http://jnep.sciedupress.com Journal of Nursing Education and Practice 2018, Vol. 8, No.

ORIGINAL RESEARCH

Knowledge, attitude and practice related to

reproductive health among female adolescents
Sharifa M. Gaferi1 , Manal F. Al-Harbi∗1 , Sahar M. Yakout2 , Aziza T. Soliman1
1
Department of Maternity and Child Health Nursing, College of Nursing, King Saud University, Riyadh, Saudi Arabia
2
Maternity and Gynecologic Nursing Department, College of Nursing, Alexandria University, Alexandria, Egypt

Received: January 21, 2018 Accepted: February 22, 2018 Online Published: March 26, 2018
DOI: 10.5430/jnep.v8n8p53 URL: https://doi.org/10.5430/jnep.v8n8p53

A BSTRACT
Objective: Reproductive health (RH) is a crucial aspect of general health; it is a reflection of health during adolescence and
adulthood. The period of adolescence in females is a period of physical and psychological preparation for safe motherhood.
As direct reproducers, adolescent girls’ health influences not only their own health but also the health of the future generation.
This study aimed to assess knowledge, hygiene practices during menses, and attitudes of female adolescents in Riyadh female
secondary schools regarding RH aspects.
Methods: A quantitative descriptive cross-sectional design was used for this study conducted on 350 female students selected
from governmental secondary schools in Riyadh using multistage random sample type. Two tools were used for data collection in
the current study: a self-administered questionnaire and an Attitudinal Assessment scale.
Results: The findings showed that more than two-thirds (66.3%) of the participants had inaccurate knowledge, while about
one-third (33.7%) of them had correct knowledge regarding RH. With respect to overall hygiene practices during menstruation,
about 95.4% had correct menstruation hygiene practice, while only 4.6% had incorrect practices. The majority (88.3%) of
students had positive attitudes regarding RH, while only 11.7% had negative attitudes. Mothers are a vital source of information
regarding RH.
Conclusions: The present study concluded that female adolescents had unsatisfactory knowledge, inadequate hygiene practices,
and positive attitudes toward RH. It is recommended to improve adolescents’ knowledge regarding RH issues and involve their
parents and teachers to provide appropriate education related to RH issues.

Key Words: Knowledge, Adolescent, Reproductive health, Practice, Attitude

1. I NTRODUCTION a girl is a period of physical and psychological preparation

The World Health Organization (WHO, 2017) identifies ado- for safe motherhood.[3] Reproductive health (RH) covers all
lescence as the period of human growth and development aspects of adolescent health. The WHO defines RH as “a
that occurs after childhood and before adulthood, from 10 state of complete physical, mental and social well-being, and
to 19 years of age.[1] This period of adolescence is further not just the absence of disease or debility, in all circumstance
categorized into three stages, namely early adolescence (10 relating to the reproductive system and its functions and pro-
to 13 years), mid-adolescence (14 to 15 years), and late ado- cesses.”[4] It is an important aspect of female adolescents’
lescence (14 to 15 years).[2] The period of adolescence for global health milestones. Menarche is one of these mile-
∗ Correspondence: Manal F. Al-Harbi; Email: drmanalalharbi@gmail.com; Address: Department of Maternity and Child Health Nursing, College of

Nursing, King Saud University, Riyadh, Saudi Arabia.

