Ayfer Gemalmaz(1) , Serpil Aydin(2) , Nazli Sensoy(3)

1. * MD, Assist.Prof, Head of Integrated Medical Applications Training Committee Dept. of Family Medicine, School of Medicine, Adnan Menderes University, AYDIN, TURKEY
2. ** MD, Assoc.Prof, Head of Community Based Medicine Training Committee Dept. of Family Medicine, School of Medicine, Adnan Menderes University, AYDIN, TURKEY
3. *** MD, Assist.Prof, Dept. of Family Medicine, School of Medicine, Afyon Kocatepe University, AFYON, TURKEY

Corresponding Address:
Mimar Sinan Mah.
Dus Bahceleri Sitesi 2. Cad 2429.
Sok No: 53 (P.K. 112) 09100 AYDIN/TURKEY
Phone: +90 256 219 6181 (home)
+90 256 219 7188 (office)
Fax: +90 256 219 2011 (office)
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Keywords: medical students, reproductive health, contraceptive methods, STDs
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Each year, it is estimated that over 585,000 women die worldwide because of complications from pregnancy, birth, and abortions because of inappropriate conditions 1. On the other hand, the rate, cost, and morbidity challenges of unwanted pregnancy and sexually transmitted diseases (STDs) are increasing each day around the world. The majority of these deaths and the inappropriate conditions may, be prevented by educating people about reproductive/sexual health (R/SH) and by increasing the usage of effective contraceptive methods 2. Therefore, developing countries should give particular importance to this issue.

Turkey is a developing country, and health indicators are not at the desired levels. Although the total birth rate in Turkey is decreasing (i.e., 2.23 per woman), infant and maternal mortality and intentional abortion rates are higher compared to developed countries, 43 per 1000 live births, 49 per 100,000 live births 3, and 11.3%, respectively 4. According to a 2003 study conducted by Hacettepe University, the overall contraceptive usage rate in Turkey is 71%, but 28.5% of sexual participants prefer traditional methods like coitus interruptus and calendar methods 4. Although the Turkish Ministry of Health (MoH) provides free family planning services, two-thirds of Turkish women still do not use contraceptives.
Despite the fact that during the last decade, when eight-year primary school education became obligatory in Turkey, the illiteracy rate remains at 12.6% 5. Since primary school graduates account for 61.1% of Turkey's total population 5; primary school teachers play an important role in public education. This may be particularly important where including reproductive health education is concerned. Primary school curricula contain R/SH instruction, but it is not clear if the goals of these programs are achieved.
Doctors comprise another important group, with responsibility for public health education. During medical school medical educators are responsible for educating students, physicians, and residents about R/SH 6. In Turkey, upon graduation medical students are mostly employed by the Ministry of Health (MoH) which provides primary care services (PCS), and the graduates deal with patients in primary care centers 7. Similarly, maternal-child health care and family planning services are provided mostly through PCS, so it is very important that future doctors be knowledgeable about these issues.

Therefore, the aims of this study were:

1. to identify the knowledge, opinions, and attitudes of the students about R/SH
   
2. to determine the effects of a medical school R/SH curriculum given in the second class
   
3. to compare the socio-demographic features, R/SH knowledge and experiences between medical and educational sciences students
   
4. to evaluate the knowledge levels of the students about R/SH, prior to their university education
   
5. to call students' attention to R/SH,
   

Setting
Adnan Menderes University, a relatively young institution, was established in 1992 in Aydin which is located in the Aegean part of Turkey. It is composed of six schools, including educational sciences and medical schools. In the School of Educational Sciences, R/SH lectures begin in the 3rd class. The School of Medicine has an integrated curriculum, which is based on community-oriented medicine. The focus of the Family Medicine Department is also community-oriented medicine and has a significant role in the curriculum. In the School of Medicine, the R/SH program begins in the second term of the second class. In addition to the second class theoretical lectures, covering R/SH care, contraceptive methods and family planning counseling, instruction in clinical skills (like applying intrauterine devices, family planning counseling and communication skills), and field experiences (like simulated patient interviews, visiting PCSs), are conducted by two of the authors (AG and SA).

Questionnaire
In this cross-sectional study, we used an anonymous, self-administered, and structured questionnaire, consisting of three parts employing 34 questions which may be either open- or closed-ended. We used related literature as well as information gathered from group discussions with the students as the basis for the questionnaire. To track the questionnaires, but still maintain anonymity, we established a tracking number for each participant. The tracking number was composed of the first letter of the participant's first name, the total number of letters in his/her mother's first name, the number of the month in which he/she was born, and his/her eye colour (e.g., S-07-December-black). The first part of the questionnaire consists of socio-demographic information of the participant: age, gender, number of siblings, place of birth, parents' level of education, and the type of high-school from which they had graduated. The second part of the questionnaire deals with attitudes towards sexual behaviors and opinions on reproductive health. The last part is geared toward assessing the basic knowledge of the participant on these subjects.

