- Email: [email protected]
Reproductive health awareness among educated young women in Egypt
International Journal of Gynecology and Obstetrics 120 (2013) 23–26
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Reproductive health awareness among educated young women in Egypt Saad El Gelany a,⁎, Ola Moussa b a b
Department of Obstetrics and Gynecology, Faculty of Medicine, El Minya University, Minya, Egypt Faculty of Nursing, El Minya University, Minya, Egypt
a r t i c l e
i n f o
Article history: Received 18 April 2012 Received in revised form 13 July 2012 Accepted 26 September 2012 Keywords: Awareness Egypt Reproductive health Young adults
a b s t r a c t Objective: To assess the awareness of female Egyptian university students regarding reproductive health (RH) issues, and determine the factors contributing to the students' awareness. Methods: A cross-sectional survey was conducted, in which 220 female Egyptian university students selected by purposive random sampling were interviewed by means of an in-depth questionnaire. The interviews were private and confidential, and the questions concerned female reproductive anatomy and physiology; sexually transmitted diseases and HIV/AIDS; personal preferences, such as age of marriage and spacing between pregnancies; and where young women can access RH care. Results: A large proportion of the participants exhibited misunderstanding or a complete lack of knowledge about important RH issues. This overall result, which was determined to be attributable to age and sociocultural factors such as education level, comes as a source of concern for both health service providers and policy makers. Conclusion: Awareness of RH is poor in Egypt, even among young women attending institutions of higher education. The present study not only highlights the persistent need for the ongoing RH information programs, but may also provide policy makers with data that will inform new strategies. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
The major human resource for the development of any nation is the energy and creativity of a healthy young-adult population. Health in general, and reproductive health (RH) in particular, refers not only to an absence of disease but also to physical, mental, and social wellbeing [1]. When young adults have limited access to RH information, however, they have insufficient access to preventive and curative services. The RH of women represents a growing concern, especially in low-income countries where, in many cases, the rates of HIV infection have become higher among women than among men [2]. In a study conducted in Jammu, a district of the Indian state of Jammu and Kashmir, Mahajan and Sharma [3] reported that girls living in urban areas had better knowledge about RH issues than girls living in rural areas. No studies of the awareness of RH among young adult women have yet been conducted in Egypt. Worldwide, most previous studies in this area have focused on the general women population rather than on a specific sector (e.g. university students). The authors' daily observation that young women at Egyptian universities have misconceptions or incorrect knowledge about RH issues prompted the present study. Its aim was to assess RH awareness among young, educated adult females in Egypt and determine the factors contributing to higher levels of awareness.
The data were derived from a large cross-sectional, communitybased survey administered at El Minya University, El Minya, Egypt, during the Fourth Annual Meeting of Women University Students held February 20–25, 2010. The sample was recruited randomly among the meeting participants so that it would be representative of female students attending all Egyptian universities. Approval for the study was obtained from the institutional ethics committee. A brief statement of the study objectives was read aloud in Arabic to inform consent. Moreover, the students were assured that their participation would be voluntary and that they would be free to leave the study at any time if they wished. Informed consent procedures were adhered to. The interviews took place at a location and times convenient for the participants. All interviews were conducted privately, and in no cases were participants' answers made available to family members or other individuals. The interview processes were rehearsed as part of the research assistants' training to ensure that confidentiality would be respected at all times. In total, 220 female Egyptian university students were selected for an interview by purposive random sampling. They were aged between 17 and 23 years, were from 14 cities, and studied at 11 universities distributed throughout Egypt. The interviewers used a structured, in-depth questionnaire consisting of both precoded and open-ended questions. The questions concerning RH were on the following topics: reproductive anatomy; physical and psychological changes during adolescence; menstrual cycle; teenage pregnancy; abortion; premarital screening
⁎ Corresponding author at: Elsalam, Eloboor, Magahagha city, El Minya, Egypt. Tel.: + 20 2 2337634; fax: + 20 2 2342503. E-mail address: [email protected] (S. El Gelany).
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.027
24
S. El Gelany, O. Moussa / International Journal of Gynecology and Obstetrics 120 (2013) 23–26
tests; best marriage age for women and men; best age for having children; preferred number of children for a family; preferred spacing between pregnancies; family planning; HIV/AIDS and sexually transmitted diseases (STDs); and adolescents' clinics and how to access them. The obtained data were coded and analyzed.
