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Women's Health Concept: A Meta-Synthesis Study.

Abstract Background It is necessary to identify unidentified or less- concentrated issues in women’s health dimension through an extended study. This study is done to identify different dimensions of women’s health among qualitative research. Method The present meta-synthesis study is done through a systematic review. The main criteria were to use qualitative studies issued in the same language and researches in which their participants were women. All the published and indexed articles related to women’s health in Iran at SID, Magiran and Iranmedex databases from 2001 to 2013 were scrutinized. Search in these databases was done using key words “health” and “women”. Finally, 29 qualitative articles were chosen. Data analysis was performed using qualitative content analysis. Results Generally, concepts extracted from women’s health dimension are classified in three main categories including personal, familial and social dimensions. Each category includes some subcategories, too. Personal factors consist of physical, psychological -emotional and spiritual; familial factors consist of fertility, husband’s support and women’s fundamental roles, and social factors consist of cultural, socioeconomically support, and women’s management issues. Conclusion In this meta-synthesis study, there was an effort to present a new interpretation of the previous studies. This study helped attain a more comprehensive and deeper knowledge about women’s health concept and reveal its different aspects, which are not assessed in the country.


Introduction
Health with all its dimensions is of human primary needs in such a way that health systems in the world try increasingly to promote their goals in giving health care to sustain a healthy society, and limited and insufficient indicators such as death is replaced by general health indicators such as welfare (1). The most generally accepted definition of health is that by world health organization in which health is defined as the state of welfare and mental, physical and social complete easement, and merely not suffering from an illness or disability is not considered as health (2). Today, the health of women, who build up half of the society's population, is not only recognized as a humane right, but its role in family and society is also gaining increasing importance (1). Breast cancer, for example, is one of the most malignant diseases among women, especially in the developing countries, which has a bad prognosis in developed steps and has a significant effect on the family's health (3). Moreover, due to many reasons, women are more vulnerable than men are. Besides biological traits, they are affected by cultural, social, economical and political factors. For example, compared with men, women are in a higher level of stigma associated with HIV (4). Although women live longer than men, they suffer more from physical illnesses, especially acute diseases and non-fatal chronic conditions. They also take more medicine (5). World health organization's reports also affirm that gender differences at birth are considered in health dimensions throughout the world (1). Employment, gender discrimination, maternal and wife roles and responsibilities, poverty, violence, education and possession are some of the factors in different cultures and societies, which are seen differently. What considered as a feminine sweet dream such as women employment in developing countries or husband's participation in house work for Chinese women is a clear and obvious right in other societies. Instead, for them, body fitness, job satisfaction or more income becomes their obsessions (6). Observing present differences about women's health, experiences, expectations and women's different groups priorities mean that there is still a room to discuss about what is considered as their health progress (7). On the other hand, major problems in women's health progress in Iran are lack of information about women's health needs in Iran, sporadic researches, loose relationship among researches, management and planning and giving services, and limited resources and professional human resources (1,7). In so doing, qualitative studies have potential power to discern the problems and scrutinize similarities and differences with deeper insight (8). However, scattered and incoherent qualitative studies are done on women's health dimension in Iran. To identify approaches to attain women's health promotion, it seems necessary to start a research to create cohesion among previous qualitative studies. The present met synthesis study was done to identify women's health concept and its dimensions through a systematic qualitative review.

Study Design
The present study is a qualitative metasynthesis. Metasynthesis is a study in which qualitative studies are synthesized in it, similarities and differences are compared, and their findings are paraphrased, and present a new interpretation, which can lead to a more comprehensive survey about the issues (9). In this systematic study, studies related to women's health concept in Iran were qualitatively analyzed.

Inclusion Criteria
One of the features of metasynthesis studies is to use articles issued in the same language (10). Therefore, one of the criteria was to use qualitative studies issued in Persian language. Of other criteria or the present study's choice were studies in which their participants were women's studies. As a result, studies about women whose participants were men were not included in the study.

Search Strategy
In the present study, qualitative articles published between 2001 to 2013 about women's health in Iran in databases such as Sid, Magiran and Iranmedex were analyzed. Search in these databases was done using key words "women" and "health". Above-mentioned studies sources were also studied, and articles, which were about women's health issues and met entering criteria were also used after systematic search, manual and library search was also done in which one related qualitative article was found and entered the study. A summary of how articles were chosen is shown in Fig.1.

Selecting Studies and Data Extraction
At first, in each of the mentioned databases, the articles' titles were analyzed. In the first level, studies whose titles clearly showed quantitative approach were deleted. In the second level, the articles, which had a quantitative approach in their abstracts, were omitted. In the third level, those studies whose participants were not solely women were eliminated from the study. At last, manual search was done, and only one article was added to the study. After search, themes, subcategories and categories of articles' findings were analyzed.

