Knowledge and practice of university students in Lebanon regarding contraception

Publication date: 2009

Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 387 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Knowledge and practice of university students in Lebanon regarding contraception B. Barbour1 and P. Salameh2 1Faculty of Public Health Section II; 2Faculty of Pharmacy, Lebanese University, Beirut, Lebanon (Corrrespondence to P. Salameh: pascalesalameh1@yahoo.com; psalameh@ul.edu.lb). Received: 28/05/06; accepted: 13/09/06 Connaissances et pratiques en matière de contraception des étudiants libanais RÉSUMÉ Nous avons évalué les connaissances et les pratiques en matière de contraception des étudiants libanais dans le cadre d’une étude transversale comparative réalisée auprès d’étudiants d’universités publiques et privées sur la base d’un questionnaire en langue arabe à remplir soi-même. Le niveau des connaissances était faible. La majorité des garçons (73,3 %) et peu de filles (21,8 %) ont déclaré avoir déjà eu des rapports sexuels : la majorité des garçons avaient utilisé un préservatif (86,1 %), mais les filles n’avaient généralement pas utilisé de contraceptifs (75,6 %). ABSTRACT We evaluated knowledge and practice of Lebanese university students regarding contra- ception in a cross-sectional, comparative study on students in public and private universities using an Arabic language self-administered questionnaire. We found low levels of knowledge of contraception. The majority of males (73.3%) and a few females (21.8%) declared previous sexual relations: the major- ity of males had used a condom (86.1%), but females had generally not used contraceptives (75.6%). لملحا عنم لوح متهاسراممو نانبل في تاعمالجا ةبلط فراعم ةملاس لاكساب ،روبرب تيدانرب ةضرعتسم ةسارد في ،لملحا عنم لوح نانبل في تاعمالجا ةبلط ىدل تاسرمالماو فراعلما ميـيقت مت :ةـصلالخا .ةيبرعلا ةغللاب ًايتاذ لمكتست ةرماتسا كلذل تمدختساو ،ةماعلاو ةصالخا تاعمالجا في بلاطلا لوح ةنراقمو مدختسا دقو ،ةقباس ةيسنج تاقلاع مله تناك هنأب )21.8( ثانلإا نم ليلقو مهنم %73.3 روكذلا مظعم ح َّصرو .لملحا تاعنام نم ًايأ %75.6 ماع لكشب ثانلإا مدختست لم ينح في ،يركذلا لزاعلا %86.1 روكذلا مظعم 388 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Introduction Public health policies and programmes are nowadays focusing on the sexual and reproductive health needs of adolescents, particularly in the developing world [1]. Adolescents are not always rational when making sexual choices: being deeply in- volved in their own bodily perceptions, strong emotions and feelings of ambiva- lence may override the perception of risk [2], despite the fact that attitude towards behaviour generally reflects an individual’s beliefs and consequences associated with engaging in the behaviour [3]. Thus, sexual habits, contraceptive use and sexually trans- mitted disease (STD) rank among the most important health issues for adolescents and young adults. In addition, early sexual ac- tivity is associated with risky behaviours such as smoking, alcohol use, multiple sexual partners and unintended pregnancy [4]. Emerging research suggests that teen- agers make decisions about contraceptive use in the context of individual sexual rela- tionships [5]. Different beliefs in males and females may also affect contraceptive use and need to be explored to develop sex edu- cation and services for this age group [6]. Media and friends, not health profes- sionals, have been reported as the primary sources of information for young women and men of all ages [7]. Hence, inadequate information is expected in youngsters. For example, in a study on Ghanaian youth, nearly all respondents (99%) knew of con- doms but less than half (48%) could identify any of 4 elements of correct use; females and sexually inexperienced youth were the least informed [8]. In a representative sample of individuals aged 16–45 years in Greece, only a small percentage of the respondents were able to answer correctly 50% or more of the questions on knowledge of basic contraceptive issues (30.6% of women and 14.7% of men), although the majority of respondents considered themselves at least adequately informed [7]. Lebanon is