Table 2 Sources of knowledge. Source Newspapers Yes No Books Yes No Internet Yes No
3. Results The mean age of the participants was 19.64 ± 1.40 years (Table 1). All were university students and nearly one-third (29.5%) were in their third year of higher education (Table 1). There were score variations about reproductive life. Whereas 70.9% of the participants clearly identified the different parts of the female reproductive system, 80.5% had knowledge of the earliest age at which a girl could conceive, and 75.5% were aware that physical and psychological changes occurred during pregnancy, only 55.0% had knowledge of the earliest age at which a boy was able to father a child. The areas in which the respondents scored lowest (40.0%) were those related to reproductive physiology. The questions related to teenage pregnancy inquired about the following: (1) the meaning of the term; (2) its associated traditions; (3) the factors contributing to the increasing prevalence of teenage pregnancy; (4) the proper age at which to have the first child; and (5) complications that can arise when pregnancy occurs at a young age. Most participants (80.0%) knew the meaning of the word “pregnancy” and 70.5% related teenage pregnancy to traditions rather than to the wishes of women. Most had knowledge of the proper age at which to have the first child and the optimal age
Table 1 Sociodemographic characteristics of the participants. Characteristic Age, y 17 18 19 20 21 22 23 Year at university 1st 2nd 3rd 4th 5th 6th Residence Urban Rural Father's education level Illiterate Reads and writes Secondary University Postgraduate Father's employment Worker Employee Farmer Special work Mother's education level Illiterate Reads and writes Secondary University Postgraduate Mother's employment In the home Outside the home
No. (%) 20 (9.1) 32 (14.5) 35 (15.7) 72 (32.3) 44 (20) 16 (7.3) 1 (0.5) 46 (21) 47 (21.4) 65 (29.5) 60 (27.3) 1 (0.5) 1 (0.5) 125 (56.8) 95 (43.2) 16 (7.3) 15 (6.8) 84 (38.2) 101 (45.9) 4 (1.8) 17 (7.7) 159 (72.3) 1 (0.5) 43 (19.5) 20 (9.1) 20 (9.1) 79 (35.1) 98 (44.5) 3 (1.4) 99 (45) 121 (55)
No. (%) 50 (22.3) 170 (77.3) 161 (73.2) 59 (26.8) 159 (72.3) 61 (27.7)
range for childbearing, and 74.1% were aware of the complications that can occur during a teenage pregnancy. The questions on abortion inquired about (1) the meaning of the term; (2) the meaning of “unsafe abortion;” (3) the difference between a legal and an illegal abortion; and (4) the complications that can occur following an abortion. Only 15.5% of the participants knew the meaning of “abortion,” 14.1% knew the meaning of unsafe abortion, 13.2% knew the meaning of “illegal abortion,” and 11% were aware of the harmful effects of an unsafe abortion. Only 56.4% of the participants were aware of the existence of premarital screening tests, but 85.0% of these understood the value of such tests. However, 44.1% had no knowledge of where to go for the tests. Most (90.0%) of the participants believed that, for women, the best age for marriage was between 20 and 30 years; 9.1% believed that a younger age was best and 0.9% did not know the best age for marriage. Even more participants (97.3%) considered the age range of 20 to 30 years to be the best age for a man to marry. Nearly half (45.0%) had incorrect knowledge of the fertile period after menstruation (Table 3). A little more than half (53.2%) believed that the first year after marriage was the best year to have one's first child, and most (84.1%) believed that being between 20 and 30 years of age was best for having children. Half (50.0%) wished to have no more than 2 children, half (50.0%) wished to have more, and 54.1% thought that the ideal spacing for children was 2 years. Only 3.2% of the participants were unaware of the existence of family planning methods (Table 3). There were 33 (15.0%) married participants. They thought they had planned their first pregnancy, but unawareness of the fertile period was the main reason for being
Table 3 Knowledge about or awareness of different areas of reproductive health. Area Knowledge of the fertile period Correct Incorrect Heard about family planning Yes No Heard about HIV/AIDS Yes No Knowledge of more than 1 route of HIV/AIDS transmission Yes No Heard about STDs Yes No Knowledge of the route of STD transmission Yes No Knowledge about STD protection Yes No
