Applied Research

International Quarterly of
Community Health Education
Student Attitudes About Reproductive Health 2021, Vol. 41(2) 133–142
! The Author(s) 2020
in Public Universities: A Cross-Sectional Study Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0272684X20916599
journals.sagepub.com/home/qch

Fatemeh Kashefi1 , Afsaneh Bakhtiari2, Hajar Pasha3,

Fatemeh Nasiri Amiri3, and Fatemeh Bakouei3

Abstract
Background: Determine attitude of young people to reproductive health issues can somewhat predict their behavior in this area.
This helps us in planning future on reproductive health. The aim of this study was to determine the attitude of reproductive health and
related factors among Iranian students in public universities in Iran.
Method: A cross-sectional study was carried out. The tool was developed based on a literature review to find out about reproductive
health attitudes and sociodemographic factors associated. The face and content validity of the questionnaire was performed using
expert judgment. Cronbach’s coefficient and test–retest were used to determine the reliability. Data were analyzed using the Statistical
Package for Social Sciences software by independent t test, ANOVA, and multiple linear regression.
Results: Out of 461 respondents, the majority of students were nonmedical sciences (81.1%). The main sources of information for
reproductive health awareness were the media (40%); 54.9% disagreed with having premarital sex in both sexes, while only 36% agreed
to postpone sexual activity until marriage in order to prevent sexually transmitted diseases. Moreover, 64% believed that contra-
ception would cause infertility in the future. The majority found the need for reproductive health services and education essential for
single youth. Multiple regression showed a poor reproductive health attitude in nonmedical students, families who did not talk about
boy–girl relationships, as well as in satellite users and hookah consumers.
Conclusion: The students’ level of attitude on reproductive health was not satisfactory. Intervention programs related to repro-
ductive health taking into account the cultural aspects of Iranian society can protect young people from risky behaviors and unwanted
pregnancies by creating a positive attitude.

Keywords
reproductive health, attitude, young adult

As a driving force, youth play a key role in the political, opportunities related to sexual health and reproduction. In
social, and cultural development of societies.1 One of the all countries, increasing access to the media, urbanization,
United Nations human development indicators for assessing and globalization play a role in changing young people’s
countries’ development and well-being is the presence of sexual values, norms, and behaviors, which are often at
young population that is considered a serious cause of odds with traditionally, culturally, and socially conservative
change, transformation, and development in all dimensions.2 attitudes toward premarital sex and gender norms. These
Countries that have properly managed their young popula- factors contribute to significant barriers that limit young
tions have achieved prosperity and development, but coun-
tries that were not successful in this regard, young people
became a serious challenge to stability and socioeconomic 1
development of communities.3 2
Student Research Committee, Babol University of Medical Sciences
Mobility Impairment Research Center, Health Research Institute, Babol
Today’s young generation is the largest in history; global- University of Medical Sciences
ly, 1.8 billion people between the ages of 15 and 24 make up a 3
Infertility and Health Reproductive Research Center, Health Research Institute,
quarter of the world’s population.4 Estimates of the popula- Babol University of Medical Sciences
tion of Iran in recent year show that about 24% of the pop-
Corresponding Author:
ulation is young people aged 15 to 29 years.5 These young Afsaneh Bakhtiari, Mobility Impairment Research Center, Health Research
people live in diverse sociocultural and economic back- Institute, Babol University of Medical Sciences, Babol 0098, Iran.
grounds but share their important challenges and Email: [email protected]
134 International Quarterly of Community Health Education 41(2)

