Impact of Reproductive Health Literacy Education on Fertility Knowledge and Childbearing Attitudes among Employed Married Women at Shiraz University of Medical Sciences (2024)

Impact of Reproductive Health Literacy Education on Fertility Knowledge and Childbearing Attitudes among Employed Married Women at Shiraz University of Medical Sciences (2024) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Reproductive Health Literacy Education on Fertility Knowledge and Childbearing Attitudes among Employed Married Women at Shiraz University of Medical Sciences (2024) Asma Zandavi, Zahra Yazdanpanahi, Bahar Morshed-Behbahani, Zahra Rastegari, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7447612/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Fertility rates have sharply declined worldwide, especially in developing countries. Many reproductive-age individuals lack reproductive health literacy, including knowledge about optimal fertility timing and infertility risks. This study evaluated the effects of reproductive health literacy education on fertility knowledge and childbearing attitudes. Method In this clinical trial study eligible participants were randomly assigned to (intervention, n = 45; control, n = 45) using simple randomization with a 1:1 allocation ratio. The randomization sequence was generated in advance using a random number table. The intervention group received five training sessions, each lasting 45–60 minutes, which were conducted twice weekly. For all 3 assessments, two questionnaires were used at all three time points (before, immediately after and one month after the intervention), participants completed two validated questionnaires: the Attitudes Toward Fertility and Childbearing Scale and the Cardiff Fertility Knowledge Scale. Data analysis was performed using independent t-test and chi-square tests, and SPSS version 22 statistical software was used to analyze the data. Results There were no significant differences in demographic characteristics between the two groups. Prior to the intervention, there was no significant difference in the mean attitudes toward childbearing scores between the groups. However, immediately after and one month after the intervention, the intervention group had a significantly greater mean attitude score toward childbearing than did the control group (P < 0.001). Although a significant difference was observed in the before fertility knowledge scores between the groups, the analyses were adjusted accordingly. Following the intervention, at both the immediate and one-month follow-ups, the intervention group demonstrated significantly greater fertility knowledge than did the control group (P < 0.001). Conclusion The study shows that reproductive health literacy education improves attitudes toward childbearing and fertility knowledge, and that higher knowledge is linked to more favorable attitudes. It supports targeted educational programs to boost reproductive health literacy and inform decision-making. Trial registration Iran Randomized Clinical Trial Center registration IRCT20240507061690N1, Date of first trial registration: 2024.05.19. Attitude toward childbearing Fertility knowledge Reproductive health literacy Figures Figure 1 Introduction One of the most important demographic changes over the last three decades has been the sharp decline in fertility rates in all regions of the world, especially in developing countries(1). According to the United Nations World Population Outlook 2017, almost half of the world's population lives in countries where fertility rates are below replacement levels. Low fertility is now a global phenomenon and can be a temporary trend driven by increased delays in marriage, childbearing, economic and social insecurity and future uncertainty(2).The fertility rate in Iran, a developing nation, has drastically decreased over the past three decades (3), with the total fertility rate (TFR) decreasing from 6.3 in 1986 to 1.62 in 2018 (4). Iran's population growth is predicted to reach 1% by 2025 (5) and drop to less than 1% by 2031 (6). Global fertility rates are decreasing because the desire to have children is closely linked to the attitudes of couples(7). Childbearing is an important factor in demography and is highly important in social and cultural affairs(8). One of marriage's and life's major objectives is to have children (9). A study by Pedro et al. (2018) revealed that individuals of childbearing age are not sufficiently aware of the optimal timing of fertility, the risk factors for infertility or the possible consequences of delayed childbearing (10). Delaying childbearing reduces the number of children that can be born in a family and increases the risk of unplanned infertility.(11) Infertility and fertility issues such as miscarriage, ectopic pregnancy, low birth weight, gestational hypertension and diabetes, maternal mortality, stillbirth, preterm labor, Down syndrome, and congenital malformations such as congenital heart disease, cleft palate, esophageal atresia, schizophrenia, poor neurodevelopment, and childhood cancer are all linked to an increase in parental age(11–13). One of the key variables influencing people's intentions to have children is their attitudes toward the problem of fertility. In many fertility theories, attitudes are among the most important factors influencing fertility and serve as a mechanism for influencing the timing of parenthood. A positive attitude toward motherhood usually leads to earlier and more frequent births, whereas a negative attitude is one of the factors reducing fertility-related outcomes(14). In recent years, attitudes toward childbearing have become much more important in view of the country's decreasing population growth rate. Programming and strategies to address this issue could lead to an increase in the desire and intention to become pregnant among women.(15, 16) Reproductive health literacy education plays a crucial role in public health, influencing both individuals and communities(17). Grasping reproductive health requires more than a simple understanding of human biology. It includes knowledge of safe sexual practices, availability of contraceptive methods, comprehension of consent, and the ability to identify indicators of reproductive health concerns. Nonetheless, deficiencies in education and prevailing cultural stigmas persist in obstructing effective dialog on these subjects, especially among young adults, who are at a pivotal point in gaining independence in their health-related choices(17, 18). Limited fertility knowledge is a contributing factor to not reaching childbearing aspirations (19) and plays a crucial role in reproductive health decisions. Many factors, such as age and lifestyle choices, can affect fertility. As fertility rates decline, researchers are focusing on fertility awareness (FA), which was defined in 2017 as understanding reproduction, personal and lifestyle risks (such as age, smoking, and obesity), and social and cultural influences on family planning. Essentially, FA helps people make informed choices about starting a family(20) As attitudes influence the behavior of individuals, it is possible to create an environment conducive to women's fertility decisions by designing and implementing appropriate training. Therefore, the present study is designed to examine the impact of fertility health literacy-based education on attitudes toward childbearing and fertility knowledge among employed married women at the university. METHODS Study design and sampling Our manuscript reporting adheres to CONSORT guidelines for reporting clinical trial. This clinical trial study, was conducted between September 2024 and December 2024 