No. (%) 121 (55) 99 (45) 205 (93) 15 (7) 211 (96) 9 (4) 191 (87) 39 (13) 198 (90) 22 (10) 165 (75) 55 (25) 154 (70) 66 (30)
S. El Gelany, O. Moussa / International Journal of Gynecology and Obstetrics 120 (2013) 23–26
pregnant earlier. Overall, 55.0% of the participants knew the danger signs of pregnancy (e.g. bleeding and elevated blood pressure). In the questionnaire, the knowledge of AIDS focused on (1) the meaning of the expanded term and its abbreviation; (2) the mode(s) of transmission and prevention; (3) the clinical symptoms; and (4) the biological symptoms. As much as 95.9% of the participants had heard of AIDS, and most (85.5%) knew what the acronym AIDS stood for. Most (87.3%) were aware of more than 1 method of transmission and knew how to protect themselves from HIV infection (Table 3). The areas in which the participants scored low related to the biological and clinical symptoms of AIDS. Knowledge of STDs included (1) the meaning of the expanded term and its abbreviation; (2) STD modes of transmission and prevention; (3) the relationships between STDs and AIDS; and (4) STD symptoms. In total, 90.0% of the respondents had heard about STDs, 75.0% were aware of how STDs can be transmitted, and 70.0% knew how to protect themselves from STD infection. However, 36.8% did not know the meaning of STD as an abbreviation; 19.1% did not know that if a partner was infected, both partners needed to be treated; and 5.5% did not know that there was a relationship between STD infection and AIDS (Table 3). Knowledge regarding the availability of adolescents' clinics scored low, as only 8.2% of the participants were aware of their existence and only 4.1% visited them when necessary. The main factors associated with a high degree of RH awareness were a higher level of education, a higher level of education for the participant's parents, exposure to the media, and living in areas with more healthcare facilities.
4. Discussion There are areas of weakness in the quality of RH services in Egypt, as Zaky et al. [4] identified. The participants' poor knowledge of important RH issues revealed by the present findings is a cause of concern for physicians and policy makers. For example, 45.0% of the participants either had incorrect knowledge about the fertile period or had never heard of it (Table 3). A high level of studies at the university, parents with a high education level, exposure to the media, and living in modernized cities were the main contributing factors to a high awareness of RH issues (there may be an association between formal education and the desire and ability to obtain extra information through the media, which are more accessible in modernized cities than in rural areas). Conversely, being a member of a conservative family and living in an area where the population is in poor health were associated with a lack of access to information and a lower level of awareness (Table 1). Young women studying at institutions of higher learning were expected to show a high level of RH awareness. Their surprisingly poor scores could indicate that the topics investigated are not discussed at the coeducational universities that many of the participants attended. Although sexuality is an essential aspect of life, and needs to be allowed for in the education of children by any means suitable to the community, tradition has caused it to be ignored by parents and teachers in Egypt. Discussion of sex-related matters is prohibited for the same reasons, and both the community and parents encourage the young to repress any form of sexual expression. Nevertheless, a study by Chohan et al. [5] concluded that adolescents going to school had a much higher awareness of sex-related matters than dropouts. In the present study, the high scores in the area of the female reproductive organs and the youngest age when conception was possible were probably due to the inclusion of these topics in the school curriculum (as was mentioned by the participants). The main source of information about the menstrual cycle was the mother (Fig. 1). The absence of this source was associated with a lack of knowledge, leaving the young person to turn to a friend, or another
25
Mother 35% Media 16%
35% 30%
Friends 15%
No one 19%
Ashamed to ask
25% 20% 15%
Other family Member 5%
10% 5% 0% Fig. 1. Sources of information regarding changes during the menstrual cycle.