people’s access to the information and services they need to issues.15,16 Meanwhile, studies showed that Iranian youth
transition to adulthood.6 have poor knowledge of reproductive health,13,14 and 8%
Youth is the time of the formation of important behavior of them have premarital sex.7 Therefore, reproductive
patterns including sexual and reproductive behaviors.7 health in single youth is less known in Iranian society. Few
Current information suggests that most young people are studies on the attitudes and beliefs of young Iranian girls
entering adulthood when they are not ready to move on. about sexual and reproductive health indicated a lack of
The transition from adolescence to adulthood without accu- information on reproductive health.3,13,15,17
rate knowledge and positive attitudes about reproductive and In addition, Indian youth often have serious misconcep-
sexual health information and services may lead to many tions about sexuality and reproduction and are unprepared
negative behavioral consequences and problems.8 In general, to make safe, informed decisions. Many hold permissive atti-
a significant proportion of young people are sexually active. tudes on the acceptability of premarital sex.18 The study of
In addition, many young girls report forced sex. As a result, Mitsiwat et al. 19 has shown that students strongly agree the
young people are exposed to poor outcomes such as prema- inclination that only females should use reproductive health
ture and unintended pregnancy, unsafe abortion, sexually service. A study among Turkish youth showed the opinion
transmitted infections, and HIV. Poor sexual and reproduc- of males about having sexual intercourse before marriage for
tive health not only affects the health and well-being of males was positive, and females were more tolerant about
young people, but they also have significant economic and males having this experience before marriage as compared
social consequences and affect education, economic partici- with females having sexual experience before marriage.20
pation, and poverty. These negative consequences extend to Empowering young people to have the highest attainable
the families of young people and future generations and can standard of sexual reproductive health is a fundamental
have a cycle of disadvantages forever.9
human right. In Asian countries, some policies include
Attitude plays an important role in the development of
approaches to create a more supportive environment for
reproductive and sexual health in young people. Rocklage
young people, increase access to comprehensive sex educa-
and Fazio10 describe attitude as a complex state of emotions,
tion, opportunities to reinforce effective attitudes, and
desires, beliefs, and prejudices that, due to different experi-
improve childbirth through sexual and reproductive health
ences in the individual, makes a person ready to behave.
services.21 However, the coverage and quality of such pro-
Awareness of attitudes relatively enables one to predict the
behavior. Negative attitudes toward reproductive health grams are poor in many countries, including Iran. Social,
issues can lead to harmful behaviors in young people. cultural, national laws and policies are the most important
Attitude is the first determinant of behavioral intention. barriers to improving the sexual reproductive health status of
Individuals’ attitudes toward different behaviors can predict youth.
their tendency to one behavior. The more favorable becomes Reproductive health is an important issue of public health
the individuals’ attitudes toward a specific behavior, the and can affect the overall health and quality of life, especially
stronger their intentions would be toward performing well in young people. Therefore, awareness of students’ attitudes
in that subject. Therefore, the first step for sexual health of toward reproductive health can help us in planning reproduc-
young people is awareness of their attitude toward reproduc- tive health education to promote youth health. There is little
tive health, and then correcting it by appropriate educational information available on the attitude of single Iranian youth,
interventions.11 especially girls, toward reproductive health. Current study is
Despite the growing trend of the young population in conducted to investigate single female students’ attitudes
Iran, their reproductive health needs have been less studied. toward reproductive health subjects.
Although some studies have been conducted in this
area,7,12,13 these studies have avoided sensitive issues, such Methods
as attitudes toward reproductive health and sexual relation-
ships, prevalence of risky sexual behaviors, and rates of A cross-sectional study was conducted in all public universi-
sexually transmitted diseases (STDs), due to cultural sensi- ties of Babol, Iran, with 461 students from November to
tivities. Instead, researchers have focused on topics such as February 2018. Babol is a city in northern Iran with three
girls’ puberty and family planning. Cultural sensitivities may public universities. A stratified sampling random method was
also be a factor affecting the poor youth awareness and atti- used to select the samples. The universities were divided into
tudes about reproductive health in Iran, as well as limiting separate strata. Then the sample size of each class was deter-
educational opportunities for questions and correct miscon- mined by proportional allocation method. Since each univer-
ceptions about youth reproductive health.14 In Iran, many sity consisted of several faculties, a number of faculties were
reproductive health services are currently provided free of randomly selected from each university. At the end, samples
charge to married couples, but it is not possible for single were selected by simple random sampling from each faculty
young ones to receive such services, and health care providers in the student gathering places at each faculty. Sample size
are often not trained to deal with youth reproductive health was estimated to determine the relationship between factors
Kashefi et al. 135

