Introduction
The school system in Austria consists of elementary schools (> 30000 pupils in Tyrol)
followed by different kinds of secondary schools, including middle schools (> 20000
pupils in
Tyrol), high schools (> 30000 pupils in Tyrol), polytechnic schools (> 1400 pupils
in Tyrol) and special need schools (> 700 pupils in Tyrol) [1 ]. Every year, 1800 students in Austria begin their medical studies, 400 of them in
Tyrol [2 ].
Sexual education is offered at different times during school life. Sexual education
starts in the fourth grade of elementary school and is continued in secondary schools.
The subject is
mainly addressed by biology teachers but may also be taught by external providers
such as social workers or medical students [3 ].
In the last ten years, improvements in sexual education programs have helped to lower
the number of teenage pregnancies in Austria by more than 50% [4 ]. However, there are no statistical records on abortions in Austria. In Germany,
around 100000 abortions are performed every year, with 6000–7000 abortions carried
out in
women under the age of 20 years and 2000–3000 in women under 18 years of age [5 ].
According to a German survey, 52% of male and 49% of female adolescents first have
sexual intercourse when they are aged between 16–18 years. Contraception methods cited
by adolescents
include condoms (56%), hormonal contraceptives (52%), intrauterine devices (copper
and hormonal) (5%) and coitus interruptus (3%) [6 ]. In
Austria, emergency contraception has been available without prescription since 2009,
and more than 120000 pills are sold every year. These sales figures indicate that
the number of emergency
contraception pills sold has more than quadrupled since they first became available
without a prescription [7 ]. This might also reflect an
increasing skepticism about hormonal contraception. Knowledge about alternatives to
hormonal contraceptives is quite limited and there are similarly large gaps in young
people’s understanding
of how contraceptives work in general, especially among users between the age of 14–19
years [6 ].
Surveys indicate that knowledge about the physiology of reproduction, contraception,
and fertility awareness is limited in adolescents [8 ]
[9 ]
[10 ]
[11 ]. Both the time to pregnancy when having regular sexual intercourse and the impact
of female age on fertility are strongly underestimated [8 ].
The awareness of endometriosis has become more widespread in the last ten years. However,
the time between initial symptoms and the final diagnosis of endometriosis is still
long (around 5
years) [12 ]. As endometriosis affects up to 300000 women in Austria [13 ], there is
an urgent need to increase the awareness of endometriosis, especially in adolescents.
Studies on gender differences in the knowledge of fertility and contraception are
controversial. While some studies report a greater awareness in women compared to
men [14 ]
[15 ], others report no significant difference [16 ] or diverging results [17 ]. In university students, female sex and the study of medicine were correlated with
a
better knowledge of fertility [15 ].
Our aim is to work closely with the local government to revise the current sexual
education program provided to pupils in Tyrol, Austria. Therefore, we developed an
online survey for pupils
and university students to allow us to assess their knowledge of reproductive health
issues including contraception, fertility and gynecological diseases. We also evaluated
the impact of
demographic characteristics to identify subgroups who are not reached with the currently
available educational programs.
Materials and Methods
Questionnaires
The development of the survey was based on questionnaires used in former studies,
with some items modified and others newly designed. First, a literature search was
carried out between
December 2021 and March 2022 to identify questionnaires with a comparable focus [9 ]
[16 ]
[18 ]. We identified three main questionnaires: a Danish study of university students
[16 ], a Canadian study of undergraduate students [18 ], and a German online survey of
adolescents [9 ]. After screening, we included items focusing on reproductive health and fertility
from the Danish [16 ] and the Canadian study [18 ] and items focusing on contraception from the German
study [9 ]. Twenty-five items for pupils and 38 items for university students (excluding demographic
aspects) were newly developed.
Multiple choice questions were chosen to provide the participants with a wide range
of possible answers. Questions using a Likert scale ranging from 1 to 10 (1 = very
strongly disagree,
10 = very strongly agree) were also included.
