Abstract
Sexual health is a multidimensional aspect of women’s well-being, yet its intersection with social determinants of health (SDH) remains critically underexplored in culturally conservative settings. In such contexts, sociocultural norms often obscure open discourse and research on sexual quality of life (QoSL), despite its central role in marital satisfaction and overall health. This study addresses this gap by examining the relationship between SDH and QoSL among married women in Behshahr, Iran. This study aimed to examine the associations between key social determinants of health and sexual quality of life, marital satisfaction, and perceived social support among married women of reproductive age in Behshahr, Iran. A descriptive cross-sectional study was conducted in 2023 among 380 married women aged 16 to 52 years, recruited through stratified random sampling from 6 healthcare centers in Behshahr, Iran. Data collection instruments included: Sociodemographic Form (SDF), Sexual Quality of Life-Female (SQOL-F) questionnaire, ENRICH Marital Satisfaction (EMS) scale, Multidimensional Scale of Perceived Social Support (MSPSS), Statistical analyses were performed using SPSS v26 and AMOS v26. Descriptive statistics (mean, SD, frequency) summarized the data. Inferential analyses included Pearson correlation, multiple linear regression (MLR), and confirmatory factor analysis (CFA). A significance level of P ≤ .05 was applied. The mean age of participants was 33.08 ± 5.31 years. The average scores were: QoSL = 90.92 ± 13.08, marital satisfaction = 162.16 ± 25.05, and perceived social support = 48.63 ± 11.62. A statistically significant but weak positive correlation was found between QoSL and marital satisfaction (r = .15, P = .004). Husband’s education, socioeconomic status, and place of residence emerged as significant predictors of QoSL. Marital satisfaction was modestly associated with women’s employment status and vehicle ownership. Perceived social support was positively influenced by socioeconomic status and number of children. Confirmatory factor analysis supported the structural relationships among the 3 constructs. Sexual quality of life and marital satisfaction are significantly shaped by social determinants such as education, occupation, socioeconomic status, and living conditions. These findings highlight the need for public health strategies and social policies that address structural inequalities to promote sexual and relational well-being among women.
Keywords
Introduction
Sexual health constitutes a fundamental aspect of women’s overall well-being, encompassing a complex interplay of psychosomatic, sociocultural, economic, and spiritual factors. It exerts a profound influence not only on individual physical and psychological health but also on the quality of interpersonal relationships and family cohesion.1 -3 As a core indicator of both physical and mental health status, sexuality plays a pivotal role in shaping marital satisfaction and enhancing life quality. A healthy sexual life is therefore recognized as an essential component of holistic health and a determinant of emotional intimacy and relational stability within the marital context.4,5 A high quality of sexual life (QoSL) is recognized as a foundational element in fostering familial health and sustaining marital compatibility. Within the broader framework of relational dynamics, sexual well-being serves as a critical determinant of marital satisfaction and long-term stability. Empirical evidence suggests that sexual satisfaction functions not merely as a component of intimate partnership, but as a dynamic contributor to overall marital fulfillment. In this context, the progression from sexual satisfaction to comprehensive marital satisfaction underscores the interdependence between physical intimacy and emotional cohesion within the marital bond. 6 Despite its centrality to overall well-being, sexual quality of life (QoSL) is frequently overlooked as a critical dimension of general quality of life (QoL), 7 QoL encompasses individuals’ subjective evaluations of their circumstances, shaped by cultural norms, personal values, goals, expectations, standards, and priorities. Within this framework, QoSL represents a distinct yet interrelated construct one that is inherently subjective and deeply influenced by an individual’s perceptions, experiences, and attitudes toward sexuality. The omission of QoSL from broader QoL assessments not only undermines the holistic understanding of health but also neglects a vital determinant of emotional and relational stability.8,9 In view of that, the QoSL is a means for delineating the relationship between sexual problems and the QoL, 10 so elevated QoSL gives rise to positive feelings of sexual desire, and consequently produces happiness and satisfaction in marriage and life.11,12 Previous studies have so far argued that low QoSL intensifies anxiety, depression, and marital complications.13,14 Moreover, sexual dysfunction as one of the sources of stress in marital life shapes the perceived QoSL, self-confidence, and interactions in individuals. 15