a developing country with conservative norms, particularly for girls, and little information exists regarding con- traception. Nevertheless, there are actual changes in social, cultural and moral norms, with large discrepancies between religions. These changes seem to exert a consider- able effect on the country’s young adult population. It is generally observed that young people tend to engage in sexual activity at younger ages than before; the use of contraception in these settings is largely unknown. This study, therefore, aimed to evaluate knowledge, attitudes and practices of Lebanese university students regarding contraception, in a comparative analysis between males and females. Methods This was a cross-sectional comparative study. The sampling frame was a list of departments of all public and private uni- versities in Lebanon, from which a random sample of 15 was drawn up. In the public university (Lebanese University) we sam- pled the faculties of arts, law and political sciences, public health, engineering, infor- mation and documentation, social sciences, literature and humanities, and sciences. The private universities selected were Kaslik Holy Spirit University, Saint Joseph Uni- versity (Uvelain campus), American Uni- versity of Science & Technology (Achrafieh campus), Notre Dame University (Loueizeh campus), Beirut Arab University, American University of Beirut and Balamand Univer- sity (Tripoli campus). Campus administrators were contacted and permission was given to enquirers to distribute questionnaires in all but the Amer- Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 389 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما ican University of Beirut campus, where permission to participate in the study was refused. A convenience sample of available students was chosen to participate to the study: a lay enquirer was sent to spend the day on campus and distribute a minimum of 100 questionnaires per campus. Students were approached during recess hours. Ex- clusion criteria were being married or of non-Lebanese nationality. A self-administered standardized ques- tionnaire was used, to be completed in the local Arabic language on campus. Closed and open-ended questions were asked. The questionnaire was based on current knowl- edge of available contraceptives and STDs; information collected was similar to that gathered by other authors [7–9]. It was divided into 5 parts: social and demographic characteristics; knowledge regarding com- monly used contraceptives; knowledge regarding the menstrual cycle and natural fertility regulation; practices regarding con- traceptive use and failure; and knowledge about STDs. The questionnaire was pilot- tested on 10 young individuals aged 18–22 years for correcting or clarifying questions when necessary. The study was carried out between April 2005 and June 2005. Students gave oral consent to participate to the study, after explaining that it was a “study done by university researchers that had extreme importance for their health” and ensuring anonymity (no names were required). To ensure maximum objectivity in students’ answers, enquirers were instructed not to give any additional clarification for ques- tions which were not understood. Questionnaires were coded and data en- tered on SPSS, version 12.0, by independent lay persons. Data entry was then controlled, and data analysed using the same software. P-value < 0.05 was considered significant. Missing values, which accounted for < 20% of answers, were not replaced, and variables were analysed as available. The chi-squared test was used for comparison between cat- egorical variables. Analysis of variance was used to compare means of continuous variables. Results We distributed 2000 questionnaires and 1410 (70.5%) were returned. There were some differences in the social and demo- graphic characteristics of the male and fe- male respondents: there were more female respondents from public universities (P < 0.0001), more Christians (P < 0.002) and more people living in Mount Lebanon (P < 0.02). Males were slightly, but statisti- cally significantly, older than females (P < 0.0001). No statistically