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stones. A female individual’s RH status is greatly influenced 1.1 Statement of the problem
by their perception to menarche during adolescence, beliefs
and attitude regarding menstruation, and more importantly, In most of the MENA countries, sexual and reproductive
the behavior during this period.[5] Another aspect of the RH health is socially and culturally sensitive issue. As a result,
is the age of marriage. Early marriage is generally associ- RH information and services do not reach the majority of ado-
ated with early childbearing and high fertility, both of which lescents, leading to misconceptions, confusion, and lack of
are health risks for women and their children.[6] In terms awareness among this vulnerable group. Few countries such
of family planning, adolescent girls globally are probably as Tunisia, Morocco, Yemen, Turkey, and Iran have begun to
the most vulnerable group as they are the victims of early focus on youth sexual and reproductive issues using interna-
marriage and early and frequent childbearing, all of which tional policy frameworks to map out their approach.[13]
lead to high morbidity and mortality.[7, 8] Controlling both Research on youth sexuality in MENA countries is still in
the number and timing of births through utilization of contra- the early phase of establishing a baseline for information
ception is associated with improved maternal and neonatal on knowledge, attitudes, and behaviors among diverse pop-
health outcomes. Reports from around the world reveal that ulations. There are some unpublished reports regarding the
many women suffer from illnesses and disabilities resulting level of sexual education imparted through the schools in the
from easily preventable pregnancies and childbirth-related Kingdom of Saudi Arabia (KSA), but no scientific, epidemi-
complications. Family planning (FP) has been associated ological survey on sexual health in KSA has been conducted
with positive health effects on children, mothers, and the among adolescent girls.[13]
entire family.[9–12]
In the new era of globalization, adolescents are exposed
to unlimited information from numerous resources. Tele- 1.2 Significance of the study
vision, movies, music, magazines, and internet play a vital
Adolescents represent great potential human resources for
role in providing information on every topic, particularly
the overall development of a nation. Presently, almost 1 in
RH. However, in many instances, the information provided
5 persons in the world is an adolescent, which is 1.2 billion
is not accurate or culturally competent. While parents and
people between the ages of 10 and 19 years, accounting for
schools should play a significant role in providing sex ed-
17 percent of the global population.[19–21] Currently, there
ucation, studies show that parents rarely talk in a timely
is a low level of access to high-quality RH information and
and comprehensive manner to their children, and schools
services, especially for adolescents.[22] There is limited dis-
are limited in what they can teach.[13] The hygiene-related
cussion of issues concerning RH in general, and specifically,
practices in the adolescent period related to menstruation can
in the MENA countries.[23] In the past few years, the issues
have an effect on their health. The event of menarche may
of RH have been increasingly perceived as a social problem;
be associated with taboos and myths existing in our tradi-
they have been emerging as a topic of increasing concern
tional society which has a negative implication for women’s
in both developed and developing countries.[24] Therefore,
health, particularly their menstrual hygiene.[14] Studies have
focusing on adolescents’ RH is both a challenge and an
shown that lack of knowledge about menstruation and lack
opportunity for healthcare providers. While adolescence gen-
of hygiene are likely to lead to STDs in adolescents.[15, 16]
erally is a healthy period of life, many adolescents are less
Therefore, accurate and adequate RH knowledge at this age
informed, less experienced, and less comfortable accessing
is crucial for proper practices and behavior regarding RH
health services for RH than do adults.[19] In this light, it is
for the future.[17] A study was conducted by Al-Quaiz et al.
essential to investigate this matter in some areas of KSA to
(2013) to assess sexual health knowledge, attitudes, and re-
establish a baseline for information on knowledge, especially
sources among adolescent girls in public and private schools
among secondary school adolescents. The Health Belief
in Riyadh, SA; it was identified that 42% of students discuss
Model (HBM) was used as the conceptual framework for
RH topics with their friends, 15.8% with their parents, and
this study. The HBM is one of the most widely used con-
17% with their household servants.[18] Adolescents often
ceptual frameworks for understanding health behaviors and
lack basic RH knowledge and behavior and are less comfort-
is believed to lay the foundation of a study, which enables
able accessing RH services than adults due to embarrassment
the researcher to identify what is known or unknown about
or discomfort in discussing sensitive topics with their health-
the topic of interest in order to conduct research that adds
care provider and less favorable attitudes toward the use of
to the body of knowledge.[25] This study aimed to assess
healthcare services and providers.[19]
the knowledge, attitude, and practices of female adolescents
regarding RH in Riyadh.
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2. M ETHODS Part II: Knowledge regarding RH aspects, which are de-

2.1 Research design scribed as follows:
A quantitative descriptive cross-sectional design was used in
this study. (1) Domain 1 (Knowledge about puberty and marriage):
Female adolescents’ knowledge regarding the female
2.2 Setting reproductive system, puberty in girls, menstrual cycle,
The study was conducted at 6 governmental secondary and marriage.
schools representing the eight educational zones of the cen- (2) Domain 2 (Knowledge about pregnancy and child-
tral Riyadh city. birth): This consists of questions about the time of
ovulation each month, timing of conception, appropri-
2.3 Population and sampling type ate age for the first pregnancy, signs of pregnancy, the
Multistage sampling technique was used as follows: ideal gap between delivery and the next one, abortion,
causes of abortion, and precautions for the prevention
Stage I: Riyadh city is divided into 5 sectors: north, south,
of abortion.
east, west, and central of city. The governmental secondary
(3) Domain 3 (Knowledge about family planning methods
schools for females in Middle of Riyadh city were selected
for females): This includes family planning methods
randomly.
and the proper way to obtain contraceptives.
Stage II: Middle of Riyadh includes 8 areas, and there are (4) Domain 4 (Knowledge about STDs): Knowledge re-
a total of 12 governmental female secondary schools dis- garding what STDs are, possibility of recovery, and
tributed in those 8 areas; six secondary schools were chosen the effect of infection of STD on RH.
by simple random sampling technique. (5) Domain 5 (Source of knowledge): This domain com-
Stage III: From each grade, 58-59 students were selected prises fourteen items that address the source of infor-
systematically, and 350 female students who met the criteria mation regarding RH.
were included in this study.
Part III: This involved obtaining an insight into the hygiene
2.4 Sample size practices during menstruation. It comprised of 10 items re-
Statistically, calculated sample size equals 350 female stu- lated to menstruation, which included the number of times of
dents from the total of 2,452 female students based on the changing sanitary pads and the method of disposal, medium
last census for the Ministry of Education at the governmen- used for cleaning, washing the genitalia while showering,
tal secondary schools in the middle of Riyadh city (Saudi number of baths taken during menstruation, activities and
Arabia Ministry of Education Census, 2014). 350 female exercise during menstruation, foods and drinks that should
students were divided on 6, the results were 58-59 students and should not be taken during menstruation, underwear type
were collected from each school. used during menstruation.