However, while the psychological and relational dimensions of QoSL have been widely discussed, its intersection with broader social and structural factors remains underexplored particularly in culturally conservative settings. Recent reviews, such as Bagherinia et al, 16 emphasize the lack of empirical studies examining how social determinants of health (SDH) including education, income, and living conditions influence women’s sexual experiences and satisfaction. This gap is especially critical given the central role of QoSL in shaping marital satisfaction and overall well-being. Given the utmost importance of the QoSL, there is a dire need to address the social determinants of health, which largely develop by economy, social policies, and politics.17 -19 Such determinants refer to the environmental conditions in which individuals are born, live, grow, learn, work, and get older, 20 and then affect their health status, performance, outcomes and risks, and QoL. The social determinants of health contain some dimensions, such as social gradient, stress, early-life experiences, social deprivation, social support, occupation, unemployment, substance use, nutrition, neighborhood, transfers, poverty and access to facilities, social welfare, and health. 21
To date, limited research has been conducted to explore the social determinants of health in relation to various dimensions of sexual health, particularly (QoSL). A recent review suggests that factors such as occupation, educational attainment, and income may significantly influence QoSL in women; however, only 4 out of 9 studies examined reported a statistically significant correlation.16,22,23 Given the established role of social determinants in shaping overall health outcomes and considering the critical importance of QoSL and marital satisfaction in the physical and mental well-being of women, families, and society at large the scarcity of studies addressing these relationships is notable.
Objective
Therefore, this study aimed to examine the associations between social determinants of health (SDH), sexual quality of life (QoSL), and marital satisfaction among married women in Behshahr, Iran. By addressing a critical gap in the literature, the study seeks to provide culturally contextualized insights that inform clinical practice, public health strategies, and future research on women’s sexual well-being in conservative societies.
Methods
Study Design and Participants
This study employed a descriptive cross-sectional design to investigate married women of reproductive age (16-52 years) attending healthcare centers in Behshahr, Iran, during the year 2023. Ethical approval was obtained from the Research Council, Student Research Committee, and the Institutional Ethics Committee of Mazandaran University of Medical Sciences (Approval Code: IR.MAZUMS.REC.1401.401) Participants were recruited through stratified random sampling from 6 designated healthcare centers to ensure representative coverage across the region. The inclusion criteria were as follows: (1) being legally married, (2) currently cohabiting with a spouse, and (3) falling within the defined reproductive age range of 16 to 52 years. Exclusion criteria were rigorously applied to minimize confounding variables and included: (1) a documented history of chronic physical illnesses (eg, diabetes, cardiovascular disease, or autoimmune disorders), (2) current or past diagnosis of psychiatric disorders (eg, depression, anxiety, or bipolar disorder), (3) self-reported or clinically diagnosed sexual dysfunction, (4) substance use including alcohol or illicit drugs within the past year, (5) ongoing or unresolved marital conflict as assessed by self-report or clinical judgment, and (6) any social instability that could interfere with study participation (eg, recent separation, domestic violence, or legal disputes). Prior to data collection, written informed consent was obtained from all participants after providing a full explanation of the study’s objectives, procedures, confidentiality measures, and voluntary nature of participation.
Sample Size
The required sample size for this study was determined based on the methodology employed by Afzali et al. 24 Using a significance level (α) of .05, a statistical power of 80% (1−β), and a margin of measurement error (d) set at 2 units, the minimum number of participants needed was calculated to be 360. The estimated variance (σ²) was set at 170.9, based on the standard deviation reported in Afzali et al (2020), which examined similar constructs in a comparable population. The margin of error (d = 2) was selected to reflect a conservative estimate of acceptable precision in QoSL scores, considering the scale’s sensitivity and the expected variability in responses. To ensure adequate statistical precision and account for potential attrition or incomplete responses, a total of 380 participants were ultimately recruited. The sample size estimation was performed using the following formula:
where Z₁−α/2 corresponds to the critical value for a 95% confidence level, Z₁−β represents the standard normal deviate for 80% power, σ² denotes the estimated variance, and d is the acceptable margin of error.