significant dif- ferences were noted for study year or region of origin (P > 0.05) (Table 1). Knowledge regarding contraceptives Books (57.5%), friends (56.2%) and school (52.0%) were the most cited sources of in- formation on sex (Table 2). No respondent cited any health professional. All males knew about the condom, but 2.8% of females had never heard of it (P < 0.0001). Males knew more about the conditions of use, contraindications and side-effects of condoms (P < 0.0001). Only half the male respondents regularly verified the expiry date before using a condom and knew when to put it on, while less than one- third knew when to remove it (Table 3). Three-quarters of males had heard about the intrauterine device (IUD) in comparison with 88.6% of females (P < 0.0001). One- third of respondents thought that an IUD was placed in the vagina, 10.7% thought it could be used by any woman, and 15.0% did not know how it is used. Significantly 390 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما more females than males knew that IUDs have side-effects and contraindications (P < 0.0001) (Table 3). About half the respondents had ever heard about the cervical cap, significantly more females than males (P < 0.0001). The majority of these, however, did not know how it is used, and more than 80% did not know if it has side-effects or how long it should be left in place. Similar findings ap- plied to the vaginal diaphragm (Table 3). Almost all females (97.9%) and males (88.1%) declared knowing about oral con- traception (Table 4). However, about half the responding males and a third of the females did not know how frequently pills are used (P < 0.003). Just over half the stu- dents stated they did not know what to do in the case of a forgotten dose. More females than males were aware of the existence of side-effects and contraindications for oral contraceptives (P < 0.0001) (Table 4). Two-thirds of respondents declared knowing about spermicidal products, but the majority of females did not know how they are used or the side-effects (P < 0.0001). Even males who declared that they knew how to use them had erroneous information (Table 4). Table 1 Social and demographic characteristics of participants Characteristic Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % University Public 290 57.4 707 78.1 < 0.0001 997 70.7 Private 215 42.6 198 21.9 413 29.3 Study year Undergraduate 395 78.2 742 82.0 0.17 1137 80.6 Graduate 88 17.4 131 14.5 219 15.5 Postgraduate 6 1.2 18 2.0 24 1.7 Region of origin Beirut 68 13.5 92 10.2 0.09 160 11.3 Mount Lebanon 204 40.4 407 45.0 611 43.3 Other 233 46.1 406 44.9 639 45.3 Residence Beirut 85 16.8 108 11.9 0.02 193 13.7 Mount Lebanon 351 69.5 689 76.1 1040 73.8 Other 69 13.7 108 11.9 177 12.6 Religion Christian 390 77.2 764 84.4 0.002 1154 81.8 Muslim 49 9.7 68 7.5 117 8.3 No answer 66 13.1 73 8.1 139 9.9 Mean (SD) age (years) 21.0 (1.9) 20.3 (1.6) < 0.0001 20.6 (1.8) SD = standard deviation. Table 2 Stated source of sexual education for university students in Lebanon Source of information No. (n = 1410) % Books 811 57.5 Friends 792 56.2 School 733 52.0 Mass media 541 38.4 Parents 420 29.8 Partners 378 26.8 University 283 20.1 Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 391 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Table 3 Knowledge of students regarding mechanical contraceptives Type of contraceptive & knowledge item Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Male condom Declare knowing about it 505 100 880 97.2 < 0.0001 1385 98.2 Never used it 46 9.1 481 54.7 527 38.1 Is disposable 248 49.1 418 47.5 0.94 666 48.1 Necessary to verify expiry date 472 93.5 816 92.7 0.09 1288 93.0 Is used On erect penis 441 87.3 749 85.1 0.87 1190 85.9 At the beginning of erection 269 53.3 260 29.5 < 0.0001 529 38.2 Just before ejaculation 39 7.7 47 5.3 0.10 86 6.2 Do not know 20 4.0 271 30.8 < 0.0001 291 21.0 Is removed While penis still erect 149 29.5 85 9.4 < 0.0001 234 16.9 On detumescence 304 60.2 376 42.7 < 0.0001 680 49.1 Do not know when to remove 44 8.7 373 41.2 < 0.0001 417 30.1 Verifies expiry date Always 284 56.2 237 26.9 < 0.0001 521 37.6 Sometimes 126 25.0 