needs. If sex and reproductive health are important, why don’t they get any help to assess their fertility condition before marriage? I have never seen a useful social network that could guide us on finding help in this field. Nobody can assist you, even relatives, friends, and colleagues. Even there is no plan including regular examination or laboratory tests in our workplace to tell us what we can do for our sexual or reproductive health". (P12)

1.3. Need to Have a High-quality Sexual Relationship

The majority of men considered high-quality and safe sex very important issues and a positive sign of sexual health. The subcategories were good sexual pleasure, proper sexual satisfaction, the safety of sex, and an appropriate sexual function.

1.3.1. A Good Sexual Pleasure

Among sexual health issues, sexual pleasure was the main topic of discussions that most men had in terms of sexual health. Most men considered good positive feelings of both partners as the criterion for sexual health.

“In my opinion, the quality of the relationship between the two sex partners is very important. I think that if both sex partners adequately enjoy sex, it means they have been successful in their sexual relationships”. (P3)

1.3.2. A Proper Sexual Satisfaction

The majority of men, while expressing the importance of sexual satisfaction in the couples’ health, referred to strategies that increased satisfaction, while others believed that a lack of sexual satisfaction could lead to being unfaithful in their relationships.

“I think because sexual issues are so important for people, sexual dissatisfaction leads to being unfaithful in their relationships”. (P9)

1.3.3. Safety of Sex

The concept of safety in the quality of sexual relationships was repeatedly discussed in the participants’ conversations of the study. From the point of view of participants, safety includes the need to have a suitable companion for good sex, elimination of stress and tensions to be able to have a good mutual relationship without thinking about others and feeling empowered.

“In terms of health, if these are marital relationships, we are more relaxed and not worried about future problems”. (P7)

1.3.4. An Appropriate Sexual Function

Most participants emphasized the need to maintain appropriate sexual functions to survive the married life and quality of sex; they also had different perspectives on premature ejaculation, one of the most commonly considered issues among participants in the study.

“You know what I mean, and it will be so stressful for a man that is unable to do sexual practice well. I cannot imagine that horrible situation”. (P 11)

2. Perceived SRH Responsibilities

The participants considered some SRH responsibilities for themselves, such as health-seeking behaviors, sexual skills, childbearing responsibilities, and ethical commitment.

2.1. Health-seeking Behaviors

Participants believed that men were responsible for checkups for their health status. However, most of them did this only when they or their friends/relatives had a specific disease. Some men were afraid to talk about their fertility and sexual problems and tried to hide them.

2.1.1. Regular Checkups Related to SRH

Almost no participant had ever been referred to a health care provider for issues related to his reproductive and sexual system before the problem occurred.

“We need to go to checkups, but I do not have enough information on essential checkups related to fertility and sexual health. For example, the only information I have on the prostate is because my uncle died due to prostate cancer; I went for a checkup, but they told me to have tests after the age of 40 years.” (P10)

2.1.2. Dealing with Fear Related to SRH

Most participants were afraid of problems with the reproductive and sexual system, and other participants believed that these problems or infertility caused serious concern. However, some of them come over the fear, and some of them do not.

“I would like to see a doctor and be tested for evaluating my fertility, but I’m afraid that the results show that I’m infertile. For this reason, I do not want to refer to the doctor to check my fertility status. But I know that I must know everything at last.” (P17)

2.2. Sexual Skills

Participants believed that for sexual success, which is a prerequisite for the continuation of marital life and is the cornerstone of a good marital relationship, sexual skills should be associated with mutual satisfaction. Sexual skills were defined as sexual negotiation, respectful sexual practice, and sexually protective behavior.

2.2.1. Sexual Negotiation

From the perspective of men, negotiation skills about sexual needs were necessary for self-confidence in sexual issues; they believed that these skills could manage the sexual problems.

“I think negotiation is one of the most important skills among couples. For example, when two people talk, they can discuss their own issues, which are much easier to solve. Negotiation can help to discover solutions, and couples also learn to understand what their partner enjoys.” (P4)

2.2.2. Respectful Sex Practice

Men believed that women’s psychological readiness and satisfaction for a sexual relationship are very important and considered a sexual skill for men. They emphasized that men should learn how to respect the women’s desires during sex.

