Final year high school students knowledge on the menstrual cycle and contraception

Final year high school students knowledge on the menstrual cycle and contraception Emma Bladin Degree Project in Social Pharmacy, 30 hp, Term 9 Department of Pharmacy Faculty of Pharmacy Uppsala University 1

Abstract Background: Contraceptives' main purpose is to prevent unwanted pregnancies. It has been of great importance to women to choose whether they want to get pregnant or not. Several studies have confirmed that there are knowledge gaps in the field of menstrual cycle and contraceptives among young people. To have optimal contraceptive use in society, there must be easily accessible information about the alternatives, the use, and potential adverse drug reactions. Aim: To examine Swedish final year high school students knowledge on the menstrual cycle and contraception. Method: A quantitative cross-sectional study was performed, and web-based questionnaires were considered the best method of collecting the data. The questionnaire was pilot tested and reviewed by an expert who has experience in developing and working with questionnaires. The high schools were primarily selected by geographical area. The selection was extended to make it possible to recruit more students. A portion of the participating students needed to study the nature science program. The study was conducted in Sweden between February 2022 and June 2022. Results: The questionnaire was completed by 139 students. Women were significantly more knowledgeable than men (61,2% vs 47,5%; p=0.00001) as well as the nature science program were significantly more knowledgeable than in the social science- and economic program (65,1% vs 54,6%; p=0.002). There was no significance between students with highly educated parents compared with low educated parents (58,9% vs 55,86 p=0.2). Conclusion: There are knowledge gaps regarding knowledge on the menstrual cycle and contraception among final year high school students. It is important to regularly teach what menstruation is and how it works biologically, and to include social, physical, practical and emotional aspects, which the student also show interest in. 2

Populärvetenskaplig sammanfattning Du kanske vet att hormonspiral inte skyddat mot könssjukdomar, min visste du att ägglossningen sker 14 dagar efter mensens första dag? Det visste i alla fall inte 56% av de 139 sistaårs gymnasieleverna som svarade på en enkät om menscykeln och preventivmedel. Syftet med studien var att undersöka sistaårs gymnasielevers kunskap om menscykeln och preventivmedel och jämföra kunskapsnivån mellan könen, gymnasieprogram och socio ekonomisk status. Detta gjordes med hjälp av en enkät med frågor och påståenden som ifrågasatte elevernas kunskap om när en kvinna kan bli gravid, när ägglossning sker, vidare hormonella preventivmedel klassas som läkemedel eller ej, vilka som är vanliga biverkningar av hormonella preventivmedel samt flytningars betydelse. Enkäten bestod av tjugo olika frågor och påståenden med olika svårighetsgrad. 88% av respondenterna visste att påstående Hormonspiral skyddar mot könssjukdomar var falskt och 84% svarade rätt på att det är under ägglossningen som kvinnan kan bli gravid. Endast 16% visste att tjocka genomskinliga flytningar är en indikation på ägglossning och mindre än hälften visste att kroppstemperaturen höjs 0,2 0,5 efter ägglossningen. Två tredjedelar visste att kvinnor generellt blöder 3 6 dagar under menstruationen. Kvinnor hade som väntat ett signifikant bättre resultat på den totala enkäten än männen. De elever som gick det naturvetenskapliga programmet hade i jämförelse med övriga gymnasielinjer (samhällsvetenskapliga- och ekonomiprogrammet) ett signifikant bättre resultat. När resultaten för de eleverna med högutbildade föräldrar jämfördes mot de eleverna med lågutbildade föräldrar noterades ingen signifikans. Kvinnohälsa omfattar allt från hormonella preventivmedel till klimakteriet och påverkar kvinnans välmående genom livet. Under tonåren speciellt finns det många faktorer som kan påverka tankar och mående menscykeln och preventivmedel är en av dem. Därför är det viktigt att ha kunskap om hur kroppen, menstruationscykeln och preventivmedel fungerar och påverkar kroppen för att vara medveten om konsekvenserna. Att ha ökad kunskap inom ämnet gynnar samtliga parter för att kunna undvika graviditet, planera graviditet, förebygga att könssjukdomar sprids och upptäcka andra infektioner i tid. 3

Acknowledgements This master thesis has been conducted at the Department of Social Pharmacy, Faculty of Pharmacy, at Uppsala University from February 2022 to June 2022. I would like to express my gratitude to my supervisor, Sofia Kälvemark Sporrong, firstly for the trust and the opportunity to immerse myself in a topic that I find interesting and supported and believed in my project. Secondly for providing me with good ideas and experience. You have been very important to me with inspiration and support during the project. I would also like to give a big thanks to all the students that participated and answered the questionnaires during the data collection. Also, thanks to their teachers who organized the meeting and made time for me to meet the classes or handed out the questionnaire themselves during lesson time. 4

List of abbreviations Abbreviations IUD PMS STD Intrauterine device Premenstrual syndrome Sexually transmitted diseases 5