78 8.9 204 14.7 Never 44 8.7 33 3.8 77 5.6 Contraindications? Yes 106 21.0 165 18.8 < 0.0001 271 19.6 No 214 42.4 200 22.7 414 29.9 Do not know 176 34.9 477 54.2 653 47.1 Side-effects? Yes 82 16.2 121 13.8 < 0.0001 203 14.7 No 238 47.1 251 28.5 489 35.3 Do not know 169 33.5 455 51.7 624 45.1 Intrauterine device Declares knowing about it 366 72.5 802 88.6 < 0.0001 1168 82.8 Is placed in the uterus 134 36.6 390 48.6 < 0.0001 524 44.9 Is in place for a long time 100 27.3 330 41.1 < 0.0001 430 36.8 Is placed in the vagina 132 36.1 247 30.8 0.08 379 32.4 Can be used by any woman 43 11.7 82 10.2 0.42 125 10.7 Is used before every intercourse 30 8.2 27 3.4 < 0.0001 57 4.9 Is placed during menstruation 20 5.5 30 3.7 0.18 50 4.3 Does not know how it is used 58 15.8 117 14.6 0.57 175 15.0 Side-effects? Yes 118 32.2 410 51.1 < 0.0001 528 45.2 No 64 17.5 89 11.1 153 13.1 Do not know 173 47.3 291 36.3 464 39.7 392 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Knowledge about sexually transmitted diseases More females than males knew about STDs (P < 0.0001), but more females than males stated they did not know how to prevent them. About 80% thought that the use of condoms may prevent STDs, while others cited erroneous measures (Table 5). Knowledge regarding menstrual cycle and natural fertility regulation We found low levels of knowledge in both male and female respondents regarding the menstrual cycle and natural fertility regulation (Table 6). The majority, males in particular, did not know what the menstrual cycle is, when ovulation occurs or when ab- Table 3 Knowledge of students regarding mechanical contraceptives (concluded) Type of contraceptive & knowledge item Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Contraindications? Yes 58 15.8 250 31.2 < 0.0001 308 26.4 No 55 15.0 460 57.4 515 44.1 Do not know 231 63.1 58 7.2 289 24.7 Cervical cap Declares knowing about it 233 46.1 544 60.1 < 0.0001 777 55.1 Is disposable 40 17.2 82 15.1 0.48 122 15.7 Changed after every intercourse 31 13.3 81 14.9 0.55 112 14.4 Is used with a spermicide 30 12.9 59 10.8 0.43 89 11.5 Is washable 40 17.2 44 8.1 < 0.0001 84 10.8 Does not know about use 126 54.1 361 66.4 0.001 487 62.7 Side-effects? Yes 25 10.7 53 9.7 0.01 78 10.0 No 31 13.3 38 7.0 69 8.9 Do not know 161 69.1 432 79.4 593 76.3 Can be left in place for 2 days 44 18.9 59 10.8 0.003 103 13.3 1 week 21 9.0 17 3.1 0.001 38 4.9 1 month 13 5.6 13 2.4 0.025 26 3.3 Do not know 146 62.7 421 77.4 < 0.0001 567 73.0 Vaginal diaphragm Declares knowing about it 262 51.9 583 64.4 < 0.0001 845 59.9 Is disposable 55 21.0 144 24.7 0.24 199 23.6 Changed after every intercourse 51 19.5 116 19.9 0.88 167 19.8 Is used with a spermicide 53 20.2 108 18.5 0.57 161 19.1 Is washable 48 18.3 46 7.9 < 0.0001 94 11.1 Does not know about its use 103 39.3 323 55.4 < 0.0001 426 50.4 Side-effects? Yes 30 11.5 80 13.7 < 0.0001 110 13.0 No 47 17.9 45 7.7 92 10.9 Do not know 166 63.4 437 75.0 603 71.4 Details about contraceptive type were filled in only by those who declared knowing about the contraceptive in question; percentages were calculated accordingly. Some totals < 100% because of missing values. Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 393 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Table 4 Knowledge of students regarding chemical contraceptives Type of contraceptive & knowledge item Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Oral contraceptive Declares knowing about it 445 88.1 886 97.9 < 0.0001 1331 94.4 Necessary to verify expiry date 417 93.7 855 96.5 0.03 1272 95.6 Frequency of use 1st–21st day of cycle 88 19.8 255 28.8 0.003 343 25.8 Every day 71 16.0 167 18.8 0.46 238 17.9 5th–25th day of cycle 52 11.7 159 17.9 0.01 211 15.9 At a fixed hour 47 10.6 176 19.9 < 0.0001 223 16.8 Do not know about use 181 40.7 311 35.1 0.003 492 37.0 In case of forgetting one tablet Skip the forgotten tablet 64 14.4 162 18.3 0.25 226 17.0 Take forgotten tablet soon 38 8.5 115 13.0 0.06 153 11.5 Take both tablets together 26 5.8 91 10.3 0.02 117 8.8 Do not know what to do 267 60.0 489 55.2 < 0.0001 756 56.8 Are there several types of pill? Yes 139 31.2 453 51.1 < 0.0001 