Measures
In this study, 4 distinct instruments were employed to assess sociodemographic characteristics, sexual quality of life, marital satisfaction, and perceived social support. Each tool was selected based on its theoretical relevance, prior validation in Iranian populations, and its capacity to yield reliable and interpretable data.
The Sociodemographic Form (SDF) was developed specifically for this research, drawing upon variables frequently cited in the literature on reproductive and sexual health. The form includes items such as age (of both the woman and her husband), number of pregnancies and children, duration and type of marriage (eg, arranged vs consensual), history of prior marriage (for either partner), living arrangements (eg, with extended family), and bedroom privacy. It also captures educational attainment, occupational status, socioeconomic indicators (such as vehicle ownership), and substance use behaviors for both the woman and her husband. While the SDF does not involve a scoring system per se, it serves as a foundational tool for descriptive statistics and for controlling confounding variables in multivariate analyses.25 -27
To assess sexual quality of life, the study utilized the Sexual Quality of Life-Female (SQOL-F) questionnaire, originally developed by Symonds et al. This instrument comprises 18 items that evaluate a woman’s emotional, psychological, and relational experiences related to her sexual life. Each item is rated on a 6-point Likert scale ranging from 1 (“strongly disagree”) to 6 (“strongly agree”), yielding a total score between 18 and 108. Higher scores reflect a more positive sexual quality of life. The Persian version of the SQOL-F was validated by Roshan Chesli et al (2018), who reported a Cronbach’s alpha coefficient exceeding .70, indicating acceptable internal consistency. Confirmatory factor analysis further supported the construct validity of the translated instrument within Iranian cultural contexts. 28
Marital satisfaction was measured using the ENRICH Marital Satisfaction (EMS) Scale, a comprehensive tool developed by Olson. The 47-item version used in this study encompasses 12 subscales, including marital satisfaction, personality issues, communication, conflict resolution, financial management, leisure activities, sexual relationship, parenting, relationships with relatives and friends, egalitarian roles, religious orientation, and idealistic distortion. Each item is scored on a five-point Likert scale, with higher scores indicating greater satisfaction. The Persian adaptation of the EMS Scale was validated by Soleimanian (1994), who reported a Cronbach’s alpha of .93, demonstrating excellent reliability. The scale has since been widely used in Iranian marital research, confirming its cultural applicability and psychometric robustness. 29
Finally, the Multidimensional Scale of Perceived Social Support (MSPSS) was employed to evaluate the participants’ perceived support from 3 sources: family, friends, and significant others. Originally developed by Zimet et al, the MSPSS consists of 12 items, each rated on a seven-point Likert scale from 1 (“very strongly disagree”) to 7 (“very strongly agree”). Subscale scores are calculated by averaging the relevant items, and higher scores denote stronger perceived support. The Persian version of the MSPSS was validated by Jokar and Salimi (2011), who examined its convergent and divergent validity through correlations with the Satisfaction With Life Scale (SWLS; Diener et al 1985) and the Social and Emotional Loneliness Scale (SELSA; Ditommaso & Spinner, 1993). The reported correlation coefficients were .77 and .42, respectively, confirming the scale’s psychometric soundness in Iranian populations. 30
Data Analysis
Descriptive statistic including mean, standard deviation (SD), frequency, and percentage were used to summarize the sociodemographic and outcome variables. The normality of continuous data was assessed using the Kolmogorov–Smirnov test, and parametric statistical methods were applied following confirmation of normal distribution. Pearson’s correlation coefficients were calculated to examine bivariate relationships among the main constructs. To identify key predictors of questionnaire scores while adjusting for potential confounders, multiple linear regression (MLR) analyses were performed. Additionally, confirmatory factor analysis (CFA) was conducted to evaluate the structural relationships among latent constructs and assess overall model fit and construct validity. In this model, standardized path coefficients (β) were reported to reflect directional and predictive associations, which conceptually differ from the bivariate correlations (r) presented earlier. All statistical analyses were performed using SPSS Statistics (version 26) and AMOS (version 26), with a significance threshold set at P ≤ .05.