Table of content 1. Introduction... 7 Preunderstanding... 7 Knowledge of reproductive health... 7 Significance of reproductive knowledge... 9 Tabooization of menstruation... 9 Significance of contraceptives... 10 Disadvantages of contraceptives... 10 Contraceptives for men... 11 The knowledge gap... 11 2. Aim and objectives... 12 Research questions... 12 3. Material and methods... 13 Ethical considerations... 16 4. Results... 18 5. Discussion... 26 Discussion on results... 26 Study strengths and limitations... 29 Future research... 30 6. Conclusion... 31 7. References... 32 8. Appendix #... 36 Appendix 1 Questionnaire... 37 Appendix 2 Information to respondents in English... 41 Appendix 3 - Translation of Swedish quotes... 41 6

1. Introduction Preunderstanding Having a reason is always important and since I started the Master of Science in Pharmacy program - medicine and social issues have always caught my attention. At the same time, interest in women's health has grown and especially young people's knowledge about the menstrual cycle and contraception. It is an area that affects all people more or less at some point in life. My own experience says that the level of knowledge is low, which is also confirmed by studies done in the field. Women s health includes everything from hormonal contraception to menopausal symptoms and affects a woman s well-being throughout life. During adolescence, many factors can affect the mind and moon. The menstrual cycle and contraceptive use are one of them. Therefore, it is important to have knowledge of how the body, the menstrual cycle, and contraceptives work and affect the body and to be aware of the consequences to be able to make knowledge-based decisions. An increased level of education can contribute to a more equal society. Furthermore, when the lecturer's in the Master of Science in Pharmacy program gave very limited lectures on contraceptives and their effects I found my reason. Knowledge of reproductive health Contraceptives' main purpose is to prevent unwanted pregnancies. It has been of great importance to women to choose whether they want to get pregnant or not which can be crucial to what their future will look like. The contraceptive pill was launched in the 1960s and became a sexual release and was of great importance to feminism (1). Several studies have confirmed that there are knowledge gaps in the field of menstrual cycle and contraceptives among young people (2-3). A study conducted by Inandi et al. (2) examined what university students aged 20-24 in Turkey knew and their opinions about reproductive health. The study found that the knowledge about reproductive health among Turkish students is limited. Another finding was that male students needed more knowledge about reproductive health than female students, but that men had more knowledge about sexually transmitted diseases, while women had more knowledge about pregnancy, childbirth, and family planning. Further, limited knowledge was also seen in a study 7

conducted by Capuano et al. (3) in Italy. A problem in Italy is unplanned teenage pregnancies as young people use the day after pills rather than long-term contraceptives and safe sexual behavior which is believed to be due to lack of knowledge. The study found that introducing effective sex and contraception programs in schools can help reduce sexual risk-taking. Additionally, a study by Lisbet et al. (4) to examine knowledge, attitudes, and practices related to conception and fertility among women of childbearing age in the United States was conducted. A quarter of the women surveyed did not know that a normal menstrual cycle can vary between 25 and 35 days and 40% were unaware that ovulation usually occurs 14 days before menstruation or that transparent discharge is a sign of ovulation. This study is another example of knowledge gaps regarding reproductive health. In Capuano et al. (3) study, students from three different cities participated, of which in one of the cities the students had to do the questionnaire before and after they had had sex education in school, which showed that the young people had significantly better knowledge after receiving sex education. According to a study conducted by The Public Health Agency of Sweden on Sexual and reproductive health and rights in Sweden 2017. The results showed that fewer women (aged 16-29 years) with higher income use birth control pills compared to women with lower income, and women with higher education in comparison with lower education. The difference in use is probably due to knowledge and fear of hormones and their adverse drug reactions. The general use of contraceptives among women depended on both age and need, but also income and level of education. (5) There are at least two reasons to increase the general knowledge about the menstrual cycle and the fertile period, firstly to avoid unintentional pregnancy when using a less effective contraceptive method, and secondly to facilitate planning in the desired pregnancy. Encouraging young people to have safe sex through proper education can also prevent sexually transmitted infections from spreading, which is another reason to increase young people's educational level around the menstrual cycle and contraception. (6) The choice of contraceptive should be based on the women s wishes and whether any risk factors can be avoided (7). 8

Significance of reproductive knowledge Another aspect of why knowledge about the menstrual cycle is important is that a regular menstrual cycle is a sign of health. Disorders of the menstrual cycle can affect the physical and mental state. For women to have good menstrual health throughout their lives, access to accurate, up-to-date, and age-appropriate information about the menstrual cycle is required. To be able to achieve health and equality, menstrual health must be given priority in order to give everyone equal opportunities to optimize their health through different stages of life. (8) A girl is born with between one and two million oocyte-containing follicles, but only four to five hundred will complete the process during ovulation. The fact that ovulation occurs indicates that the woman is in good health and understanding fertility can therefore be very useful. By being able to identify gynecological dysfunctions, for example, genital infections can be detected at an early stage. (9) To have an optimal contraceptive use in society, there must be easily accessible information about the alternatives, the use and potential adverse drug reactions. The same contraceptive does not suit everyone, a varied range is therefore the prerequisite for her to be able to initiate and want to continue with her contraceptive method. (10) Tabooization of menstruation Every woman is affected by menstruation in different ways. How to handle and talk about menstruation differs depending on societal and cultural norms. Several cultures subordination women precisely for the reason that they menstruate. Further, other cultures associate menstruation with strength. (11) Menstruation is for millions of girls around the world associated with pain, anxiety, isolation and shame. Access to sanitation products may be limited in several low-income and middleincome countries, which increases the risk of infections and diseases. (12) In the UK, one in ten girls aged 14-21 regularly could not afford sanitary products, which resulted in several people being forced to stay home from school. (13) Menstrual poverty is not just about money, but taboos around menstruation result in it being rarely talked about in the family or at school. In a study conducted by Plan International UK, (13) 42% of the teenage girls stated that they had temporarily used toilet paper and socks as 9

