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Effects of Reproductive Health Education on Knowledge and Attitudes Among Female Adolescents in Saudi Arabia

Tork, Hanan Mohamed Mohamed; Al hosis, Khalid Fahad

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doi: 10.1097/jnr.0000000000000105
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International interest in the reproductive health (RH) and well-being of adolescents has grown since the 1994 International Conference on Population and Development, which called for specific efforts by government and civil society to understand and meet the unique reproductive and sexual health needs of adolescents (Innovations in Family Planning Services, Technical Assistance Project, 2012). The term “adolescent” refers to individuals between the ages of 10 and 19 years. Adolescence is the period of transition from childhood to adulthood. Significant physical and psychological changes take place during these formative years (World Health Organization [WHO], 2006).

Adolescence is a decisive period for girls around the world. What transpires during a girl’s teenage years shapes the direction of her life and that of her family. Puberty that occurs during adolescence marks a time of heightened vulnerability to leaving school, early marriage, and pregnancy (Unicef Research Report, 2012). Adolescent girls are less likely than older women to access RH care, including modern contraception and skilled assistance during pregnancy and childbirth. Many have little control over household income and limited knowledge about RH issues and lack the ability to make independent decisions about their health (Guttmacher Institute, 2009). Moreover, they often do not have access to healthcare that meets their specific needs (Malleshappa, Krishna, & Nandini, 2011). The need to address these problems through RH education has been recognized at various national and international forums. Among the several options available, creating awareness among adolescents appears to be an important and potentially effective tool.

The reproductive pattern in the Kingdom of Saudi Arabia (KSA) is characterized by pregnancies starting at an early age, by high fertility throughout the reproductive span, by low educational attainment of the mother, and by poor coverage by antenatal services (Mesleh, Al-Aql, & Kurdi, 2001).

Babay, Addar, Shahid, and Meriki (2004) evaluated the age of menarche in KSA as one of the pubertal indicators and reported the mean age of menarche as 13.05 years. According to the WHO, the priority components of national RH include premarital, antenatal, obstetric, newborn, and postpartum healthcare. In addition, contraception should be made available upon request to married couples. Furthermore, the WHO issued specific regulations regarding the premarital medical examination (WHO, 2008).

Recent research has identified a substantial deficiency in the availability of tailored preventive, primary, and specialty healthcare services for the physical, psychological, and developmental needs of adolescents (Al-Gelban, 2009). Therefore, the absence of specialized adolescent healthcare facilities poses a significant challenge to national healthcare systems, particularly in the KSA where the pediatric age group and associated facilities recognize patients only from fetal life up to 12 years old (Al-Makadma & Al-Tannir, 2010). A comparative survey carried out in all Gulf countries that studied the presence or absence of health-related courses in intermediate and secondary school curricula found no courses dealing with the reproductive system or health behaviors related to menstruation (Fetohy, 2007). Unfortunately, this result supports a previous study that concluded that the curricula of schools in Saudi Arabia do not address health education (Karachi & Elzubian, 1997).

This study aimed to assess the RH knowledge of female adolescents aged between 14 and 19 years enrolled in secondary schools and in the preparatory year of university. In addition, we assessed the effectiveness of an RH education program (RHEP) in improving the related knowledge of female adolescents.

Significance of the Study

Healthy adolescents are critical to a nation’s future health and viability. In the KSA, adolescents and young adults (10–24 years old) comprised an estimated 30% of the population in 2012 (Population Reference Bureau, 2012). Adolescents in the KSA are not treated as a distinct group and seek healthcare in either the pediatric or adult departments (Abou-Zeid, Hifnawy, & Abdel Fattah, 2009). Therefore, adolescents may encounter difficulties in obtaining proper information about their physical and sexual development. A recent study targeting healthcare professionals in the KSA noted that this issue needs further study and clarification (Al-Makadma & Al-Tannir, 2010).

Study Methodology

Study Design

A pretest/posttest design was utilized in the study, with one preintervention survey and one postintervention survey.

Participants and Setting

This intervention study was conducted on 309 female adolescents. Although the WHO defines adolescence as the period from 10 to 19 years old (WHO, 2006), the age of participants in this study ranged between 14 and 19 years, which reflects the practice of similar studies (Ali & Rizvi, 2010; Malleshappa et al., 2011) designed to capture the greater interest in gaining reproductive-health-related knowledge of girls in the latter stage of adolescence. The study recruited students enrolled in their preparatory (first) year at Qassim University and in three secondary schools in Qassim District, KSA, as participants.