“I think sexual issues must be respected during sexual relationships, e.g., it is important to know whether my behavior in this position is acceptable to my partner; did I consider all ethical issues during sexual relationships?” (P3)

2.2.3. Sexually Protective Behavior

All the participants knew that condoms protect them from unwanted pregnancy and STIs. However, they sometimes were reluctant to use it even in high-risk conditions, or they did not have the skill of convincing their partner to agree to its use.

“I think if I tell my sexual partner that I want to use a condom, my partner will be upset by my demand. One of my friends suggested that I tell my partner that I am ill in such cases. But, in my opinion, this way is ineffective, and my partner will get annoyed.” (P12)

2.3. Childbearing Responsibilities

Study participants believed that a responsible man should consider some issues such as financing, parental maturity, parenting skills, and family planning before childbearing.

2.3.1. Financing and Providing Children’s Welfare

Participants of the study had different perspectives on the relationship between childbearing and financial and social welfare; however, the majority of them believed that they should have appropriate conditions for childbearing.

“In our society, economic issues are the major problems that force people to have only one child, or not have any children.” (P1)

2.3.2. Parents’ Emotional Maturity and Skill

Some participants believed that men could accept the responsibility for childbearing only when they achieve emotional maturity to adapt to the difficulties of admitting a child in their lives.

“In today’s society, economic and psychological problems are highly prevalent, whereas many people cannot even manage their own personal lives. In my opinion, egocentrism and selfishness make people unable to reach parental maturity, and these make them think negatively about bringing up children and childrearing.” (P11)

2.3.3. Family Planning Responsibility

From the perspective of all participants, family planning was a shared responsibility for women and men. In this respect, some participants believed that men sometimes had a major responsibility.

“In my opinion, although both men and women are responsible for prevention of unwanted pregnancy, more responsibility is with men.” (P13)

2.4. Ethical Commitment

All men in this study believed that they should be loyal to their marital life and also maintain a healthy and ethical lifestyle to succeed in childrearing in a faithful manner.

2.4.1. Commitment to Marriage

The participants believed that to reach SRH, we need to rely on committed marital life.

“When a man marries, he is committed to his family (wife and child). In my opinion, the concept of commitment applies for different issues. In other words, we should be committed to all issues of life. I know a lot of people who, despite being married, are not committed to their marital relationship and they have sex with others.” (P9)

2.4.2. Commitment to Child Upbringing

The participants described their efforts to provide a suitable behavioral pattern and avoid having a risky behavior to prevent the effect of that on his or her child. They believed that they were committed to rear the children in a good manner. Therefore, they tried to avoid communicating with some people with risky behavior.

“In many cases, I have been denied by my relatives; for example, if someone drinks alcohol, I will not associate with him at all, even if the person is my father. Someone who does an unpleasant act, I’ll cut off all contacts with him /her” (P14)

3. Men’s Perception of the Trends of Social and Cultural Norms

This concept includes changing SRH priorities and changing marital priority.

3.1. Changing SRH Priorities

This category includes “acceptance of not having a child to save the marriage” and “significance of sexual rights” and describes what changes are seen in men’s attitudes in the fields of fertility and infertility and sexual relationships. Study results show a change in men’s attitudes from traditional perspectives to modern approaches. Many participants stated that marriage could be continued even if the woman could not be fertile.

3.1.1. Acceptance of Not Having Children to Save the Marriage

Although many men explicitly stated the importance of having a child in their life, some believed that having a good common life in a situation where fertility was not possible for couples was acceptable.

“I like to have a kid so much, but if my wife could not be pregnant, it would be no matter. I want to continue to live with her.” (P 9)

3.1.2. Significance of Sexual Rights

Participants focused on the rights and needs of women/spouses in sexual intercourse; they believed that both woman and man should enjoy sex; otherwise, it would be selfish and could cause infidelity.

“I believed that not only should I be satisfied, both the man and the women have the right to enjoy sex and reach orgasm. In the past years, there was absolute manhood, but today, each partner expects everything to be good in sex” (P16)

3.2. Changing Marital Prototype

This category includes an attitude toward cohabitation and doubt about selecting a good wife.