The questionnaire for pupils consisted of 39 questions, the one for university students
had 53 questions. Topics covered included demographic aspects (8), reproductive health
(8 male /9
female pupils vs. 13 male/14 female students), contraception (5 pupils vs. 12 students),
satisfaction with current contraception (both 9), fertility (both 4) and gynecological
diseases (4
pupils vs. 6 students).
To compare the knowledge of female health issues between pupils and university students,
ten identical questions were identified in both questionnaires ([Table 1 ]).
Table 1
Questions evaluating knowledge of female health issues including fertility.
1.
How long is the menstrual cycle?
2.
At what time during the menstrual cycle is it likely that a pregnancy will occur with
unprotected sexual intercourse (click on the timeline)?
3.
What is the period of time during which an oocyte can be fertilized?
4.
How long after sexual intercourse are sperm capable of fertilizing an oocyte?
5.
What is the period of time during which the “morning-after pill” can be taken to prevent
pregnancy?
6.
Which contraceptive methods protect against sexually transmitted diseases?
7.
What is the most important risk factor for infertility?
8.
What is the most important risk factor for miscarriage?
9.
From what age does a woman’s fertility decrease?
10.
What symptoms can occur when suffering from endometriosis?
The survey was conducted with SurveyMonkey (License acquired in March 2022).
Data
The ethical committee of the Medical University of Innsbruck, Austria, approved the
study (AN 1012/2022). It was conducted in accordance with the Declaration of Helsinki.
The prospective
cross-sectional survey was carried out in Tyrol, Austria, between April and July 2022.
Participation in the study was voluntary, and data was collected anonymously. The
invitation to
participate in the study including web links and QR codes to the questionnaires, was
distributed online via emails to various study program directors and study representatives
or school
principals. Consent to participate in the study was given online at the beginning
of each questionnaire.
Data processing was done in accordance with the EU General Data Protection Regulation
(GDPR). The requirements for participating in the study were sufficient German language
skills and
current registration as a pupil or university student in Tyrol.
Data analysis and statistics
Each correct answer was given one point, except for question six, which had the option
of giving multiple answers (two points). This resulted in a range of 0–11 points.
Statistical analysis
was conducted using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk,
NY, USA). T-tests, ANOVA and chi-square test were used for group comparisons and Cohen’s
d for effect
size. The confidence interval (CI) was 95% and a two-sided p value of < 0.05 was considered
statistically significant. Effect sizes were estimated using Hedges’ g in t-tests,
with
g = 0.3, g = 0.5 and g = 0.8 and phi in chi-square tests, with ϕ = 0.1, ϕ = 0.3 and
ϕ = 0.5 indicating small, medium, and large effect sizes, respectively [19 ].
Results
Study Population
A total of 906 participants responded to the survey, of whom 369 were pupils (median
age 15.63 ± 1.3 years) and 537 were university students (median age 23.82 ± 4.3 years).
The adolescents
participating in this online study attended the following type of schools: lower secondary
school (“Mittelschule”): n = 75 (20.3%); pre-vocational school (“polytechnische Schule”):
n = 42
(11.4%); apprenticeship training (“Berufsschule/Lehre”): n = 2 (0.5%); intermediate
or higher vocational school (“berufsbildende mittlere und höhere Schule”): n = 68
(18.4%); higher general
secondary school (“allgemeinbildende höhere Schule”): n = 182 (49.3%).
More female than male persons participated (232 female pupils [62.87%], 438 female
students [81.56%]). Demographic characteristics of the study population (age, gender,
nationality,
religious beliefs, family, and sexual history) are presented in [Table 2 ].
Table 2
Study population’s demographics, family, and sexual history.
Pupils
Students
Female
Male
Total
Female
Male
Total
1 Percentage of respective gender group.
+ Number of subjects who have children and mean number of their children.
* Number of subjects who wish to have children and mean age they wish to have their
first child.