592 44.5 No 25 5.6 39 4.4 64 4.8 Do not know 251 56.4 378 42.7 629 47.3 Cannot be used at all ages 173 38.9 372 42.0 < 0.0001 545 40.9 Cannot be used by all women 212 47.6 549 62.0 < 0.0001 761 57.2 Side-effects? Yes 181 40.7 537 60.6 < 0.0001 718 53.9 No 30 6.7 43 4.9 73 5.5 Do not know 188 42.2 276 31.1 464 34.9 Spermicide Declares knowing about it 319 63.2 598 66.1 0.42 917 65.0 How used 15 min before intercourse 91 28.5 88 14.7 < 0.0001 179 19.5 Just before intercourse 53 16.6 91 15.2 0.57 144 15.7 2 h before intercourse 61 19.1 34 5.7 < 0.0001 95 10.4 After ejaculation 10 3.1 7 1.2 0.04 17 1.9 In the vagina 63 19.7 98 16.4 0.20 161 17.6 On external genitalia 35 11.0 70 11.7 0.75 105 11.5 Do not know 93 29.2 345 57.7 < 0.0001 438 47.8 After use, the woman can wash 20 minutes after intercourse 73 22.9 100 16.7 0.001 173 18.9 2 hours after intercourse 47 14.7 57 9.5 104 11.3 6 hours after intercourse 20 6.3 33 5.5 53 5.8 Do not know when 158 49.5 387 64.7 545 59.4 Side-effects? Yes 56 17.6 81 13.5 < 0.0001 137 14.9 No 57 17.9 42 7.0 99 10.8 Do not know 190 59.6 454 75.9 644 70.2 Details about contraceptive type were filled in only by those who declared knowing about the contraceptive in question; percentages were calculated accordingly. Some totals < 100% because of missing values. 394 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما stinence should be practised for natural fer- tility regulation (P < 0.05 for all). However, the majority of females declared they knew about the Ogino–Knauss (rhythm), Billings and temperature methods, although their knowledge lacked precision in most cases. Practices regarding sexual habits and contraception We found that 135 (26.7%) males and 708 (78.2%) females declared never having had a sexual relationship. Of those who had, around two-thirds of males and a quarter of females had used contraception, mainly the condom for males (86.1%) and oral contra- ceptives for females (56.3%) (Table 7). Sexual intercourse occurred most often at home in the absence of parents (54.3%) or in a beach chalet (49.6%) (Table 6). In sexu- ally active individuals, about 48% of males and 60% of females had ever had sexual relationships without using a contraceptive; the chief declared reason was extra-vaginal intercourse. Nevertheless, 34% of all re- spondents thought that intercourse without penetration could lead to pregnancy. The majority of those who had sexual experience would not seek help from health professionals for contraception; however, females who would stated they would mainly ask a gynaecologist and males a pharmacist. Half of all sexually active individuals would opt for an abortion if pregnancy occurred, and a quarter would use the morning after pill (Table 7). Discussion In this study, we found a low level of knowl- edge of contraception. We had expected a higher level of knowledge in this educated group of the Lebanese population. Greater knowledge of contraceptive issues was found among the better-educated women and men in Greece [7]. Our sample also revealed low use of contraceptive methods, particularly for females. This is in contrast to a study conducted in Brazil among 952 university undergraduates aged up to 24 years, where contraceptive use was high, especially for condoms and the pill [9]. Accordingly, in young Lebanese having a lower education, we would anticipate much lower levels of knowledge and use of con- traception: this accounts for the urgency of the problem in Lebanese society. Sources of sexual information were mainly friends, books, school and mass media, with 0% for health professionals. The mass media are known to shape at- titudes and beliefs in young people [10], and it is becoming more accessible to Lebanese youth. In addition to printed media, there is high access to material on the Internet and television [10]. Furthermore, friends play a critical role in the sexual behaviours of adolescents [11]. This source of information is expected to be of low quality [7]. In our study, the majority of males and a very few females declared having had sex- Table 5 Knowledge of university students in Lebanon regarding prevention of sexually transmitted disease (STD) Variable Boys (n = 505) Girls (n = 905) No. % No. % Knows about STDa 459 90.8 872 96.4 STDs prevented by: Intimate washing 67 13.3 149 16.5 Condoms 417 82.5 715 79.0 Spermicides 53 10.4 81 8.9 Coitus interruptus 38 7.6 60 6.6 Sexual intercourse without penetration 65 12.8 132 14.6 Do not know how to preventa 33 6.6 125 13.8 aSignificant at P < 0.0001. Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 395 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Table 6 Knowledge regarding menstrual cycle and regulation of natural fertility Question Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Ogino–Knauss method Declares knowing about it 333 65.9 732 80.9 < 0.0001 1065 75.5 Menstrual cycle is from: 1st day of menses to 1st day of next menses 117 35.1 407 55.6 < 0.0001 524 49.2 Last day of menses to 1st day of next menses 66 19.8 153 20.9 219 20.6 1st day of menses to last day of next menses 40 12.0 39 5.3 79 7.4 Do not know 91 27.3 101 13.8 192 18.0 Ovulation occurs:: 14 days after menses 113 33.9 322 44.0 0.003 435 40.8 14 days before menses 76 22.8 228 31.1 0.007 304 28.5 In general, at the mid cycle 89 26.7 176 24.0 0.31 265 24.9 It varies with women 27 8.1 48 6.6 0.34 75 7.0 During menstruation 14 4.3 15 2.0 0.04 29 2.7 Do not know 64 19.2 62 8.5 < 0.0001 126 11.8 Abstinence should be practised: On the day of ovulation 56 16.8 144 19.7 0.24 200 18.8 One week before menses 37 11.1 61 8.3 0.16 98 9.2 One week after menses 46 13.8 51 7.0 < 0.0001 97 9.1 1 week around ovulation 71 21.3 313 42.8 < 0.0001 384 36.1 Do not know 127 38.1 207 28.3 0.002 334 31.4 Billings method Declares knowing about it 251 49.7 611 67.5 < 0.0001 862 61.1 Cervical secretions are: Abundant during ovulation 66 26.3 314 51.4 < 0.0001 380 44.1 Abundant away from ovulation 30 12.0 67 11.0 0.67 97 11.3 Transparent during ovulation 56 22.3 163 26.7 0.19 219 25.4 Transparent away from ovulation 34 13.5 87 14.2 0.80 121 14.0 Elastic during ovulation 40 15.9 207 33.9 < 0.0001 247 28.7 Elastic away from ovulation 14 5.6 50 8.2 0.19 64 7.4 Do not know 96 38.2 149 24.4 < 0.0001 245 28.4 396 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما ual relations. The reasons for the difference may include differences in socioeconomic status in the sample, since it is constituted of more females from public universities, and lower socioeconomic status is associated with higher religiosity in young Lebanese adults [12]. Differences between males and females in religiosity or inequity in sexual experiences in the view of society are also possible. Religiosity is known to affect sexual behaviour, with more frequent attendance at religious services and stronger religious beliefs associated with delaying sexual initiation [5,13]. Indeed, Lebanese females are particularly religious [12], and the Lebanese society encourages sexual experience for males but prohibits it for females. With these reported low levels of knowl- edge, systematic and responsible educa- tion in the promotion of good reproductive health is very important in Lebanon. Policy- makers should recognize the importance of designing interventions that give adoles- cents the skills they need to feel effective in their ability to communicate about sex and contraception [14]. Although family plan- ning efforts have generally been conducted through public facilities, some countries are now placing a significant emphasis on private channels of delivery [10], focusing work on fostering youngsters’ identities and promoting their ability to take care of themselves [3]. Findings in conservative societies have even shown the normative influence of parents, older family members and extended family members, even in sexual decision-making [2]. Accordingly, prevention approaches should concentrate on providing information and motivation for abstinence or safer sex [15]. Lebanese students have cited having sex mainly in the absence of their parents. However, there is an association between the amount of unsupervised time and sexual behaviours, with STD rates suggestive of particularly risky sexual behaviours [16]. As youths come of age, parents probably believe that it is