2.5 Sample criteria Tool II: A three point Likert-type scale was developed to as-
The inclusion sampling criteria were: Secondary school girls sess students’ responses to attitude items regarding RH. This
of all grades (1st, 2nd, 3rd), Saudi & non-Saudi nationali- scale consist of 8 items that include the adolescents’ attitude
ties, enrolled in a governmental school in Riyadh city during towards puberty, menstrual cycle, pregnancy and childbirth,
the time of the study, willingness to participate in the study, family planning methods, STDs, and the use and access of
while the exclusion criterion was refusal to participate in this RH services for adolescents.
study.
2.7 Pilot study
2.6 Tools of data collection
Two tools were used for data collection in the current study. To assess the clarity, feasibility, and applicability of the tools
used in this study for data collection, a pilot study was con-
Tool I: The self-administered questionnaire: The question-
ducted with 10% of the predetermined sample size according
naire was designed by the researchers, and it consists of three
to the study criteria. The results of the pilot study helped
parts as follows:
in the necessary modifications of the tools according to the
Part I: Included participants’ sociodemographic data such as, content validity and results of the pilot study. The sample
educational level, mother’s age, mother’s level of education used in the pilot study was excluded from participation in
and employment status, menstrual and gynecological history. the main study.
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2.8 Reliability and validity of the instrument cies, means, and standard deviations. p-value was significant
The content validity of the questionnaire was reviewed by at < .05. Chi-squared test was used to examine the distribu-
five experts from the same field in order to establish the rele- tion of the data, and independent sample t-test was used to
vance of the questionnaire items to the study objectives. The compare the variables.
experts conducted their review separately. To sustain the
self-determination of the reviews, all reviewers were asked
3. R ESULTS
to carry out the reviews alone; the reviewers’ identities were
not revealed to each other aside from the researcher. The More than half (52.3%) of the adolescents’ age ranged from
results indicate that expert reviews have a significant im- 17 to 19 years, while less than half (43.1%) were aged 15 to
pact on identifying the issues with the questions. Therefore, 17 years old. Regarding the student’s grades, 31.4%, 42%,
some changes were applied based on experts’ recommenda- and 26.3% were in the 1st, 2nd, and 3rd grades, respectively.
tions. The internal consistency was also measured. Student’s More than half (56.3%) of their mothers had completed com-
answers related to knowledge were scored and calculated. pulsory school education, while 28% completed university
According to the answers, students’ responses were evaluated education. Regarding the age, about 61.4% of mothers were
using the model key answer sheet previously prepared by aged 35 to 45 years old. The majority of the mothers (79%)
the researchers based on literature review. To score students’ were unemployed.
knowledge regarding RH, correct and complete answers were With respect to knowledge of female adolescents regarding
scored as 2, while an incorrect wrong answer was scored puberty and marriage as shown in Table 1, it is evident that
zero. An attitudinal assessment scale—a three-point Likert- more than half (54.3%) of the participants had correct knowl-
type scale (agree, uncertain, disagree)—was developed to edge about the female reproductive organs, while 45.2% did
examine students’ responses to the items assessing attitude not have correct knowledge, with no significant statistical
towards RH. It consists of 8 statements to which the students differences (p = .086). More than half (59.4%) had correct
were asked to respond by selecting one of the choices. To knowledge about puberty signs in girls, while 40.3% have
score students’ attitude towards RH, a score of 3 was given incorrect knowledge. The differences are highly significant
for ‘agree’, 2 for ‘uncertain’ and 1 for ‘disagree’. Each ques- with p < .000. Concerning knowledge about menstrual cy-
tion was scored, and the maximum possible attitude score cle, it was noticed that female adolescents had a high rate
was 24 points. The total score ranging from 21-24 indicates of correct answers (92%) about the cause of menstruation
a positive attitude towards RH, and a total score less than 12 with significant differences (p < .000). Regarding knowledge
(50%) indicates negative attitude towards RH. about marriage, the majority (88%) had correct knowledge
about the appropriate age for marriage with significant dif-
2.9 Ethical consideration ference (p < .000).
Approval from the KSU Nursing College and Ministry of
Health were obtained prior to data collection. The partici- Table 2 shows the distribution of female adolescents in terms
pants were provided the data collection tool, which contained of knowledge about pregnancy and childbirth.
the study explanation, its purpose, and the instructions for Table 3 shows that most of the students (87.1%) had correct
the participants. The responses were anonymous, and their knowledge about contraceptive pills, and 72% were knowl-
consent to share the results in the study was obtained. Par- edgeable about breastfeeding as a method of family planning
ticipation was voluntary, and the participants had the right (p < .000). Knowledge about female sterilization and male
to withdraw from the study at any time without affecting sterilization was poor (85% and 79%, respectively) with a
their rights. All answers were kept confidential and for the significant difference (p < .000).
purpose of the current study. There was no known harm or
Table 4 shows the distribution of female adolescents in terms
conflict to the participants in relation to participation in this
of their knowledge about STDs. For 15% and 16.4% of
study.
the female adolescents, the sources of knowledge about fe-
2.10 Data analysis male reproductive system and STDs were books, newspapers,
magazines, school textbooks, Fiqh books, while the source
After data collection, the data were checked for their quality
of knowledge about puberty.
and completeness. Each questionnaire was coded and scored
on the basis of the appropriate scoring method. Data were Table 5 shows the distribution of female adolescents accord-
loaded and analyzed using Statistical Package for Social ing to their RH practices during menstruation. Most of fe-
Science (SPSS) Version 22 (SPSS Inc, IBM). Descriptive male students (99.4%, 93.7%, 93.4%, 92.9%, 87.7%, 87.1%,
statistics were used to describe the sample variables frequen- and 85.1%) had correct practices with respect to the number
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of times of changing sanitary pads each day, the way of dis- However, more than two-third (68.6%) had incorrect knowl-
posing sanitary pads, washing the genitalia while showering, edge about the tools used for cleaning during menstrual cycle,
foods and drinks that should not be taken during menstrua- and also the majority (82.6%) did not practice any activities
tion, number of baths during the menstrual cycle, underwear or exercise during menstrual cycle (p < .000).
type used, and towels used during menstruation, respectively.