affecting reproductive health attitude at 95% confidence level its relevance to the concept. After collecting the expert opin-
and 80% test power to identify the relationship (r ¼ .15). ions, changes were made to the tool.
Inclusion criteria included willingness to participate in the For quantitative assessment of content validity, Lawsheis
study, age 18 to 29 years, female, and single at the time of the model was used. To confirm that the content selected was the
study. Exclusion criteria included withdrew from further most important and accurate, content validity ratio was used.
cooperation and incomplete answer to the questionnaires. The content validity index (CVI) was also measured to ensure
Before the distribution of questionnaires, the purpose of that the tool questions were optimally designed. The expert
the study was completely explained to the students. It took opinion was classified as follows: necessary, useful but not
about 10 minutes to complete the questionnaire and was col- necessary, and not necessary. A content validity ratio above
lected immediately upon completion. This study was 0.59 was accepted. To calculate the CVI, the questionnaire
approved by the Ethical Committee of Babol University was given to the previous expert panel, and their opinions
of Medical Sciences, Iran (IR.MUBABOL.HRI. were collected for each question based on a 4-part spectrum
REC.1397.129). All participants provided an informed writ- from 0 to 3 (irrelevant, somewhat relevant, relevant, and
ten and signed consent form. All questionnaires were completely relevant). After validation, three attitude ques-
anonymous. tions, removed and finally, 16 questions remained. The CVI
At first, the questionnaire was prepared by reviewing value was 0.82. Cronbach’s alpha was used to control the
resources and articles related to reproductive health. The reliability. For this purpose, a pilot study was carried out,
self-administered questionnaire consisted of three parts: and the questionnaire was completed by 30 students from a
(a) demographic characteristics (age, level of education, university other than the actual study participants’. After
place of residence, parents’ education and occupation, confirmation of initial reliability, the study was conducted.
family income from individual perspective), (b) life style The standardized Cronbach’s alpha reliability coefficient was
(religious viewpoint, talking about reproductive health con- 0.890.
cepts in family, receiving information from parents about the
relationship between boys and girls, source of information, Data Analysis
living situation with parents, watching satellite, smoking cig-
The data were analyzed using Statistical Package for Social
arette and hookah and drinking alcohol, and going to parties
Sciences version 20.0. Comparisons among groups were
with their peers), and (c) attitude about reproductive health
made using appropriate inferential tests such as t test and
consisted of 16 questions.
ANOVA. Multiple linear regression was used to determine
Attitude was determined based on 5-point Likert scale
the predictors of reproductive health attitude. We introduced
with a maximum score of 5 and minimum score of 1. The
in these models the main explanatory variables that were
scores of 5 to 1 were assigned to questions 1–5, 7, 10–12, and
associated with reproductive health attitude at p < .05 in
14–15 from strongly agree to strongly disagree and for ques-
the bivariate analysis. To estimate the proportion of variance
tions 6, 8, 9, 13, and 16 from strongly disagree to strongly
in reproductive health attitude that can be accounted for by
agree, respectively. The overall score was 0 to 80. To deter-
sociodemographic and life style factors, multiple linear
mine the mean score of reproductive health attitude in terms regression analysis was performed. The level of significance
of quartiles, the scores were categorized in the following was set at 0.05.
approach: individuals in the first quartile scored less than
54, second quartile scored 55 to 58, third quartile scored 59
to 63, and fourth quartile scored equal or more than 64. Results
In this study, after designing the questionnaire, validity The mean age of the participants was 21.21  2.24 ranged
including face and content validity as well as Cronbach’s between 18 and 29 years. About 18.9% of samples were stu-
alpha coefficient was used to determine validity and internal dents of medical sciences, and the rest were nonmedical;
consistency, respectively. Qualitative method was used to 76.8% were undergraduate, and 23.2% postgraduate or gen-
evaluate face validity, similar to the method used for content eral practitioner students (Table 1). The mean of the repro-
validity. Qualitative and quantitative methods were used to ductive health attitude was 58.34  7.05, ranging from 38 to
assess content validity. For the qualitative method, the 80; 29.9% of individuals were in the first quartile (score 54),
experts were asked to write their ideas about grammar, the 22.3% in second quartile (score 55–58), 25.8% in third quar-
use of correct words, the questions importance, located ques- tile (score 59–63), and 21.9% in fourth quartile (score 64).
tions in proper place, and the time needed to complete the This means that 47.7% of individuals had good reproductive
questionnaire. The necessary changes were made to the ques- health attitude.
tionnaire based on the opinions of the experts. The main sources of information for reproductive health
An independent panel (n ¼ 10) was used to ascertain con- was the media (40%) including books and magazines,
tent relevance. They assessed the questionnaire in terms of movies, radio, television, and internet and then they referred
content clarity (i.e., suitability and cognitive complexity) and to friends (21.9%) and family (19.2%). Receiving
136 International Quarterly of Community Health Education 41(2)

Table 1. Relationship Between Demographic Characteristics and Reproductive Health Attitude (n ¼ 461).

