ORIGINAL RESEARCH Reproductive health of medical students: exploring knowledge, experiences, and behaviors

Introduction: Sexually transmitted infections (STIs) along with unintended pregnancies, gender-based violence, and gender inequality represent a serious risk to reproductive health in adolescent age. Comprehensive Sexual Education (CSE) plays a central role among public health interventions designed to prepare young people for these challenges. The aim of our research was to examine knowledge, experience, and behaviors regarding reproductive and sexual health among the population of medical students, as well as the possible connection between reproductive health, information, and study success. Material and methods: A total of 186 second-year and 214 fifth-year medical students were included in the study as a convenient sample taken by random selection. We used a questionnaire of the World Health Organization designed for adolescent sexual and reproductive health. Data were analyzed with the IMB SPSS 25 software. Results: For the second-year students, primary source of information about sex are conversations with their family and friends (37.6%), while for the fifth-year students it is the faculty curriculum (34.7%). Students with personal experience of STIs showed higher average level of knowledge about STIs and reproductive health (p=0.011). Significant positive correlation between the average grade and the level of knowledge about reproductive health was found (r=0.150; p=0.03). Conclusion: This study has shown the diverse sexual life of young medical students in Serbia, combined with risky habits and attitudes, also similarly represented in the world. Further research is needed in order to formulate public health policies adjusted to the needs of the Serbian youth.


Introduction
World Health Organization (WHO) defines reproductive health as "a state of complete physical, mental and social well-being, not merely the absence of infirmity, in all matters concerning the reproductive system, its functions, and processes. Reproductive health implies that people can have a satisfying and safe sex life, to be able to reproduce and to have the freedom to decide whether, when, and how often to do so" (1). Acknowledging that people don't partake in sexual relations merely for reproduction, WHO recognized the need for defining fundamental sexual rights. In its Geneva report in 2002 (2), ten fundamental sexual rights were drafted, which are shown in Table  1:  (3,4). Pornography and unmoderated online content give a distorted picture of optimal sexual practices and deprive young people of the necessary knowledge to maintain their reproductive health and well-being (5,6). This is why many studies are focused on the sexual habits of young people, especially adolescents, exploring their knowledge, attitudes and practices (7)(8)(9)(10). Furthermore, specific public health intervention programmes are designed to tackle the growing challenges in maintaining the youth's reproductive health, such as increasing STIs in the student population (11)(12)(13). According to previous research, determinants such as demographic characteristics, socioeconomic status, and sexual orientation are significantly correlated with the student population's level of knowledge about reproductive health, sexual education, and sexual habits (3)(4)(5)15).
Comprehensive Sexuality Education (CSE) "aims to equip children and young people with knowledge, skills, attitudes, and values that will empower them to maintain their reproductive and sexual health" (16).
As future health care providers and medical professionals with scientific knowledge in this field, medical students could be a role model for their peers. In addition to the standard ways of informing themselves about sexual and reproductive health (family, friends, media, internet), medical students also learn about these topics during the medical school curriculum, as well as in different extracurricular activities (workshops, seminars, elective courses).
Our research aimed to examine knowledge, experience, and behaviors regarding reproductive and sexual health among a population of medical students at the University in Belgrade and the potential association between reproductive health knowledge and overall success in higher education.

Material and methods
This cross-sectional study was conducted at the Faculty of Medicine, University of Belgrade, in November 2019. The respondents included in our research were students of the second and fifth years of medical studies. Our convenient sample of students was created by randomly selecting classes on two randomly selected days of the week.
Our research instrument was designed as a questionnaire based on previous work published by John Cleland in cooperation with WHO (17). The questionnaire consisted of 71 multiple-choice questions divided into four segments: sociodemographic characteristics, social and sexual practices, questions on reproductive health, and knowledge assessment. The last segment of the questionnaire was reduced to a series of ten questions, with each correct answer being scored by one point. A maximum of 10 points was given to a student who answered all ten questions correctly (Table 2).

4.
How much time does it take for an HIV test to be certainly positive or negative after a risky sexual intercourse?

5.
Do you think that HBV infection is common? 6. Do you think that HBV can be easily transmitted through sexual intercourse? 7. Do you think that HCV can be easily transmitted through sexual intercourse? 8. Is syphilis common in our country? 9. Which virus causes genital herpes? 10. Which microorganisms are often associated with the inability to conceive?

Statistical analysis
The data were processed using the IMB SPSS 25 software. Descriptive statistics used were: measures of central tendency, measures of variability and relative numbers, and methods of inferential statistics: a) methods for assessing the significance of difference: Chi-square test for categorical data and Student's T-test for numerical data, and b) methods for estimation significance of association, Spearman rank correlation coefficient.
P<0.05 was considered statistically significant.

Demographic data
The study included 400 subjects, students of the second and the fifth year of integrated academic studies of medicine (186 and 214 students, respectively), of which 105 (26.3%) were male, and 295 (73.7%) were female.
The mean age of the subjects in the second year of medical studies was 20.3 ± 1.12 years, in the fifth year, 23.7 ± 1.41 years. No statistically significant difference in age was observed between male and female subjects (p = 0.469). There was a statistically significant difference in the average grade during the study between the second-and fifth-year medical students (p<0.001), i.e., in the second-year students, the average grade was 8.3 ± 0.8, and in the fifth-year students 8.6 ± 0.8. Regarding origin, 87% of respondents came from urban areas in Serbia and reported that they lived with their parents. Students who moved to Belgrade mostly lived in rented apartments (33.8%), homes (13.5%), or apartments (9.5%). In terms of work history, 5.2% of fifth-year college students reported being once employed.
A more detailed sociodemographic profile of the respondents included in the study is shown in Table 3.