menstrual protection. 80% of teenage girls had experienced menstrual symptoms (such as unusually heavy or irregular bleeding) but did not consult a doctor. This is the result of a taboo topic. In the life of every healthy teenage girl, menstruation is a normal and regular event and therefore influential people - such as community leaders, teachers, and health workers - need to prioritize menstruating girls and women. Education is the key to sustainable social change and boys and girls must be educated about menstruation and reproductive health so that menstruation and sexual health become something you can talk about openly. Having menstruation is a good sign of health. (12) Parents often feel unprepared and uncomfortable when it comes to menstruation, and mothers are expected to be one of the most important sources of information on the subject, which can reinforce the taboo and the negative attitude. Menstrual taboos can harm girls and women's health and well-being as a lack of knowledge can lead to connections such as anxiety and depression linked to the menstrual cycle never being drawn. A poorer state of health can have a hormonal cause and an awareness of this would have been helpful. (13) Significance of contraceptives The use of contraceptives is important to achieve a healthy sex life and avoid unwanted pregnancies and sexually transmitted diseases. Many women today have children later in life, which requires many years of reliable contraception that have to suit the individual user. The view of sex has changed in today's society and the number of sexual contacts has increased as it is more accepted with sex without an established love relationship. A functioning contraceptive use is therefore of great importance. (14) Contraception gives women the power to decide for themselves over their lives. Having the opportunity to be able to decide when and who she should have children with, if she even wants children, is a fundamental pillar for reducing poverty in society. Women can then finish school, work and earn their own money. (10) Disadvantages of contraceptives All drugs have adverse drug reactions, and one adverse drug reaction that can occur when taking hormone-based contraceptives is spottings, which can also be a sign of genital 10

infection, pregnancy or cervical cancer. Other occurring adverse drug reactions are decreased libido, headache, nausea, depression, irritability, increased discharge and pigmentation. (7) These factors are often the reason why women stop taking contraceptives (14). A study conducted by Zethraeus et al (15). determined whether there is a causal effect of oral contraceptive treatment on general well-being and depressed mood in healthy women. The study found that there is a statistically significant reduction in general well-being with oral contraceptives compared to placebo in healthy women. Contraceptives for men The contraceptives available today for women are very effective in avoiding accidental pregnancy. Some women cannot use them due to adverse drug reactions or health conditions. Today, condoms or vasectomy can be used as male contraceptives, but they are also not idealistic for all men, so there is a need for alternative contraceptives for men. (16) Condoms have a high failure rate and surgical vasectomy is not certainly reversible. (17) The knowledge gap Several previous studies have confirmed that there are knowledge gaps regarding the menstrual cycle and contraception (2-3). This hasn t been examined in Sweden amount young people before and it is of great importance to highlight this subject to reduce stigmatization and spread knowledge. There is a complex subject since taboos, culture, and attitudes play a major role in the acquisition of knowledge. This type of knowledge can be especially important in the young years and there is therefore of special interest to conduct this study and examine high school students knowledge on the menstrual cycle and contraception. 11

2. Aim and objectives The aim of this study was to examine Swedish final year high school students knowledge on the menstrual cycle and contraception - focus on birth control pills and intrauterine devices - and compare the level of knowledge between the sexes, study programs, and parents education level. Research questions o What are the differences in knowledge on the menstrual cycle and contraceptives between the natural science programs and other programs (the social science programs and economic program)? o What are the differences in knowledge on the menstrual cycle and contraceptives between the sexes? o What are the differences in knowledge on the menstrual cycle and contraception between high-educated parents and low-educated parents? 12

3. Material and methods A quantitative cross-sectional study was considered most appropriate since the aim was to examine final year high school students knowledge of the menstrual cycle and conception, and also to compare between groups. Therefore, questionnaires were considered the best method of collecting the data. The following studies with a similar aim Adejobe B et al, Lisbet S et al and Cegolon L also used questionnaires. The questionnaire was created by myself with inspiration from previous literature (4,18, 19). The questionnaire was pilot tested on 3 people from the target group, one of them was allowed to do the think-aloud method which means that the respondent tells what he/she thinks when they answer the questions, which facilitates the development of the questionnaire (20). The other pilot testers were allowed to provide feedback after completing the questionnaire. The questionnaires were reviewed for the layout and language by an expert who has experience in developing and working with questionnaires. A web-based questionnaire was considered to be the most suitable option as the questionnaires were to be distributed to many students in a short time. For this Google form was used. That was also suitable for the target group as girls and boys aged 18-19 are daily used to handling mobile phones. Further, data collection and analysis were facilitated by using a web-based questionnaire as the data were collected directly in excel. The questions were in Swedish as the target group was Swedish high school students. The questionnaire can be found in Appendix 1 and comprised a total of 20 questions divided into four parts. Part one collects information about the respondent such as gender, high school program, parents' highest completed education and whether the respondent has attended the entire primary school in Sweden or not. Part two included knowledge questions about how the menstrual cycle and contraception work, part three contains true or false statements about the menstrual cycle and contraception and part four a question for reflection. The questionnaire ended with a question about what the respondent wanted to know more about. The menstrual cycle and contraception knowledge was assessed based on questions that asked the respondent about how many days a normal regular menstrual cycle is, when during the menstrual cycle the woman can become pregnant, common adverse drug reactions from hormonal contraceptives, myths and true and false claims about the menstrual cycle and contraception. 13