Variables Group N (%) Mean score Test p value

Age (year) 23 389 (84.4) 58.32  6.84 t ¼ 0.179 .858

24 72 (15.6) 58.48  8.13
Faculty Medical/premedical 132 (28.6) 62.79  7.83 t ¼ 6.845 .000
Nonmedical 329 (71.4) 57.31  6.44
Place living City 383 (83.1) 58.71  7.01 t ¼ 2.47 .014
Rural 78 (16.9) 56.56  7.00
Student education Bachelor 354 (76.8) 57.62  6.69 F ¼ 17.566 .000
Masters/general practitioner 30 (6.5) 56.26  6.27
PhD 77 (16.7) 62.48  7.49
Mother education Elementary/ 134 (29.1) 58.05  7.11 F ¼ 1.840 .160
High school 172 (37.3) 57.77  6.90
Colleague 154 (33.4) 59.20  7.11
Father education Elementary 112 (24.3) 56.93  7.07 F ¼ 3.806 .023
High school 144 (31.2) 58.15  6.67
Colleague 203 (44) 59.19  7.19
Mother job Housewife 322 (69.8) 58.39  6.86 F ¼ 6.974 .000
Employee 80 (17.4) 57.96  6.97
Self-employed 40 (8.7) 55.75  7.57
Retired 18 (3.9) 64.66  6.05
Father job Unemployed 7 (1.5) 52.00  5.50 F ¼ 6.081 .000
Self-employed 245 (53.1) 57.60  6.75
Employee 132 (28.6) 58.60  7.43
Retired 76 (16.5) 60.78  6.71
Income Adequate 349 (75.7) 58.48  7.18 t ¼ 0.459 .469
Inadequate 112 (24.3) 57.92  6.62
Religious Very religious 8 (1.7) 59.62  8.91 F ¼ 3.927 .009
Religious 90 (19.5) 59.42  7.98
Somewhat religious 245 (53.1) 58.80  6.67
Not quite religious 118 (25.6) 56.91 6.64

40
35
30
25
20
15
10
5
0
I do not Family Teacher Relaves Friends Health Media
speak care
provider

Figure 1. Frequency Distribution of the Students, by Most Important and Preferred Sources of Information on Reproductive Health.
Source: Media included Books/magazines, Videos/films, Radio/television, internet.

information from health system, relatives, and teachers were boyfriends, but 54.9% considered having sex for single
the least used resources (Figure 1). boys and girls as an inappropriate behavior. In addition,
Regarding the relationship between boys and girls, 58% 56% believed that a girl should remain virgin until marriage;
believed that single boys or girls could have girlfriends or besides the majority of students, 83.7% considered
Kashefi et al. 137

premarital sexual relationship to be inappropriate also for sciences or nonmedical, using satellite and hookah as well
boys; 48.4% stated that having premarital sexual relationship as talking with parents about girl–boy relationships
is incompatible with their religious beliefs. Regarding STDs, (Table 4). The assumptions of normality, linearity, and
only 36% of students agreed that the best way to prevent homoscedasticity of residuals were met. In combination, soci-
STDs and unwanted pregnancies is to delay sexual activity odemographic factors accounted for a significant 11.7% and
until marriage. Also, 56.4% found it appropriate to teach lifestyle factors for a significant 18.6% of the variability in
contraceptive and STDs preventive methods to single reproductive health attitude.
youth; 63.6% of the students believed using contraceptive
methods may cause infertility in the future. About the repro-
Discussion
ductive health needs of youth, over 70% of students believed
that single youth need reproductive health education. More A considerable proportion of the university students did not
than 80% of students found it necessary to have access to have a positive attitude toward reproductive health. The lack
educational booklets on contraceptive and STDs, to have sex of a proper attitude on reproductive health was reported in
and premarital preparation classes, and to establish repro- most of the developing countries.18,21,22 Negative health atti-
ductive and sexual health clinics for young people (Table 3). tude among youths may lead to risky behaviors, unsafe
Table 2 shows the results of the bivariate analyses for sexual practices, STDs, and unwanted pregnancies.23,24
demographic and life style factors. Medical group students, This finding is consistent with study by Soleymani et al.25
urban resident, PhD students, with father higher education, regarding sexual and reproductive health among university
and with parents working in government positions had a students in Malaysia. On the other hand, Michaud et al.26
better attitude toward reproductive health (p < .001, found a completely negative approach to sexual and repro-
p < .05). Similar results were obtained for students who con- ductive health among university students in Europe. This
sidered themselves religious and talked to their parents about contradiction between attitudes highlights the importance
the concepts of reproductive health and the relationships of sociocultural and religious factors over reproductive
between girls and boys (p < .001, p < .01), while students health education and services widely available in most devel-
who used satellites, cigarettes, and hookahs had a weaker oping countries.
attitude toward reproductive health, compared with others According to learning theories, attitude is a state of mental
(p < .001). and neurotic readiness that is formed through experience and
A standard multiple regression was conducted to estimate has a direct and dynamic impact on the individual’s response
the prediction of attitude by sociodemographic and lifestyle to all subjects and situations affiliated with attitude.
factors. Multiple linear regression analysis showed that Although the increased level of awareness can lead to a pos-
reproductive health attitude was significantly associated itive effect toward reproductive health, but it is not enough
with the type of faculty of the students, whether medical for developing a positive attitude and preventing risky sexual

