Knowledge of combined oral contraceptives among young females in Riyadh.
High fertility level is a major concern, and regulation of fertility plays an important role in improving both maternal and child health.  The Saudi community has seen a recent change in the sociodemographic pattern related to women's education and career. These changes have played a role in tendencies toward fertility regulation behaviors such as birth spacing and the use of contraceptives.  Oral contraceptive pills are considered effective, with a low pregnancy rate theoretically if taken consistently and correctly, but with higher actual pregnancy rates due to inconsistent or incorrect use.  Oral contraceptives are hormonal preparation pills that may contain progestin alone or combination of both hormones estrogen and progestin. The combined pill has both contraceptive and noncontraceptive benefits such as reductions in dysmenorrhea, acne, ovarian cancer, and endometrial cancer. [3,4] As much as combined oral contraceptives (COCs) can be beneficial, they carry a number of risks. These include increased chance of developing venous thromboembolism, myocardial infarction, stroke, breast cancer, and cervical cancer.  COCs are absolutely contraindicated in case of thromboembolic disorders, cerebrovascular or coronary artery disease, estrogen-dependent neoplasia, undiagnosed abnormal genital bleeding, or history of liver tumors.  Side effects from COCs include breakthrough bleeding, weight gain, mood changes, breast tenderness, headaches, and nausea. [5,7] The purpose of this study was to assess the knowledge of COCs among young females in Riyadh, which in turn can help planning strategies for improvement.
MATERIALS AND METHODS Subjects and Setting
In this cross-sectional study, a structured online questionnaire was electronically disseminated; utilizing social media, among young females aged 18-40 living in Riyadh who were willing to participate in the survey. Demographic data, as well as responses to the questionnaire assessing five domains (type, risk, side effects, contraindications, and use of COCs), were collected and then analyzed. The questionnaire was initially developed in English, translated to Arabic, made available online (https://www.surveymonkey.com/r/ contraception_Riyadh) during the month of September 2016 and invitations to participate in the survey were sent through social media.
Sample Size and Data Analysis
Assuming a margin of error of 5%, population proportion of 50% and confidence interval of 95%, a sample size of 384 was targeted in this study.  426 complete responses were collected during the survey period and were all included in the analysis. A descriptive analysis was used to present the data and frequency (%) was used for categorical variables.
During the month of September 2016, 426 females living in Riyadh completed our survey. Of those, 67.1% were aged between 18 and 30 years old, while 32.9% were between 31 and 40 years old. 64% of respondents were married and about 60% were current or previous users of contraceptive pills. Our sample was well educated with 81.46% of them holding a university degree, whereas the majority of them (85.92%) had a monthly income of <15000SR (Table 1).
The scoring system used and scores for individual questions in the survey are detailed in Tables 2 and 3. Our sample scored well below average for all of the five domains in the questionnaire, and poor/very poor knowledge level was noted across all domains of the questionnaire (Figure 1 and Table 3).
Sixty four percent of couples worldwide are using some form of contraception. The percentage varies across different countries and regions and is lower in the least developed countries.  Studies conducted in Saudi Arabia showed variable levels of use of contraception in different geographic areas. For example, low levels of use of contraceptives were observed in Abha and Qassim (27% and 44%, respectively), while high levels of contraceptives use among Saudi females were observed in Al-Khobar with a rate of 74.8%. [10,11] In Riyadh, Mahboub et al. found that 86.6% of Saudi women have ever used contraception, and the most commonly used method was contraceptive pills (64.9%).  Working status of women as well as husband approval were found to be significant factors affecting women's attitude toward the use of contraception.  Al-Sheeha also concluded that being a working woman as well as education level were important determinants of using contraceptives (odds ratio 2.6 and 2.1, respectively). 
Five domains were used in our questionnaire in assessing the level of knowledge on COCs among women in Riyadh, namely, type of available oral contraceptives, risks of using COCs, side effects, appropriate use, and contraindications (Table 3). Our study population consisted of 426 females aged 18-40. Most of them were married (64.08%), well-educated (81.46%) and have used or currently using OCPs (59.39%). However, overall mean scores were low (<2.5), indicating poor level of knowledge and awareness in all of the five domains. The study sample scored highest in side effect domain (2.4), and lowest in risk domain (1.2) (Figure 1).
Possible reasons for the poor score include limited information given by physicians at the time of prescribing COCs as well as the fact that some women initiate COCs over the counter without a physician consultation. Only 1.4% of our sample had low education (below high school), while over 81% of them had a university degree but still scored below average in the questionnaire, which makes "level of education" a less likely contributing factor, although a direct relationship was not examined in our study. In contrast, Al-Shamrani et al. found that higher levels of education were associated with better knowledge of contraceptive pills among Saudi women (P < 0.001). 
Our results are comparable to Al-Sheeha who conducted a study in Al-Qassim, examining the perception regarding the use of different types of contraceptives among Saudi women attending primary care clinics in 2010. Participants had low knowledge level regarding the variety of contraceptive methods.  Similar findings were also reported by Al-Mansour et al. in their study of contraceptive use among 388 women in Al-Khobar.  The majority of women in their study (68.3%) had poor knowledge on contraceptives.  In addition, in Jeddah, Iftikhar and Aba Al Khail studied 357 women and also found that women in their study group had poor level of knowledge on OCPs. 
Physicians have a central role in explaining available types of contraceptive pills, screening for contraindications, explaining risks, and potential side effects as well as advising on appropriate use of contraceptives to women seeking contraception. Oral contraceptives should not be dispensed over the counter without a valid prescription. Moreover, educational campaigns can assist in improving women's knowledge on the topic.