Data Analysis
Each qualitative study was carefully read, and findings were hi-lighted. In this study, content analysis was used to analyze the data. In this method, analysis units included themes and categories extracted from studies. A code was allocated to each of the analysis units. Then, similar codes were mingled, and data reduction continued until categories appeared. In fact, codes were unlocked to be placed in sub-categories based on their semantic similarities.
In addition, each one of the 29 studies was independently examined by the two researchers in order to extract the similar codes reported by articles.
In order to increase credibility, external check method was used (11). In so doing, codes and extracted categories were given to two experienced professors in qualitative research. In placing some codes, there was a slight dispute, which was resolved finally, and some changes occurred.

Results
The summary of the chosen qualitative studies is shown in Table 1. After analyzing codes, three categories were extracted which each of them had one subcategory (Table 2). Major categories are as followed: Women's health personal factors: These factors lie in three classes: Physical, psychological -emotional and spiritual. Physical dimension includes menopause as a physiologic phenomenon, end of femininity and senility. Psychosocial dimension is women's attitudes and reactions to the realities affected by experiences, knowledge, fear and women's self-efficacy. Spiritual dimension includes subcategories such as coping and positive thinking. Women's health familial factors: These factors are classified in three subcategories: fertility, husband's support and women's fundamental roles.
In fertility category, these subcategories are inserted: understood sexual experiences and pregnancy.
In husband's support category, some subcategories such as understanding women's issues, positive attitudes towards women, love and participation in family planning are included. In women's fundamental roles category, which includes wife, maternal and supervisor's role, these subcategories are clarified: skill to solve marital problems, maternal experience, sweet and sour of motherhood and child's gender. Women's health social factors: These factors are classified in three categories of cultural, socioeconomically support, and women's management issues, and subcategories of attitude change, financial support, social interaction and preventive services.

Discussion
The results of the present study can be a conclusion from qualitative studies, which focused on women's health issues from their own viewpoints. These categories are the result of a re-analysis of data from a different perspective

Personal Factors
The present study showed that women's health personal factors include dimensions such as physical, psycho-social and spiritual. It also showed that health is only feasible when balance is among these dimensions; this category matched other studies (12)(13)(14).
In physical dimension, there are physiological periods and pathological conditions. What attained from the review of the studies showed that most of the women's health related studies in Iran mostly focused on one of women's physiological issues ; that is, menopause (15). As the results of one study showed, studies done so far on women are centered around menopause, productivity and menstruation (12,14). This study showed that qualitative study is just done on one of women's physiological issues-menopause in Iran (15,16). It seems that every physiological period in women's life, such as puberty, is associated with certain problems. To unveil these unknown needs of women in every physiological period different study with qualitative approach may prove helpful. Another subcategory of physical dimension is the pathological problems, which includes coping with illness, other and illness and society and illness. Reviews showed that qualitative studies about pathological problems of women in Iran just paid attention to issues such as breast cancer, health problems in women with diabetes, and experiences of women suffering from vitiligo (17)(18)(19)(20). Nevertheless, a lack of many studies including diseases such as osteoporosis, anemia, hirsutism and melisma, which in some ways affect women's function and appearance, is felt. The performed quantitative studies could only provide statistics information for researchers and could not solve women's problems in these regards.
In women's health psycho-social dimension, women's attitude and primary and secondary reaction was situated. In this regard, the studies were also allocated to patients suffering from breast cancer and menopause (16,21). Meanwhile, in studies performed in other contexts, it is specifically scrutinized (13,14,22). Self-care technique was focused on in a qualitative study in physiological health dimension (23). It seems this health dimension is of high importance in health, in such a way that it can affect other health demotions, too. Therefore, it is necessary to have a qualitative study with different approaches and with this certain attitude done.
In spiritual dimension, coping and positive thinking are located. This dimension, in findings of some studies, was offered with titles such as religious beliefs, and spiritual supportive system was considered as one of the major themes in breast cancer and do women's only supportive system while confronted with different kinds of abuses (14,24). In present studies, there also was found no study solely related to this health dimension, and these themes were extracted from other studies (17,25). In another study, using religions approach named divine dispensation and illness and religions appeal (26). However, this study showed used religious believes in persons at different societies make inner calm at them.