Data
The target population of this study was the second class medical students and the third class educational sciences students at Adnan Menderes University. Permission was obtained from the Medical Directorate of the University. Confidentiality and anonymity were assured to the students. All participation was voluntary and based on oral informed consent. For both sets of students, questionnaires were distributed and collected by trained interviewers prior to the beginning of the educational period. For the medical school students, the questionnaires were given again after the students had completed the educational period on this subject. The questionnaire was not given again after the lectures in educational sciences school as the lectures were not given by the authors. The educational sciences students can be considered as a control group for the pre-educational knowledge level and socio-demographic features. The cut-off point of the total knowledge score was determined as 20 over 30, and students obtaining more than 20 points were considered to be "successful."

Statistical Analysis
The answers for open-ended questions were categorized for data entry. The socio-demographic features were given as means ± standard deviations (SD). Chi square, student t- test, ANOVA, and correlation analyses were performed for the statistical evaluation. A p value smaller than 0.05 was accepted as statistically significant.

All of the students in the second class of medical school (n=63) and 76 of 101 (75.2%) students in the third class of the School of Educational Sciences participated in the study. The mean age of the total group was 20.1±1.4 years (minimum 17, maximum 24). Females comprised 51.8% of the group. There was a larger number of females in the School of Educational Sciences (p=0.024). Table 1 shows gender distribution according to the schools.

*p:0.024

The educational level of the participants' mothers was low. The illiteracy rate was 12.2%. Primary school graduates accounted for 41.7%, while high school/university graduates numbered 36.6%.
The educational level of the fathers was better. Only 3.6% of the fathers were illiterate. Primary school graduates totaled 25.4%, while high school/university graduates totaled 58.3%. The questionnaires revealed that the fathers of the medical students had higher levels of education than those of the educational sciences students (p<0.05).

The students were similar in other socio demographic features. The mean sibling number was 2.9±1.7. The students were mostly from the Aegean part of Turkey and generally lived separately from their families. Only 13.7% lived with their families in Aydin. 75 (54%) students (mostly medical students) had graduated from special high schools, where the curricula offered more foreign language and science lectures than the ordinary high schools. In general, the medical students graduated from the special high schools, and this fact was statistically significant (p=0.000).

Of the total participants, 26 students were smokers and 39 students drank alcohol. The mean age when these students started to smoke was 16.9±2.4 years. Between the schools, there was no difference in the rates for drinking alcohol and smoking. The mean age of adolescence was 13.4±1.2 years. 69.8% of the students had a girl/boyfriend. Of the total, 25.2% (mostly males, p=0.000) had some sexual experience. Flirting and sexual experience rates were similar for both gender in both schools. The mean age of the students when they had their first sexual encounter was 17.9±1.7 years. Among those who were sexually active, only 31.4% used contraception, mostly condoms.

Only 38 students (27.3%) thought their knowledge of R/SH was adequate. However, between the educational sciences and the medical students, the medical students thought that they were more knowledgeable (p=0.000). Both sets of students obtained their first knowledge of R/SH, mostly from their friends and mothers, but 56 students stated that they had no knowledge of this subject at all. Of those 56 students, the majority were medical students (p=0.000). Only 30 (21.6%) students stated that they had gained sufficient knowledge of R/SH during their secondary or high school education, and, again, the rate was higher among the medical students (p=0.025).

Typically, students preferred to talk about R/SH issues with their girl/boy friends (39.5%), and secondly with their mothers (25.9%). A total of 20 students preferred to speak with health professionals about R/SH issues, while the remaining stated that they had no one to talk with, about such issues. 37.4% of the students preferred to get their knowledge from their friends, 36.0% from their mothers, and 13.7% from multimedia resources. Typically, the educational sciences students preferred obtaining R/SH information from the media and their parents as compared to the medical students (p=0.01).
In general, R/SH knowledge did not differ according to gender or previous formal education, except medical students were more knowledgeable about STD prevention measures (p=0.04).

The students, who had experience in flirting, scored higher in their knowledge of STD prevention and contraceptive methods as well as had a higher overall knowledge score (p=0.015, p=0.045, p=0.029, respectively). The students, who had some sexual experience, knew much more about STD prevention measures (p=0.046). The students, who experienced abuse, could list the names of more STDs than the other participants (p=0.004); and they achieved higher scores in overall knowledge, but it was not statistically significant.

Tables 2, 3, and 4 list the STDs, contraceptive methods, and STD prevention measures respectively that were recorded by the students in the questionnaire.

*P <0.05

The mean knowledge score of the whole group was 19.8±3.4 (10-26) over 30. There was no statistical significance based on gender or previous formal education. The "successful" group was composed of 70 (50.4%) students.

The mean knowledge score of medical students before and after R/SH lectures improved from 20.2±3.6 to 26.1±2.6 (p=0.000). Prior to the lectures, 36 medical students (57.1%) comprised the "successful" group. After the lectures, this number increased to 60 students (95.2%) (p=0.000).