family member, or the media. Less than 10% of the participants said it was against tradition to ask about menstruation. The high scores concerning knowledge about pregnancy were attributed to the family, the media, and friends. The problems associated with teenage pregnancy mentioned by the participants were nutritional deficiencies, weight loss, and death. Few stated that teenage pregnancy may cause maternal hypertension, prematurity, low birth weight, and stillbirth. Teenage pregnancy is a worldwide problem, caused by early sexual activity in high-income countries and a tradition of early marriage in low-income countries such as Egypt. The satisfactory scores concerning teenage pregnancy were probably due to the university education; at the same time, attending a university acted as a form of protection from this type of pregnancy. Unsafe abortion is a leading cause of death in low-income countries, especially among teenagers. A study found that 72% of the deaths occurring in Nigeria among women aged 19 years and older were due to complications of unsafe abortion [6]. In the present study, 91.8% of the respondents believed that abortion was legal when the fetus and/or the mother were at risk, and the remaining 8.2% believed that the main cause of abortion was unplanned pregnancy. Infection with HIV pre-eminently concerns women, especially in low-income countries. The rate of HIV infection was found to be 2.5 times higher among young women than among young men in Mozambique, and it was found to be 2 to 8 times higher among sexually active girls aged 15 to 19 years than among their male counterparts in Kenya and Zambia [2,7]. In the present study, the low scores concerning the clinical and biological symptoms of AIDS were attributed, in part, to the relative deficiency of the curriculum on this subject. Similar results were reported by Aggarwal and Kumar [8] in 1997. On the other hand, the scores concerning the transmission and prevention of HIV infection were high. Transmission by having sexual intercourse with multiple partners and by receiving contaminated blood products were correct responses regarding the routes of transmission (Table 3). Incorrect routes (e.g. transmission by handshake) were also mentioned. These findings concerning HIV/AIDS are more or less similar to those of studies from other countries. For example, it was reported that 60% of adolescents in Bangladesh have never heard of AIDS, 37% of non-married Indian women aged 15 to 24 years have ever heard of AIDS, and 25% of Nepalese women in the same age group have ever heard of AIDS [9]. The definition STD and the need for the partner to also receive treatment were 2 areas in which the participants scored low (these results are similar to results obtained in Jammu, India, by Mahajan and Sharma [3]). As for the scores concerning menstruation, sexuality, and psychological attitudes, they were considered inadequate by the authors. Many difficulties face women attending RH clinics In Egypt, as Zaky et al. [10] reported, and these difficulties may cause both the poor RH awareness and knowledge of the female population and the poor attendance rates at the clinics. One study reported that a
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large proportion of married adolescents were unaware of the existence of emergency obstetric care, and married women younger than 20 years had very little knowledge of the life-threatening conditions that may develop during pregnancy or delivery [11]. Media exposure was significantly associated with a high level of awareness of different RH issues, as it allows communication by different means (e.g. dramas, documentaries, or songs). In the present study, television and the Internet were the most common types of media used (approximately 55% and 75%, respectively), which indicates that mass media are effective in disseminating information Table 2. In a similar study, 85% of Bangladeshi adolescents were found to have access to mass media, but that only 55% of Indian and 38% of Nepalese adolescents did [9]. One of the lessons from the present study is the necessity to develop culturally appropriate messages that can be accepted by the target population. These messages could be delivered by different means, such as television, leaflets, educational programs, and healthcare workers promoting their messages within the university itself. This could most likely be achieved via a reinforcement of the links between health professionals and policymakers, social scientists, researchers, jurists, and human rights activists, as noted by Aida in 2000 [12]. The findings of the present study may help healthcare authorities and policy makers to formulate interventions to improve the awareness of university students regarding RH in Egypt. Acknowledgments The project was funded by El Minya University as a field support grant. Conflict of interest The authors have no conflicts of interest.