The questionnaire was intended to contain different degrees of difficulty. The degree of difficulty was assessed according to previous studies (4,18,19), the people who pilot-tested the questionnaire, and my own hypothesis based on my own experiences. The questions were designed to make sure that the words were simple and clear enough to be understood by the final year high school students. The people who pilot-tested the questionnaire judged that they understood the questions even though they did not know all the correct answers. High school students knowledge on the menstrual cycle and contraception was assessed by questions that required an answer and they always had the opportunity of a Don't know response. A Don't know answer was calculated as an incorrect answer. The following questions were categorized as easy questions: How many days is a normal regular menstrual cycle (number of days between the first day of the period and the first day of the next period)? (Hur många dagar är en normal regelbunden menscykel (antal dagar mellan mensens första dag och nästkommande mens första dag)?) How many days is it generally common to bleed during menstruation? (Hur många dagar är det generellt vanligt att blöda under menstruationen?) When during the menstrual cycle can a woman become pregnant? (När under menscykeln kan kvinnan bli gravid?) IUDs protect against sexuallt transmitted diseases (Hormonspiral skyddar mot könssjukdomar.) The following questions were categorized as more challenging questions: The woman saves eggs by eating hormonal contraceptives. (Kvinnan sparar ägg genom att äta hormonella preventivmedel) Birth control pills stop ovulation. (P-piller stoppar ägglossningen) The task of discharge is to clean and keep the vagina clean. (Flytningars uppgift är att städa och hålla rent i slidan) IUDs and birth control pills are classified as drugs. (Hormonspiral och p-piller är klassificerat som läkemedel) Body temperature increases 0.2-0.5 C after ovulation. (Kroppstemperaturen ökar 0,2 0,5 C efter ägglossningen) 14

An egg survives for one day in the womb while sperm can survive for about 5 days. (Ett ägg överlever i ett dygn i livmodern medan spermier kan överleva ca 5 dygn) Finally, the following questions were categorized as difficult questions: What can thich transparent discharges (egg white-like) in women be a sign of? (Vad kan tjocka genomskinliga flytningar (äggviteliknande) hos kvinnor vara ett tecken på?) Which statement is correct? (Vilket påstående är korrekt?) What are the common adverse drug reactions of hormonal contraceptives? (Vilken/vilka är VANLIGA biverkningar av hormonella preventivmedel?) The ovaries produce new eggs as long as the women i fertile. (Äggstockarna producerar nya ägg så länge kvinnan är fertil/fruktbar) Twenty-four high schools in Sweden were contacted and asked if they wanted to participate. The schools were primarily selected by geographical area as the primary purpose was for me to go and hand out the questionnaires myself in the schools. Thereafter, the geographical area was increased to make it possible to recruit more students. The requirements for the schools were that there should be high schools with students in year 3. Further, as one of the research questions was to examine the differences in knowledge on the menstrual cycle and contraceptives between the natural science programs and other programs, there was of great importance in recruiting some students who studied the nature science program. The request contained a short description of the aim of the project and contact information to me and my supervisor. For the schools/classes that said yes, an appointment was booked for me to hand out the questionnaires. Alternatively, for schools that were interested but did not have the opportunity to receive me a link and QR code for the questionnaire were sent to the teacher. The teacher also received instructions to inform that the questionnaire is individual, voluntary, and anonymous. The teacher then had the opportunity to hand out the QR code during lesson time when possible. For the classes that I visited personally, the course lecturer introduced me, and I gave a brief explanation about the purpose, background of the questionnaire study and that the participation was voluntary. The students were asked to respond individually to the 15