Socioeconomic status (SES) was operationalized as a composite index comprising 4 indicators: educational attainment, household income level, residential area quality, and vehicle ownership. Each component was categorized and scored, and the aggregate score was used to classify SES into 4 levels: low, medium, good, and high.
Results
A total of 380 married women participated in the study, with a mean (SD) age of 33.8 (5.31) years. The sociodemographic profile of the participants (Table 1) reveals a relatively well-educated sample, with 43.9% of women and 39.5% of their husbands holding university degrees. The majority of women were housewives (70.5%), while most husbands were self-employed without fixed income (51.8%). Socioeconomic status was predominantly medium (49.5%) or good (28.9%), with only 2.9% reporting high SES. Most participants lived in moderate (46.6%) or good urban areas (33.4%), and a substantial majority (74.5%) had access to private cars. Nearly all women had wanted marriages (97.6%), and 91.3% had separate bedrooms, suggesting a relatively stable domestic environment. The mean age of participants was 33.08 years (SD = 5.31), and the average duration of marriage was 7.91 years (SD = 4.61).
Distribution of Sociodemographic Variables.
Table 2 presents the descriptive statistics for the 3 main constructs. The mean score for Quality of Sexual Life (QoSL) was 90.92 (SD = 13.08), indicating a moderately high level of sexual well-being. Marital satisfaction averaged 162.16 (SD = 25.05), and perceived social support was 48.63 (SD = 11.62), suggesting moderate support levels.
QoSL, Marital Satisfaction, and Perceived Social Support Scores of Participants (n = 380).
Table 3 shows the Pearson correlation coefficients among the 3 constructs. A weak but statistically significant positive correlation was found between QoSL and marital satisfaction (r = .15, P = .004), indicating that higher sexual quality of life is associated with greater marital satisfaction. However, no significant correlations were observed between QoSL and perceived social support (r = .01, P = .968), nor between marital satisfaction and social support (r = −.01, P = .944), suggesting that perceived support may not directly influence these domains.
Pearson Correlation Coefficient of QoSL, Marital Satisfaction, and Perceived Social Support Scores of Participants (n = 380).
Table 4 presents the results of the multiple linear regression analysis examining predictors of Quality of Sexual Life (QoSL). Three variables emerged as statistically significant contributors to QoSL scores.
Multiple Linear Regression Predicting Quality of Sexual Life (QoSL).
First,
Second,
Third,
Other examined variables including age, duration of marriage, personal and spousal occupation, vehicle type, perceived social support, and reproductive history did not show statistically significant associations with QoSL in this model.
Table 5 presents the regression results for marital satisfaction. Two variables were statistically significant. Employed women reported lower marital satisfaction compared to housewives (B = −8.92, P = .007), possibly due to role strain or time conflicts. This association may also reflect broader contextual or psychological factors, or selection effects whereby women experiencing relational dissatisfaction are more likely to seek employment. Additionally, vehicle ownership was positively associated with marital satisfaction: women with private cars had significantly higher scores than those using public transportation (B = +12.83, P = .001). Other factors, including SES, education, and QoSL, did not reach statistical significance in this model.
Multiple Linear Regression Predicting Sexual Satisfaction.
Table 6 explores predictors of perceived social support. Medium SES was positively associated with support levels (B = +5.28, P = .005), and number of children also showed a significant positive effect (B = +6.16, P = .026), suggesting that larger families may foster stronger support networks. Other variables, including education, occupation, and place of residence, were not significant.
Multiple Linear Regression Predicting Perceived Social Support.