References [1] ICPD. Proposed domains and indicators linked to the definition of RH adopted at the International Conference on Population and Development (ICPD) in 1994. http://www.who.int/topics/reproductive_health/en/. Published 1994. [2] Machel JZ. Unsafe sexual behaviour among schoolgirls in Mozambique: a matter of gender and class. Reprod Health Matters 2001;9(17):82-90. [3] Mahajan P, Sharma N. Awareness level of adolescent girls regarding HIV/AIDS (a comparative study of rural and urban areas of Jammu). J Hum Ecol 2005;17(4):313-4. [4] Zaky HH, Khattab HA, Galal D. Assessing the quality of reproductive health services in Egypt via exit interviews. Matern Child Health J 2007;11(3):301-6. [5] Chohan APV, Singh S, Trivedi SJ, Zaveri H. Towards Better Reproductive Health: an Intervention Experience with the Under Privileged Adolescents of Vadodara, Gujarat. Vadodra: Baroda Citizen's Council; 1998. [6] Shane B. Family planning saves lives, prevents abortion. Popul Today 1997;25(3): 1-2. [7] Clark S. Early marriage and HIV risks in sub-Saharan Africa. Stud Fam Plann 2004;35(3):149-60. [8] Aggarwal AK, Kumar R. Awareness of AIDS among school children in Haryana. Indian J Public Health 1996;40(2):38-45. [9] Khan MA. Knowledge on AIDS among female adolescents in Bangladesh: evidence from the Bangladesh demographic and health survey data. J Health Popul Nutr 2002;20(2):130-7. [10] Zaky HH, Khattab HA, Nahal N. Experiences of women using reproductive health services in Egypt: one health system in two governorates. Qual Prim Care 2010;18(5):345-52. [11] Barkat A, Majid M. Adolescent Reproductive Health In Bangladesh Status, Policies, Programs, and Issues. http://www.policyproject.com/pubs/countryreports/ARH_ Bangladesh.pdf. Published January 2003. [12] el Dawla AS. Reproductive rights of Egyptian women: issues for debate. Reprod Health Matters 2000;8(16):45-54.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Reproductive health awareness among educated young women in Egypt Saad El Gelany a,⁎, Ola Moussa b a b
Department of Obstetrics and Gynecology, Faculty of Medicine, El Minya University, Minya, Egypt Faculty of Nursing, El Minya University, Minya, Egypt
a r t i c l e
i n f o
Article history: Received 18 April 2012 Received in revised form 13 July 2012 Accepted 26 September 2012 Keywords: Awareness Egypt Reproductive health Young adults
a b s t r a c t Objective: To assess the awareness of female Egyptian university students regarding reproductive health (RH) issues, and determine the factors contributing to the students' awareness. Methods: A cross-sectional survey was conducted, in which 220 female Egyptian university students selected by purposive random sampling were interviewed by means of an in-depth questionnaire. The interviews were private and confidential, and the questions concerned female reproductive anatomy and physiology; sexually transmitted diseases and HIV/AIDS; personal preferences, such as age of marriage and spacing between pregnancies; and where young women can access RH care. Results: A large proportion of the participants exhibited misunderstanding or a complete lack of knowledge about important RH issues. This overall result, which was determined to be attributable to age and sociocultural factors such as education level, comes as a source of concern for both health service providers and policy makers. Conclusion: Awareness of RH is poor in Egypt, even among young women attending institutions of higher education. The present study not only highlights the persistent need for the ongoing RH information programs, but may also provide policy makers with data that will inform new strategies. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
The major human resource for the development of any nation is the energy and creativity of a healthy young-adult population. Health in general, and reproductive health (RH) in particular, refers not only to an absence of disease but also to physical, mental, and social wellbeing [1]. When young adults have limited access to RH information, however, they have insufficient access to preventive and curative services. The RH of women represents a growing concern, especially in low-income countries where, in many cases, the rates of HIV infection have become higher among women than among men [2]. In a study conducted in Jammu, a district of the Indian state of Jammu and Kashmir, Mahajan and Sharma [3] reported that girls living in urban areas had better knowledge about RH issues than girls living in rural areas. No studies of the awareness of RH among young adult women have yet been conducted in Egypt. Worldwide, most previous studies in this area have focused on the general women population rather than on a specific sector (e.g. university students). The authors' daily observation that young women at Egyptian universities have misconceptions or incorrect knowledge about RH issues prompted the present study. Its aim was to assess RH awareness among young, educated adult females in Egypt and determine the factors contributing to higher levels of awareness.
The data were derived from a large cross-sectional, communitybased survey administered at El Minya University, El Minya, Egypt, during the Fourth Annual Meeting of Women University Students held February 20–25, 2010. The sample was recruited randomly among the meeting participants so that it would be representative of female students attending all Egyptian universities. Approval for the study was obtained from the institutional ethics committee. A brief statement of the study objectives was read aloud in Arabic to inform consent. Moreover, the students were assured that their participation would be voluntary and that they would be free to leave the study at any time if they wished. Informed consent procedures were adhered to. The interviews took place at a location and times convenient for the participants. All interviews were conducted privately, and in no cases were participants' answers made available to family members or other individuals. The interview processes were rehearsed as part of the research assistants' training to ensure that confidentiality would be respected at all times. In total, 220 female Egyptian university students were selected for an interview by purposive random sampling. They were aged between 17 and 23 years, were from 14 cities, and studied at 11 universities distributed throughout Egypt. The interviewers used a structured, in-depth questionnaire consisting of both precoded and open-ended questions. The questions concerning RH were on the following topics: reproductive anatomy; physical and psychological changes during adolescence; menstrual cycle; teenage pregnancy; abortion; premarital screening
⁎ Corresponding author at: Elsalam, Eloboor, Magahagha city, El Minya, Egypt. Tel.: + 20 2 2337634; fax: + 20 2 2342503. E-mail address: [email protected] (S. El Gelany).