3.2.1. An Attitude Toward Cohabitation

From the perspective of younger and more educated participants, cohabitation could be a new approach to answer their sexual needs. Some men believed that cohabitation was a prerequisite for marriage.

“My wife and I lived together in a house before getting married. Some people do this,.” (P18)

3.2.2. Doubt About Selecting a Good Wife

About half of the participants were confused about the characteristics of a good girl to marry. Some of them did not trust the girls who had had sexual relationships with other men before marriage and believed that such girls were unsuitable for marriage. For some men, virginity was not a matter of choosing a spouse. There was not a consensus about that.

“A girl has a right to have sex before marriage just like men. What should they do with their sexual needs?” (P 5).

“In my opinion, a girl who has sex with me has probably been in a relationship with other men and is not trustworthy for a marital relationship. Although some men who know that a girl previously had sex with others, they marry her; I believe that their relationships are often temporary.” (P5)

DISCUSSION

This study is the first to investigate the perceptions of Iranian men in terms of SRH, using the qualitative approach, emerging three main themes with related categorizes, including perceived SRH Needs, perceived SRH responsibilities, and men’s perception of the trends of social and cultural norms. From the perspective of Iranian men, SRH is described in terms of three concepts of needs, responsibilities, and social norms affecting these aspects of their health.

Perceived SRH Needs

The majority of the participants reported difficulties in accessing related health service centers and increasing their awareness about SRH. The first issue of concern is that Iranian men have limited access and utilization; therefore, men’s sexual and reproductive needs, especially younger men, rank higher than other health-related needs. ¹⁷ There is an inadequate basis for understanding the men’s SRH needs, especially HIV/AIDS prevention, ¹⁸ and we know that men are alert about their needs to promote their SRH. ¹⁹ Despite basic steps taken to promote the men’s health in recent years, no specific program is available to encourage their participation in SRH education programs. Since sexual issues in the Middle East and North Africa (MENA), including Iran, are often a taboo, health care providers lack adequate knowledge and skills to provide the sexual services needed. ¹ If men’s health is neglected, they may have different sexual and reproductive behaviors based on the type of information they obtain from different sources that may not be correct. ²⁰ Hence, it seems that raising awareness and knowledge of the health team to increase the participation of men and the use of services provided should be prioritized.

Most men do not refer to a doctor if they have problems with their SRH because of lacking sufficient awareness about SRH issues. Men in all age groups are much more likely to be exposed to health risk factors than women, while they are less likely to receive preventive programs and services. In addition, approximately 29.70 % of Iranian men had experienced at least one STIs-associated symptom during the previous year, which is one of the most important causes of male infertility. ²¹ One of the concerns of men in this study was infertility. Considering the importance of childbearing for Iranian men, they were eager to be informed about their fertility status. Male infertility rates are dramatically rising, and environmental factors play an important role in pathogenesis. ²² Hence, using strategies and designing preventive programs for infertility and its related treatments is one of the essential measures needed to be taken for male reproductive health. ²³

Iran has a “concentrated epidemic”, the largest epidemic of HIV in the Middle East (30). Although the incidence of HIV in three key populations (injection drug users, sex workers, and prisoners) has declined, because of the excessive spread of HIV/AIDS through sexual transmission, it is still considered a critical risk factor for SRH. ²⁴ Approximately half of HIV/AIDS transmission is due to sexual transmission, and unfortunately, men’s awareness of preventing HIV/AIDS is still inadequate. According to the National AIDS Committee of the Iranian Ministry of Health (2015), only 11.7% of young people responded to questions about awareness and prevention of HIV. ²⁴ Most males do not seek to resolve their sexual issues using a suitable approach; they lack the awareness needed to receive timely services and participate in SRH programs. Hence, it is critical to pay attention to the unmet needs of men’s reproductive and sexual health by designing comprehensive programs, gender-sensitive and culture-based interventions.