on 90 married employee women at Shiraz University of Medical Sciences, Iran, and approved by the Ethics Committee of Shiraz University of Medical Sciences. The sample size was considered 74 people (37 people in each group) after reading relevant articles (21). consulting with statisticians, and using the following formula, which increased to 90 people (45 in each group). after considering 20% attrition. α = 0.05 (first type error) β = 0.10, second type error $$\:\mathbf{n}=\varvec{\rho\:}\frac{{({\mathbf{z}}_{1-\frac{\varvec{\alpha\:}}{2}}+{\mathbf{z}}_{1-\varvec{\beta\:}})}^{2}}{{\left(\varvec{d}\right)}^{2}}$$ Eligible participants were recruited through convenience sampling from five selected medical centers affiliated with Shiraz University of Medical Sciences. After recruitment, participants who met the inclusion criteria and consented to participate were randomly allocated into the intervention (n = 45) and control (n = 45) groups using simple randomization with a 1:1 allocation ratio. The randomization sequence was generated in advance using a random number table, and allocation concealment was ensured using sealed opaque envelopes. Participants were assured that they could leave the study at any time and that they could refuse to answer questions The inclusion criteria were married and of childbearing age, with no history of infertility. They were living with their spouse, and either had no children or were parents of only one child with at least a two-year delay in subsequent pregnancy. The participants were employed in administrative units of Shiraz University of Medical Sciences, held Iranian nationality, and consented to participate in the research by completing the informed consent form. They had no diagnosed or treated physical diseases that could have affected pregnancy, and they did not have any mental illness or use psychiatric medications, psychotropic drugs, narcotics, or alcoholic beverages. Exclusion criteria included incomplete or noncompletion of the questionnaire, unwillingness to continue participating in the research after entering the study or during follow-up, failure to attend more than two sessions of the educational program, and divorce from the spouse during the study. Intervention implementation In this clinical study participants were employed married women with inclusion criteria and were divided into two groups of 45 people (Fig. 1 ). After written informed consent was obtained, the pretest was first conducted in the intervention and control groups, and demographic questionnaires, Soderberg's attitudes toward childbearing, and Cardiff fertility knowledge were completed in both groups before the intervention. In the intervention group, after the pretest, the intervention was carried out in the form of reproductive health literacy training classes by the researcher in five sessions, each session lasting 45–60 minutes, twice a week. The content of the training provided included: meeting with the participants and explaining the program, familiarizing them with the concept of fertility, recognizing the causes of infertility, familiarizing them with the consequences of delaying childbearing, and familiarizing them with new methods of preserving fertility. The training was provided by the researcher through lectures, face-to-face training, group discussions, and the presentation of an educational booklet. To complete the content of each session and further learn, the participants in the intervention group were also given a booklet and asked to study the materials related to each session before the start of the next session. The content of each training session was also given to the intervention group on the same day, and the materials of the session were reviewed briefly before the beginning of the class. Owing to the busy schedule, time and place constraints of the samples, face-to-face training was provided to a number of people who were unable to participate in the lecture-based training. After the end of the educational intervention, the samples in both the intervention and control groups again completed the childbearing attitudes and fertility knowledge questionnaires twice, immediately and after 4 weeks of training, to examine educational retention. Notably, no intervention was performed in the control group, but at the end of the study, to maintain educational justice, the educational content was provided to the control group in the form of a booklet. Table 1 The educational contents of the training sessions Session Educational content Educational materials Educational methods time schedule 1 Meeting with participants and explaining the program 1. Familiarizing with the importance of fertility in society 2. Understanding the factors affecting fertility rates and sex-specific fertility Computer-Photo-PowerPoint- Educational Booklet Lecture - Group Discussion - 45–60 min 2 Introduction to the concept of fertility 1. Introduction to the anatomy and physiology of the reproductive system 2. Introduction to the female reproductive cycle Computer-Photo-PowerPoint- Educational Booklet- Educational video Lecture - Group Discussion - Face-to-Face Training 45–60 min 3 Understanding the causes of infertility 1. Definition of infertility 2. Male factor 3. Female factor (maternal age and decreased ovarian reserve, ovulation disorders, fallopian tube disorders, uterus) 4. Unexplained infertility 5. Fertility treatments and success rates Computer-Photo-PowerPoint -Educational Booklet Lecture - Group Discussion - Face-to-Face Training 45–60 min 4 Introduction to new methods of fertility preservation Planning for pregnancy Computer-Photo-PowerPoint -Educational Booklet Lecture - Group Discussion - Face-to-Face Training 45–60 min 5 Understanding the consequences of delaying childbearing 1. Disruption in intergenerational relationships 2. Weakening of family support networks 3. Disruption in the natural reproductive and childbearing process a) (unwanted infertility and permanent childlessness b) Increased risk of miscarriage, reduced live births, and increased pregnancy risks c) Reduced desired family size and completed fertility) Computer- PowerPoint- Educational Booklet Lecture - Group Discussion - Face-to-Face Training 45–60 min Data gathering instruments The data collection instruments used in this study included a sociodemographic questionnaire, the Attitudes toward Fertility and childbearing scale (ATFCS), and the Cardiff Fertility Knowledge Scale (CFKS). Sociodemographic questionnaire This questionnaire included questions on age, spouse’s age, duration of marriage, age of previous child, education level, spouse’s education level, and economic status. Attitudes toward fertility and childbearing scale The scale was developed by Soderberg, Landgren, Kristensson, and Hildingsson in 2013 to assess women's attitudes toward fertility and childbearing. The Latin version comprises 27 items and three subscales: It is scored on a 5-point Likert scale: completely agree (5) to completely disagree (1), with higher scores indicating a more positive attitude toward fertility and childbearing. The Persian version of the Fertility and Childbearing Attitudes Scale was developed by Baezzat and colleagues in 2016, and consists of 23 items and four subscales. The subscales include: the following: 1. Child as a cornerstone of life (items 1, 2, 3, 4, 6, 8, 23, and 27) 2. Child as an obstacle (items 14, 15, 16, 17, 18, and 19); 3. Postponement of fertility to the future (items 5, 7, 10, 12, and 13); 4. Fertility requiring the fulfillment of prerequisites (items 11, 20, 21, and 25). Notably, items 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 25 are reverse scored. The scale was developed