Table 2. Relationship Between Life Style Factors and Reproductive Health Attitude (n ¼ 461).

Variables Group N (%) Mean score Test p value

Talking about reproductive health Completely disagree 69 (15) 56.92  6.67 F ¼ 3.757 .011
concepts of in family Disagree 91 (19.7) 57.54  6.83
Agree 232 (50.3) 59.81  7.21
Completely agree 68 (14.8) 60.11  6.71
Getting informed on boy and girls Nothing 95 (20.6) 59.36  6.60 F ¼ 5.444 .005
relationships by parents Up to certain level 277 (60.1) 57.54  6.90
A lot 86 (18.7) 60.06  7.57
Living with parents Living with both 418 (90.7) 58.33  6.90 F ¼ 0.956 .385
Living with one 27 (5.9) 57.25  8.56
None of them 15 (3.3) 60.40  8.38
Satellite Yes 204 (44.3) 56.51  6.70 t ¼ 5.127 .000
No 256 (55.5) 59.82  6.99
Cigarette Yes 29 (6.3) 54.68  4.65 t ¼ 2.911 .004
No 432 (93.7) 58.59  7.11
Hookah Yes 53 (11.5) 55.22  5.70 t ¼ 3.469 .001
No 408 (88.5) 58.75  7.11
Alcohol Yes 18 (3.9) 57.16  6.67 t ¼ 0.726 .468
No 443 (96.1) 58.39  7.06
Party Yes 289 (62.7) 58.40  7.34 t ¼ 0.230 .818
No 168 (36.4) 58.24  6.52
138 International Quarterly of Community Health Education 41(2)

Table 3. Distribution Responses to Statements About Aspects of Reproductive Health Attitude.