Table 1. Distribution of female adolescents related to their knowledge about puberty and marriage (n = 350)
Correct Answers Incorrect Answers
Items p value
No. % No. %
Knowledge of female adolescents regarding the female reproductive system
Female reproductive organs 190 54.3 158 45.2 .086
Knowledge about puberty in girls
Puberty signs in girls 208 59.4 141 40.3 .000
Knowledge about menstrual cycle
Cause of menstruation 321 91.7 29 8.3 .000
Source of menstrual blood 244 69.7 106 30.3 .000
Menstrual blood discharge site 201 57.4 149 42.6 .005
Knowledge about Marriage
Appropriate age for marriage 307 87.7 43 12.3 .000
Note. N.B significant at .05.

Table 2. Distribution of Female Adolescents in terms of knowledge about Pregnancy and Childbirth (n = 350)
Correct Answers Incorrect Answers
Items p value
No. % No. %
Time of ovulation each month 41 11.7 309 88.3 .000
Timing of conception 5 1.4 345 98.6 .000
Appropriate age for the first pregnancy 317 90.5 33 9.5 .000
Signs of pregnancy 219 62.6 131 37.4 .000
Ideal gap between delivery and the next one 206 58.8 144 41.2 .001
Meaning of abortion 24 6.9 326 93.1 .000
Causes of abortion 273 78 77 22 .000
Precautions for the prevention of abortion 320 91.4 30 8.6 .000

Table 3. Distribution of Female Adolescents in terms of knowledge about Family planning methods (n = 350)
Correct Answers Incorrect Answers
Items p value
No. % No. %
Known family planning methods
Female sterilization (severing the fallopian tubes) 54 15.4 296 84.6 .000
Contraceptive pills 305 87.1 45 12.9 .000
Intrauterine device (IUD) 221 63.1 129 36.9 .000
Breastfeeding 252 72 98 28 .000
Hormonal injection 81 23.1 269 76.9 .000
Condom 145 41.4 205 58.6 .001
Male sterilization 74 21.1 276 78.9 .000
Localized methods 56 16 294 84 .000
Temperature measurement/evaluation method 96 27.4 254 72.6 .000
Isolation (withdrawal) 81 23.1 269 76.9 .000
Obtaining contraceptives
The proper way to obtain contraceptives 279 79.7 71 20.3 .000

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Table 4. Distribution of Female Adolescents related to knowledge About sexually transmitted diseases (n = 350)
Correct Answers Incorrect Answers
Items p value
No. % No. %
1. Sexually transmitted diseases are
Gonorrhea 132 37.7 218 62.3 .000
Syphilis 108 30.9 242 69.1 .000
Chlamydia 35 10.0 315 90 .000
Human immunodeficiency virus, HIV/AIDS 293 83.7 57 16.3 .000
Genital herpes/ulcer 130 37.1 220 62.9 .000
2. The possibility of recovery from all sexually transmitted diseases
Recovery from sexually transmitted diseases 152 43.4 198 56.6 .014
3. Curable sexually transmitted diseases
Curable sexually transmitted diseases 16 4.6 334 95.4 .000
4. Effect of infection of sexually transmitted diseases on RH
The effect of infection of STD on RH 162 46.3 188 53.7 .165

Table 5. Distribution of Female Adolescents in terms of practices regarding RH during menstruation (n = 350)
Correct Answers Incorrect Answers
Items p value
No. % No. %
Number of times of changing sanitary pads per day 348 99.4 2 0.6 .000
Towels used during menstruation 298 85.1 52 14.9 .000
Number of baths during the menstruation 307 87.7 43 12.3 .000
Genitalia washing 327 93.4 23 6.6 .000
Tools used for cleaning during menstruation 110 31.4 240 68.6 .000
The method of disposing sanitary pads 328 93.7 22 6.3 .000
Activities and exercises during menstruation 61 17.4 289 82.6 .000
Foods and drinks that should not be taken during menstruation 325 92.9 25 7.1 .000
Foods and drinks that should be taken during menstruation 154 44 196 56 .032
Underwear type used during menstrual cycle 305 87.1 45 12.9 .000

Table 6 illustrates that the highest positive attitudes (96.6% changes and attention to personal hygiene during menstrua-
and 96.3%) were toward education about puberty associated tion, respectively.