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.027
24
S. El Gelany, O. Moussa / International Journal of Gynecology and Obstetrics 120 (2013) 23–26
tests; best marriage age for women and men; best age for having children; preferred number of children for a family; preferred spacing between pregnancies; family planning; HIV/AIDS and sexually transmitted diseases (STDs); and adolescents' clinics and how to access them. The obtained data were coded and analyzed.
Table 2 Sources of knowledge. Source Newspapers Yes No Books Yes No Internet Yes No
3. Results The mean age of the participants was 19.64 ± 1.40 years (Table 1). All were university students and nearly one-third (29.5%) were in their third year of higher education (Table 1). There were score variations about reproductive life. Whereas 70.9% of the participants clearly identified the different parts of the female reproductive system, 80.5% had knowledge of the earliest age at which a girl could conceive, and 75.5% were aware that physical and psychological changes occurred during pregnancy, only 55.0% had knowledge of the earliest age at which a boy was able to father a child. The areas in which the respondents scored lowest (40.0%) were those related to reproductive physiology. The questions related to teenage pregnancy inquired about the following: (1) the meaning of the term; (2) its associated traditions; (3) the factors contributing to the increasing prevalence of teenage pregnancy; (4) the proper age at which to have the first child; and (5) complications that can arise when pregnancy occurs at a young age. Most participants (80.0%) knew the meaning of the word “pregnancy” and 70.5% related teenage pregnancy to traditions rather than to the wishes of women. Most had knowledge of the proper age at which to have the first child and the optimal age
Table 1 Sociodemographic characteristics of the participants. Characteristic Age, y 17 18 19 20 21 22 23 Year at university 1st 2nd 3rd 4th 5th 6th Residence Urban Rural Father's education level Illiterate Reads and writes Secondary University Postgraduate Father's employment Worker Employee Farmer Special work Mother's education level Illiterate Reads and writes Secondary University Postgraduate Mother's employment In the home Outside the home
No. (%) 20 (9.1) 32 (14.5) 35 (15.7) 72 (32.3) 44 (20) 16 (7.3) 1 (0.5) 46 (21) 47 (21.4) 65 (29.5) 60 (27.3) 1 (0.5) 1 (0.5) 125 (56.8) 95 (43.2) 16 (7.3) 15 (6.8) 84 (38.2) 101 (45.9) 4 (1.8) 17 (7.7) 159 (72.3) 1 (0.5) 43 (19.5) 20 (9.1) 20 (9.1) 79 (35.1) 98 (44.5) 3 (1.4) 99 (45) 121 (55)
No. (%) 50 (22.3) 170 (77.3) 161 (73.2) 59 (26.8) 159 (72.3) 61 (27.7)
range for childbearing, and 74.1% were aware of the complications that can occur during a teenage pregnancy. The questions on abortion inquired about (1) the meaning of the term; (2) the meaning of “unsafe abortion;” (3) the difference between a legal and an illegal abortion; and (4) the complications that can occur following an abortion. Only 15.5% of the participants knew the meaning of “abortion,” 14.1% knew the meaning of unsafe abortion, 13.2% knew the meaning of “illegal abortion,” and 11% were aware of the harmful effects of an unsafe abortion. Only 56.4% of the participants were aware of the existence of premarital screening tests, but 85.0% of these understood the value of such tests. However, 44.1% had no knowledge of where to go for the tests. Most (90.0%) of the participants believed that, for women, the best age for marriage was between 20 and 30 years; 9.1% believed that a younger age was best and 0.9% did not know the best age for marriage. Even more participants (97.3%) considered the age range of 20 to 30 years to be the best age for a man to marry. Nearly half (45.0%) had incorrect knowledge of the fertile period after menstruation (Table 3). A little more than half (53.2%) believed that the first year after marriage was the best year to have one's first child, and most (84.1%) believed that being between 20 and 30 years of age was best for having children. Half (50.0%) wished to have no more than 2 children, half (50.0%) wished to have more, and 54.1% thought that the ideal spacing for children was 2 years. Only 3.2% of the participants were unaware of the existence of family planning methods (Table 3). There were 33 (15.0%) married participants. They thought they had planned their first pregnancy, but unawareness of the fertile period was the main reason for being