Total n (%)
232 (62.9%)
137 (37.1%)
369 (100%)
438 (81.6%)
99 (18.4%)
537 (100%)
Median age
15.84 ± 1.3
15.28 ± 1.1
15.63 ± 1.3
23.74 ± 4.4
24.13 ± 3.6
23.82 ± 4.3
Nationality1 n (%)
Austrian
205 (88.4%)
117 (85.4%)
322 (87.3%)
283 (64.6%)
67 (67.7%)
350 (65.2%)
German
5 (2.2%)
4 (2.9%)
9 (2.4%)
73 (16.7%)
11 (11.1%)
84 (15.6%)
Other
22 (9.5%)
16 (11.7%)
38 (10.3%)
82 (18.7%)
21 (21.2%)
103 (19.2%)
Religious beliefs1 n (%)
Christianity
188 (81%)
117 (85.4%)
305 (82.7%)
332 (75.8%)
67 (67.7%)
399 (74.3%)
Atheism/agnosticism
34 (14.7%)
10 (7.3%)
44 (11.9%)
101 (23.1%)
30 (30.3%)
131 (24.4%)
Islam
8 (3.5%)
7 (5.1%)
15 (4.1%)
4 (0.9%)
1 (1.01%)
5 (0.9%)
Judaism
0 (0%)
1 (0.7%)
1 (0.3%)
0 (0%)
0 (0%)
0 (0%)
Other
2 (0.9%)
2 (1.5%)
4 (1.1%)
1 (0.2%)
1 (1%)
2 (0.4%)
Study subject1 n (%)
Medicine
–
–
–
230 (52.5%)
72 (72.7%)
302 (56.2%)
Other
–
–
–
208 (47.5%)
27 (27.3%)
235 (43.8%)
Sexual orientation1 n (%)
Heterosexual
185 (79%)
121 (88.3%)
306 (82.9%)
380 (86.8%)
84 (84.9%)
464 (86.4%)
Homosexual
7 (3%)
7 (5.1%)
14 (3.8%)
10 (2.3%)
7 (7.1%)
17 (3.2 %)
Bisexual
19 (8.2%)
4 (2.9%)
23 (6.2%)
35 (8 %)
5 (5 %)
40 (7.5%)
Asexual
1 (0.4%)
0 (0%)
1 (0.3%)
1 (0.2%)
1 (1 %)
2 (0.4 %)
Other
20 (8.6%)
5 (3.7%)
25 (6.8%)
12 (2.7%)
2 (2 %)
14 (2.6 %)
Sexual History1 n (%)
Sexual experience
64 (27.7%)
27 (19.7%)
91 (24.7%)
406 (92.7%)
88 (88.9%)
494 (92%)
Family planning1 n (%)
Has children
0 (0%)
2 (1.5%)
2 (0.5%)
16 (3.7%)
4 (4%)
20 (3.7%)
Number of children
0 ± 0
4 ± 0
4 ± 0
1.44 ± 0.81
1.25 ± 0.5
1.40 ± 0.
Wants to have children
156 (67.2%)
91 (68.4%)
247 (67.7%)
318 (75.4%)
68 (71.6%)
386 (74.8%)
Average age for first child*
26.3 ± 3.6
26.8 ± 5.7
26.5 ± 4.5
28.3 ± 3.4
29.1 ± 2.5
28.4 ± 3.3
Chi-square test was performed to compare the study populations’ nationalities, religious
beliefs, sexual orientation, and sexual experience. Significant differences in the
number of male
and female participants with a small effect size relating to gender and educational
status were present in the Austrian [χ2 (1) = 24.93, p < 0.001, ϕ = 0.19] and German cohorts
[χ2 (1) = 5.91, p = 0.015, ϕ = 0.25] and in the subgroup that had already had sexual intercourse
[χ2 (1) = 6.84, p = 0.009, ϕ = 0.108], resulting in a higher
participation of male pupils and female students than expected. These differences
were also present with a small effect size in the subgroup analysis of Christians
[χ2 (1) = 41.66,
p < 0.001, ϕ = 0.24] and heterosexual orientation [χ2 (1) = 43.39, p < 0.001, ϕ = 0.24]. There was no significant difference in the distribution
of male and female
participants with regards to atheistic/agnostic belief, homosexual and bisexual orientation.
Questionnaires
Pupils
369 of the 532 questionnaires were analyzed further. The following reasons led to
exclusion from the study: not being a pupil (n = 4), missing or declined consent (n = 23),
incomplete
questionnaire (n = 35), not answering any items evaluating knowledge (n = 91), age
above 18 years (n = 8), and identifying as non-binary (n = 2) due to the small number
([Fig. 1 ]).
