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Comparing the effectiveness of sexual skills training and communication skills training on the sexual attitudes of married women

Introduction Family is the basic unit in every society. Currently the institution of marriage, as the foundation of this important unit, faces a lot of challenges in modern societies.1 The prevalence of sexual dysfunction is high around the world, and this disorder has a pronounced effect on couples’ quality of life, mood, and social activities. Approximately 31.5% of women in Iran have at least one sexual dysfunction.2 A high prevalence of sexual dysfunction is the result of inadequate knowledge or inappropriate attitudes toward the natural phenomenon of sexual desire.2 Research shows that sexual attitudes, sexual knowledge, and comfort with sexuality demonstrated by professionals influences the way in which they address the sexual problems of those who seek their help.3 Sexual attitudes are affected by many factors, such as gender, age, previous experience, family background and current family structure, immediate environment, various subcultures and social structures, traditions, religious beliefs, and moral attitudes.4 Knowledge, emotions, evaluations, and behaviors related to sexuality constitute sexual attitudes.4 The sexual attitude of an individual may manifest in positive or negative sexual behaviors formed in accordance with knowledge or lack of knowledge along with emotions, thoughts and beliefs about sexuality.4 One of the variables that affects couples’ sexual attitudes is their communication skills. Adjusting the interpersonal relationship is a core need for a successful marital life; it can also be counted on to facilitate a stable and satisfying marriage.5 Lack of proper communication skills has been shown to be a major issue leading to dissatisfaction in couples’ lives.1 Communication skills have been among top three significant problems reported in distressed marriages,


Introduction
Family is the basic unit in every society. Currently the institution of marriage, as the foundation of this important unit, faces a lot of challenges in modern societies. 1 The prevalence of sexual dysfunction is high around the world, and this disorder has a pronounced effect on couples' quality of life, mood, and social activities. Approximately 31.5% of women in Iran have at least one sexual dysfunction. 2 A high prevalence of sexual dysfunction is the result of inadequate knowledge or inappropriate attitudes toward the natural phenomenon of sexual desire. 2 Research shows that sexual attitudes, sexual knowledge, and comfort with sexuality demonstrated by professionals influences the way in which they address the sexual problems of those who seek their help. 3 Sexual attitudes are affected by many factors, such as gender, age, previous experience, family background and current family structure, immediate environment, various subcultures and social structures, traditions, religious beliefs, and moral attitudes. 4 Knowledge, emotions, evaluations, and behaviors related to sexuality constitute sexual attitudes. 4 The sexual attitude of an individual may manifest in positive or negative sexual behaviors formed in accordance with knowledge or lack of knowledge along with emotions, thoughts and beliefs about sexuality. 4 One of the variables that affects couples' sexual attitudes is their communication skills. Adjusting the interpersonal relationship is a core need for a successful marital life; it can also be counted on to facilitate a stable and satisfying marriage. 5 Lack of proper communication skills has been shown to be a major issue leading to dissatisfaction in couples' lives. 1 Communication skills have been among top three significant problems reported in distressed marriages, along with difficulties in sexual expression and personality factors. 1 Communication skills training has therefore been extensively studied in the context of couples' relationships and interactions. 1 Investigations have been carried out around the roots of marital relationships date back to the late 1960s. From 1971 on, more than 79 studies about the relationships between spouses have been conducted, consisting of 40 quantitative and 39 qualitative research studies. 6 Rezazadeh concluded that communication problems are among the most common problems couples report. Over 90% of troubled couples consider communication the main problem in their relationships. 7 In addition to communication, sexual problems are also common and can directly or indirectly affect many aspects of couples' relationships and lives. 8 Research shows that attitudes, fears or memories are some of the factors affecting underlying sexual problems. 9 One of the problems in Iranian society today is a lack of adequate information on sexual skills as well as incorrect attitudes and beliefs about this issue. 10 In other words, there is often no precise understanding of sexual issues. Related to this, misunderstandings and social and cultural barriers to training concepts and positive expressions of sexual health leads to a lack or low levels in both the quantity and quality of available sexual health services and related issues. 11 Training for sexual skills is a process during which people acquire information and knowledge about their sexuality. This training can bring about intimacy and sexual satisfaction between couples and reduce the incidence of such problems, ultimately increasing their marital and life satisfaction. 12 Numerous studies have evaluated the effectiveness of sexual skills training on women's sexual attitudes and skills. In this regard, a study by Shahsia and colleagues revealed that training for sexual skills has a significant effect on increased marital satisfaction. 13 In another study, Karimi et al also found that sexual skills training improved marital satisfaction. 14 In addition, the results of a study by Shams Mofaraheh et al showed that marital counseling can increase sexual satisfaction. 15 Dehghani et al investigated the effectiveness of sexual skills training on couple' sexual attitudes and concluded that teaching sexual skills has a significant positive influence on people's sexual attitudes. 16