Our study was cross-sectional, which was relatively easy to conduct as well as helpful in generating and supporting a hypothesis for poor knowledge of COCs among young women in Riyadh. Limitations of our study include recall bias among respondents as well as using social media, which could have potentially created "closed loop responses" and therefore, may have affected our sample representation. Moreover, correlation between poor knowledge and other parameters was not specifically examined in our study.
This survey clearly indicated a poor level of knowledge on COCs among females in Riyadh. Increasing awareness through health education campaigns as well as family planning clinics with a focus of contraceptive counseling is recommended.
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Thamer Alsulaiman (1), Meshail Alamer (2), Ghadah Alrajeh (2), Qamar Khojah (2), Shorouq Alrumaihi (2), Ohoud Almutairi (2)
(1) Department of Family Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia, (2) College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia
Correspondence to: Thamer Alsulaiman, E-mail: email@example.com
Received: November 15, 2016; Accepted: December 06, 2016
Caption: Figure 1: Overall mean scores per domain.
Table 1: Baseline characteristics of female responders (n = 426) Parameter Percentage Age 18-30 67.1 31-40 32.9 Marital status Married 64.08 Single 35.92 Highest education University degree 81.46 High school degree 17.14 Below high school 1.4 Income Above 15000SR 14.08 8000-15000SR 34.27 Below 8000 51.64 Current or previous user of oral contraceptives Yes 59.39 No 40.61 Table 2: Scoring system used for rating respondents' answers Percentage of correct Equivalent Description answers per question (%) score [greater than or equal to]90-100 5 Excellent knowledge [greater than or equal to]70-89 4 Good knowledge [greater than or equal to]50-69 3 Average knowledge [greater than or equal to]30-49 2 Poor knowledge <30 1 Very poor knowledge Table 3: Scores for individual questions in the questionnaire (n=426) Domain Question Percentage Equivalent of correct score answers (%) Type All COCs are made of the 32.86 2 same hormone All COCs work in the 42.96 2 same way Some COCs have one 46.95 2 hormone while others have two Hormone concentration 71.13 4 varies between COCs My doctor can adjust the 54.46 3 strength of hormones of COCs if I develop side effects COCs are the most 28.87 1 prescribed type of oral contraceptives to Saudi women Risks COCs can cause breast 22.07 1 cancer COCs can cause cervical 18.31 1 cancer COCs can cause clotting 38.03 2 in legs and lungs COCs can cause ovarian 12.68 1 cancer COCs can cause 11.50 1 osteoporosis Side effects COCs can cause weight 64.79 3 gain COCs can cause 38.5 2 hypertension COCs can cause 20.19 1 infertility COCs can cause 65.96 3 depression COCs can affect 59.15 3 lactation during breastfeeding Use I should immediately 6.57 1 stop COCs if I develop any side effects COCs work by killing 36.62 2 sperms COCs work by preventing 47.89 2 ovulation COCs prevent sexually 44.37 2 transmitted infections Best day to start COCs 16.67 1 when using for the first time is during the first day of period COCs can be used to 40.61 2 treat acne and heavy menstrual bleeding Using antibiotics while 60.33 3 on COCs can reduce their efficacy and lead to pregnancy Vomiting and diarrhea 24.88 1 can reduce COCs efficacy and lead to pregnancy I have to use the 27 1 hormone pills for 21 days followed by sugar pills for 7 days and then start a new pack During the sugar pill 19.72 1 week, I must wait for my period to finish before starting hormone pills I am aware of the 7-day 21.13 1 rule Contraindications I can immediately start 41.31 2 COCs after giving birth I must wait at least 6 42.49 2 weeks after giving birth before starting COCs I must stop COCs if I 50.94 3 develop migraine with aura Smoking while taking 36.85 2 COCs increases the risk of heart attacks I shouldn't use COCs if 40.85 2 I have severe hypertension I shouldn't use COCs if 24.18 1 I have morbid obesity Domain Question Mean score for domain Type All COCs are made of the 2.3 same hormone All COCs work in the same way Some COCs have one hormone while others have two Hormone concentration varies between COCs My doctor can adjust the strength of hormones of COCs if I develop side effects COCs are the most prescribed type of oral contraceptives to Saudi women Risks COCs can cause breast 1.2 cancer COCs can cause cervical cancer COCs can cause clotting in legs and lungs COCs can cause ovarian cancer COCs can cause osteoporosis Side effects COCs can cause weight 2.4 gain COCs can cause hypertension COCs can cause infertility COCs can cause depression COCs can affect lactation during breastfeeding Use I should immediately 1.5 stop COCs if I develop any side effects COCs work by killing sperms COCs work by preventing ovulation COCs prevent sexually transmitted infections Best day to start COCs when using for the first time is during the first day of period COCs can be used to treat acne and heavy menstrual bleeding Using antibiotics while on COCs can reduce their efficacy and lead to pregnancy Vomiting and diarrhea can reduce COCs efficacy and lead to pregnancy I have to use the hormone pills for 21 days followed by sugar pills for 7 days and then start a new pack During the sugar pill week, I must wait for my period to finish before starting hormone pills I am aware of the 7-day rule Contraindications I can immediately start 2 COCs after giving birth I must wait at least 6 weeks after giving birth before starting COCs I must stop COCs if I develop migraine with aura Smoking while taking COCs increases the risk of heart attacks I shouldn't use COCs if I have severe hypertension I shouldn't use COCs if I have morbid obesity COCs: Combined oral contraceptives
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|Title Annotation:||Research Article|
|Author:||Alsulaiman, Thamer; Alamer, Meshail; Alrajeh, Ghadah; Khojah, Qamar; Alrumaihi, Shorouq; Almutairi,|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Apr 1, 2017|
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