by Baezzat and colleagues and has a Cronbach’s alpha coefficient of 0.792, confirming its internal consistency and reliability. The content validity of the instrument was reverified by five faculty members from the Nursing and Midwifery School of Iran. Furthermore, the internal consistency (Cronbach’s alpha) for the entire attitudes scale was 0.728, with subscale alphas of 0.763 for "Child as a cornerstone of life," 0.757 for "Postponement of fertility to the future," 0.666 for "Child as an obstacle," and 0.856 for "Fertility requiring the fulfillment of prerequisites"(14, 22). Cardiff fertility knowledge scale (CFKS) The Persian version of the Cardiff Fertility Knowledge Scale (CFKS) was used to assess fertility knowledge. The CFKS consists of 13 items measuring knowledge about facts, risks and myths of fertility. The participants responded to all the items as true, false or not known. A correct answer is assigned one point, and an incorrect or ‘do not know’ answer is assigned zero points. The scores for this measure ranged from 0 to 13. The Cronbach’s alpha coefficient of the CFKS was 0.79, which is satisfactory for most countries(23, 24). Statistical analysis In examining the relationship between the target variable (quantitative variable) and demographic characteristics, an independent two-sample t- test was used to compare the means between the levels of the two-level variable, and an analysis of variance with pairwise comparisons was used to compare the means between multilevel variables by post hoc testing. The relationships between quantitative variables were assessed via Pearson's correlation test, and the relationships between qualitative variables were assessed via the chi-square test. To examine and evaluate the main objective, a repeated measures test was used to compare the mean changes in the attitudes toward childbearing and fertility knowledge scores between the two groups before, immediately after, and one month after the intervention. The analyses were performed with SPSS software (version 22). Results There were no significant differences between the two groups in terms of sociodemographic characteristics (Tables 2 and 3 ). The independent t- test revealed no significant difference between the mean scores of attitudes toward childbearing in the intervention and control groups before the study (P = 0.568). However, the difference between the two groups was significant immediately after the intervention (P < 0.001) and during the one-month follow-up (P < 0.001), with the intervention group having a higher attitude score than did the control group. On the basis of the results of the repeated measures analysis of variance, the score of attitudes toward childbearing was significantly different between the intervention group before the intervention, immediately after the intervention, and one month after the intervention (P < 0.001), but there was no significant difference in the control group (P = 0.957). (Table 4 ). Table 4 Comparisons of the mean scores of attitudes toward childbearing within and between the intervention groups and the control group before, immediately after, and one month after the intervention Variable name Group Before Mean ± SD immediately Mean ± SD After 1 month Mean ± SD (p value w *) Attitude toward childbearing score Intervention 15.78 ± 67.95 12.43 ± 77.40 11.54 ± 82.53 P < 0001 Control 16.17 ± 66.02 16.10 ± 66.15 16.05 ± 65.24 0/957 (p value b **) 0/568 P < 0001 P < 0001 *Repeated measures test ** Two-sample independent t- test W: Within group. B: Between -group The interaction effect between time and group was statistically significant (p = 0.003), indicating that the overall effects of time and group cannot be interpreted independently. The attitude scores toward childbearing among individuals changed significantly over time (p = 0.008), and there was also a significant difference between the two groups (p < 0.0001). In other words, the attitude scores within each group and between the two groups significantly changed following the intervention and over time. This suggests that the effects of the groups differ at different times, so the results should be interpreted with caution as marginal effects. The findings indicate that there was no significant difference between the intervention and control groups before the intervention (p = 0.568). However, immediately after and one month following the intervention, the attitude scores differed significantly between the intervention and control groups (p = 0.0001), with the intervention group having higher attitude scores. This finding demonstrates that training was effective in improving individuals’ attitudes toward childbearing. (Table 5 ) Table 5 " Repeated- measures ANOVA for comparing attitudes toward childbearing across three time points between the intervention and control groups." Variable name Source F P value* ŋ 2 D Attitude toward childbearing score Group 31.544 P < 0001 0.264 1.1978 Time 5.148 0.008 0.055 0.4825 Interaction 31.544 0.003 0.065 0.5273 ŋ 2 : Eta squared d: Cohen’s effect size *Repeated measures test Independent t tests revealed a significant difference between the mean scores of fertility knowledge in the intervention and control groups before the study (P = 0.036). This suggests that, before the educational intervention, the control group had better fertility knowledge. Consequently, to accurately assess the effect of the intervention over time, the pretest effect must be controlled for, and an adjusted analysis should be utilized. The effects of these two time points are not eliminated by adjusting for the baseline; instead, each individual is compared to their own prior state. Additionally, the difference between the two groups was significant immediately after the intervention (P < 0.001) and during the one-month follow-up (P < 0.0001), with the intervention group having a higher fertility knowledge score than did the control group. The results of repeated measures analysis of variance, revealed that the score of fertility knowledge was significantly different between the intervention group before the intervention, immediately after the intervention, and one month after the intervention (P < 0.0001), but there was no significant difference in the control group (P = 0.441). (Table 6 ). Table 6 Comparisons of the mean scores of fertility knowledge within and between the intervention groups and the control group before, immediately after, and one month after the intervention Variable name Group Before Mean ± SD immediately Mean ± SD After 1 month Mean ± SD (p value w *) Fertility knowledge Cardiff score Intervention 5.62 ± 2.70 11.91 ± 1.48 12.08 ± 0.92 P < 0001 Control 6.91 ± 3.03 6.44 ± 2.726 6.15 ± 2.61 0.441 (p value b **) 0.036 P < 0001 P < 0001 The interaction effect of time and group is not statistically significant (p = 0.67), allowing us to interpret the main effects of time and group independently. The fertility knowledge scores of individuals did not significantly differ over time (p = 0.244); however, there was a statistically significant difference between the two groups (p < 0.0001). In other words, the fertility knowledge scores within each group did not change significantly over time, but there was a significant difference between the two groups immediately after the intervention and during the follow-up period. The results in Tables 6 indicate a significant difference between the intervention and control groups at, immediately postintervention, and one month after the intervention. Specifically, individuals in the intervention group had higher scores immediately after and one month following the intervention, suggesting that the educational program was effective