Materials and Methods
The number of studies conducted on the provision of training and awareness and its relation to changing attitudes reflect the importance of the training factor in creating a positive and healthy attitude towards sexual issues. Since sexuality and attitudes regarding sexual issues are integral parts of marriage, it is useful to determine whether sexual skills training or communication skills training can lead to changes in sexual attitudes, help create more positive attitudes in individuals, and whether training at the beginning of marital life reduces couples' problems in this area. Considering the above issues, it seems that learning about sexual issues as well as communication skills can help prevent the occurrence of sexual disorders and help couples to deal with sexual issues and adopt more positive attitudes. Therefore, since there has been less attention given to the evaluation and comparison of the effectiveness of sexual skills training and communication skills training on women's sexual attitudes in previous research, this study aimed to compare the effectiveness of sexual skills training along with communication skills training on sexual attitudes of married women aged 18 to 45 years old in Tabriz.

Research Method
The research design was a quasi-experimental pre-post comparison study consisting of three groups: a sexual skills training group, a communication skills training group, and a control group. The statistical population of the current study consisted of all the married women aged 18 to 45 years old in Tabriz in 2014. The sample was composed of 45 women selected through cluster sampling from 4 regions of Tabriz from one clinic in each region (four clinics in total). These clinics provided couples therapy, sex training, communication services, etc. The 45 participants were randomly placed into one of three groups, with 15 individuals per group. The requirements for admission to the study were having a diploma, no specific history of mental illness, willingness to participate, and obtaining informed consent. Before starting the training sessions, all individuals filled out a pre-test based on the Sexual Knowledge and Attitudes Scale (SKAS). The subjects in the experimental groups (sexual skills training group, communication skills training group) then received training for eight sessions of 60 to 90 minutes each, while the control group received no training. After the sessions, all groups completed post-tests. The researchers had complete pre-post data for 36 participants in all, 12 in each group. The data were analyzed using analysis of covariance (ANCOVA). The sexual skills training and the communication skills training programs are summarized in Tables 1 and 2.

Research Instruments
The SKAS was designed by Basharat and Kolagari to measure knowledge of and attitudes towards sexual issues in marital relationships. The scale includes 30 items that measure two variables of sexual knowledge and sexual attitudes via a 5-point Likert scale ranging from 1 (low) to 5 (high). Each of the two subscales of this scale includes 15 items and the lowest and the highest scores in each of the subscales by participants will be between 15 and 75. Higher scores on the subscale of sexual knowledge indicate higher sexual knowledge and higher scores in the sexual attitudes subscale shows more positive attitudes towards sexual relationships. Basharat and Kolagari administered the SKAS to a sample of 837 (451 females, 386 males). The  Cronbach's alpha coefficients of the subscales of sexual knowledge and sexual attitudes for the subjects' score were calculated as 0.88 and 0.87, respectively, indicating good internal consistency. 17 Test-retest reliability of the SKAS was also calculated to be in the range of 0.76-0.87. All correlations were statistically significant. It was concluded that the SKAS can be considered as a reliable and valid scale to measure sexual knowledge and attitude in Iranian samples. 17 It should be noted that in this study, the sexual attitudes subscale score was also used.