Data Collection

Data collection was carried out at the school sites during school hours with the verbal consent of the respective school principals. Approval from the directors of the educational regions was obtained beforehand. A female researcher explained the purpose of the study and method of completing the questionnaire and confirmed through verbal affirmation the willingness of students to participate in the study. Two research assistants distributed and collected the research instruments as well as handled various organizational duties. Data collection took place from September to November 2012.


Three hundred nine adolescent girls participated in the pretest assessment. A 59-item structured questionnaire was administered. The questionnaire assessed the knowledge and perceptions of the study population regarding different aspects of RH. The questionnaire was adapted from a core questionnaire developed by the WHO (2005), which was divided into six sections: social and demographic variables, knowledge about reproductive physiology, awareness of contraceptive methods, awareness of sexually transmitted infections and AIDS, attitudes regarding marriage, and sexual behaviors and experiences. The questionnaire used in this study omitted the section on sexual behaviors and experiences to conform to cultural sentiments and to incorporate insights gained from the study’s exploratory phase. We devised a summary index that assigned a score of 1 for each correct response and 0 for each incorrect or “don’t know” response, yielding a potential total score range from 0 to 59. The cover sheet was coded without names or identifiable data.


The effectiveness of the RHEP has been shown in a study of adolescents in different districts in India (Malleshappa et al., 2011; Rao, Lena, Nair, Kamath, & Kamath, 2008) as well as in other countries such as Nepal (Adhikari, Nepal, & Tamang, 2004). The program was organized in three sessions held on consecutive days. Each session lasted for 2 hours. The program included a didactic lecture by one of the researchers followed by interactive discussion. Multiple teaching methods including a lecture using a PowerPoint presentation, discussion, and experience sharing were used. The program addressed topics including anatomy and physiology of the female reproductive system, physical and psychological changes during puberty, the mechanism of the menstrual cycle, disturbances of menstruation and their causes, conception, antenatal care, contraceptive methods, and sexually transmitted diseases (STDs). Program presentations used simple language and culturally nonsensitive terms. The RHEP was translated into Arabic to be applicable to adolescents in the KSA. The back-translation technique, the most common and highly recommended procedure for verifying research tool translation (Hilton & Skrutkowski, 2002), was used to create the Arabic version of the questionnaire from the original English version. Some modifications were carried out on the translated version of RHEP to simplify the language and avoid culturally sensitive terms. The effect of the RHEP was evaluated immediately after the intervention using the same questionnaire. Data collection was carried out between September and November 2012.

Statistical Analysis

Descriptive and inferential statistics were used. Frequencies, percentages, means, and standard deviation were calculated for all variables. A chi-square test tested the effect of the intervention, and McNemar’s test tested the related qualitative variables. Normality tests were used to determine the indications for parametric and nonparametric tests. The results showed an abnormal distribution for data. Therefore, nonparametric tests were used. The Wilcoxon signed rank test was used to test the study hypothesis.


Three hundred nine female adolescents completed the RHEP. Participant ages ranged from 14 to 19 years, with a mean age of 15.4 ± 1.2 years. With regard to the educational level of parents, over 60% of fathers of both secondary school students and university preparatory year students held a secondary level of education or higher. Mothers were relatively less well educated. The family income of over 70% of participants was more than 1300 USD (Table 1).

Sociodemographic Characteristics of Participants (N = 309)

Table 2 shows that participants’ knowledge regarding puberty and menstruation improved significantly after the intervention (p < .005). Their knowledge about the uterus as the source of bleeding during menstruation improved from 50.8% to 80.9% (p = .00). In addition, findings revealed that 42.4% of the participants had knowledge related to menstruation before reaching the age of menarche, with most in this category reporting their mother as their source of this knowledge and the remainder educated by their elder sisters, relatives, friends, grandmother, teachers, nurses, TV, and/or magazines. Table 3 shows that students’ knowledge related to risky practices during pregnancy such as smoking and hard work improved significantly from 48.2% to 87.4% and from 61.5% to 85.4%, respectively, after intervention (p = .00). Table 4 shows students’ awareness regarding different contraceptive methods. Remarkable postintervention improvements were noticed with regard to awareness of contraceptive pills, intrauterine devices, and injectable hormones (p = .00).

Knowledge Related to Puberty and Menstruation (N = 309)
Knowledge Related to Pregnancy and Antenatal Care (N = 309)
Knowledge Related to Contraceptive Methods (N = 309)

On the basis of the results described in Table 5, a Wilcoxon test was conducted to evaluate whether the RHEP improved the knowledge of participants related to puberty and menstruation. The results indicated a significant difference (posttest > pretest) for secondary school participants (p < .05), for preparatory year participants (p < .05), and for the total sample (p < .05).