Basic parameters of sexual (reproductive) health of medical students
Out of the total number of respondents included in the study, 96.2% of the secondyear students and 91.5% of the fifth-year students stated that they were heterosexual, and 7 (3.8%) and 18 (6.5%) were nonheterosexual orientation (p = 0.052). Our respondents most often had their first sexual intercourse at 18. There was a statistically significant difference in the initiation of sexual activity (p = 0.001) in favor of younger students, who, on average, engage in first sexual intercourse almost a year earlier than their older counterparts did (17.54 vs. 18.32, respectively). There is a growing trend in the total number of sexual partners during life, with 25 (14.5%) second-year students having a total of more than three partners, while this is the case for 47 (23.4%) fifth-year students. Also, 39 (22.5%) second-year students did not yet have sexual intercourse compared to 21 (10.4%) fifth-year students (p = 0.002). Regarding the use of contraceptives and protection against STIs, looking at the total number of sexually active fifth-year students, 121 (65.8%) use a condom, while this is the case with 102 (74.5%) second yearsexually active students. Detailed information on medical students' sex life and habits is presented in Table 5. The level of reproductive health knowledge and safe and risky sexual practices A statistically significant difference in reproductive health knowledge was found between those with and without previous experience of STIs (p=0.011) showing that those who experienced STIs have higher level of knowledge. Students aware that condom is not an effective method for protection of all sexually transmitted infections have shown statistically higher level of knowledge on reproductive health (p<0.001). No difference was found in number of correct/incorrect answers and other respondents' risky attitudes and practices. Furthermore, a slight positive significant correlation between the average grade during the study and the level of knowledge about STIs, could be identified (Spearman rank correlation r=0.150; p=0.03).

Discussion
The results of our study indicate that a significant number of medical students at the University of Belgrade consume tobacco products (28.8%), which does not match the results of the similar research in Hungary reported last year (18), where is a higher prevalence of consumption of smokeless tobacco forms, as well as among medical students at Saint Louis University in Missouri -6.6% (19). This speaks in favor of the fact that tobacco consumption is more represented in our area than in other developed countries (20)(21)(22). When it comes to alcohol consumption, our students consume alcohol to a similar extent as students in the world, which is confirmed by the mentioned studies (23,24). It is essential to emphasize that alcohol is an independent risk factor for risky sexual habits, such as promiscuity and sexual aggression (23,25), and is also associated with a higher prevalence of HIV infection among the general and especially student population (26)(27)(28). Interestingly, the sources of information on sex and reproductive health differ concerning the year of study and emphasize the positive impact of teaching at the faculty, where we notice that fifth-year students acquire information and necessary knowledge through lectures (34.7%), unlike their younger colleagues. The latter reach them first through conversations with relatives and friends (37.6%) or the media (32.8%). This is also confirmed by the Swiss study from 2019 and Turkey (29,30). However, nursing and medical students from Madrid University (31) most often access information about sex and contraception through the Internet. In our study, there was a statistical trend to more openly express personal sexual orientation among older students (8.5%), which is very important because homosexuality has been associated for years with more unrestrained sexual habits, as well as a higher prevalence of STIs, primarily HIV infection and AIDS (32) and especially such students in foreign schools have been the subject of stigmatization and harassment (32,33). Additionally, one of the reasons for this population's reproductive and sexual health vulnerability could be the provision of poor-quality service by health workers (34). Similar results were obtained by Quetta and co-workers in their study with the population of Chinese medical students from 2016 (35), but also in a survey conducted in Bosnia and Herzegovina in 2017 (36).
When we examined the contraception and STI prevention method among our students, we found that the dominant instrument of protection was a condom in both groups of respondents, younger (70.8%) and older (64.7%). However, it was noticed that 9.1% of fifth-year students do not use any protection. If we take into account that the practice of interrupting intercourse mainly implies not using protection, it can be said that 18.7% of our sexually active fifth year students do not use protection. In a Greek study among medical students, Dinas and colleagues showed that a condom is the main instrument for protection against unwanted pregnancy (45.1%). Still, oral contraceptive pills are more common (4.9%), and 4.9% of female students stated they did not use protection (37). In 17 % of cases, Spanish students declared that they don't use contraception (38). The study results also indicate that students of the younger generation (second year of study) entered the first sexual intercourse on average a year earlier than their older colleagues from the fifth year of study. These results coincide with the results of other studies (39,40).

Conclusions
The results of our study show the diverse sexual life of young medical students in Serbia, combined with risky habits and attitudes, which are similarly represented in the world. However, there is still not enough knowledge and awareness about the importance of STIs, the development of healthy lifestyles, and within that, sexual habits and attitudes. Thus, we could ensure the preservation of the reproductive health of the generative population of our country, and first of all, medical students who are future providers of health and educational services. It would be interesting to conduct a similar national study among younger adolescents and high school pupils to design and implement more effective prevention programs at the beginning or before the start of sexual activities of young people.