create the summary of the findings "Methods 67
To develop a sexual needs rehabilitation framework, three following steps were con- 68
ducted. 69
Step one: Primary needs assessment 70
The focus of the needs assessment was to assess sexual needs in Iranian women post- 71
SCI. Both quantitative and qualitative phases were conducted followed by a review of 72
literature. 73
Sampling was carried out from women with SCI who referred to the Brain and Spinal 74
Injury Research Center (BASIR) registry system in Imam Khomeini Hospital, Teh- 75
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ran/Iran. BASIR is a multidimensional referral center that contains a variety of services 76
such as physiotherapy, occupational therapy, psychological consultations, sexual and 77
family counseling, neurosurgery, urology, proctology, pain clinic, and rehabilitation 78
specialists. 79
Of the 205 women who were contacted via their cell phones, those who were eligible 80
and agreed to participate the study were selected. Inclusion criteria included at least 18 81
years of age, sexually active, injury in thoracic or lumbar area, at least one year passed 82
since injury, and had no medical diseases other than SCI affecting their health. After a 83
telephone screening was conducted, 161 were found not eligible to enter the study and 84
only 44 women were qualified to be interviewed. Of the 44 eligible women, 31 agreed 85
to participate in the study. The main reason for decline was the fact that 13 women did 86
not like reporting their ideas about sexual life despite of confidentiality ethical consid- 87
erations. 88
All women in the study completed the socio-demographic and clinical traits form, Sex- 89
ual Quality of Life-Female (SQOL-F), and Female Sexual Function Index (FSFI) 90
through interviews over the telephone because they could not easily attend to the sam- 91
pling center due to mobility restrictions. 92
Moreover, to explore how Iranian women with SCI understand sexuality, a qualitative 93
phase was conducted. Of 31 women, only 24 women with SCI agreed to answer open- 94
ended questions through the telephone interview. 95
Interviews lasted between 45 to 60 minutes and were tape recorded and transcribed. Ba- 96
run & Clarke’s thematic analysis approach was applied to qualitative data analysis. We 97
have done a review of relevant and available literatures finally. 98
Step two: Prioritizing Identified needs 99
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A variety of 10 professionals from various fields of expertise (sexual and reproductive 100
health, Health education, psychology, neurology, and rehabilitation) debated and dis- 101
cussed identified needs. We received several recommendations which addressed con- 102
text-based specification of needs beyond the appraisal and comprehend perspective 103
when categorizing the extracted list of needs. This was done to determine the order for 104
dealing with a series of needs domains in post- SCI according to prioritizing criteria. 105
Prioritizing framework for the ranking of needs was conducted based on specific crite- 106
ria including; importance, urgency, cost-benefits, availability of services, the effect of 107
identified needs on individual health, and the enhancement of relationships for women 108
post-SCI. The final product of this step; needs domain; had provided materials for the 109
next step. 110
Step three: Framework development 111
In this step, we designed a sexual needs rehabilitation framework based on the needs 112
assessment in Iranian woman with post-SCI. We categorized sexual needs rehabilitation 113
in three subcategories as main need, need domain, and preliminarily needs in Sexual- 114
post SCI. 115
The chart in Figure 1 shows all explained steps. 116
Ethical Considerations 117
The Ethics Research Committee of Tehran University of Medical Sciences (TUMS) 118
approved the study ongoing 2014. All participants were informed about the research 119
objectives. Informed consent was obtained from all participants. 120
121
Results 122
Findings from the present study are reported in three main steps, separately. 123
Step 1: Primary assessment 124
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Demographic characteristics 125
The mean age of participants in the quantitative assessment was 35.42±6.51. Most 126
women were housewives; 29 (93.5%) and twenty three (74.2%) of the participants had 127
completed high school. The socio-demographic characteristics and reproductive traits of 128
the study sample are shown in Table 1. 129
The mean duration of injury was 36.32±19.21. The most frequent underlying causes of 130
SCI were traffic injuries in 23(74.2%), falls in 6 (19.3), and side effects of surgery in 131
2(6.5%). 132