Students’ Knowledge and Attitudes About Reproductive Health Before and After Intervention (N = 309)

In addition, a Wilcoxon test was conducted to evaluate whether the RHEP improved the knowledge of participants related to pregnancy and antenatal care. The results indicated a significant difference (posttest > pretest) for secondary school participants (p < .05) and for the total sample (p < .05) but a nonsignificant difference (posttest = pretest) for preparatory year students (p > .05).

Addressing whether the RHEP improved the attitude of participants regarding marriage and having smaller families, Table 5 indicated a significant difference (posttest > pretest) for secondary school participants (p < .05), for preparatory year participants (p < .05), and for the total sample (p < .05).

Addressing whether the RHEP improved the knowledge of participants related to contraceptive methods, findings indicated a significant difference (posttest > pretest) for secondary school participants (p < .05), for preparatory year participants (p < .05), and for the total sample (p < .05). Participants were asked in an open-ended question to name the types of STDs about which they had heard. In the preintervention assessment, nearly all (93%) reported having heard about HIV/AIDS. In terms of preintervention–postintervention comparisons, awareness of syphilis as a type of STD increased from 25% to 55% and awareness of gonorrhea increased from 10% to 45%. On the basis of the abovementioned results, RHEP improved the knowledge of participants regarding their RH.


This study evaluated the effectiveness of health education in improving the knowledge of and attitudes toward RH of adolescent girls in Saudi Arabia. Significant positive changes were observed in both facets. Significant improvements were identified in terms of the knowledge of participants related to puberty, the menstrual cycle, pregnancy, and STDs. Various studies have shown the effectiveness of interventions in increasing knowledge of RH (Parwej, Kumar, Walia, & Aggarwal, 2005; Rao et al., 2008; Shetty & Kowli, 2001). This study indicated that participants had reasonable knowledge regarding certain aspects of RH. This is may be because of the better literacy rate of secondary school students compared with illiterate adolescents and to the better education received by students in urban areas compared with those in rural areas.

Participants identified mothers as an important source of information on menstruation. This finding concurs generally with other studies (Dasgupta & Sarkar, 2008; WaterAid, 2009). According to Adinma and Adinma (2008), information on menstruation given by mothers is often incomplete and incorrect and typically based on cultural myths. Therefore, this information source may contribute to the perpetuation of negative or distorted perceptions and practices of menstruation. In view of the limited information provided to adolescent girls in Saudi Arabia, usually from mothers, family members, and peers, it is not surprising that only half of the participants correctly identified that menstrual blood originated in the uterus. This may reflect that teachers do not sufficiently provide knowledge in this regard and that girls do not attempt to learn more on their own. This finding may highlight the need for the school curriculum to provide more RH information, including information related to menstruation, to students.

This study supports that the adolescent girls remain largely unaware of contraceptive methods. The findings of this study regarding contraception awareness concur with findings of several Indian studies (Kumar, Raizada, Agarwal, & Kaur, 2000; Malleshappa et al., 2011; Rao et al., 2008). Similar findings have also been noted in other developing countries (Kibret, 2003).

This study has certain limitations that need to be taken into account when considering the study and its contributions. This study focused on RH, a subject too vast to cover all relevant issues in a single questionnaire. Because of time constraints, the number of questions was limited, and some RH issues, such as postnatal care and reproductive tract cancers, were not included. Other issues such as sexual violence were too sensitive to be approached or too culturally nuanced to be properly interpreted by respondents and thus were not included. In addition, the results were based on adolescents’ self-reports. Although every effort was made to assure the participants that their responses would be kept confidential, the possibility remains that some may have underreported their knowledge regarding STDs or contraceptive methods to avoid embarrassment. Moreover, because all participants were preparatory year and secondary school students in the Qassim District, study results cannot be generalized automatically to students in other regions or to illiterate adolescents in the KSA. Therefore, there is a need for a large-scale nationwide survey that addresses both urban and rural areas adequately. In conclusion, this study indicates that adolescent girls in Saudi Arabia remain largely unaware of many aspects of RH, especially with regard to contraceptive methods and STDs. On the basis of the findings, we conclude that the RHEP is an effective tool for improving the RH knowledge of adolescent girls.

Ethical Considerations

The Deanship of Scientific Research, Qassim University, and the administration of educational regions for the participating schools gave ethical approval for this research. Regarding the students, return of a completed questionnaire was interpreted as consent to participate. The confidentiality of information was maintained by assigning identification numbers to each participant. All participants were given contact telephone numbers to enable them to obtain further details about the study.


The authors thank all participating school students, preparatory year students, the administrative authorities of the schools, and the Deanship of the preparatory year for their enthusiasm and willingness to take part in this study.


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    reproductive health; knowledge; attitude; female adolescent

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