Findings of a study conducted on American Indian and Alaska Native men who used sexual health services showed that men with higher levels of education and income had more access to private insurance and STIs or HIV clinics. In general, men who used other health care services were more likely to benefit from these sexual health services. ²⁵

Perceived SRH Responsibilities

Men have poor SRH-seeking behaviors, ¹⁸ which may compromise their health as well as their family’s well-being. From the perspective of all men of this study, they are responsible for their family’s health. There are many factors related to shared decision-making, including childrearing responsibilities and participation in family planning programs, which are the duty of both men and their spouses. Although Iranian men face difficulties in achieving these abilities and adapting to their family role as a father, in many countries in the MENA region, participation in SRH activities is still limited. ^{26 , 27} The involvement of men in prenatal care is one of the main strategies for promoting the health of men and women.

Given that SRH challenges, including sexual disorders, STIs such as HIV/AIDS, and cancers, can hurt marital relationships, empowering family physicians and religious leaders in sexual and reproductive issues can reduce the problems in this area. ²⁸ Although general practitioners talk with patients about the signs and symptoms of STIs, they often have difficulties discussing sexual issues; they believe that men should be more responsible for their sexual health issues. ²⁹

One important concept emerged in this study was ethical commitment. Ethical commitment to the spouse, marriage, and family is an essential factor ensuring the continuity of marriage and marital satisfaction. ³⁰ Couples’ commitment plays an important role in maintaining the health of the family ³¹ and reducing the divorce rate which is a matter of great concern in many communities such as Iran. Due to the high rate of divorce in society, it is believed that marital commitment alone can reflect the overall functioning of marriage. Hence, effective interventions and policies related to couple’s fidelity in marriage must be developed to strengthen the foundation of the family.

Men’ Perception of the Trends of Social and Cultural Norms

Men’s perception of sexual and reproductive issues has been changed due to social and cultural norms. Also, they are changing their attitudes from traditional to modern. Although men had a major role in making decisions related to sexual and reproductive issues in traditional societies, nowadays, they believe that couples should be involved in making decisions about their sexual relationships and fertility. In addition, they perceived the rights and needs of women/spouses in sexual intercourse; they believed that both woman and man should enjoy sex.

The participants of this study were not confident about the characteristics of a good girl suitable for marriage. In this regard, if we intend to target Islamic lifestyle, strategic plans and policies should be implemented to provide necessary requirements for marriage. An empowerment framework should consider male involvement in different dimensions of sexual and reproductive health. ^{32 , 33}

Sexual issues management may influence the community’s mental health and prevent many social vulnerabilities. Shifting to modernity may lead to some sexual misconduct behaviors. Some of the important structures in forming social and cultural norms are environment, regulations, and policies. ³⁴ Adopting policies and decisions in accordance with social change can improve behavioral norms and reduce social vulnerabilities. The World Health Organization (WHO) recommends a multi-sectoral approach in the five key areas of human rights and policy, law, culture and society, education, economy, and health systems. ³⁵ Therefore, an inter-sectional cooperation is needed to achieve SRH in the community.

This study’s main strength is that the participants were purposefully selected, with maximum diversity, from the province of Alborz. However, like other qualitative studies, the generalizability of our findings to other populations, particularly adolescents who experience changed norms, may be limited. Moreover, the unwillingness of participants to express sensitive sexual and reproductive issues could also affect the study results; the researchers, nevertheless, tried to reduce this limitation by establishing a friendly and trusting relationship, especially during a qualitative interview. Further studies on other sensitive populations, in particular male adolescents, are recommended to assess the viewpoints and situations of these populations about their perception of SRH.

CONCLUSION

This study revealed that the majority of the participants believed that their SRH needs had not yet been addressed. Moreover, while they mainly accepted their essential role in terms of the SRH of the spousal relationship, they often had difficulties fulfilling their responsibilities due to inadequate access to reproductive services. These services need to be culturally bounded and compatible with social norms. The current reproductive care services need to be upgraded to provide essential care for both genders, considering socio-cultural values. Our study findings can be used to design interventions and programs to promote male SRH.

ACKNOWLEDGEMENT

This study was a Joint Research project between Shahid Beheshti University of Medical Sciences (SBMU) and Alborz University of Medical Sciences (ABZUM), which was approved by the ethics committee of the Research Institute for Endocrine Sciences (RIES). The authors also wish to acknowledge Ms. Niloofar Shiva for the critical editing of the English grammar and syntax of the manuscript.

Conflict of Interest: None declared.

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