in enhancing fertility knowledge scores. (Table 7 ). Table 7 Comparison of the mean scores of fertility knowledge between the intervention and control groups before, immediately after, and one month after the intervention Variable name Source F P value*** ŋ 2 D Fertility knowledge Cardiff score Group 322.156 P < 0001 0.787 3.844 Time 1.375 0.244 0.016 0.255 Interaction 0.183 0.67 0.002 0.0895 Discussion This study was conducted to determine the effects of educational interventions based on reproductive health literacy on the attitudes toward childbearing and fertility knowledge of employed married women at Shiraz University of Medical Science. The results demonstrated that attitudes toward childbearing and fertility knowledge were initially low in the pretest but increased significantly after the intervention at both assessment points. According to many fertility theories, attitudes are among the most significant variables affecting fertility and can be affected when a person becomes a parent. While a negative attitude is one of the factors lowering fertility-related outcomes, a positive attitude toward motherhood typically results in earlier and more frequent births (14). Few interventional studies have examined the effect of education on attitudes toward childbearing. A study by Ansari Majd et al. (2019) revealed that an educational program based on a meta-theoretical model was effective in determining women's attitudes(25). Additionally, Mohammadi et al. (2024) conducted an educational intervention on the basis of the stages of change in the attitudes toward and stages of change in the childbearing behavior of married women and concluded that the stages of change in the intervention group changed significantly in a positive direction and that people were promoted from the pre thinking stage to the action stage.(26) Moridi et al. (2024) concluded that education based on the transtheoretical model improved women's attitudes toward childbearing(27). Furthermore, Rahimi et al. (2025) explored the effects of motivational interviewing on attitudes and intentions to have children in women providing health services, and reported that attitudes toward having children (P < 0.01) and intentions to have children (P < 0.01) were significantly greater in the intervention group than in the control group immediately and one month after the intervention.(28) Fertility knowledge is the process by which men and women become aware of their potential for reproduction(29). The general public's knowledge of fertility is lacking, according to earlier research. They also concluded that household income, age, and university education all have an impact on fertility knowledge.(30–33) Additionally, Mena et al. (2023) explored whether fertility awareness training improves knowledge of the reproductive cycle and may reduce the time to pregnancy in infertile women and reported that after women receive fertility awareness training, the score on frequently asked questions increases after training compared with the score on frequently asked questions before training.(34) Carla Conceição et al. (2017) demonstrated the effectiveness of a video intervention on fertility knowledge among university students and concluded that participants in the intervention group significantly increased their knowledge about fertility issues, infertility risk factors, and the definition of infertility. As a result, a short video intervention is effective in increasing short-term knowledge about reproductive health and infertility.(35)Furthermore, Garcia et al. (2016) conducted tailored education to increase knowledge and awareness about fertility. They concluded that only the tailored group showed a significant increase in fertility knowledge scores with education. Information regarding a woman's most fertile age and childbearing restrictions was the most useful information. Therefore, tailored oral education increases fertility knowledge in young women, especially in relation to their reproductive lifespan.(36) We believe that " face-to-face training" played a crucial role in this outcome for two reasons: first, the random nature of our study ensured that the groups were initially balanced; second, the information provided to the intervention and control groups differed. In the intervention group, information was delivered orally in a face-to-face manner along with an educational booklet, which helped attract women’s attention to their incorrect responses. In contrast, the control group received no intervention. Therefore, we conclude that the observed increase was primarily due to the method of information delivery. While there was a trend toward higher attitudes and knowledge in the intervention group, without the booklet accompanying personalized information, sufficient interest and retention are less likely to occur. Overall, delayed childbearing has changed due to economic and social factors such as job opportunities for educated people, access to higher education, and education itself, which can enable women to make informed reproductive decisions in the future. In recent years, one of the keys to changing couples' attitudes toward childbearing has been through various means. Limitations and strengths A major strength is its focus on an under researched yet influential group of working women in the medical field along with the use of a structured, evidence-based educational program. Follow-up assessments were conducted immediately after the intervention and one month later, allowing short-term impact evaluation. However, the study faced limitations such as participants’ limited cooperation due to demanding work schedules, which may have affected engagement and response rates. Additionally, the findings may not be generalizable to nonacademic or culturally different populations. Conclusions On the basis of the results of this study, educational intervention based on reproductive health literacy can effectively improve attitudes toward childbearing and fertility knowledge. Attitudes toward fertility and childbearing are key determinants of fertility behaviors; the more favorable these attitudes are, the stronger individuals’ intentions are to have children, which may also lead to an increase in the number of children they decide to have. Considering the importance of addressing population decline in the country, this educational approach can serve as an effective means of preparing individuals for behavioral change and motivating them to consider having more children. In light of the declining population, education on reproductive health literacy and awareness of the consequences of delayed pregnancy are crucial. A lack of knowledge can lead to infertility and a reduction in birth rates. Therefore, the findings of this study could significantly contribute to the development of policies and counseling programs aimed at supporting families and increasing fertility rates. According to the findings of this study, future research should focus on implementing additional behavioral strategies aimed at enhancing attitudes toward having children. Moreover, it is advisable for future studies to include extended follow-up periods to better understand the lasting impact of these approaches from fertility-related perspectives, which can ultimately aid in addressing demographic issues. Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Ethics Committee of Shiraz University of Medical Sciences with the code number of REC1403.009. Moreover, the study is also registered on the clinicaltrials.gov website under the registry number 20240507061690N1. The date of the first trial registration was 2024.05.19. Participants were informed about confidentiality and signed a written informed consent before participating in the study, also the ethical approval and consent to participate were obtained. Consent for publication The use of the article's contents in articles or any other scientific writing is permitted, provided that the source is cited and in compliance with the publishing regulations of Shiraz University of Medical Sciences. Competing interests The authors declare to the journal that this article has no Competing of interest. Funding This research has no funding. Availability of data and materials Copying (by any method) of the full text or of the findings is only possible with the coordination of the supervisor and the registered author and according to the instructions provided by the Central Library of Shiraz University of Medical Sciences (details are available through the relevant faculty library). Acknowledgements This article was extracted from the research proposal approved by Shiraz University of Medical Sciences (IRCTID: IRCT20240507061690N1). The authors would like to thank Shiraz University of Medical Sciences for financially support and Center for Development of Clinical Research of Namazi Hospital for statistical assistance also the authors wish to thank all participants for their cooperation References Hosseini H A-SJ. 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The effect of motivational interviewing on attitude and intention for childbearing in healthcare provider women. BMC psychology. 2025;13(1):1-11. Bodin M, Käll L, Tydén T, Stern J, Drevin J, Larsson M. Exploring men’s pregnancy-planning behaviour and fertility knowledge: a survey among fathers in Sweden. Upsala journal of medical sciences. 2017;122(2):127-35. Almeida-Santos T, Melo C, Macedo A, Moura-Ramos M. Are women and men well informed about fertility? Childbearing intentions, fertility knowledge and information-gathering sources in Portugal. Reproductive health. 2017;14(1):1-9. Heywood W, Pitts MK, Patrick K, Mitchell A. Fertility knowledge and intentions to have children in a national study of Australian secondary school students. Australian and New Zealand Journal of Public Health. 2016;40(5):462-7. Maeda E, Sugimori H, Nakamura F, Kobayashi Y, Green J, Suka M, et al. A cross sectional study on fertility knowledge in Japan, measured with the Japanese version of Cardiff Fertility Knowledge Scale (CFKS-J). Reproductive health. 2015;12(1):1-12. Mbugua SM, Karonjo JM. Reproductive health knowledge among college students in Kenya. BMC public health. 2018;18:1-7. Mena GP, and McLindon LA. Fertility awareness education improves fertility cycle knowledge and may reduce time-to-pregnancy in subfertile women. Human Fertility. 2023;26(2):405-12. Conceição C, Pedro J, Martins MV. Effectiveness of a video intervention on fertility knowledge among university students: a randomised pre-test/post-test study. The European Journal of Contraception & Reproductive Health Care. 2017;22(2):107-13. García D, Vassena R, Prat A, Vernaeve V. Increasing fertility knowledge and awareness by tailored education: a randomized controlled trial. Reproductive biomedicine online. 2016;32(1):113-20. Tables Tables 2 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table2and3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7447612","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":529997417,"identity":"441f02d6-fe4b-4bcd-877c-affcc941c72f","order_by":0,"name":"Asma Zandavi","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Asma","middleName":"","lastName":"Zandavi","suffix":""},{"id":529997424,"identity":"2f4bfd7d-3fcc-4b36-89ef-0a2a8a92cd82","order_by":1,"name":"Zahra 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(2024)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOne of the most important demographic changes over the last three decades has been the sharp decline in fertility rates in all regions of the world, especially in developing countries(1). According to the United Nations World Population Outlook 2017, almost half of the world's population lives in countries where fertility rates are below replacement levels. Low fertility is now a global phenomenon and can be a temporary trend driven by increased delays in marriage, childbearing, economic and social insecurity and future uncertainty(2).The fertility rate in Iran, a developing nation, has drastically decreased over the past three decades (3), with the total fertility rate (TFR) decreasing from 6.3 in 1986 to 1.62 in 2018 (4). Iran's population growth is predicted to reach 1% by 2025 (5) and drop to less than 1% by 2031 (6). Global fertility rates are decreasing because the desire to have children is closely linked to the attitudes of couples(7). Childbearing is an important factor in demography and is highly important in social and cultural affairs(8). One of marriage's and life's major objectives is to have children (9). A study by Pedro et al. (2018) revealed that individuals of childbearing age are not sufficiently aware of the optimal timing of fertility, the risk factors for infertility or the possible consequences of delayed childbearing (10). Delaying childbearing reduces the number of children that can be born in a family and increases the risk of unplanned infertility.(11) Infertility and fertility issues such as miscarriage, ectopic pregnancy, low birth weight, gestational hypertension and diabetes, maternal mortality, stillbirth, preterm labor, Down syndrome, and congenital malformations such as congenital heart disease, cleft palate, esophageal atresia, schizophrenia, poor neurodevelopment, and childhood cancer are all linked to an increase in parental age(11\u0026ndash;13). One of the key variables influencing people's intentions to have children is their attitudes toward the problem of fertility. In many fertility theories, attitudes are among the most important factors influencing fertility and serve as a mechanism for influencing the timing of parenthood. A positive attitude toward motherhood usually leads to earlier and more frequent births, whereas a negative attitude is one of the factors reducing fertility-related outcomes(14). In recent years, attitudes toward childbearing have become much more important in view of the country's decreasing population growth rate. Programming and strategies to address this issue could lead to an increase in the desire and intention to become pregnant among women.(15, 16)\u003c/p\u003e\u003cp\u003eReproductive health literacy education plays a crucial role in public health, influencing both individuals and communities(17). Grasping reproductive health requires more than a simple understanding of human biology. It includes knowledge of safe sexual practices, availability of contraceptive methods, comprehension of consent, and the ability to identify indicators of reproductive health concerns. Nonetheless, deficiencies in education and prevailing cultural stigmas persist in obstructing effective dialog on these subjects, especially among young adults, who are at a pivotal point in gaining independence in their health-related choices(17, 18). Limited fertility knowledge is a contributing factor to not reaching childbearing aspirations (19) and plays a crucial role in reproductive health decisions. Many factors, such as age and lifestyle choices, can affect fertility. As fertility rates decline, researchers are focusing on fertility awareness (FA), which was defined in 2017 as understanding reproduction, personal and lifestyle risks (such as age, smoking, and obesity), and social and cultural influences on family planning. Essentially, FA helps people make informed choices about starting a family(20) As attitudes influence the behavior of individuals, it is possible to create an environment conducive to women's fertility decisions by designing and implementing appropriate training. Therefore, the present study is designed to examine the impact of fertility health literacy-based education on attitudes toward childbearing and fertility knowledge among employed married women at the university.