appropriate to leave them increasingly on their own. However, parents Table 6 Knowledge regarding menstrual cycle and regulation of natural fertility (concluded) Question Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Temperature method Declares knowing about it 285 56.4 656 72.5 < 0.0001 941 66.7 Temperature taken: Before getting up in morning 139 48.8 448 68.3 < 0.0001 587 62.4 Any time of the day 55 19.3 65 9.9 < 0.0001 120 12.8 Always by same route 72 25.3 239 36.4 0.001 311 33.0 With same thermometer 74 26.0 222 33.8 0.02 296 31.5 Is higher after ovulation 106 37.2 309 47.1 0.006 415 44.1 Is lower after ovulation 30 10.5 101 15.4 0.05 131 13.9 Coitus interruptus Declares knowing about it 354 70.1 612 67.6 0.25 966 68.5 Ejaculation away from vulva 246 69.5 409 66.8 0.35 655 67.8 Details about contraceptive type were filled in only by those who declared knowing about the contraceptive in question; percentages were calculated accordingly. Some totals < 100% because of missing values. Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 397 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما Table 7 Practices regarding sexual habits and contraception Questiona Males (n = 505) Females (n = 905) P-value Total (n = 1410) No. % No. % No. % Already had sexual relations No, never 135 26.7 708 78.2 < 0.0001 843 59.8 Yes, with vaginal penetration 241 47.7 63 7.0 < 0.0001 304 21.6 Already used contraceptionb 237 64.1 48 24.4 < 0.0001 285 50.3 Yes, without penetration 137 27.1 78 8.6 0.005 215 15.2 Male condomc 204 86.1 2 4.2 < 0.0001 206 72.3 Yes, with anal penetration 128 25.3 28 3.1 < 0.0001 156 11.1 Oral contraceptivec – – 27 56.3 27 9.5 Spermicidal productsc 2 0.8 2 4.2 4 1.4 Coitus interruptusc 1 0.4 1 2.1 2 0.7 Would seek help for contraceptionb No 231 62.4 119 60.4 0.02 250 44.1 Yes, gynaecologist 24 6.5 63 32.0 < 0.0001 87 15.3 Yes, pharmacist 47 12.7 13 6.6 < 0.0001 60 10.6 Yes, general physician 31 8.4 10 5.1 0.003 41 7.2 Yes, midwife 11 3.0 12 6.1 0.46 23 4.1 Yes, social worker 12 3.2 6 3.0 0.30 18 3.2 Yes, nurse 7 1.9 8 4.1 0.50 15 2.6 Had sex without contraceptionb No 193 52.2 80 40.6 0.004 273 48.1 Yes, extra-vaginal 60 16.2 43 21.8 0.55 103 18.2 Yes, because unplanned 45 12.2 25 12.7 0.40 70 12.3 Yes, during infertile days 35 9.5 30 15.2 0.20 65 11.5 Where do you usually have sexb Home, parents absent 203 54.9 105 53.3 0.30 308 54.3 Beach chalet 196 53.0 85 43.1 0.23 281 49.6 Car 158 42.7 77 39.1 0.90 235 41.4 Dormitory rooms 111 30.0 32 16.2 0.002 143 25.2 Beach 103 27.8 36 18.3 0.05 139 24.5 Forest 94 25.4 32 16.2 0.05 126 22.2 Night club 82 22.2 30 15.2 0.15 112 19.8 Home, parents present 50 13.5 33 16.8 0.12 83 14.6 Movie theatre 58 15.7 24 12.2 0.50 82 14.5 University 44 11.9 17 8.6 0.41 61 10.8 Public place (road, garden) 30 8.1 18 9.1 0.42 48 8.5 Thinks sex without penetration can lead to pregnancy 173 34.3 310 34.3 0.94 483 34.3 Would abort a pregnancyb 187 50.5 102 51.8 0.06 289 51.0 Would use morning after pillb 84 22.7 49 24.9 0.86 133 23.5 Some totals < 100% because of missing values. aMore than one answer possible. bPercentages calculated for those who declared previous sexual relations. cPercentages calculated for those who used contraception. 398 La Revue de Santé de la Méditerranée orientale, Vol. 15, N° 2, 2009 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما acceptable (30%), but we had no means of evaluating reasons for refusal. Informa- tion bias is also possible, as in all surveys; the sensitivity of the subject increases the risk of false answers, particularly regard- ing practices. However, we doubt that any measurement error would be sufficient to change the shape of our results. We believe that this study is reasonably able to depict the reality of contraception in young Lebanese university students, but the results cannot be extrapolated to other young Lebanese. References 1. Erulkar A et al. Behavior change evalua- tion of a culturally consistent reproductive health program for young Kenyans. In- ternational family planning perspectives, 2004, 30(2):58–67. 2. Dei M et al. The resistance to contracep- tive use in young Italian women. European journal of contraception and reproductive health care, 2004, 9:214–20. 