Table 6. Distribution of Female Adolescents in terms of their attitude toward RH (n = 350)

Positive Attitude Negative Attitude p
Items
No. % No. % value
Education about puberty and associated changes is essential for
317 90.6 33 9.4 .000
adolescent girls
Attention to personal hygiene during menstruation is essential to avoid
337 96.3 13 3.7 .000
infections and STD
Pregnancy at young age affects the health of the fetus and the mother 167 47.7 183 52.3 .000
Closed rapprochement of pregnancy and childbirth affects the mother
158 45.1 192 54.9 .000
and fetus
The use of family planning methods is useful 230 65.7 120 34.3 .000
STDs affect the fetus 258 73.7 92 26.3 .000
Adolescent girls are in need of RH services 194 55.4 156 44.6 .000
Adolescents need to know about the health services for RH 250 71.4 100 28.6 .000

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Table 7 shows that a positive statistically significant corre- as well as information about pregnancy and childbirth (p =
lation was found between educational level of the students .008).
(p = .01) and their mother (p = .001) and their knowledge
Table 8 illustrates the inversed correlation between adoles-
about the female reproductive system. A significant positive
cents’ ages with their practice regarding underwear type
correlation was found between students’ information about
used during menstrual cycle (p = .043); while a positive cor-
puberty in girls and their educational level (p = .008). In-
relation was found with their mothers’ age (p = .038) and
versed correlation between information about the menstrual
mothers’ educational level (p = .000).
cycle and mother’s employment status was found (p = .034),

Table 7. Correlations between Demographic profile of the mothers and Female adolescents and their Knowledge of RH (n
= 350)
Demographic data
Adolescents’ Mother’s Mother’s
No. Knowledge Adolescents’ Mother’s
Educational Educational employment
Age age
level level status
Knowledge of Correct N 190 190 190 190 190
adolescents regarding Incorrect N 156 156 156 156 156
1.
the female t -.809 2.580** 1.568 3.287** -1.204
reproductive system Sig. .419 .010 .118 .001 .229
Correct N 207 207 207 207 207
Knowledge about Incorrect N 141 141 141 141 141
2.
puberty in girls t 1.310 2.655** -.639 -.587 1.241
Sig. .191 .008 .523 .557 .216
Correct N 264 264 264 264 264
Knowledge about the Incorrect N 84 84 84 84 84
3.
menstrual cycle t .473 1.390 -1.342 1.754 -2.125*
Sig. .637 .165 .180 .080 .034
Correct N 306 306 306 306 306
Knowledge about Incorrect N 42 42 42 42 42
4.
marriage t .453 .586 -.260 1.149 1.028
Sig. .651 .558 .795 .251 .305
Correct N 184 184 184 184 184
Knowledge about
Incorrect N 164 164 164 164 164
5. pregnancy and
t .916 1.423 .267 -.667 -2.648**
childbirth
Sig. .360 .156 .789 .506 .008
Correct N 108 108 108 108 108
Knowledge about
Incorrect N 240 240 240 240 240
6. family planning
t -.361 -.321 -.999 .091 .205
methods for females
Sig. .719 .749 .318 .928 .838
Correct N 132 132 132 132 132
Knowledge about Incorrect N 216 216 216 216 216
7.
STDs t -.655 .466 .573 -.646 1.504
Sig. .513 .641 .567 .519 .133
Correct N 149 149 149 149 149
Knowledge about Incorrect N 199 199 199 199 199
8.
request for treatment t -.145 .590 -.879 -.325 -2.140*
Sig. .885 .556 .380 .745 .033
* Correlation is significant at .05 levels (2-tailed). ** Correlation is significant at .01 levels (2-tailed).

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Table 9 revealed that attitudes toward menstrual cycle had view regarding STDs (p = .004). A statistically positive
a statistically positive significant relationship with students’ significant relationship was found between point of view
age (p = .015) and mother’s age (p = .015); while mother’s regarding RH services and adolescences’ age (p = .002), ed-
education level was inversely correlated with point of view ucational level (p = .002), and mothers’ employment status
regarding family planning methods (p = .004) and point of (p = .049).