Familial Factors
In women's health familial factors, there are subcategories such as fertility, husband's support and women's fundamental roles. Women's fertility dimension consists of sexual experiences and pregnancy. There are qualitative studies in Iran on sexual pleasure, women's sex related issues, women's sexual issues in pregnancy menopause and after delivery (27)(28)(29)(30). In each of these studies, unwillingness to have sexual intercourse or its decrease is observed in women participations. Meanwhile, in other societies, besides the above issues, some other issues such as partner's sexual violence or familial sexual violence are concentrated (13,24). The results of this systematic study show that women's sexual affairs have an important role in family stability. Different sexual assaults, which may obsess women, are still unaccounted for and must be said by women themselves. Pregnancy is another subcategory of familial factors. Some studies are done in this field named "Nulliparouse women's birth experiences" and "explaining the psychological feelings of infertility patients" (25,31). It is reported in a study that childbirth is one of the most important crises in women, and childbirth experience is one of the most important experiences in women's lives which mothers always keep in mind (22).Researchers also extracted in a study some psychological changes, physical changes obstetrician's support, coping and attitude change as childbirth experiences (25). studies show that as maternal experience is kept in mind for mothers, but infertile women, in contrast, are confronted with psychological, familial and treatment problems during their lifetime. Which each could be best analyzed in a separate qualitative study. The systematic review showed that most pregnancy related issues in Iran were about childbirth experience but other studies paid attention to issues such as transition to motherhood, needed supports for this period and husband's presence at birth time (22,32). Husband's support is one of the other subcategories of familial factors, which include understanding women issues and participation in family planning. In a study covering explanation of women's attitude about men's participation and its consequences, it is shown despite the emphasis which studies had on men's attitude change towards their wives responsibilities and men's participation in family planning, in many hospital and clinics, parental care and family planning , men are not even allowed to enter (33). However, there are some studies about husband's presence at the time of childbirth in other societies (32). Woman's fundamental role is a mother subcategory of familial factors, which was specifically scrutinized in two studies named, the theoretical explanation" and" family Dynamism (34,35). The results of these studies were consistent with the findings of a study in which woman was introduced as the family strength foundation (5). Other studies came to this conclusion that mother's illness affects the whole family (3), or family affects woman's health (14). Of course due to women's diverse role in family and its different dimensions, qualitative studies seem inevitable to unveil woman's other roles in family such as emotional role, woman's role in economics and family management in order that woman's position is better understood in Iranian society, and then identifying these potentialities, we can take advantages in promoting women's health, their families and the society.

Social Factors
Social factors are another category effective in women's health, which bears subcategories of culture factors, socio-economical support and management of women's affairs. The results of this study show that cultural factors are among women's problems. As the findings of qualitative studies in other societies showed, women suffer from a higher level of stigma than men (4). Even studies done on women's different abuses showed that there are still many unknown dimensions in this field, which require qualitative research to identify and explain them (12). Moreover, those working in health centers said because of the variety of people coming to health centers, sexual violence from partner is still unaccented for and needs studies. Social insecurity is the main reason for such violence (12,13). However, in the recent research, only one of the studies was specifically allocated to social factors affecting women's health, which the above information was extracted from (6). Studies with different approaches including phenomenology and grounded theory are necessary in knowing cultural factors, comprehending phenomenon or its formation process. Financial support and social interaction are subcategories of socio economical factors. The systematic review of the present study showed that no study specifically analyzed these issues, and these categories are extracted from the results of a number of studies (6,26). The lack of qualitative studies with women's attitude in identifying and explaining social-economic factors affecting women's health is deeply felt. The review of literature also showed that financial abuses are among issues, which women, especially, with aging would confront. It is not-worthy that these abuses, due to neglect, may remain unknown (24). Since wom-en are of vulnerable groups whose problems may remain unknown dimensions through close relation that is, doing qualitative research. Preventive services are the subcategory of women's issues management, which includes training and notifying, easy access and giving supportive services. These subcategories are extracted not only from the results of issues related to women's issue management but also from the results of other studies (33,36,37). It is worth-mentioning that recent study showed that the study concentrating on women's service management reflected the attitudes of health authorities rather women's attitudes (38). In one of the studies of the systematic review, participants said consulting services in preventive pregnancy, no time is allocated to wife and her husband (33). This shows health system officials look sex education as a stigma. The recent study showed that only one qualitative study was done about sexual trainings' during puberty. Its findings showed although sexual training is a taboo, girl's receiver sexual trainings from their friends or through the internet, which is incorrect (39). Nonetheless, other studies showed sexual training in HIV patients could reach these people to an acceptable level of protective behaviors (40). Regarding supportive services, a qualitative study was done on screening cervical cancer in working women in which participants said even if screening was done, they evaded follow-up because of financial issues, not having time, employer's not cooperation, etc (37). Reviews show although screening is temporally done in women's health dimension in Iran, no good results are attained from screening due to the lack of participants, follow-up. This is an evidence that why health system officials should analyze women's problems from women's perspectives, and then make their plans operational. If the health system management does not identify women's needs, the planning's in this regard will be good for nothing. Therefore, it appears that pay attention to health concept has the potential to improve the well-being status of women. It is recommended that policymakers devote more resources to health promotion for women. There are necessary steps in more researches on exploring the different aspects of women health concept.
Finally, it should be mentioned that different qualitative methodologies, which used in this study such as phenomenological studies, grounded theories and content analyses, may not provide a clear image of the concept be under study. In addition, there are many issues to be considered in the selection of a sample of studies for meta-synthesis.

Limitation
Since meta-synthesis uses an interpretive approach, it is possible that various commentators have differing interpretations of the findings that this limitation is uncontrollable by researcher.

Conclusion
In present research, the researchers tried to perform metasynthesis on qualitative studies related to women's health, and important diminutions of women's health in Iran. Systematic review showed us that few and scattered qualitative studies were done on women's health. Due to the nature of qualitative studies which give us precious information, their comprehensive review in the form of metasynthesis will lead us to a deeper and more comprehensive understanding about the phenomenon being studies. In fact, although this metasynthesis showed that studies done on women's health are not coherent, it can draw identified diminutions in women's health as a map for doing coherent studies for future.

Ethical considerations
Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.