Fig. 1
Flow chart depicting identification, screening, and inclusion process. Out of 1184
questionnaires, 532 were answered by pupils and 652 by students. After applying the
exclusion criteria, 369 remained in the pupil cohort and 537 in the student cohort.
Participants who identified as non-binary were excluded due to the small number in
each
subgroup.
Students
In total, 652 university students participated. Exclusion criteria were: not being
a student (n = 3), missing or declined consent (n = 6), incomplete questionnaire (n = 20),
not answering
any items evaluating knowledge (n = 85), and identifying as non-binary (n = 1) due
to the small number. 537 questionnaires were analyzed in the student group ([Fig. 1 ]).
Reproductive health issues
Pupils had significantly less knowledge about reproductive health issues than students
(4.3 vs. 7.6, t = 26.55, p < 0.001; g = 1.79). There was a significant gender difference
with a
medium effect size showing higher scores for females than males (6.6 vs. 5.2, t = 8.11,
p < 0.001; g = 0.61). Higher education led to significantly higher scores, with the
highest scores
for female students (female pupils vs. male pupils: 4.8 vs. 3.6) and female students
vs. male students (7.6 vs. 7.4), [F(3, 902) = 256.89, p < 0.001].
In the student group, medical students had a significantly higher score compared to
non-medical students, with a medium effect size (7.1 vs. 6.0, t = 7.01, p < 0.001;
g = 0.61).
Pupils and students who had already had sexual intercourse had significantly more
knowledge resulting in a large effect size and achieved 2.5 more points on average
than participants
without sexual experience (7.1 vs. 4.6, t = 17.22, p < 0.001; g = 1.2).
The overall percentage of questions answered correctly is shown in [Fig. 2 ].
Fig. 2
Percentage of correctly answered questions. The percentage of all correct answers
for the pupil and student cohorts are shown for each individual question listed in
[Table 1 ].
Detailed analysis
1. How long is the menstrual cycle?
The definition of eumenorrhea is a menstrual cycle length of 25–35 days. In the pupil
cohort (n = 369), 40.4% (n = 149) gave the correct answer. The reported mean was 17.3
days (SD = 17.2
days). In the student cohort (n = 537), 93.7% (n = 503) gave the right answer, with
a mean of 27.2 days (SD = 4.6 days) for the whole student subgroup. A statistically
significant
difference with a large effect size was observed for the reported mean (t = 10.28,
p < 0.001; g = 0.89) as well as the number of correct answers [χ2 (1) = 307.84,
p < 0.001, ϕ = 0.58] ([Fig. 3 ]
a +b ).
Fig. 3
Bar chart of menstrual cycle length. The bar chart above depicts the answers to question
1 “How long is the menstrual cycle?” as given by (a ) pupils (n = 369)
and (b ) students (n = 537). The days reported by respondents are depicted on the horizontal
axis and the cumulative number of (a ) pupils or (b ) students who chose
the corresponding answer on the vertical axis.
2. At what time during the menstrual cycle is it likely that pregnancy will occur
with unprotected sexual intercourse (click on the timeline)?
The highest chance for a pregnancy is between day 9 and 14 of a menstrual cycle [20 ].
In the pupil cohort, 58.8% (n = 217/369) gave the correct answer (mean: day 13.6,
SD = 5.7 days). In the student cohort, 84.5% (n = 454/537) gave the correct answer
(mean: day 14.3,
SD = 2.8 days). The mean of the days reported by respondents was statistically significant
with a neglectable effect size (t = 2.22, p = 0.027; g = 0.17) as was the number of
correct given
answers with a small effect size [χ2 (1) = 75.41, p < 0.001, ϕ = 0.29]. As question 1 and 2 are correlated, a joint evaluation
was performed: 25.7% (n = 95) of pupils answered
both questions, 47.7% (n = 176) answered one and 26.6% (n = 98) answered no question
correctly compared to 62.2% (n = 334) in the student group who answered both questions,
35.0% (n = 188)
who answered one and 2.8% (n = 15) who answered no question correctly ([Fig. 4 ]).