The Confirmatory Factor Analysis (Figure 1) provided a structural validation of the relationships among the 3 core constructs. The model revealed a statistically significant standardized path coefficient from marital satisfaction to QoSL (β = .18, P = .001), indicating that higher relational satisfaction predicts improved sexual quality of life. This finding reinforces the theoretical view that emotional and relational stability serve as foundational drivers of sexual well-being. In contrast, the path from marital satisfaction to perceived social support was not statistically significant (β = .04, P = .379), suggesting that relational satisfaction may not directly influence perceived support levels in this context. Additionally, the path from QoSL to social support was omitted due to its lack of significance, aligning with the bivariate correlation results in Table 3. It is important to note that Figure 1 displays standardized path coefficients (β), which reflect predictive strength within the structural model and differ from Pearson’s r values used in Table 3. This distinction accounts for the slight variation in reported effect sizes and highlights the importance of interpreting each analytic approach within its methodological framework.
Structural model of the relationships among sexual quality of life, marital satisfaction, and perceived social support: standardized path coefficients (β).
Discussion
The primary objective of this study was to examine the relationship between social determinants of health and 3 key domains of women’s well-being: sexual quality of life (QoSL), marital satisfaction, and perceived social support. By focusing on married women, the research aimed to identify how sociodemographic and structural factors shape intimate and relational experiences within the context of reproductive health.
These results are consistent with and extend the work of Vakili et al, 22 who demonstrated that structural determinants particularly partner education and economic conditions play a pivotal role in shaping women’s sexual health literacy and autonomy. Similarly, our findings align with the systematic review by Bagherinia et al, 16 which emphasized the interconnectedness of socioeconomic indicators, partner education, and environmental context in determining women’s sexual satisfaction and relational stability. By confirming these associations in our sample, we contribute further evidence to the growing body of literature that situates women’s sexual and relational health within broader social frameworks. These findings underscore the need for public health strategies that address not only individual-level factors but also the structural conditions that shape intimate life.
The observed weak but statistically significant positive correlation between sexual quality of life (QoSL) and marital satisfaction in this study (r = .15) warrants cautious interpretation. While this finding may be broadly compatible with integrative models of couple functioning, the modest effect size suggests that sexual fulfillment and emotional intimacy are not strongly interdependent in this sample. Possible explanations for this weak association include cultural factors such as the prioritization of family stability or economic security over sexual intimacy as well as potential measurement limitations or the influence of unmeasured moderating variables. Beaulieu et al 4 emphasized that sexual satisfaction and emotional closeness can be mutually reinforcing, creating a feedback loop that enhances overall relationship quality. However, our findings only partially reflect this dynamic, and do not support a strong reciprocal relationship. This alignment is further supported by studies such as research by Fallahchai et al 31 in Iranian populations confirmed that sexual satisfaction was a significant predictor of marital adjustment, particularly among women. These studies reinforce the notion that QoSL is not merely a private or individual experience but is deeply embedded in the relational context. These studies reinforce the notion that QoSL is not merely a private or individual experience but is deeply embedded in the relational context. Additionally, a study conducted in 2020 in Sari, Iran, investigated the social determinants of health associated with sexual satisfaction among women and reported findings consistent with those of the present study. Specifically, the husband’s occupation particularly employment in low-income or labor-intensive roles was identified as a significant predictor of reduced sexual satisfaction, reinforcing the socioeconomic dimension of intimate well-being. 24 In a separate study from the same region and year, researchers focused on the social determinants contributing to low libido and hypoactive sexual desire disorder (HSDD) among women of reproductive age. While certain determinants, such as economic hardship and psychosocial stressors, were found to influence libido, the prevalence of HSDD remained largely unaffected, suggesting that chronic sexual dysfunction may be less responsive to contextual variables and more closely tied to enduring psychological or physiological factors. 32
In our study, employed women reported significantly lower sexual satisfaction compared to housewives. While role strain and competing responsibilities may plausibly contribute to this outcome, this interpretation remains speculative. Alternative explanations should also be considered, such as selection effects where women experiencing relational dissatisfaction may be more likely to seek employment or the possibility that employment reflects broader structural or psychological factors not captured in this study. Future research is needed to explore the directionality and contextual moderators of this association.