questionnaire and not to do any research on the internet. The questionnaire was completed by the students during lecture and the seating arrangement remained the usual. The questionnaire was web-based, and the students scanned a QR code with their phone to gain access. The questionnaire began by providing the respondent with some information in Swedish, see Appendix 2. Required time for completion of the questionnaire was 5 to 10 minutes and all the questions were mandatory. After completion, the students had the opportunity to ask questions. A score of 1 was assigned to each of the correct responses and a summary score was generated (range 0-14). The score was analyzed individually, and an average value was counted for the sexes and each high school program. All the data was handled in excel. The entire study population's answers were first analyzed, and which question was most correct and not was presented. The question about common adverse drug reactions was analyzed separately with a bar diagram. The different variables - sexes (male vs female), high school program (nature science program vs other programs) and parents education level (two highly educated parents vs no parent is highly educated) were separated and the differences were studied. To confirm a significance, t-test was used (p<0,05). For the question what would you like to know more about the menstrual cycle and contraception? the students had the opportunity to write what they wanted to know more about. The answers were categorized according to what they answered in the following categories: Adverse drug reactions; male contraceptives; PMS; what different discharges mean; hormone-free contraceptives; hormones, mood, and menstrual cycle; ovulation; different contraception and how it works. Responses that could not be categorized were cited. Ethical considerations Menstrual health and contraception are important subjects and although they can be sensitive, it is important to implement the study to highlight potential knowledge gaps and contribute to future research. All persons in the study were informed about the purpose of the study, that the participation was voluntary, and the participant had the right and opportunity to suspend their participation 16

until the questionnaire was submitted. Once the survey had been submitted, the data were deidentified. All persons in the study had reached the age of 18 years (21). Ethical challenges include how the collected primary data shall be stored to avoid risk of unauthorized access to the data. The data was anonymous, when the respondent submitted the questionnaire, it was not possible to link the answers to an individual. Another ethical consideration that should be considered is the factor that the menstrual cycle and conception is a taboo and sensitive topics. This was kept in mind while the questionnaire was developed and handed out to the students. No approval from the Swedish Ethical Review Authority was needed as this is a master thesis at Uppsala University and it is young people's knowledge that will be tested and not their health, sexlife or sexual orientation are not exposed. 17

4. Results The final sample consisted of 139 students. Selection and dropout can be seen in flowchart below (figure 1). Figure 1. Flowchart selection Respondents were divided by 3 high school programs as follows: Nature science programs: 24% (n=33) Social science program: 33% (n=46) Economic program: 43% (n=60) The students were divided into three groups depending on genders: male, female or genderqueer. Resulting in a sample size of 42 (30%), 93 (67%) and 4 (3%) respectively. As there were only 4 participants who belonged to the genderqueer group, this category was 18

excluded when the sexes were compared. As can be seen in table 1 the majority, 93% of the students, had taken the entire primary school in Sweden. 64 percent had at least one parent who had college or university as the highest completed education. Table 1. Student characteristics Student characteristics Variables Classes Totalt n (%) Nature science program (n) Social science program (n) Economic program (n) Sex/gende r Female 93 (67) 17 37 39 Male 42 (30) 14 9 19 Genderqueer 4 (3) 2 0 2 I have read primary school in Sweden (grades 1-9): The entire primary school in Sweden Yes, parts of primary school No, read primary school in another country 129 (93) 28 42 59 9 (6) 4 4 1 1 (1) 1 0 0 What is your mother's / guardian's highest level of education? What is your father's / Elementary school 12 (9) 4 3 5 High school 34 (25) 0 19 15 College or university 89 (64) 28 22 39 Other / not relevant 4 (3) 1 2 1 Elementary school 8 (6) 1 3 4 High school 47 (34) 5 23 19 19

guardian's highest completed education? College or university 77 (55) 26 15 36 Other / not relevant 7 (5) 1 5 1 The majority (88%) agreed that intrauterine device (IUD) do not protect against sexually transmitted diseases. Eighty-four percent of the students correctly defined that ovulation is when during the menstrual cycle a woman can become pregnant. Seventy seven percent answered correctly how many days a normal menstrual cycle is and the major part (71%) knew that the task of discharge is to clean and keep the vagina clean. Approximately 60% of the students knew that birth control pills stop ovulation and 66% knew that you generally bleed 3-6 days during menstruation. More than half of the participants (60%) answered correctly ( FALSE ) that women save eggs by taking hormonal contraceptives. Forty-two percent did not know that an egg can survive for one day in the womb while sperm can survive for about 5 days. Only half of the students knew that IUDs and birth control pills are classified as drugs. Sixty-five percent of the students did not know that the ovaries do not produce new eggs as long as the woman is fertile. Only 16 percent answered correctly on What can thick transparent discharge (egg white-like) in women be a sign of?. Sixty percent did not know that the body temperature increases 0.2-0.5 C after ovulation. 20

Figure 2. Question and statements from questionnaire. Percent (%) answered correctly. High schools students knowledge As can be seen in Figure 2, 81 percent were aware of sadness as a common adverse drug reaction of hormonal contraception. 59 percent knew about decrease libido as a common adverse drug effect and 74 percent were aware of acne. 40 percent of the student mistakenly through thrombus is a common adverse drug reaction. Less than one-fifth (18%) were wrong that increased body hair is a common occurrence. 21

Figure 3. Question about common drug adverse reactions of hormonal contraceptives. Percent (%) answered. Several options could be ticked in. Question What are the common adverse drug reactions of hormonal contraceptives? Among females compared to males, females were significantly (p=0,00001) more knowledgeable as the average score in percent for the questionnaire were 61,2% among females and 47,5% among males. The nature science program received 65,1% and were significantly (p=0,002) more knowledgeable than other programs (social and economic) as received an average score of 54,6%. There is no significance between the knowledge level for students with two highly educated parents and two low educated parents (58,9% vs 55,9%, p=0,20). 22