3. Villarruel A et al. Predictors of sexual intercourse and condom use intentions among Spanish-dominant Latino youth: a test of the planned behavior theory. Nurs- ing research, 2004, 53(3):172–81. 4. Gokengin D et al. Sexual knowledge, at- titudes and risk behaviors of students in Turkey. Journal of school health, 2003, 73(7):258–63. 5. Manlove J, Ryan S, Franzetta K. Contra- ceptive use and consistency in U.S. teen- agers’ most recent sexual relationships. Perspectives on sexual and reproductive health, 2004, 36(6):265–75. 6. Bender S, Kosunen E. Teenage con- traceptive use in Iceland: a gender per- spective. Public health nursing, 2005, 22(1):17–26. 7. Tountas Y et al. Information sources and level of knowledge of contraception issues among Greek women and men in the reproductive age: a country-wide survey. European journal of contracep- tion and reproductive health care, 2004, 9:1–10. 8. Glover EK et al. Sexual health experi- ences of adolescents in three Ghanaian towns. International family planning per- spectives, 2003, 29(1):32–40. 9. Machado Pirotta KC, Schor N. Intenções reprodutivas e práticas de regulação da fecundidade entre universitários [Repro- ductive intentions and fertility regulation practices among university students]. Re- vista de saúde pública, 2004, 38(4):495– 502. 10. Katende C, Gupta N, Bessinger R. Facil- ity-level reproductive health interventions and contraceptive use in Uganda. Interna- tional family planning perspectives, 2003, 29(3):130–7. 11. Harper G et al. The role of close friends in African American adolescents’ dating and sexual behavior. Journal of sex research, 2004, 41(4):351–62. 12. Baalbaky G. Religiosity in Lebanese youth. In: God and the right to the differ- ence. Kaslik, Lebanon, Holy Spirit Univer- sity, 2005. and community members should consider increasing opportunities for supervised ac- tivities, which could reduce risk-taking among youth [16]. We are aware of the possible biases that could arise from the study methodology: selection bias is possible due to the nature of the sample; however, we have no reason to believe that it would affect our results, since availability of students in the campus is theoretically unrelated to their sexual knowledge and practices. Refusal rate was Eastern Mediterranean Health Journal, Vol. 15, No. 2, 2009 399 ٢٠٠9 ،٢ ددعلا ،شرع سمالخا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قشرل ةيحصلا ةلجلما World Health Day 2009: Save lives. Make hospitals safe in emer- gencies World Health Day 2009 focuses on the safety of health facilities and the readiness of health workers who treat those affected by emer- gencies. Health centres and staff are critical life-lines for vulnerable people in disasters - treating injuries, preventing illnesses and caring for people’s health needs. They are cornerstones for primary health care in communities—meet- ing everyday needs, such as safe childbirth services, immunizations and chronic disease care that must continue in emergencies. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences. World Health Day is one of WHO’s most visible opportunities to raise awareness of global health priorities. This year, WHO and international partners will underscore the importance of investing in health infra- structure that can withstand hazards and serve people in immediate need. They will also urge health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the con- tinuity of care. 15. Eisenberg M et al. Parents’ beliefs about condoms and oral contraceptives: are they medically accurate? Perspectives on sexual and reproductive health, 2004, 36(2):50–7. 16. Cohen D et al. When and where do youths have sex? The potential role of adult supervision. Pediatrics, 2002, 110(6):66– 74. 13. Rostosky SS et al. Coital debut: the role of religiosity and sex attitudes in the Add Health Survey. Journal of sex research, 2003, 40(4):358–67. 14. Halpem-Felsher B et al. Adolescents’ self efficacy to communicate about sex: its role in condom attitudes, commitment and use. Adolescence, 2004, 39(155):443– 56.

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