However, not all empirical findings align with the assumption that sexual satisfaction consistently predicts marital satisfaction. For example, Nickull et al 33 conducted a network analysis and found that while sexual pleasure and desire are central to relationship satisfaction, their influence can be moderated by contextual stressors such as caregiving burdens or financial instability. In such cases, couples may maintain sexual intimacy even when broader relational satisfaction declines. Additionally, Waddell et al 34 demonstrated that gendered attitudes particularly hostile and benevolent sexism significantly shape relationship dynamics, with women sometimes reporting high relational satisfaction despite low sexual fulfillment due to internalized norms or relational expectations. These findings underscore the importance of examining sexual satisfaction within broader psychosocial and cultural frameworks, rather than treating it as a universally predictive variable.
Taken together, these findings suggest that while the link between QoSL and marital satisfaction is robust across many contexts, it is not universal. The strength and direction of this association may be contingent upon broader psychosocial factors, including communication patterns, cultural scripts, and the presence of structural stressors. Our study contributes to this nuanced understanding by highlighting the importance of considering both individual and contextual variables when evaluating relational health.
It is also important to consider the distribution of QoSL scores in our sample. The mean score of 90.92 out of 108 (approximately 84%) indicates a relatively high level of reported sexual quality of life. This may reflect a potential ceiling effect in the SQOL-F instrument, suggesting limited sensitivity in capturing subtle variations among individuals with high sexual well-being. Moreover, given the cultural sensitivity surrounding sexual topics in conservative societies such as Iran, the influence of social desirability bias should be acknowledged. Participants may have provided responses that align with perceived social norms or expectations, potentially inflating the reported scores. These methodological considerations should be taken into account when interpreting the findings and designing future studies in similar contexts.
Strengths and Limitations of the Study
This study offers several methodological and conceptual strengths that enhance its scientific contribution to the field of women’s sexual health and social determinants of well-being. First and foremost, the use of rigorously validated psychometric instruments including the Sexual Quality of Life-Female (SQOL-F), ENRICH Marital Satisfaction (EMS) Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS). ensures high internal consistency and construct validity across key domains. These tools have been previously adapted and psychometrically tested in Iranian populations, thereby reinforcing the cultural relevance and reliability of the measurements employed. The relatively large sample size (n = 380) further strengthens the study’s statistical power, allowing for more precise estimation of effect sizes and increasing the generalizability of findings within the target population of married women of reproductive age. The sampling strategy, which involved random selection from multiple healthcare centers, also contributes to the representativeness of the data and reduces selection bias. From an analytical standpoint, the application of multivariate statistical techniques including multiple linear regression and confirmatory factor analysis (CFA) provides a robust framework for examining complex interrelationships among variables. These methods allow for the simultaneous control of confounding factors and the validation of latent constructs, thereby enhancing the interpretability and theoretical coherence of the results. Conceptually, the study addresses a culturally sensitive and underexplored area in the literature: the intersection of sexual quality of life, marital satisfaction, and social determinants of health in women. In sociocultural contexts where sexuality is often stigmatized or marginalized, this research contributes to a more holistic understanding of women’s health and highlights the need for integrated approaches in reproductive health policy and practice.
Nonetheless, several limitations must be acknowledged. The cross-sectional design inherently restricts causal inference, as it captures data at a single point in time and cannot establish temporal or directional relationships among variables. Longitudinal studies would be required to confirm the causal pathways suggested by the observed associations.
Additionally, the reliance on self-reported data introduces the potential for response bias, particularly in domains related to sexual behavior, marital dynamics, and socioeconomic status. Given the cultural sensitivities surrounding these topics, participants may have underreported or overreported certain experiences, thereby affecting the accuracy of the findings. This includes the potential influence of social desirability bias, particularly in responses related to sexual quality of life. The relatively high mean QoSL score observed in our sample may reflect participants’ tendency to align their answers with perceived social norms or expectations, rather than their actual experiences. Another notable limitation is the absence of a standardized, multidimensional instrument for assessing social determinants of health. While the study incorporated key sociodemographic variables, the lack of a unified framework may have constrained the depth of analysis and limited the ability to capture more nuanced structural and contextual factors. Finally, the study sample was restricted to married women, which limits the generalizability of the findings to other groups such as unmarried, divorced, or widowed women. These populations may experience different patterns of sexual health and relational satisfaction, influenced by distinct social and psychological determinants.