Table 8. Correlations between Demographic profiles of Female Adolescents and their mothers toward RH Practice (n = 350)
Demographic data
No. Practice Adolescents’ Mother’s Mother’s
Adolescents’ Mother’s
Educational Educational employment
Age age
level level status
Number of times Correct N 347 347 347 347 347
of changing Incorrect N 1 1 1 1 1
1.
sanitary pads t -.680 -1.393 .429 -1.092 -.493
each day Sig. .497 .164 .668 .276 .623
Correct N 297 297 297 297 297
Towels used Incorrect N 51 51 51 51 51
2. during
menstruation t -1.300 -.555 -.797 .220 .379
Sig. .194 .579 .426 .826 .403
Correct N 306 306 306 306 306
Number of baths Incorrect N 42 42 42 42 42
3. during the
menstruation t -1.552 -1.804 .483 1.385 -.583
Sig. .122 .072 .630 .167 .560
Correct N 326 326 326 326 326
Genitalia Incorrect N 22 22 22 22 22
4.
washing t -1.379 -.348 .086 -.570 -.229
Sig. .169 .728 .932 .569 .819
Correct N 109 109 109 109 109
Tools used for Incorrect N 239 239 239 239 239
5. cleaning during
menstruation t -1.086 -.464 .172 .711 -.870
Sig. .278 .643 .863 .478 .385
Correct N 327 327 327 327 327
The way of Incorrect N 21 21 21 21 21
6. disposing
sanitary pads t .310 .253 .669 -.337 -.123
Sig. .757 .801 .504 .736 .902
Correct N 62 62 62 62 62
Activities and Incorrect N 286 286 286 286 286
7. exercise during
menstruation t .542 .440 -.556 -1.121 .504
Sig. .588 .660 .578 .263 .615
Foods and drinks Correct N 25 25 25 25 25
should not be Incorrect N 323 323 323 323 323
8.
taken during t -1.166 -.720 .903 1.515 -1.002
menstruation Sig. .244 .472 .367 .131 .317
Foods and drinks Correct N 179 179 179 179 179
that should be Incorrect N 169 169 169 169 169
9.
taken during t -.195 -.880 -.957 -.791 .264
menstruation Sig. .846 .380 .339 .429 .792
Correct N 304 304 304 304 304
Underwear type Incorrect N 44 44 44 44 44
10. used during
menstruation t -2.026* -.722 2.080* .377** -.335
Sig. .043 .471 .038 .000 .738
* Correlation is significant at .05 levels (2-tailed). ** Correlation is significant at .01 levels (2-tailed).

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Table 9. Correlations between Demographic profile of Female adolescents and their mother regarding RH Attitude (n =
350)
Demographic data
Adolescents’ Mother’s Mother’s
No. Attitude Adolescents’ Mother’s
Educational educational employment
Age age
level level status
Positive N 316 316 316 316 316
Attitude towards Negative N 32 32 32 32 32
1.
puberty t .159 -.182 .867 -1.180 1.622
Sig. .874 .855 .386 .239 .106
Positive N 335 335 335 335 335
Attitude toward Negative N 13 13 13 13 13
2.
menstrual cycle. t 2.434* .852 2.444* 1.236 1.654
Sig. .015 .395 .015 .217 .099
Positive N 247 247 247 247 247
Attitude towards
Negative N 101 101 101 101 101
3. pregnancy and
t -1.124 -.391 .664 -1.044 1.647
childbirth
Sig. .262 .696 .507 .297 .100
Positive N 229 229 229 229 229
Attitude towards
Negative N 119 119 119 119 119
4. family planning
t 1.673 .819 -1.389 -2.925** .017
methods
Sig. .095 .413 .166 .004 .986
Positive N 257 257 257 257 257
Attitude towards Negative N 91 91 91 91 91
5.
STDs t 1.153 1.941 .530 -2.911** 1.104
Sig. .250 .053 .596 .004 .270
Positive N 261 261 261 261 261
Attitude towards
Negative N 87 87 87 87 87
6. reproductive
t 3.048** 3.180** .326 -1.681 1.978*
health services
Sig. .002 .002 .745 .094 .049
* Correlation is significant at .05 levels (2-tailed). ** Correlation is significant at .01 levels (2-tailed).

4. D ISCUSSION more than half of the female adolescents had correct knowl-
edge about the signs of sexual maturation in females such as
The age of female adolescents in the current study ranged
breast development, pubic hair development, menstruation,
from 15 to 19 years. The age of 52.3% of the participants
increase in height and weight, which may be due to the in-
ranged from 17 to 19 years, while 34.1% were aged 15 to
formation they achieved in courses on religion and biology.
17 years, which is similar to the findings reported by Mittal
This is in line with a study conducted in Baghdad City, which
and Goel (2010) and Akhtar et al. (2012), who assessed the
reported that half of the adolescent girls had good awareness
knowledge and perception about the RH issues among un-
about pubertal changes (primary sex characteristics, attaining
married adolescent girls aged 15-19 years. More than half of
sexual maturity, onset of menstruation and pubic hair).[29]
their respondents were aged 18-19 years (55%).[26, 27] In the
The present study showed that 91.7% of female adolescents
present study, the majority (88.3%) of the students females
gave correct answers about the cause of menstruation as a
being menstruated between age of 11 to less than 15 years
normal sign of growth and puberty, while only 8.3% girls did
old, and about two-thirds had regular cycles, which coincide
not know the cause of menstruation. This finding is similar
with the studies conducted in India by Savanthe et al. (2016)
to the study results of Savanthe et al., who reported that most
and Kamath et al. (2013).[14, 28] In the same context, abdom-
of the students (86%) understand that menstruation is normal
inal pain followed by back pain was found to be the most
phenomenon[28] and another finding by Das et al. (2016) in
frequent complaint during menstruation among the students
a study conducted among high school girls in Vadodara city,
in the present study, which is similar to the results reported by
wherein 70% identified that menstruation is a normal process.
Savanthe et al.[27] Regarding knowledge about puberty and
However, the findings of another study are consistent with
menstruation, the results of the current study revealed that
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the current results as it reported that 70% of the girls thought