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and sampling\u003c/h2\u003e\u003cp\u003e Our manuscript reporting adheres to CONSORT guidelines for reporting clinical trial. This clinical trial study, was conducted between September 2024 and December 2024 on 90 married employee women at Shiraz University of Medical Sciences, Iran, and approved by the Ethics Committee of Shiraz University of Medical Sciences. The sample size was considered 74 people (37 people in each group) after reading relevant articles (21). consulting with statisticians, and using the following formula, which increased to 90 people (45 in each group). after considering 20% attrition.\u003c/p\u003e\u003cp\u003eα\u0026thinsp;=\u0026thinsp;0.05 (first type error) β\u0026thinsp;=\u0026thinsp;0.10, second type error\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\mathbf{n}=\\varvec{\\rho\\:}\\frac{{({\\mathbf{z}}_{1-\\frac{\\varvec{\\alpha\\:}}{2}}+{\\mathbf{z}}_{1-\\varvec{\\beta\\:}})}^{2}}{{\\left(\\varvec{d}\\right)}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEligible participants were recruited through convenience sampling from five selected medical centers affiliated with Shiraz University of Medical Sciences. After recruitment, participants who met the inclusion criteria and consented to participate were randomly allocated into the intervention (n\u0026thinsp;=\u0026thinsp;45) and control (n\u0026thinsp;=\u0026thinsp;45) groups using simple randomization with a 1:1 allocation ratio. The randomization sequence was generated in advance using a random number table, and allocation concealment was ensured using sealed opaque envelopes. Participants were assured that they could leave the study at any time and that they could refuse to answer questions\u003c/p\u003e\u003cp\u003eThe inclusion criteria were married and of childbearing age, with no history of infertility. They were living with their spouse, and either had no children or were parents of only one child with at least a two-year delay in subsequent pregnancy. The participants were employed in administrative units of Shiraz University of Medical Sciences, held Iranian nationality, and consented to participate in the research by completing the informed consent form. They had no diagnosed or treated physical diseases that could have affected pregnancy, and they did not have any mental illness or use psychiatric medications, psychotropic drugs, narcotics, or alcoholic beverages.\u003c/p\u003e\u003cp\u003eExclusion criteria included incomplete or noncompletion of the questionnaire, unwillingness to continue participating in the research after entering the study or during follow-up, failure to attend more than two sessions of the educational program, and divorce from the spouse during the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIntervention implementation\u003c/h3\u003e\n\u003cp\u003eIn this clinical study participants were employed married women with inclusion criteria and were divided into two groups of 45 people (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After written informed consent was obtained, the pretest was first conducted in the intervention and control groups, and demographic questionnaires, Soderberg's attitudes toward childbearing, and Cardiff fertility knowledge were completed in both groups before the intervention.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the intervention group, after the pretest, the intervention was carried out in the form of reproductive health literacy training classes by the researcher in five sessions, each session lasting 45\u0026ndash;60 minutes, twice a week. The content of the training provided included: meeting with the participants and explaining the program, familiarizing them with the concept of fertility, recognizing the causes of infertility, familiarizing them with the consequences of delaying childbearing, and familiarizing them with new methods of preserving fertility. The training was provided by the researcher through lectures, face-to-face training, group discussions, and the presentation of an educational booklet. To complete the content of each session and further learn, the participants in the intervention group were also given a booklet and asked to study the materials related to each session before the start of the next session. The content of each training session was also given to the intervention group on the same day, and the materials of the session were reviewed briefly before the beginning of the class. Owing to the busy schedule, time and place constraints of the samples, face-to-face training was provided to a number of people who were unable to participate in the lecture-based training. After the end of the educational intervention, the samples in both the intervention and control groups again completed the childbearing attitudes and fertility knowledge questionnaires twice, immediately and after 4 weeks of training, to examine educational retention. Notably, no intervention was performed in the control group, but at the end of the study, to maintain educational justice, the educational content was provided to the control group in the form of a booklet.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe educational contents of the training sessions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducational content\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEducational materials\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducational methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003etime schedule\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMeeting with participants and explaining the program\u003c/p\u003e\u003cp\u003e1. Familiarizing with the importance of fertility in society\u003c/p\u003e\u003cp\u003e2. Understanding the factors affecting fertility rates and sex-specific fertility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputer-Photo-PowerPoint- Educational Booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLecture - Group Discussion -\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntroduction to the concept of fertility\u003c/p\u003e\u003cp\u003e1. Introduction to the anatomy and physiology of the reproductive system\u003c/p\u003e\u003cp\u003e2. Introduction to the female reproductive cycle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputer-Photo-PowerPoint- Educational Booklet- Educational video\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLecture - Group Discussion - Face-to-Face Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstanding the causes of infertility\u003c/p\u003e\u003cp\u003e1. Definition of infertility\u003c/p\u003e\u003cp\u003e2. Male factor\u003c/p\u003e\u003cp\u003e3. Female factor (maternal age and decreased ovarian reserve, ovulation disorders, fallopian tube disorders, uterus)\u003c/p\u003e\u003cp\u003e4. Unexplained infertility\u003c/p\u003e\u003cp\u003e5. Fertility treatments and success rates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputer-Photo-PowerPoint -Educational Booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLecture - Group Discussion - Face-to-Face Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntroduction to new methods of fertility preservation\u003c/p\u003e\u003cp\u003ePlanning for pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputer-Photo-PowerPoint -Educational Booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLecture - Group Discussion - Face-to-Face Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstanding the consequences of delaying childbearing\u003c/p\u003e\u003cp\u003e1. Disruption in intergenerational relationships\u003c/p\u003e\u003cp\u003e2. Weakening of family support networks\u003c/p\u003e\u003cp\u003e3. Disruption in the natural reproductive and childbearing process\u003c/p\u003e\u003cp\u003ea) (unwanted infertility and permanent childlessness\u003c/p\u003e\u003cp\u003eb) Increased risk of miscarriage, reduced live births, and increased pregnancy risks\u003c/p\u003e\u003cp\u003ec) Reduced desired family size and completed fertility)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputer- PowerPoint- Educational Booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLecture - Group Discussion - Face-to-Face Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData gathering instruments\u003c/h3\u003e\n\u003cp\u003eThe data collection instruments used in this study included a sociodemographic questionnaire, the Attitudes toward Fertility and childbearing scale (ATFCS), and the Cardiff Fertility Knowledge Scale (CFKS).\u003c/p\u003e\n\u003ch3\u003eSociodemographic questionnaire\u003c/h3\u003e\n\u003cp\u003eThis questionnaire included questions on age, spouse\u0026rsquo;s age, duration of marriage, age of previous child, education level, spouse\u0026rsquo;s education level, and economic status.\u003c/p\u003e\n\u003ch3\u003eAttitudes toward fertility and childbearing scale\u003c/h3\u003e\n\u003cp\u003eThe scale was developed by Soderberg, Landgren, Kristensson, and Hildingsson in 2013 to assess women's attitudes toward fertility and childbearing. The Latin version comprises 27 items and three subscales: It is scored on a 5-point Likert scale: completely agree (5) to completely disagree (1), with higher scores indicating a more positive attitude toward fertility and childbearing. The Persian version of the Fertility and Childbearing Attitudes Scale was developed by Baezzat and colleagues in 2016, and consists of 23 items and four subscales. The subscales include: the following: 1. Child as a cornerstone of life (items 1, 2, 3, 4, 6, 8, 23, and 27) 2. Child as an obstacle (items 14, 15, 16, 17, 18, and 19); 3. Postponement of fertility to the future (items 5, 7, 10, 12, and 13); 4. Fertility requiring the fulfillment of prerequisites (items 11, 20, 21, and 25). Notably, items 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 25 are reverse scored. The scale was developed by Baezzat and colleagues and has a Cronbach\u0026rsquo;s alpha coefficient of 0.792, confirming its internal consistency and reliability. The content validity of the instrument was reverified by five faculty members from the Nursing and Midwifery School of Iran. Furthermore, the internal consistency (Cronbach\u0026rsquo;s alpha) for the entire attitudes scale was 0.728, with subscale alphas of 0.763 for \"Child as a cornerstone of life,\" 0.757 for \"Postponement of fertility to the future,\" 0.666 for \"Child as an obstacle,\" and 0.856 for \"Fertility requiring the fulfillment of prerequisites\"(14, 22).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCardiff fertility knowledge scale (CFKS)\u003c/h2\u003e\u003cp\u003eThe Persian version of the Cardiff Fertility Knowledge Scale (CFKS) was used to assess fertility knowledge. The CFKS consists of 13 items measuring knowledge about facts, risks and myths of fertility. The participants responded to all the items as true, false or not known. A correct answer is assigned one point, and an incorrect or \u0026lsquo;do not know\u0026rsquo; answer is assigned zero points. The scores for this measure ranged from 0 to 13. The Cronbach\u0026rsquo;s alpha coefficient of the CFKS was 0.79, which is satisfactory for most countries(23, 24).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eIn examining the relationship between the target variable (quantitative variable) and demographic characteristics, an independent two-sample t- test was used to compare the means between the levels of the two-level variable, and an analysis of variance with pairwise comparisons was used to compare the means between multilevel variables by post hoc testing. The relationships between quantitative variables were assessed via Pearson's correlation test, and the relationships between qualitative variables were assessed via the chi-square test. To examine and evaluate the main objective, a repeated measures test was used to compare the mean changes in the attitudes toward childbearing and fertility knowledge scores between the two groups before, immediately after, and one month after the intervention. The analyses were performed with SPSS software (version 22).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were no significant differences between the two groups in terms of sociodemographic characteristics (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe independent t- test revealed no significant difference between the mean scores of attitudes toward childbearing in the intervention and control groups before the study (P\u0026thinsp;=\u0026thinsp;0.568). However, the difference between the two groups was significant immediately after the intervention (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and during the one-month follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the intervention group having a higher attitude score than did the control group. On the basis of the results of the repeated measures analysis of variance, the score of attitudes toward childbearing was significantly different between the intervention group before the intervention, immediately after the intervention, and one month after the intervention (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but there was no significant difference in the control group (P\u0026thinsp;=\u0026thinsp;0.957). (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparisons of the mean scores of attitudes toward childbearing within and between the intervention groups and the control group before, immediately after, and one month after the intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eimmediately Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfter 1 month\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(p value \u003csub\u003ew\u003c/sub\u003e*)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAttitude toward childbearing score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.78\u0026thinsp;\u0026plusmn;\u0026thinsp;67.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.43\u0026thinsp;\u0026plusmn;\u0026thinsp;77.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.54\u0026thinsp;\u0026plusmn;\u0026thinsp;82.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.17\u0026thinsp;\u0026plusmn;\u0026thinsp;66.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.10\u0026thinsp;\u0026plusmn;\u0026thinsp;66.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.05\u0026thinsp;\u0026plusmn;\u0026thinsp;65.