Taken together, while the study offers valuable insights and methodological rigor, its limitations underscore the need for future research employing longitudinal designs, broader sampling frameworks, and more comprehensive tools to assess the multifaceted nature of sexual health and its social determinants.
Recommendations for Future Research
While the present study offers valuable insights into the relationship between sexual quality of life (SQoL), marital satisfaction, and social determinants of health, several avenues for future research remain essential to deepen understanding and enhance generalizability. First, longitudinal studies are strongly recommended to establish causal pathways between SQoL and marital satisfaction. The cross-sectional nature of the current research limits temporal inference; thus, prospective designs would allow for the examination of how changes in sexual well-being influence relational dynamics over time, and vice versa. Moreover, future investigations should aim to include more diverse demographic groups. The current study focused exclusively on married women of reproductive age, which restricts the applicability of findings to broader populations. Including unmarried, divorced, widowed, and LGBTQ+ individuals would provide a more comprehensive understanding of how sexual health and relational satisfaction manifest across different social identities and relationship structures. Such inclusivity is particularly important given the sociocultural variability in experiences of intimacy, stigma, and access to support. Another critical recommendation involves the development or adoption of standardized, multidimensional instruments for assessing social determinants of health. While this study utilized key sociodemographic variables, the absence of an integrated tool may have limited the analytical depth. Future research would benefit from employing validated frameworks that capture structural, environmental, and psychosocial dimensions of social determinants, thereby allowing for more nuanced and policy-relevant analyses. Finally, qualitative research is needed to complement quantitative findings and uncover the lived experiences underlying statistical associations. In-depth interviews, focus groups, and narrative approaches could illuminate the subjective meanings women assign to sexual satisfaction, marital harmony, and social support. Such methods would enrich the empirical literature by capturing emotional, cultural, and relational complexities that are often obscured in survey-based studies. Collectively, these recommendations underscore the importance of methodological diversity, demographic inclusivity, and theoretical expansion in advancing the field of sexual and relational health within the context of social determinants.
Policy Recommendations
The findings of this study underscore the urgent need for policy frameworks that recognize sexual quality of life and marital satisfaction as integral components of public health and social well-being. Given the demonstrated influence of socioeconomic factors such as income level, employment status, housing conditions, and access to transportation on women’s sexual health, it is imperative that policymakers adopt a multidimensional and equity-oriented approach.
First, national health strategies should explicitly incorporate sexual health as a priority area, ensuring that services addressing sexual and relational well-being are accessible, affordable, and culturally sensitive. This includes the development of comprehensive sexual education programs tailored to the needs of married women, with a focus on communication, emotional intimacy, and mutual respect within relationships.
Second, targeted social policies are needed to mitigate the structural barriers that undermine sexual satisfaction and relational harmony. Investments in economic empowerment, housing stability, and transportation infrastructure particularly in underserved regions can have a direct and measurable impact on women’s intimate lives and overall health.
Third, the expansion of psychosocial support services, including counseling and mental health care focused on sexual and marital issues, should be prioritized. These services must be integrated into primary health care systems and delivered by trained professionals who are equipped to navigate the cultural sensitivities surrounding sexual health.
Finally, the establishment of national indicators and surveillance mechanisms for sexual quality of life and marital satisfaction would enable evidence-based policymaking. By systematically monitoring these dimensions, governments can better allocate resources, evaluate interventions, and promote gender-responsive health policies that reflect the lived realities of women.
In sum, advancing sexual health equity requires a coordinated policy response that bridges health, social welfare, and gender justice domains. Only through such integrative efforts can the structural determinants of sexual well-being be effectively addressed and the rights and dignity of women fully upheld.
Conclusion
This study provides compelling evidence that sexual quality of life and marital satisfaction among married women are shaped by a constellation of social determinants of health, including economic status, employment, housing conditions, and access to transportation. These findings challenge the notion that sexual well-being is solely a private or clinical matter, instead positioning it as a socially embedded phenomenon influenced by structural inequities and contextual realities.