Strongly
Items Strongly agree Agree No idea Disagree disagree

1. Single boys should not have girlfriends. 40 (8.7) 34 (7.4) 118 (25.6) 116 (25.2) 153 (33.2)
2. Single girls should not have boyfriends. 35 (7.6) 36 (7.8) 123 (26.7) 115 (24.9) 152 (33)
3. It is not appropriate for single boys and girls to have sexual 161 (34.9) 92 (20) 88 (19.1) 48 (10.4) 72 (15.6)
relationship, even if they love each other.
4. Girls should remain virgin until they get married. 171 (37.1) 87 (18.9) 94 (20.4) 39 (8.5) 70 (15.2)
5. My religious beliefs and personal attitudes are inconsistent 131 (28.4) 92 (20) 106 (23) 51 (11.1) 81 (17.6)
with premarital sex.
6. Premarital sex is forbidden for girls but not for boys. 18 (3.9) 12 (2.6) 45 (9.8) 65 (14.1) 321 (69.6)
7. The best way to prevent STDs and unwanted pregnancy is to 81 (17.6) 85 (18.4) 128 (27.8) 62 (13.4) 105 (22.8)
delay sexual activity until marriage.
8. Using contraceptives can cause infertility in the future. 25 (5.4) 70 (15.2) 198 (43) 71 (15.4) 97 (21)
9. Teaching contraception methods and STDs promotes sexual 27 (5.9) 45 (9.8) 129 (28) 112 (24.3) 148 (32.1)
freedom.
10. Educational leaflets on contraceptive methods and STDs 206 (44.7) 158 (34.3) 69 (15) 13 (2.8) 15 (3.3)
should be available to young people.
11. Sexual relationship and premarital preparation classes should 246 (53.4) 155 (33.6) 40 (8.7) 12 (2.6) 8 (1.7)
be considered for young people
12. Reproductive and sexual health clinics should be available for 246 (53.4) 157 (34.1) 4.3 (9.3) 8 (1.7) 7 (1.5)
young people.
13. Single youth do not need reproductive health education, 22 (4.8) 25 (5.4) 84 (18.2) 135 (29.3) 194 (42.1)
because they do not have sexual relations.
14. Young people should be aware of contraceptive methods. 237 (51.4) 156 (33.8) 52 (11.3) 9 (2) 7 (1.5)
15. Contraceptive methods such as condoms should be accessible 169 (36.7) 114 (24.7) 138 (29.9) 26 (5.6) 14 (3)
to young people.
16. The best way to prevent STDs and unwanted pregnancy is not 38 (8.2) 45 (9.8) 64 (13.9) 58 (12.6) 256 (55.5)
to give information to young people.
Abbreviation: STDs, sexually transmitted diseases.

Table 4. Multiple Linear Regression Analysis Showing Factors Associated with Reproductive Health Attitude.

Unstandardized Unstandardized
Models 1a coefficients b SE Sig. 95% CI Models 2b coefficients b SE Sig. 95% CI

Faculty 4.920 1.215 0.000 2.533 to 7.307 Satellite 2.953 0.661 0.000 1.653–4.252
Place living 0.719 0.444 0.417 2.460–1.022 Cigarette 2.291 1.478 0.122 0.614–5.195
Student education 0.23 0.181 0.973 1.315–1.361 Hookah 1.962 0.146 0.035 2.291–4.215
Father education 0.643 0.436 0.140 0.213–1.499 Reproductive health 0.101 0.702 0.885 1.481–1.279
conceptsc
Mother job 0.044 0.323 0.911 0.733–0.821 Boy and girls 1.951 0.855 0.023 2.271–3.630
relationshipsd
Father job 1.128 0.458 0.14 1.228–2.028 Religious 0.026 0.464 0.956 0.886–0.937
R ¼ 0.117.
a 2

R ¼ 0.186.
b 2
c
Talking about reproductive health concepts of in family.
d
Informing young people about boy-girl relationships by parent.

behaviors, because sometimes people’s viewpoints and beliefs we change a person’s attitude, we can change their behavior.
are formed without prior training. Factors such as economic Therefore, the more we know about the existing attitudes, the
issues, health policies, and cultural planning are required to easier it would be to change these behaviors.11
access health services and motivate individuals.27 Attitudes Recognizing and altering students’ negative attitudes
play a very important role in one’s life, thoughts, and per- toward sexual and reproductive health concepts is one of
sonal and social behaviors. Psychologists believe that when the effective ways to improve their performance and to
Kashefi et al. 139