Table 2. Distribution of gender, program and parents education level average score on questionnaire Different variables average score on questionnaire Variables Classes Amount of respondents Average score on entire questionnaire, amount score Average score on entire questionnaire, percent % Sexes Male 42 6,66 47,5 Female 93 8,60 61,2 High school program Nature science 33 9,11 65,1 Social science and economics 106 7,65 54,6 Parents education level Both parents are high educated ( college or university) No parent is highly educated (<college or university) 65 8,24 58,87 37 7,82 55,86 The following section presents students answers for the question What would you like to know more about the menstrual cycle and contraception? and can be seen in table 3. The answers were divided into categories and some unique answers were quoted. The answers were provided in Swedish and are here translated into English. Among both sexes, most wanted to know more about male contraceptives, hormones, mood, and the menstrual cycle. Females also wanted to be more aware of adverse drug reactions, what different discharges means and different contraceptives and how they work in the body. 23

Table 3. Subject/categories students wanted to know more about the menstrual cycle and contraception. What would you like to know more about the menstrual cycle and contraception? Category Male (n) Female (n) Adverse drug reactions 3 10 Male contraceptives 6 13 PMS 2 6 What different discharges mean 2 9 Hormone-free contraceptives - 2 Hormones and mood, menstrual cycle 5 13 Ovulation - 3 Different contraception and how it works 2 9 How to know what is normal and not, we are not learning that in school. F1. Everything, I'm a woman but there's a lot I do not know that I want to learn." F2. "Who do you go to when you get too old for the youth clinic, and what does it cost with contraception?" F3. I think I know most things, but it's always fun to learn more! maybe more about not everyone having regular menstruation + endometriosis? and then I know that there are some rumors and stuff about when one can get pregnant, etc. and how to avoid it, so maybe to deny such things. F4 "Generally, more alternative to some form of 'basic knowledge' as I know very little about this subject." M1. "Everything basic that you should know if, for example, you want to have children with your 24

wife if you have one." M2. How it affects parts of the world where there is no access to contraception. What differences it can create. M3 25

5. Discussion In the following section final year high school students knowledge on the menstrual cycle and contraception will be discussed, which questions were most correctly answered and why, how the answers differ between the sexes, different high schools programs, and other factors that may have influenced the answers. Furthermore, the study strengths and limitations of the study will be discussed. Finally, future research and suggestions will be presented. Discussion on results The overall aim of this study was to examine the knowledge on the menstrual cycle and contraception among final high school year students in Sweden. This was done with a quantitative questionnaire that questioned students knowledge. The study identifies knowledge gaps surrounding the menstrual cycle and conception in students and highlights areas the participants have more and less understanding of. Firstly, the students indicate acceptable understanding when it comes that IUDs do not protect against STDs, when during the menstrual cycle a woman can become pregnant and how many days a normal regular menstrual cycle is, these were categorized as easy questions and many correct answers were expected (see Figure 2). A study conducted in Sweden in 1992 examined the sexual behaviors among youth clinic visitors, 9277 young persons participated, their mean age was 17.5 years and 93 percent of them were females and more than 99% knew of the condom method as protection against STDs. (22) Furthermore, as can be seen in Figure 2 as many as 71 percent of the students knew the fact that the task of discharges is to clean and keep the vagina clean. On the other hand, many students have limited understanding of when the ovulation is happening during the cycle, what thick transparent discharges is a sign of (ovulation) furthermore also not knowing that the body temperature increases 0,2-0,5 C after ovulation. That might correlate with a low perception of the risk for pregnancy as can negatively influence their contraceptive use, sexual behaviors, and ability to pay attention to signs that indicate ovulation as can lead to unintended pregnancy. Lisbeth et al. confirm the knowledge gaps regarding ovulation as 40% in their study were unaware that ovulation usually occurs 14 days before menstruation or that transparent discharge is a sign of ovulation. 26

The questions belonged to different degrees of difficulty as described in the method. The three questions with the most correct answers belonged to the category easy questions, and a high number of correct answers were expected. IUDs protect against sexually transmitted diseases (88%) When during the menstrual cycle can a woman become pregnant? (84%) How many days is a normal regular menstrual cycle? (77%) The question that was categorized as difficult questions belonged to the bottom with the fewest correct answers. Which statement is correct? (44%) The ovaries produce new eggs as long as the woman is fertile (35%) What can thick transparent discharge (egg white-like) in women be a sign of? (16%) Unexpected results were that more than 70 percent knew that the task of discharges is to clean and keep the vagina clean, this is surprising as many students wanted to know more about discharges, but it could be that the students know the task of discharges but not what different discharges say about where you are in the menstrual cycle and that certain discharges can be symptoms of infections. The hypotheses and expectations according to the different degrees of difficulty partly agree with the result. Only half of the students knew that IUDs and birth control pills are classified as drugs which may influence the understanding of mechanisms of action and potential adverse drug reactions. One potential reason why half of the students knew that IUDs and birth control pills are classified as drugs may be that contraceptives are prescribed and must be picked up at a pharmacy - like other medicines. One reason why the other half of the students did not know IUDs and birth control pills are classified as drugs could be that contraceptives do not need to be prescribed by a doctor. In Sweden, midwives are allowed to prescribe contraceptives and there is no need for going to the hospital. The youth clinic you can go to until you are approximately 23 years old. For the question what are common adverse drug reactions of hormonal contraceptives, students were allowed to tick several alternatives. All the listed options were adverse drug reactions to hormonal contraceptives, and the purpose was to get an overview of whether students are aware of decreased libido, acne, and sadness as a common adverse drug reaction 27