be due to the information received from their mothers and
that menstruation is an unnatural process.[30] relatives as well as school lessons. On the other hand, long-
term contraceptive methods were relatively unknown among
Shatha (2013) reported that adolescents’ answers about the
the students in the current study similar to other adolescents
site of menstrual blood were correct (76.0%).[29] This co-
in the previous studies.[36–41]
incides with the findings of the present study; 69.7% of
the adolescents had correct knowledge that the source of Knowledge about female sterilization and male sterilization
menstrual blood source is the uterus, while it is inconsistent was poor, which is somewhat similar to a study done by
with the finding of Savanthe et al.’s study (2016).[28] More- Patanwar et al. (2013) who reported that only 14.1% of ado-
over, Bhattacharjee et al. (2013) reported that approximately lescents had knowledge about female sterilization, and 7%
one-third of their sample correctly identified the source of had knowledge about male sterilization.[35] This result con-
menstrual blood (30%).[31] tradicts that of Gollakota et al.’s study (2015), who reported
higher knowledge among female adolescents regarding fe-
This study reported that information regarding different as-
male and male sterilization in their study.[42]
pects of menstruation was obtained from various resources
such as mothers, relatives, media (TV or Internet), which HIV/AIDS was the most known STD among the adolescents
is similar to the results found by Dasgupta et al. (2008) of the current study, and this is expected due to a current
in a study conducted in Kolkata.[32] Further, another study worldwide pandemic of the disease. This is consistent with
carried out in Tirupati by Reddy et al. (2005) found that the studies of Abiodun et al. (2016), Patanwar et al. (2013),
mothers (61.2%) were the primary source of information and Gollakota et al. (2015).[35–42] The adolscents in the
about menstruation. Therefore, it can be said that mothers current study were aware of STDs like Syphilis, Gonorrhea,
are mainly the primary source of information for this im- and ulcer in the genital area. Although chlamydial infec-
portant topic.[33] This could be due to good communication tions are the major causes of pelvic inflammatory diseases,
between the mothers and daughters as many mothers are tubal occlusions, and infertility, only 10% of the students
being educated nowadays. Female students had inadequate in the current study were aware of it. This is closely con-
knowledge regarding the time of ovulation per month and sistent with Gollakota et al.’s (2015) results.[42] The main
the timing of conception. This may be due lack of discussion sources of information regarding STDs for the students in
regarding some RH topics in the school or family. Similar re- the current study were school textbooks, Internet, followed
sults were found by Parasuraman et al. (2005),[34] Patanwar by the mother and TV. They learned about the topics in the
et al. (2013), and Abiodun et al. (2016).[35, 36] In addition, courses discussed in the school classes as it was the major
the majority of the girls in the current study had adequate source of knowledge regarding STDs. On the other hand,
knowledge about the appropriate age for the first pregnancy mothers, relatives, and the Internet were reported as the least
to be above 20-30 years; this is in agreement with a study common source of STD information. This is may be due
by Patanwar et al. (2013)[35] and Lamadah et al. (2015).[37] to the society in the Middle East where parents hesitate to
Among the respondents of the present study, more than half discuss some important RH issues with their daughter and
of adolescent girls stated that the ideal gap between delivery even sons. These findings were similar to the findings of
and the next one is more than 2 years. This is consistent with a study done in Nepal and Bangladesh.[43] Regarding the
the study done in Ludhiana, which showed that 62% of the cure for STDs, the majority of the students in the current
adolescent girls preferred a gap of more than 2 years between study had incorrect knowledge about curable diseases; this
the pregnancies.[38, 39] The Child Marriage Restraint Act of is consistent with the studies of Patanwar et al. (2013).,[35]
1978 raised the legal age for marriage from 15 to 18 years for and Masood et al. (2015), which reported wrong perception
girls. Awareness regarding the appropriate age for marriage among their samples.[44] Most of the female adolescents
was very high in the current study. These results are similar in the present study had overall incorrect knowledge about
to a study done by Fatemeh et al. (2015).[40] RH. The findings of the current study are similar to those of
Lamadah et al.’s study (2015), which reported low overall
Regarding the knowledge about family planning methods,
knowledge in their sample.[37] However, the results of the
oral contraceptive pills (OCP) was the most known contra-
current study contradict with that of Farih et al. (2014) who
ceptive method. This is in agreement with the findings of
reported that half of their study sample had a good level of
the study done in Ethiopia (2014) and Nigeria (2016). It
knowledge.[23]
was not surprising that 72% of the female adolescents gave
correct answers regarding breastfeeding as a family planning The current study revealed that the majority of girls who
method followed by intrauterine devices (IUD), which may followed correct hygienic practices during menstruation with