Fig. 4
Bar chart on the probability of pregnancy depending on the timepoint of intercourse
during the menstrual cycle. The bar chart above depicts the answers to question 2
“At what time during the menstrual cycle is it likely that pregnancy will occur with
unprotected sexual intercourse (click on the timeline)?” as given by (a ) pupils (n = 369)
and (b ) students (n = 537). The day of the menstrual cycle given by respondents is on the
horizontal axis and the cumulative number of (a ) pupils or (b ) students
who chose the corresponding answer is shown on the vertical axis.
3. What is the period of time during which an oocyte can be fertilized?
An oocyte can be fertilized during a period of between 24 [21 ] and 48 hours.
In the pupil cohort, 41.5% (153/369) gave the correct answer (mean: 21.9 hours, SD = 20.8
hours) and 65.7% of the student cohort gave the correct answer (353/537, mean: 30
hours,
SD = 19.4 hours). The mean time reported by respondents was statistically significant
with a small effect size (t = 6.01, p < 0.001; g = 0.41) as was the number of correct
answers
[χ2 (1) = 52.26, p < 0.001, ϕ = 0.24].
4. How long after sexual intercourse are sperm capable of fertilizing an oocyte?
Sperm can fertilize an oocyte between 3–5 days after ejaculation [21 ].
The correct answer was given by 46.1% (170/369) of the pupil cohort and 62.6% (336/537)
of the student cohort. The mean reported by participants was 8.7 days (SD = 14.3 days)
in the pupil
cohort and 8.2 days (SD= 13.8 days) in the student cohort. The number of correct answers
was statistically significant with a small effect size [χ2 (1) = 24.15, p < 0.001,
ϕ = 0.16]. No significant difference was detected in the responses to the mean number
of days (t = 0.55, p = 0.58; g = 0.04).
5. What is the period of time during which the “morning-after pill” can be taken to
prevent pregnancy?
Emergency contraception can be taken up to 72 (levonorgestrel) or 120 hours (ulipristal
acetate) after intercourse.
15.2% (56/369) of the pupils and 41.3% (222/537) of the students answered this question
correctly. The mean was 31.4 hours (SD = 23.8 hours) for the pupil cohort and 48.3
hours (SD = 23.4
hours) for the student group. The mean reported by participants was statistically
significant with a medium effect size (t = 10.59, p < 0.001; g = 0.72) as was the
number of correct
answers although the effect size was small [χ2 (1) = 70.4, p < 0.001, ϕ = 0.28].
6. Which contraceptive methods protect against sexually transmitted diseases?
Barrier methods like a condom or a dental dam protect against sexually transmitted
infections. Since this was a multiple-choice question, both answers were given a separate
point if
chosen.
In the pupil cohort, 98.1% (362/369) answered “condom” and 34.1% (126/369) gave “dental
dam” as the correct answer. Since multiple choice was an option, 34.1% (n = 126) chose
both, 64.0%
(n = 236) chose one and 1.9% (n = 7) no right answer.
In the student cohort, 99.8% (536/537) responded “condom” and 57.7% (310/537) “dental
dam”. 57.5% (309) gave both options, and 42.5% (228) only one option. No incorrect
answers were
given.
The number of times the correct answer “condom” was given was statistically significant
with a negligible effect size [χ2 (1) = 7.3, p = 0.01, ϕ = 0.09]; similarly, the number
of times “dental dam” was given was also statistically significant with a small effect
size [χ2 (1) = 48.72, p < 0.001, ϕ = 0.23].
7. What is the most important risk factor for infertility?
The most important risk factor for infertility is female age [22 ]
[23 ]. Other
options to choose from included male age, smoking, long-term use of the contraceptive
pill, stress, and unknown.
In the pupil cohort, 41.5% (153/369) and 58.7% of the student cohort (315/537) answered
this question correctly, which was statistically significant with a small effect size
[χ2 (1) = 25.9, p < 0.001, ϕ = 0.17]. The top three answers given were female age (41.5%),
unknown with 20.6%, and smoking with 15.4% in the pupil subgroup compared to female
age (58.7%), stress (17.1%) and smoking (10.1%) in the student subgroup.