make better decisions in this area. It also has psychological Almost two thirds of young people in the present study
feedback including increased self-esteem and reduced anxiety believed that using contraceptives would lead to future infer-
and stress, which can lead to a positive and helpful attitude tility. This view may be the result of their understanding of
toward sexual and reproductive health.10 the experience of young couples who had infertility, while
The results of present study on boy and girl relationships infertility may occur as a result of concurrent STDs in
showed that 58% of youth believed that boys or girls could these couples. Training programs for single young people
have partners, and 45.1% were not disagreed about having should include this message that “infertility does not
sexual relationship for single boys and girls. Only 56% of happen as a result of using contraceptive methods, but
girls believed that girls should remain virgin until marriage, rather, it results from not using contraceptive methods and
and of course, the majority of the participants (83.7%) con- having STDs.”
sidered premarital sex to be inaccurate for boys as well. In The need for reproductive health education programs and
Iranian sociocultural context, there is less interaction services was mentioned by 80% of the participants in the
between girls and boys before marriage, because they are present study. However, some believe that giving information
separated from elementary school to university, and any rela- about reproductive health encourages young people to
tionship is considered taboo. Also, in Iranian culture, like engage in inappropriate sexual behaviors, but based on the
other traditional societies,28 it is preferred that the virginity results of present study, 80% of students were disagreed with
of the girls remains intact until the night of the marriage. this idea. There is evidence that sex education may prevent
Starting a sexual activity only after marriage is very valuable risky sexual behaviors and is not associated with increased
in the Islamic culture of our country, while more than half of sexual activity in youth.25 There is no doubt that a supportive
young people begin sexual activity as a teenager in many environment is essential to improve the reproductive health
other parts of the world.8 However, a relatively large percent- programs. Appropriate social, political, and cultural support
age of the samples in the present study did not prohibit sex as well as access to reproductive health information and serv-
for single youth. The study of Shahhosseini et al.7 in Iran ices for young people is also essential in every community.
showed that sexual relationship is common during youth The most important source of information for university
friendship, especially in the form of anal sex or even oral students about reproductive health was the media (40%) and
sex to prevent unwanted pregnancy and to remain virginity. their friends (21.9%). Only 19.2% of participants mentioned
Therefore, the authors believe that it is necessary to design their families as the source of information. These results are
and implement sexual and reproductive health education consistent with studies in Iran and other countries on univer-
content based on safe contraception methods. sity students.13,17,19,25 In contrast, a study on Chinese univer-
In the present study, the majority of young people were sity students found that mostly they receive information
also disagreed on having premarital sexual relationship for about sexual relationship through magazines and friends.31
boys. This is inconsistent with the results of some available Although parents are important sources of information
researches. The study of Mohammadi et al.13 on 15- to 18- about sexual behaviors, most students did not mention
year-old males in Tehran showed that although two thirds of them as their source of information. A study in Malaysia
respondents were agreed that women should not have sex found that students were less likely to talk with parents
before marriage, only half of them had the same opinion about sexual relationships, because they feared that their
about men. Gender-based double standards have been simi- parents think they had sex.23 The role of the health system
larly addressed in other studies.18,24 Results of several studies as an information source was minimal in the present study;
have also shown that boys have more premarital sexual rela- however, physicians and health personnel are the most reli-
tionship than girls.20 This increases the STDs in men and also able sources of information. Therefore, it seems that health
transmits it to their spouses after marriage. The available professionals, especially physicians, should be involved in
statistics show that the prevalence of STDs in newly married sexual education and reproductive health programs in youth.
women has increased substantially,29 and along with Multiple regression analysis results showed that medical
increased STDs in women, infertility, and ectopic pregnan- students had a better attitude toward reproductive health
cies rates have also increased.30 In this regard, only 36% of than other students. This finding is consistent with the results
our participants believed that the best way to prevent STDs is of Simbar et al.12 They showed that students of health scien-
to delay sexual activity until marriage, while the majority of ces had higher sexual and reproductive knowledge than other
them were agreed about teaching contraceptives and STDs to students. This may be partly due to the college courses
single young population. Simbar et al.12 showed that 8% of including sexual and reproductive health issues. The results
Iranian students had started sexual relationship before mar- were also supported by a study among Malaysian university
riage; the results indicated that reproductive health programs students.25 Therefore, providing an educational program on
promoting abstinence as the only strategy cannot be always sexual and reproduction health is essential for nonmedical
effective, and these programs should have other health mes- students. It should be noted that the more positive approach
sages for those who are sexually active. of medical students on reproductive health is especially
140 International Quarterly of Community Health Education 41(2)