Sexual quality of life and sexual function 133
The total mean score of SQOL-F was 60.47±1.53 which was defined as poor SQOL in 134
9.7% of the participants, moderate SQOL in 67.7% of those and good SQOL in only 135
22.6%. The total mean score of FSFI was 50.54±11.35. More details are shown in Table 136
2. Of all the FSFI domains, the minimum mean score was for the domain of desire; 137
3.89±1.56. By considering the cutoff value< 27 in the Iranian version of the FSFI, sexu- 138
al dysfunction was defined in 3.2% of women. Adjusting for probable confounders, the 139
proportional odds regression model showed a significant relationship between the spinal 140
cord injury (AOR=4.2, 95% CI: 1.8–9.2) and being non-college-educated (AOR=3.1, 141
95% CI: 1.2–5.9) or employed (AOR=1.8, 95% CI: 1.1–1.8).Being in one of the moder- 142
ate or poor quality of life classes was also considered. Scores of SQOL-F and FSFI do- 143
mains, except satisfaction, were significantly worse in cases versus controls (P<0.001). 144
Findings from this part of the research study were comprehensibly discussed in the pre- 145
vious publication (17). 146
Iranian women perspective about sexuality in post-SCI 147
In order to explore women’s sexual understanding post- SCI in the qualitative assess- 148
ment, three main themes were extracted as "dilemma leading to limited sexual activity", 149
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"seeking positive sexual adjustment", and "lack of client-based sexual and reproductive 150
health education/counseling in the rehabilitation process". More details are shown in 151
Table 3 and a discussion about the finding is available in the previous publication (21). 152
All participants stated that their sexual relationship was notably affected by their injury. 153
They compared their sexual experiences pre- and post- SCI and described that their 154
sexual ability had decreased. Moreover, they highlighted sexual problems including 155
anorgasmia, no genital sensation, as well as low sexual desire and inadequate vaginal 156
lubrication. Depression, hopelessness, urinary incontinence, bowel incontinence, limita- 157
tion in mobility, and spasticity were additional SCI related concerns expressed by some 158
of our respondents. Difficulties in marital relationships were the other challenges ex- 159
pressed by the most participants. Our women understood fading out emotional intima- 160
cy. They believed that coping with a decline in emotional intimacy is not easy. 161
For most women in this study, SCI was a hindrance for sexual activity. Almost all par- 162
ticipants expressed that their sexual activity was limited post injury and they were not 163
enable to cope with this problem. However, they declared in that they tend to experi- 164
ence a successful sexual relationship despite the recent dilemma. All participants point- 165
ed out that physical rehabilitation was the main focus of the rehabilitation team and that 166
there was significantly less attention paid to sexuality education. Although the main fo- 167
cus of the research was sexual alternation and related needs after SCI, a majority of the 168
participants discussed their reproductive health concerns. These concerns included 169
mensuration patterns, power of fertility, and application of suitable family planning 170
methods. All of the participants declared that they had not received, or were not receiv- 171
ing, effective sexual and reproductive health education and counseling from the heath 172
rehabilitation team. More discussion about the finding is available in the previous pub- 173
lication (22). 174
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Step 2: Prioritizing identified needs 175
According to results from sexual functioning and sexual quality of life in Iranian wom- 176
en with SCI, findings indicate that the most important needs associated with sexuality 177
aspects of life were related to alternations in sexual function post-SCI. Identified needs 178
included permanent and temporary changes in sexual function after injury, psycho- 179
sexual problems after SCI, complications which related to sexual function, intimate and 180
romantic relationships with husbands, and sexual and communication skills. These 181
needs domains were prioritized by the expert panel are shown in Table 4. 182
Step 3: framework development 183
Based on the findings from step two, all sexual rehabilitative needs prioritized by expert 184
panels; reported in table 4; were categorized thought a thematic analysis approach. In 185
continue, a conceptual framework in Sexual rehabilitation needs emerged with one 186
main need, two needs domain, and four needs in women post-SCI. More details are 187
shown in Figure 2. "