8. What is the most important risk factor for miscarriage?
The most important risk factor for miscarriage is female age [24 ]. Other response options were male age, smoking, long-term use of
the contraceptive pill, stress, excessive physical activity, and unknown.
A total of 20.3% (75/369) of pupils compared to 45.4% (244/537) of students answered
this question correctly, which was statistically significant with a small effect size
[χ2 (1) = 60.46, p < 0.001, ϕ = 0.26]. The top three possible answers given by the pupil
cohort were smoking (33.1%), female age (20.3%) and unknown (17.9%), closely followed
by excessive physical activity (17.6%). In the student subgroup, the leading answer
was female age (45.4%) followed by smoking with 22.0%, and stress with 15.5%.
9. At what age does a woman’s fertility begin to decrease?
Female fertility begins to decrease at around 30–35 years of age [25 ]
[26 ].
11.9% of pupils (44/369) and 56.1% (301/537) of students identified the proper answer,
which was statistically significant with a medium effect size [χ2 (1) = 180.62,
p < 0.001, ϕ = 0.45]. Pupils tended to overestimate female fertility with a decrease
in fertility starting at 42.6 years of age (SD = 9.27 years). In the student cohort,
a mean of 35.9
years (SD = 5.4 years) was chosen (t = 12.36, p < 0.001; g = 0.92). There also was
a significant gender difference between males, who selected a lower age than females
(37.9 ± 6.7 vs.
40.7 ± 10.4, t = 3.83, p < 0.001; g = 0.36).
10. What symptoms can occur when suffering from endometriosis?
This question was a multiple-choice question with correct response options including
menstrual pain, pain during intercourse, gastrointestinal problems, pain during defecation,
and pain
while urinating [27 ]. Irrespective of how many correct answers were given, the maximum point was 1.
In the pupil cohort, 23.8% (88/369) gave at least one correct answer. The answer chosen
most often was menstrual pain with 21.1%, followed by unknown with 20.3%, and heavy
menstrual
bleeding with 17.9%. All four correct answers were chosen by 3.8%, three by 5.1%,
two by 7.9%, and one by 7.0%.
In the student cohort, 89.9% (483/537) gave at least one correct answer. When we considered
the answers chosen most often by this subgroup, menstrual pain was identified as a
symptom by
86.8%, followed by heavy menstrual bleeding (76.4%), and dyspareunia (76%). All four
answers were given by 40.2%, three by 17.9%, two by 21.6%, and one by 10.2%.
When the number of correct answers in the pupil and student cohorts were compared,
a statistically significant large effect size was observed [χ2 (1) = 410.01, p < 0.001,
ϕ = 0.67].
Discussion
This prospective cross-sectional online survey was designed to assess pupils’ and
students’ knowledge of reproductive health issues including fertility, gynecological
diseases, and
contraception. Pupils were found to have less knowledge of the surveyed topics than
university students. Furthermore, females, persons who had had sexual intercourse,
and persons studying
medicine demonstrated a significantly better knowledge of the topics.
When the questions were analyzed for the pupil cohort, the three questions with the
lowest number of correct answers were: “At what age does a woman’s fertility begin
to decrease?” with
11.9%, “What is the period of time during which emergency contraception can be taken
to prevent pregnancy?” with 15.2%, and “What is the most important risk factor for
miscarriage?” with
20.3%. In the student cohort, the questions: “What is the period of time during which
emergency contraception can be taken to prevent pregnancy?” with 41.3%, “Which is
the most important risk
factor for miscarriage?” with 45.4% and “At what age does a woman’s fertility begin
to decrease?” with 56.1% had the lowest rates of correct answers. The question with
the highest number of
correct answers in both cohorts was “Which contraceptive methods protect against sexually
transmitted diseases?” with 98.1% of correct answers in the pupil and 99.8% in the
student cohort,
respectively. This shows that knowledge was lowest with regards to fertility issues
and emergency contraception whereas the knowledge of how to prevent sexually transmitted
infections was
high.