Results
The descriptive indicators for the variable of sexual attitudes for all three groups are presented in Table  3. As can be seen, the highest average was seen in the experimental group in sexual skills (42.7, SD 1.70) and the lowest average was seen in the control group (39.9, SD 2.05). Given the administration of a pre-test and a post-test, the one-way ANCOVA was used as an inferential analysis of the data. In this regard, before the implementation of one-way ANCOVA, the homogeneity assumption of the error variance was evaluated whose results are illustrated in Table 4. Table 4 shows that the assumption for the homogeneity of error variance is achieved, since the calculated F values (1.67) at the level of P < 0.05 are not significant. As shown in Table 5, the difference between the trainings is significant after the control and elimination of pre-test impact (P ˂ 0.05). Thus, the communication skills training method appears to be more effective in increasing sexual attitudes in comparison with the sexual skills training method. In order to determine the difference between the two experimental groups, the consequential least significant difference (LSD) test was used and its results are presented in Table 6. As shown in Table 6, the results of the consequential LSD test indicate a significant difference (P < 0.05) between the group that experienced the communication skills training method and the group that experienced the sexual skills training method in affecting women's sexual attitudes positively.

Discussion
The purpose of this study was to compare the effectiveness of sexual skills training and communication skills training on sexual attitudes of married women. The results of the present study showed that sexual skills training and communication skills training had differing impacts on the sexual attitudes of married women, with the greatest impact associated with communication skills training. The findings of the study were consistent with the results of studies by Sung and Lin, 18 Rashid and Hosseini Nazarlou, 19 Ghorbani and Khalaj, 20 Hajinia and Khalatbari, 21 Mobredi et al, 22 Gunderson and McCary, 23 Nezami et al 24 and Jamali et al. 25 Despite the fact that sexual relating is a complex web of emotions, attitudes, and behaviors, those members of society with various forms of visual, auditory, or physical challenges are often neglected in sexuality-related research. 26 Currently, there is a variety of therapies and interventions that target sexual attitudes, each of which has a different orientation. 27 Among the factors affecting sexual attitudes is communication skills, or the ability to communicate effectively and efficiently with others. 28 These are often required in the area of sexuality and sexual issues. Couples can learn and use communication skills to improve their relationships.
The results of some studies suggest that a chief cause of marital conflict is the inability and weakness in couples' skills to control and resolve their conflicts. Thus, many interventions are aimed at flaws in communication skills, and these can reduce marital conflict. 29 In addition, spouses' attitudes towards sexual issues are of critical importance for marital accord. Beliefs and non-adaptive attitudes play an important role in the arousal and the orgasm stages between spouses. Healthy attitudes towards sexual relationships can lead to more pleasurable sexual experiences and orgasm. Having sexual needs met plays a major role in relationship and personal health in reducing tension and stress and helps prevents harassment and violence, thus contributing to enjoyable and productive relationships. If one partner considers sexual activity unpleasant, they will be less inclined to desire sex; in some cases, dissatisfied partners may use adverse sexual behaviors against their partners, including physical or verbal aggression. This dynamic suggests that beliefs and attitudes about sex and sexual roles has a critical impact on violence and instability in marital relationships. 30

Conclusion
In explaining the findings of this study, it can be stated that ineffective communication brings about an interpersonal Based on the research in the field, some studies have highlighted the theoretical importance of sexual attitudes and have advised therapists and consultants to address changes in incompatible attitudes and beliefs as one of the main tasks of treatment in couples and individual therapy. The significant correlation between sexual knowledge and sexual attitudes raises the point that as individuals' sexual knowledge increase, their attitudes towards sexual issues will be more flexible and positive. 31 Both communication and sexual skills play an important role in marital life, and both are effective items in the relationship between couples and can have important effects on cohabitation. However, there is no study that examines which of these can play a more crucial role in affecting sexual attitudes. Therefore this study examined both types of skills training to evaluate the results in order to design couples' educational programs to impact their attitudes more effectively. Therefore, it is recommended that future research examine the role of sexual knowledge and provide the necessary training in order to increase this knowledge, with a special attention to couples. Due to the limited scope of this training for females, researchers are recommended to conduct this research in the future on both genders. Moreover, in the absence of follow-up, follow-up tests are suggested to be performed at different intervals after the intervention. Finally, because of group and public education, these trainings do not address the skills required of each individual, which is also one of the limitations of the present study along with the small sample size.