Table 3 Knowledge about or awareness of different areas of reproductive health. Area Knowledge of the fertile period Correct Incorrect Heard about family planning Yes No Heard about HIV/AIDS Yes No Knowledge of more than 1 route of HIV/AIDS transmission Yes No Heard about STDs Yes No Knowledge of the route of STD transmission Yes No Knowledge about STD protection Yes No
No. (%) 121 (55) 99 (45) 205 (93) 15 (7) 211 (96) 9 (4) 191 (87) 39 (13) 198 (90) 22 (10) 165 (75) 55 (25) 154 (70) 66 (30)
S. El Gelany, O. Moussa / International Journal of Gynecology and Obstetrics 120 (2013) 23–26
pregnant earlier. Overall, 55.0% of the participants knew the danger signs of pregnancy (e.g. bleeding and elevated blood pressure). In the questionnaire, the knowledge of AIDS focused on (1) the meaning of the expanded term and its abbreviation; (2) the mode(s) of transmission and prevention; (3) the clinical symptoms; and (4) the biological symptoms. As much as 95.9% of the participants had heard of AIDS, and most (85.5%) knew what the acronym AIDS stood for. Most (87.3%) were aware of more than 1 method of transmission and knew how to protect themselves from HIV infection (Table 3). The areas in which the participants scored low related to the biological and clinical symptoms of AIDS. Knowledge of STDs included (1) the meaning of the expanded term and its abbreviation; (2) STD modes of transmission and prevention; (3) the relationships between STDs and AIDS; and (4) STD symptoms. In total, 90.0% of the respondents had heard about STDs, 75.0% were aware of how STDs can be transmitted, and 70.0% knew how to protect themselves from STD infection. However, 36.8% did not know the meaning of STD as an abbreviation; 19.1% did not know that if a partner was infected, both partners needed to be treated; and 5.5% did not know that there was a relationship between STD infection and AIDS (Table 3). Knowledge regarding the availability of adolescents' clinics scored low, as only 8.2% of the participants were aware of their existence and only 4.1% visited them when necessary. The main factors associated with a high degree of RH awareness were a higher level of education, a higher level of education for the participant's parents, exposure to the media, and living in areas with more healthcare facilities.
4. Discussion There are areas of weakness in the quality of RH services in Egypt, as Zaky et al. [4] identified. The participants' poor knowledge of important RH issues revealed by the present findings is a cause of concern for physicians and policy makers. For example, 45.0% of the participants either had incorrect knowledge about the fertile period or had never heard of it (Table 3). A high level of studies at the university, parents with a high education level, exposure to the media, and living in modernized cities were the main contributing factors to a high awareness of RH issues (there may be an association between formal education and the desire and ability to obtain extra information through the media, which are more accessible in modernized cities than in rural areas). Conversely, being a member of a conservative family and living in an area where the population is in poor health were associated with a lack of access to information and a lower level of awareness (Table 1). Young women studying at institutions of higher learning were expected to show a high level of RH awareness. Their surprisingly poor scores could indicate that the topics investigated are not discussed at the coeducational universities that many of the participants attended. Although sexuality is an essential aspect of life, and needs to be allowed for in the education of children by any means suitable to the community, tradition has caused it to be ignored by parents and teachers in Egypt. Discussion of sex-related matters is prohibited for the same reasons, and both the community and parents encourage the young to repress any form of sexual expression. Nevertheless, a study by Chohan et al. [5] concluded that adolescents going to school had a much higher awareness of sex-related matters than dropouts. In the present study, the high scores in the area of the female reproductive organs and the youngest age when conception was possible were probably due to the inclusion of these topics in the school curriculum (as was mentioned by the participants). The main source of information about the menstrual cycle was the mother (Fig. 1). The absence of this source was associated with a lack of knowledge, leaving the young person to turn to a friend, or another
25
Mother 35% Media 16%
35% 30%
Friends 15%
No one 19%
Ashamed to ask
25% 20% 15%
Other family Member 5%
10% 5% 0% Fig. 1. Sources of information regarding changes during the menstrual cycle.