In the second class of medical school after the R/SH lectures, students scored higher in their knowledge of STD prevention, contraceptive methods, and overall knowledge (p<0.001). There was no significant difference in their knowledge of STD prevention measures after the lectures.

It is known that knowledge, opinion, and attitudes are related to behaviors, as knowledge and attitudes are predictive factors for reproductive behaviors 1. We planned to determine the knowledge, attitudes, and opinions in order to highlight the behavior of future public educators. The mean age of our group when they had their first sexual experience was below 18, which is concordant with other studies 8,9. The rate of premarital sexual experience among university students in the literature varied widely from 12 to 86% 8,9. Our students' sexual experience rate of 25.2% can be considered as low, which may be due to the Turkish culture. In our study, we found that one-third of the sexually active students used contraceptive methods compared to 69-89% in the referenced studies. These differences can be due to a lack of awareness and the intimate nature of this subject in Turkish culture. Most of our students preferred condoms as the primary contraceptive method, which is concordant with these studies.
It is interesting that medical students stated that their R/SH knowledge was sufficient; because there was no significant difference between the mean knowledge scores of the two groups. Also, 35 medical students declared that they had no R/SH knowledge. This statement of sufficient R/SH knowledge can most likely be related to a lack of insight by the medical students, or to being overly confident because they are in medical school. 78.4% (109 students) of the whole group also revealed that during primary and high school, they did not get sufficient R/SH education. It can be considered a conflict that most of the medical students neither acquired their R/SH knowledge from school nor from another source, but they thought their R/SH knowledge was sufficient. Only 14.4% of the students preferred to talk about R/SH issues with health professionals. This may be due to the lack of experience by the physicians or possibly, due to the intimate nature of the subject. It is very important for primary care physicians to recognize and search for opportunities to educate patients regarding R/SH during their visits.

Because 13.7% of the students preferred multimedia as an information source, media resources have the duty to provide correct knowledge and to direct the public about this intimate subject. In a study conducted in Nigeria 9, the most common source for information is health workers, followed by TV-radio-newspapers, friends, and lastly parents. Contrary to this study, our students commonly preferred friends, parents, media, and lastly health workers as a source of information. This can indicate cultural differences and to miss the opportunity to use the patient visits as a source of education.
The most known STD was AIDS which was concordant with other studies 8,9. In our study, AIDS was followed by hepatitis B and C and gonorrhea. Chinese students named syphilis as the second most common STD 8.

The most commonly named contraceptive method in our study was the condom, followed by oral contraceptives, the intrauterine device, vasectomy, tubal ligation, and coitus interruptus. In a Nigerian study 9, the first common contraceptive method was also the condom (83.4%), but the second most common method was the calendar method (43.5%), which none of our students mentioned. In the Nigerian study, they indicated coitus interruptus as the third method (36.4%), but in our study, the rate of coitus interruptus was very low. It can be said that our students knew very much about effective contraceptive methods, despite the fact that the use of contraceptive methods among the sexually active students was low. This means that knowledge has not been converted into behavior.
Condom use was also the most commonly mentioned measure to prevent STDs, followed by obeying the hygienic rules, and having a single sex partner. In Zhang's study 8, having a single sex partner ranks first (40%), followed by condom use (22%), and obeying the hygienic rules (15%). The differences in the ranking between Zhang's study and ours could be dependent upon our students' attitudes because polygamy is illegal and having multiple sexual partners is a sin according to the Islamic beliefs, and more than 90% of the Turkish population is Muslim.

Improvements in the results of the mean knowledge scores as well as higher scores in STD prevention and contraceptive methods indicate that our second class curriculum on R/SH was quite effective. However, the class material should be rearranged to emphasize those subjects in which the students have the least knowledge. The fourth class lectures on these subjects are taught by the obstetrics/gynecology training committee. This study can be conducted again with these same students at their fourth year level to determine if there is any improvement in their knowledge and attitudes after the fourth class lectures.

There are some limitations of this study: (1) the questionnaire was not validated; (2) the educational sciences students were taught only once, and there was no follow-up with absent educational students; and (3) as we did not perform the lectures in educational sciences school, we did not evaluate the effect of reproductive health lectures on that group.

We consider our study to be a beginning as it serves to identify the knowledge, opinions, attitudes, awareness, and experiences of our students in R/SH. This study pointed out that students had insufficient education about R/SH before continuing their education at the university level. Consequently, R/SH education should be provided earlier because it takes a long time for knowledge and opinions to change behaviors. As retention of knowledge about R/SH decreases year by year 10, we have to intensify it by additional lectures to the third year curriculum.

New strategies and educational programs should be planned to encourage the use of effective contraceptive methods and prevention of STDs among university students. Further studies are needed to assess their ongoing knowledge, improvements, and attitudes about this issue before graduation.

We thank our students and acknowledge Janice O. Vantrease for her grammatical review, Dr. Mark Gelula and Dr. Pat Bloom for their valuable suggestions.