So far, few studies have compared the knowledge of pupils and that of university students
for this topic. Surveys into pupils’ knowledge of fertility are especially rare. A
Canadian study
which included 772 high school students (377 female, 392 male) with a mean age of
17.5 years showed that the issue of infertility was known to 79% of participants;
however, the Canadian
infertility rate was underestimated [28 ]. Another Canadian study focusing on female undergraduate students (n = 360, age
range 18–42
years) showed that women’s age was identified as the strongest risk factor for infertility
by only 45.5% of all participants and as the strongest risk factor for miscarriage
by only 24.7% of
all participants [18 ]. Our results showed similar percentages: less than half of the pupils correctly
identified female age as a risk
factor for infertility (41.5%) and for miscarriage (20.3%) compared to students, where
the respective rates were 58.7% and 45.4%.
Regarding female fertility, pupils expected a decline in fertility at an average age
of 42.6 years compared to students who expected a decline from 35.9 years. Both cohorts
thus misstated the
age at which the decline of female fertility becomes relevant [25 ]
[26 ]. Moreover,
females estimated the decline in fertility as starting significantly later (40.7 years)
than males did. In a population-based internet survey in Denmark and the United Kingdom
(1237
participants, 1000 females and 237 males), males overestimated the age at which female
fertility and the chance of pregnancy declines. It should be mentioned that – compared
to our study – the
latter cohort was older (43% were 25–34 years old) and the educational status was
primarily postgraduate (45%) [14 ].
This misperception of fertility and female age can be due to the presence in the media
of stories of older mothers which do not report on the use of assisted reproductive
technologies. This
can create false images of fertility at an advanced age.
When students studying medicine were compared with those studying for non-medical
degrees, the medical students had significantly higher scores, as was also shown in
another publication [15 ]. In our study, 70.8% female and 67.4% male participants wish to have children in
the future. The proposed mean age for having a first
child for females was 26.3 years in the pupil group and 28.3 years in the student
group whereas for males it was 26.8 years in the pupil and 29.1 years in the student
group. These results are
in line with a German online survey [15 ], a Danish cross-sectional study [16 ], and
a Canadian survey, where 63.7% of participants planned to get pregnant between 25–30
years of age [18 ]. Factors affecting the decision to
postpone pregnancy or not included stable partnership, good economic status, and having
completed education [15 ]
[29 ]. Other possible socio-political reasons could be state legislations on parental
leave, childcare allowance, options for and costs of
childcare.
The age at which respondents wished to have their first child given above does not
match the current mean age in Austria, which is 31.5 years for women and 34.3 years
for men [4 ].
Sexual education plays a major role in providing knowledge on gynecological issues
and reproductive medicine. A survey by the German Federal Centre for Health Education
(Bundeszentrale für
gesundheitliche Aufklärung = BzGA) of 3556 teenagers (aged 14–17 years) showed that
only 12% of female and 2% of male pupils received sexual education from physicians,
and that teachers and
parents were the leading sources of information [30 ]. The International Planned Parenthood Federation and the German Federal Centre for
Health Education have proposed that sexual education should start in childhood and
continue into adolescence and adulthood. The Austrian Society for Family Planning
and the Ministry for Family
and Youth recommend including sexual education in the training of teachers and kindergarten
teachers [31 ]. The aim is to prevent the lack
of knowledge identified in this prospective cross-sectional study, especially with
regards to fertility and the decline in fertility.
To our knowledge, this is the first study comparing pupils’ and students’ knowledge
of gynecological and reproductive medicine.
A strength of this study is the large number of participants. Moreover, 40% of our
study cohort consisted of pupils, which allowed us to perform a valid comparison between
pupils’ and
students’ responses.
This study is limited by the higher number of participating females compared to males,
especially in the student group, which could be due to the higher number of female
medical students in
Tyrol (54.7% female students vs. 45.3% male students enrolled to study medicine at
the Medical University of Innsbruck in 2021/2022). In addition, most questions looked
at female aspects of
reproduction, due to the complexity of menstrual cycles, the earlier decline in fertility,
and as well as our decision to focus on those topics.