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respect to the type of towels used were those who used san- usefulness of family planning methods for female RH, STD
itary pads (85.1%). This is consistent with the findings of risk for the fetus, and the need for RH services to be accessi-
Bhattacherjee et al. in West Bengal, India, who reported ble for adolescents, which is consistent with the study results
about 71.3% of their study subjects used sanitary pads as of Lamadah et al. and Tegegn et al.[19–37, 48–51] However,
absorbents.[31] The common use of pads may be a result these results contradict those of Fetohy who found that the
of high availability and increased awareness from television mean score of students’ attitudes toward personal hygiene
regarding availability and use of sanitary napkins. Moreover, during menstruation was low among adolescents.[5] The par-
a high percentage (99.4%) of girls correctly answered the ticipants had negative attitudes toward teenage pregnancy
question on frequency of changing sanitary pads per day. In and close frequency of pregnancies that may threaten the
contrast, a study by Mudey et al. reported that cleanliness of mother’s and fetal health, which contradicts the results of
external genitalia was unsatisfactory.[15] Lamadah et al.[37] This may be a result of social traditions
that prefer pregnancy at a young age and gestations that are
The present study showed that 93.7% girls followed correct
not spaced apart.
practices on methods of disposal of used sanitary pads in-
cluding using the correct place for waste disposal. The same
results were reported by other studies.[28] Incorrect hygiene 5. C ONCLUSION
practices were common; 68.6% of female adolescents used In the light of the current study findings, it is concluded
soap or shampoo for cleaning the external genitalia in the that RH knowledge among the adolescents was unsatisfac-
current study. This is consistent with a study by Sreedhar tory based on the correct answers (33.7%), while more than
et al. who reported soap and water were the most common two-thirds (66.3%) of the participants had incorrect knowl-
materials used by girls (82.2%) for cleaning the external edge. The present study revealed that the majority of the
genitalia.[45] There are different beliefs and taboos related adolescents did not have correct knowledge about puberty,
to restricted movement and feeding patterns during men- pregnancy and childbirth, family planning methods, STDs,
struation in different cultures, which guide the menstrual and request for treatment. On the other hand, adolescents had
practices of female adolescent. Bathing during menstruation correct knowledge about the appropriate age for marriage
is traditionally forbidden in rural cultures in Egypt and Pak- and HIV than other STDs. Regarding the hygiene practices,
istan.[46, 47] Aktar et al. and Mohite et al.[16, 17] reported that most students had correct practices with respect to menstrua-
almost all girls practiced similar personal hygiene during tion, while a few had incorrect practices. The majority had
menstruation. However, in the present study, a high per- positive attitudes regarding RH, while a few had negative
centage of female students reported that they take a shower attitudes.
every day (87.7%) or after 1-2 days (93.4%) during men-
struation and that washing the genitalia while showering is Recommendations
recommended, which is in contrast with Bhattacherjee et (1) Health care professionals and nurses must be trained
al.’s study in West Bengal, which observed that less than properly to provide RH services at schools and primary
one third of girls practiced good personal hygiene. Mudey health care settings.
et al. reported that only 34.33% of the girls cleaned their (2) Primary health care practitioners should be well-
genitalia.[15–31, 48–51] prepared to provide education about RH to increase
parental involvement to improve care quality for ado-
Activities and exercise restrictions were varied among the
lescents.
girls in the present study as the majority of them did not
attend schools or perform routine household work or par- (3) Safe RH can be achieved by incorporating family edu-
ticipate in family events; they preferred to sleep and rest. cation, which focuses on learning about living, family,
This is possibly due to different rituals in the community; and social relationships through well prepared nurses
the girls followed the practices of their mothers or other who can provide education at schools for parents and
elderly women in the family. These findings were consis- teachers.
tent with other previous studies on adolescents in similar (4) Future nursing research should focus on RH. A sim-
communities.[45–47, 52] The majority of female adolescents ilar study can be conducted on the same topic with a
in the present study followed correct RH practices, which is broader perspective by evaluating a few schools from
consistent with the study by Gothankar et al. in India. [53]
In each region in the KSA.
regard to female adolescents’ attitude toward aspects of RH,
the majority had positive attitude regarding the importance C ONFLICTS OF I NTEREST D ISCLOSURE
of puberty education, personal hygiene during menstruation, The authors declare that there is no conflict of interest.
Published by Sciedu Press 63
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2018, Vol. 8, No. 8

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