important, because of its impact on the attitudes and behav- sensitive topics regarded taboos by many youths who are
iors they will show in their professional life. reluctant to talk about them. This can also be a limitation
In the present study, satellite use was associated with a of this study. A socially desirable response bias and an infor-
negative approach to reproductive health. Some studies mation bias were considered in this study. Also data were
have reported an increased chance of sexual activity with collected from specified age group of female students and
access to satellite TV.13 It remains unclear to what extent may not be representative of the whole range of sexual repro-
access to satellite television and the internet can affect ductive health perceptions among females. The main advantage
Iranian youth’s attitudes and behaviors on reproductive of this study was the homogeneity of the samples. Samples were
and sexual health. In the study of Ayatollahi et al.,6 some all university students, young, single, and female.
Iranian youths expressed concern that internet and satellite It is recommended that cohort studies on reproductive
TV could significantly expose young people to pornographic health attitudes be conducted on unmarried, sexually active
content contrary to Iranian cultural and religious norms. A young people. Findings on comparing reproductive and
report by the National Youth Organization presented that sexual health attitudes of boys and girls to develop gender-
about one fifth of youth visit pornographic sites during surf- based support programs are also helpful. Among these sup-
ing the internet, while three quarters of subjects were male.32 portive programs can be paid to impact assessment
It should be noted that having personal communications ser- university-based sex education includes sexual orientation
vice allows communication between men and women in a and gender identity to better meet the needs of young
way that is not possible in public spaces. Despite the poten- people and to address attitudes that lead to discrimination,
tial of the internet and other technologies to influence atti- bullying and harassment.
tudes and behaviors, most Iranian families still believe that
young people should wait for marriage to begin sexual rela-
tionship. This belief seems to be more rigid for girls than Conclusion
boys. However, more researches should be conducted to dis- Students’ attitudes toward reproductive health were moder-
cover youth norms and attitudes about sex. ate, and there are misconceptions about sexual issues.
The results of the present study showed that those who Designing and implementing education in the field of repro-
used hookah had a more negative approach to reproductive ductive health and sexual relations, taking into account the
health. The study of Mohammadi et al.13 showed that youth cultural aspects of Iranian society, can protect young people
who had permissive attitudes toward sexual relationship and from risky behaviors and unwanted pregnancies by creating a
those who drink alcohol or smoke cigarette had a higher positive attitude. Given the role of the media as the largest
chance of having sexual relationship. They suggested two source of youth information in this study, their role is very
probable explanations in this regard: first, drug abuse and important. Education for parents, especially mothers, as well
premarital sex may both indicate a general tendency to risky as university teachers, health care providers, and members of
behavior and second, drug abuse affects both the skill and religious organizations about how to communicate and pro-
ability to make rational decisions, thus increases the likeli- vide information to young people should not be ignored.
hood of sexual contact.
The results of present study showed that young people Acknowledgments
whose parents informed them about the relationships
The authors would like to thank all students who participated in this
between boys and girls had a much better attitude than study.
others. The generation gap is a common obstacle to establish
friendly relationships between young people and their Declaration of Conflicting Interests
parents.7 Parents have an important responsibility to moni-
tor and advice their children in the social contexts of devel- The author(s) declared no potential conflicts of interest with respect
oping countries.16 Establishing a friendly and trusting to the research, authorship, and/or publication of this article.
relationship between young people and parents, who have
adequate knowledge and skills, encourages children to talk Ethics Approval and Consent to Participate
to their parents rather than relying on invalid information The study was approved by the ethics committee of Babol
from peers or searching for information in magazines, por- University of Medical Sciences (IR.MUBABOL.HRI.
nographic websites, and erotic visual programs. To strength- REC.1397.129). All participants provided an informed written and
en the parent–child communication about reproductive and signed consent form.
sexual health issues, we can learn from experiences of family
reproductive education programs designed and developed in Funding
other countries,33 but it is recommended to adapt such pro- The author(s) disclosed receipt of the following financial support for
grams to the cultural and social context of each community. the research, authorship, and/or publication of this article: This
The use of self-administered questionnaires may be con- study was financially supported by Babol University of Medical
sidered a limitation of the present study. Sexual issues are Sciences with grant number 9706011. The Research Deputy of
Kashefi et al. 141

Babol University of Medical Sciences financially supported this 16. Nanbakhsh H, Salarilak S, Islamloo F, et al. Assessment of
study. women’s satisfaction with reproductive health services in
Urmia University of Medical Sciences. East Mediterr Health J
ORCID iD 2008; 14: 605–614.
17. Ghabili K, Shoja MM and Kamran P. The Iranian female high
Afsaneh Bakhtiari https://orcid.org/0000-0002-4732-6900
school students’ attitude towards people with HIV/AIDS: a
cross-sectional study. AIDS Res Ther 2008; 5: 15.
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Author Biographies
Fatemeh Kashefi is a master of Midwifery, Member of Staff Fatemeh Bakouei is an assistant professor, faculty of Nursing
of Health Center. and Midwifery, Babol University of Medical Sciences, Babol,
Iran.
Afsaneh Bakhtiari is an assistant professor, faculty of Health,
Babol University of Medical Sciences, Babol, Iran.