family member, or the media. Less than 10% of the participants said it was against tradition to ask about menstruation. The high scores concerning knowledge about pregnancy were attributed to the family, the media, and friends. The problems associated with teenage pregnancy mentioned by the participants were nutritional deficiencies, weight loss, and death. Few stated that teenage pregnancy may cause maternal hypertension, prematurity, low birth weight, and stillbirth. Teenage pregnancy is a worldwide problem, caused by early sexual activity in high-income countries and a tradition of early marriage in low-income countries such as Egypt. The satisfactory scores concerning teenage pregnancy were probably due to the university education; at the same time, attending a university acted as a form of protection from this type of pregnancy. Unsafe abortion is a leading cause of death in low-income countries, especially among teenagers. A study found that 72% of the deaths occurring in Nigeria among women aged 19 years and older were due to complications of unsafe abortion [6]. In the present study, 91.8% of the respondents believed that abortion was legal when the fetus and/or the mother were at risk, and the remaining 8.2% believed that the main cause of abortion was unplanned pregnancy. Infection with HIV pre-eminently concerns women, especially in low-income countries. The rate of HIV infection was found to be 2.5 times higher among young women than among young men in Mozambique, and it was found to be 2 to 8 times higher among sexually active girls aged 15 to 19 years than among their male counterparts in Kenya and Zambia [2,7]. In the present study, the low scores concerning the clinical and biological symptoms of AIDS were attributed, in part, to the relative deficiency of the curriculum on this subject. Similar results were reported by Aggarwal and Kumar [8] in 1997. On the other hand, the scores concerning the transmission and prevention of HIV infection were high. Transmission by having sexual intercourse with multiple partners and by receiving contaminated blood products were correct responses regarding the routes of transmission (Table 3). Incorrect routes (e.g. transmission by handshake) were also mentioned. These findings concerning HIV/AIDS are more or less similar to those of studies from other countries. For example, it was reported that 60% of adolescents in Bangladesh have never heard of AIDS, 37% of non-married Indian women aged 15 to 24 years have ever heard of AIDS, and 25% of Nepalese women in the same age group have ever heard of AIDS [9]. The definition STD and the need for the partner to also receive treatment were 2 areas in which the participants scored low (these results are similar to results obtained in Jammu, India, by Mahajan and Sharma [3]). As for the scores concerning menstruation, sexuality, and psychological attitudes, they were considered inadequate by the authors. Many difficulties face women attending RH clinics In Egypt, as Zaky et al. [10] reported, and these difficulties may cause both the poor RH awareness and knowledge of the female population and the poor attendance rates at the clinics. One study reported that a
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large proportion of married adolescents were unaware of the existence of emergency obstetric care, and married women younger than 20 years had very little knowledge of the life-threatening conditions that may develop during pregnancy or delivery [11]. Media exposure was significantly associated with a high level of awareness of different RH issues, as it allows communication by different means (e.g. dramas, documentaries, or songs). In the present study, television and the Internet were the most common types of media used (approximately 55% and 75%, respectively), which indicates that mass media are effective in disseminating information Table 2. In a similar study, 85% of Bangladeshi adolescents were found to have access to mass media, but that only 55% of Indian and 38% of Nepalese adolescents did [9]. One of the lessons from the present study is the necessity to develop culturally appropriate messages that can be accepted by the target population. These messages could be delivered by different means, such as television, leaflets, educational programs, and healthcare workers promoting their messages within the university itself. This could most likely be achieved via a reinforcement of the links between health professionals and policymakers, social scientists, researchers, jurists, and human rights activists, as noted by Aida in 2000 [12]. The findings of the present study may help healthcare authorities and policy makers to formulate interventions to improve the awareness of university students regarding RH in Egypt. Acknowledgments The project was funded by El Minya University as a field support grant. Conflict of interest The authors have no conflicts of interest.
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