The results of the qualitative section indicated that the important health problems posed to violated women included lack of sensitivity to health, increased high-risk behaviors, ineffective life skills, insufficient family and social support, spouse's disregard for the physical, sexual, and mental health of women, as well as a health system and reproductive health unresponsive to the needs of violated women. These problems result in special reproductive health needs at individual, family, and community levels. It is essential to identify the health needs of violated women in order to promote their general health and fertility. Therefore, in the second part of this study, based on the data obtained from the qualitative section, the Reproductive Health Needs of Domestic Violated Women scale (RHNVWS) was designed.
To design this questionnaire, all stages of psychometrics assessment, including face validity, content validity, item analysis, construct validity, and reliability were thoroughly performed. Based on the results of exploratory factor analysis and using Varimax rotation, four latent factors were extracted that explained 47.62% of the total variance of the reproductive health needs of women subjected to domestic violence. These factors included: men's participation, self-care, support and health services, and sexual and marital relationships, which yielded a 39-item questionnaire.
The items were scored on a five-point Likert scale ranging from always (5) to never (1), and in some items, from very much (5) to very low (1). Cronbach's alpha coefficient for the whole instrument was calculated at 0.94. As evidenced by the results of the present study, the 12-item construct of men's participation had the highest variance (20.51) among the constructs of this tool. In this construct, the factor loading of items ranged from 0.41–0.73; therefore, it can be concluded that men play a key role in the promotion of women's reproductive health .
The results of a study carried out by Akhavan and Simbar (2016) demonstrated that men's involvement in reproductive health brings about the following consequences: raising awareness and information transfer to their wives, improving the coverage of family planning services, investing in prevention and control of sexually transmitted infections, increasing men's involvement in pregnancy issues, including early initiation of prenatal care and adoption of appropriate health behaviors . These results largely overlap with the items of male participation in the present questionnaire and highlight the importance of assessing the needs of this area of reproductive health.
Self-care is a key strategy for health promotion and disease prevention . In the RHNVWS, the 13-item construct of self-care accounted for 13.24% of the variance. In this construct, the factor loading of items varies from 0.43–0.64 and examines important aspects of self-care in the reproductive health of violated women. Another construct in the present instrument was support and health services. This 7-item construct accounts for 8.83% of the total variance. The factor loading of the items varies from 0.45–0.65, and the items include the support and services that violated women receive from their families, communities, and health centers.
The results of a study conducted by Khani et al. (2017) pointed out that the health systems that are unresponsive to sanitary needs and the non-response of the behavioral counseling centers to violence against women are among the important sexual and reproductive health needs of women . The need to have access to a responsive health system in providing appropriate services and counseling is assessed in different items of the construct of support and health services. According to the World Health Organization, satisfying and safe sex life is one of the aspects of access to sexual rights . The fourth 7-item construct of the present questionnaire is related to sexual and marital relationships which accounts for 5.02% of the variance of the instrument and assesses the various dimensions of sexual and marital relationships. In this construct, the factor loading of the items varies from 0.72 − 0.40.
The Centers for Disease Control and Prevention (CDC) has developed a tool to assess the reproductive health needs of conflict-affected women based on WHO and CDC studies. This instrument encompasses 10 sections, namely demographic characteristics, safe motherhood, family planning, marriage and marital life, sexual history, sexually transmitted infections, knowledge, beliefs and attitudes about HIV and AIDS, gender-based violence, female genital mutilation, and mental health .
Another questionnaire similar to the one used in the current study is the Reproductive Health Needs Assessment Questionnaire, developed in consultation with the International Organization for Migration and the United Nations Population Fund. The mentioned questionnaire consists of 114 items in the following sections: demographic information, safe motherhood, family planning, history and practice of sexual activity, sexually transmitted infections, HIV and AIDS, and gender-based violence .
The construct of self-care in the present study included items related to family planning, safe motherhood, sexually transmitted infections, HIV and AIDS which were assessed in separate sections in the two mentioned questionnaires. In addition, the sections on marriage, marital life, and sexual history in the two questionnaires were in line with the construct of sexual and marital relationships in the present questionnaire. The two aforementioned instruments have been prepared based on a review of various studies, and their psychometric assessment was limited to content validity. A large number of items and the method of recording the answers in the mentioned questionnaires made them time-consuming for both the respondent and researcher.
The instrument in the present study was exclusively designed for conflict-affected women, and its validity has been confirmed by examining the face validity, content, and constructs validity. Moreover, reliability was validated by Cronbach's alpha method. In addition, apart from using transcriptions and opinions of key participants, the items were extracted from interviews with violated women. The present researcher designed this questionnaire to represent reality from the participants' perspectives since the subjects of the present study are a certain group of women who have different experiences.
In the present study, it was attempted to design a valid questionnaire with minimum possible items. Therefore, these scales assess the reproductive health needs of women subjected to domestic violence in four important areas; moreover, it can be applied in a short time due to ease of answering using the Likert scale. One of the strengths of the current study is that the needs assessment was based on interviews with two target groups, including women subjected to intimate partner violence and key informants. The consideration of this critical issue in needs assessment increases the reliability of the results.
The results of the current study were confirmed in terms of face validity, content validity, construct validity, and reliability. Therefore, this instrument can be used as a valid and reliable tool for the assessment of the reproductive health needs of women with experience of domestic violence.