By adopting a multidimensional lens, the research highlights the need to move beyond biomedical and individualistic models of sexual health. It underscores the importance of addressing broader socioeconomic and environmental factors that condition women’s ability to experience sexual autonomy, emotional intimacy, and relational fulfillment.
However, the observed correlation between sexual quality of life and marital satisfaction, while statistically significant, was modest in strength. This suggests that the relationship between these domains is more complex than expected and may be moderated by cultural norms, psychological factors, or unmeasured contextual variables. Such nuance reinforces the importance of cautious interpretation and the need for further research using longitudinal and culturally sensitive designs.
In sum, sexual quality of life and marital satisfaction must be recognized not only as indicators of individual well-being but also as reflections of broader societal conditions. Addressing these dimensions through interdisciplinary research and inclusive policy design remains essential for advancing health equity, gender justice, and the holistic well-being of women.
Footnotes
Acknowledgements
The authors would like to express their gratitude to the Student Research Committee of Mazandaran University of Medical Sciences, Sari, Iran, for the approval of this project with the code no. 15122 and the National Code of Ethics in Biomedical Research (IR.MAZUMS.REC.1401.401).
Table of Abbreviations
| Abbreviation | Full term | Explanation |
|---|---|---|
| QoSL | Quality of sexual life | A multidimensional construct assessing emotional, psychological, and relational aspects of a woman’s sexual experience. It reflects subjective well-being in sexual domains and is considered a key indicator of marital harmony and overall health. |
| QoL | Quality of life | A broad measure of an individual’s overall well-being, encompassing physical, psychological, social, and environmental dimensions. QoSL is a subdomain within this framework. |
| SD | Standard deviation | A statistical measure indicating the dispersion or variability of data points around the mean. Used to describe the distribution of scores in the study. |
| SDF | Sociodemographic form | A custom-designed questionnaire used to collect background variables such as age, education, occupation, socioeconomic status, and family structure. It helps control for confounding factors in analysis. |
| SQOL-F | Sexual quality of life-female | A validated instrument comprising 18 items that assess women’s perceptions of their sexual well-being. It includes emotional, psychological, and interpersonal dimensions, scored on a Likert scale. |
| EMS | ENRICH marital satisfaction | A comprehensive scale measuring marital satisfaction across 12 subdomains, including communication, conflict resolution, sexual relationship, and financial management. |
| MSPSS | Multidimensional scale of perceived social support | A 12-item scale evaluating perceived support from family, friends, and significant others. It is used to assess the psychosocial context influencing health outcomes. |
| MLR | Multiple linear regression | A statistical technique used to examine the relationship between one dependent variable and multiple independent variables simultaneously. Applied to identify predictors of QoSL and marital satisfaction. |
| CFA | Confirmatory factor analysis | A statistical method used to test the validity of measurement models and the relationships among latent constructs. It confirms the theoretical structure of the instruments used. |
| SPSS | Statistical package for the social sciences | A software suite used for data management and statistical analysis. In this study, it was employed for descriptive and inferential statistics. |
| AMOS | Analysis of moment structures | A structural equation modeling software used alongside SPSS to perform CFA and test complex relationships among variables. |
Ethical Considerations
The Student Research Committee of Mazandaran University of Medical Sciences, Sari, Iran, approved the project under code no. 15122 and the National Code of Ethics in Biomedical Research (IR.MAZUMS.REC.1401.401). The study was conducted in full compliance with institutional guidelines and the ethical principles outlined in the Declaration of Helsinki.
Informed Consent
All participants received detailed information regarding the objectives, procedures, potential risks, and benefits of the study. Written informed consent was obtained from each participant prior to data collection, ensuring voluntary participation and adherence to ethical standards.
Author Contributions
In this study, SKH was the supervisor. FH contributed to conceptualizations and research design, and FH was responsible for data collection. The first draft of the manuscript was also written by SKH and FH, managing reviewer comments, drafting responses, and revising the manuscript was conducted by RA and all authors provided feedback on previous versions. Of note, all authors read and approved the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.