of hormonal contraceptives. More than 70 percent of the students knew that decreased libido, acne and sadness are common adverse drug reactions. The purpose of the question was also to see if they thought blood clots are a common adverse drug reaction which is important to know that it is not. Forty percent believed that thrombus is common and can negatively influence the initiation of hormonal contraception. Since the aim was to examine Swedish final year high school students knowledge on the menstrual cycle and contraception and compare the level of knowledge between the sexes, study programs, and socio-economic status. The study conducted by Adejoke B et al categorized those with >70% correct answers as high knowledge and those < 70% as low knowledge. If applied to this study, one-fourth of the final high school year students have high knowledge. Factors that could influence the results of the questionnaire and to be examined were gender, high school program, and the parents' education level. Women had significantly better results on the questionnaire than men, but the difference is not considered as women are expected to have more knowledge about the menstrual cycle as they are those who actually bleed every month, take hormonal contraceptives, and experience mood swings, PMS and other related symptoms. The students of the nature science program had significantly higher knowledge than in the social science- and economic program (58.9% vs 57.3%; p=0.002). One potential reason for that is the education students received in school. This is consistent with the nature programs study Biology 2 which contains the following What happens in the body during menstruation, love, sex, and pregnancy. How sexually transmitted diseases and unwanted pregnancies can be prevented. (23) Individuals who decide to study nature may also have a more natural interest in the body and biological functions which may have influenced the results. A previous study conducted by The Public Health Agency of Sweden on Sexual and reproductive health and rights in Sweden 2017 concluded differences in contraceptive use and level of education among women (5). According to students' knowledge on the menstrual cycle and contraception, there is no significance between students with highly educated parents and low educated parents. That may imply that parents are not the primary source of information about the menstrual cycle and contraception. 28

The main indication for hormonal contraceptives is to prevent unwanted pregnancy and as the Medical Products Agency's treatment recommendations say, the woman should be satisfied with her contraceptive method when life situation and lifestyle are to be considered. The woman should be informed about fertility, the menstrual cycle, and how various contraceptives work, also possible adverse drug reactions and any positive health effects must be communicated. (7) Students, both women, and men show curiosity and interest in the menstrual cycle and contraception as several of them expressed they want to know more about male contraceptives, hormones, mood, and the menstrual cycle. It is important to regularly teach what menstruation is and how it works biologically, but it is also important to include the social, physical, practical, and emotional aspects, which the students also show interest in. It should be clear that everyone's menstruation is unique and experienced differently and learn the right knowledge to be able to identify both healthy and unhealthy symptoms. (13) As one student expressed How to know what is normal and not, we are not learning that in school. F1. Study strengths and limitations In this study, major limitations have been identified. Only three people pilot tested the questionnaire, and only one person did the think-aloud method. Three people can not cover for everyone who participated in the study and there is room for misunderstanding and that shall be kept in mind when studying the results. Another limitation is that the result may have been affected depending on if I was present in the classroom or if the teacher handed out the questionnaire. For the classes where I was present, I could check that they were the right people who responded to the questionnaire or that the students did not cooperate with each other. That responsibility was transferred to respective teachers. It may also have affected the students' willingness to respond seriously during the times I was present or the other way around. Students may also have misunderstood questions if there were words or sentences, they did not understand, or if they did not take the time to read the question properly, which may have influenced the result. Finally, the study is limited by a relatively small sample size compared to previous studies (4,18,19) and the population was not a random selection which means that several ethnicities, sexual orientations, and backgrounds may have been excluded. A big challenge regarding this 29

study was the recruitment of study participants, selection, and dropout. The participants who chose to answer the questionnaire honestly may have had a greater interest in the topic and also knew better, while for example many men may not get involved as much and did not answer the questions seriously and that was why the women got a significantly better result. Students who chose not to answer the questionnaire may not have been so familiar with the subject and did not want to answer because they did not have that much knowledge in the subject. The strengths of the study the questionnaire covered a large area, and the questions were carefully selected according to the purpose. There were questions with varying degrees of difficulty to suit as many people as possible and there were a fair number of questions and thus were not time-consuming for the respondent. Future research Clarification of the influence of socio-economic factors such as cultural and geographic that may affect men and women's knowledge of the menstrual cycle and contraceptives would be of interest. Additionally, where young people obtain the most information about the menstrual cycle and contraceptives to be able to develop that source (for example school, the pharmacy, or social media) with easily accessible and right information would be of value. During the autumn semester 2022, sex and cohabitation (sex-och samlevnad) will change their name to sexuality, consent, and relationships (sexualitet, samtycke och relationer). This means, among other things, that students 'health and well-being must be promoted, students' ability to make conscious and independent choices must be strengthened, and knowledge about power structures linked to gender and honor-related violence and oppression (24). It would therefore be of interest to remake this or a similar study again to evaluate the extent to which the educational material affects students' knowledge of the menstrual cycle and contraception. As this study took place for a limited time, there was no time to include more high school programs, but for future research, a study with a similar purpose on a larger study population would be of interest. 30

6. Conclusion This master's thesis regarding knowledge on the menstrual cycle and contraception can be summed up by the fact that there are knowledge gaps among final year high school students. Sexes and high school programs have significance when it comes to students' knowledge of the menstrual cycle and contraception. Women were more knowledgeable than men as well as the nature science program were more knowledgeable than other high school programs that participated. Socio-economic status as the parents' education level has no significant impact on the level of knowledge. There is a need for more studies in the field as there is an interest from the students. Studies like this are of great importance to highlight and reduce stigmatization. 31

7. References 1. Andersson S. History of the Conception pill The Swedish Association for Sexual Enlightenment, RFSU. [updated December 11, 2017; cited November 16, 2021]. Available via:https://www.rfsu.se/sex-och-relationer/for-dig-somundrar/preventivmedel/p-piller/p-pillrets-historia/ 2. Inandi T, Tosun A, Guraksin A. Reproductive health: knowledge and opinions of university students in Erzurum, Turkey. The European Journal of Contraception & Reproductive Health Care, 8:4, 177-184. Available via: https://www-tandfonlinecom.ezproxy.its.uu.se/doi/pdf/10.1080/ejc.8.4.177.184?needaccess=true 3. Capuano S, Simeone S, Scaravilli G, Raimondo D, Balbi C. Sexual behavior among Italian adolescents: Knowledge and use of contraceptives. The Europeans Journal of Contraception & Reproductive Health Care, 14:4, 285-289 Available via: https://www-tandfonlinecom.ezproxy.its.uu.se/doi/pdf/10.1080/13625180902926920?needaccess=true 4. Lisbet S Lundsberg Ph.D, M.P.H, Lubna Pal M.B.B.S, M.R.C.O.G., M.S, Aileen M. Gariepy M.D., M.P.H, Xiao Xu Ph.D, et al. Knowledge, attitudes, and practices regarding conception and fertility: a population-based survey among reproductive-age United States women. Fertility and Sterility. Volume 101, Issue 3, March 2014, Pages 767-774.e2. Available via: https://www-sciencedirectcom.ezproxy.its.uu.se/science/article/pii/s0015028213034250?via%3dihub 5. Sexual and reproductive health and rights in Sweden 2017. [Internet]. The Public Health Agency of Sweden. [published 19 June 2019]. Available via: https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/s/sexualand-reproductive-health-and-rights-in-sweden-2017/?pub=61789 6. Szűcs M, Bitó T, Csíkos C, Párducz Szöllősi A, Furau C, Blidaru I et al. Knowledge and attitudes of female university students on menstrual cycle and contraception. 32

Journal of Obstetrics and Gynaecology, 37:2, 210-214. Available via: https://www- tandfonline- com.ezproxy.its.uu.se/doi/pdf/10.1080/01443615.2016.1229279?needaccess=true 7. Contraception treatment recommendation [Internet]. The Medical Product Agency. [updated April 16, 2014; cited November 16, 2021]. Available via: https://www.lakemedelsverket.se/48e08d/globalassets/dokument/behandling-ochforskrivning/behandlingsrekommendationer/behandlingsrekommendation/behandlings rekommendation-antikonception.pdf 8. Hennegan J, Winkler I, Bobel C, Keiser D, Hampton J, Larsson G, Chandra-Mouli V.menstrual health: a definition for policy practice and research. Sexual and Reproductive Health Matters. Pages 31-38. Volume 29, 2021. Available via: https://www-tandfonlinecom.ezproxy.its.uu.se/doi/full/10.1080/26410397.2021.1911618?src=recsys 9. Vigil P, Blackwell L, Cortés M. The Importance of Fertility Awareness in the Assessment of a Woman s Health. The Linacre Quarterly 79 (4) (November 2021): 426-450. Available via: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6027096/pdf/10.1179_00243631280 4827109.pdf 10. RFSU. Contraception gives women the power to decide for themselves over their lives. [cited Mars 2, 2022]. Available via: https://rfsu.ineko.se/files/sv- SE/26873/RelatedFiles/preventivmedel_faktablad.pdf 11. Bitzer J, Tschudin S, Stadlmayr W. Menstruation, and its impact on women s health. Zentralbl Gynakol. 2005 Oct, 127 (5): 282-7. Available via: https://pubmed-ncbinlm-nih-gov.ezproxy.its.uu.se/16195970/ 12. Normalizing menstruation, empowering girls. The Lancet Child & Adolescent Health. Volume 2, Issue 6, P379, June 01, 2018. Available via: https://www.thelancet.com/journals/lanchi/article/piis2352-4642(18)30143-3/fulltext 33