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0/957\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(p value\u003c/b\u003e \u003csub\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sub\u003e\u003cb\u003e**)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Repeated measures test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e** Two-sample independent t- test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eW: Within group. B: Between -group\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe interaction effect between time and group was statistically significant (p\u0026thinsp;=\u0026thinsp;0.003), indicating that the overall effects of time and group cannot be interpreted independently. The attitude scores toward childbearing among individuals changed significantly over time (p\u0026thinsp;=\u0026thinsp;0.008), and there was also a significant difference between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In other words, the attitude scores within each group and between the two groups significantly changed following the intervention and over time. This suggests that the effects of the groups differ at different times, so the results should be interpreted with caution as marginal effects. The findings indicate that there was no significant difference between the intervention and control groups before the intervention (p\u0026thinsp;=\u0026thinsp;0.568). However, immediately after and one month following the intervention, the attitude scores differed significantly between the intervention and control groups (p\u0026thinsp;=\u0026thinsp;0.0001), with the intervention group having higher attitude scores. This finding demonstrates that training was effective in improving individuals\u0026rsquo; attitudes toward childbearing. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\" Repeated- measures ANOVA for comparing attitudes toward childbearing across three time points between the intervention and control groups.\"\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSource\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eŋ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAttitude toward childbearing score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.1978\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4825\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInteraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.5273\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eŋ\u003csup\u003e2\u003c/sup\u003e: Eta squared d: Cohen\u0026rsquo;s effect size\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Repeated measures test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIndependent t tests revealed a significant difference between the mean scores of fertility knowledge in the intervention and control groups before the study (P\u0026thinsp;=\u0026thinsp;0.036). This suggests that, before the educational intervention, the control group had better fertility knowledge. Consequently, to accurately assess the effect of the intervention over time, the pretest effect must be controlled for, and an adjusted analysis should be utilized. The effects of these two time points are not eliminated by adjusting for the baseline; instead, each individual is compared to their own prior state. Additionally, the difference between the two groups was significant immediately after the intervention (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and during the one-month follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with the intervention group having a higher fertility knowledge score than did the control group. The results of repeated measures analysis of variance, revealed that the score of fertility knowledge was significantly different between the intervention group before the intervention, immediately after the intervention, and one month after the intervention (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), but there was no significant difference in the control group (P\u0026thinsp;=\u0026thinsp;0.441). (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparisons of the mean scores of fertility knowledge within and between the intervention groups and the control group before, immediately after, and one month after the intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eimmediately Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfter 1 month\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(p value\u003csub\u003ew\u003c/sub\u003e*)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFertility knowledge Cardiff score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.62\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.726\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.441\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(p value\u003c/b\u003e\u003csub\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sub\u003e\u003cb\u003e**)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe interaction effect of time and group is not statistically significant (p\u0026thinsp;=\u0026thinsp;0.67), allowing us to interpret the main effects of time and group independently. The fertility knowledge scores of individuals did not significantly differ over time (p\u0026thinsp;=\u0026thinsp;0.244); however, there was a statistically significant difference between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In other words, the fertility knowledge scores within each group did not change significantly over time, but there was a significant difference between the two groups immediately after the intervention and during the follow-up period. The results in Tables\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e indicate a significant difference between the intervention and control groups at, immediately postintervention, and one month after the intervention. Specifically, individuals in the intervention group had higher scores immediately after and one month following the intervention, suggesting that the educational program was effective in enhancing fertility knowledge scores. (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the mean scores of fertility knowledge between the intervention and control groups before, immediately after, and one month after the intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSource\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value***\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eŋ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFertility knowledge Cardiff score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e322.156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.787\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.844\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.255\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInteraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0895\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted to determine the effects of educational interventions based on reproductive health literacy on the attitudes toward childbearing and fertility knowledge of employed married women at Shiraz University of Medical Science. The results demonstrated that attitudes toward childbearing and fertility knowledge were initially low in the pretest but increased significantly after the intervention at both assessment points. According to many fertility theories, attitudes are among the most significant variables affecting fertility and can be affected when a person becomes a parent. While a negative attitude is one of the factors lowering fertility-related outcomes, a positive attitude toward motherhood typically results in earlier and more frequent births (14). Few interventional studies have examined the effect of education on attitudes toward childbearing. A study by Ansari Majd et al. (2019) revealed that an educational program based on a meta-theoretical model was effective in determining women's attitudes(25). Additionally, Mohammadi et al. (2024) conducted an educational intervention on the basis of the stages of change in the attitudes toward and stages of change in the childbearing behavior of married women and concluded that the stages of change in the intervention group changed significantly in a positive direction and that people were promoted from the pre thinking stage to the action stage.(26) Moridi et al. (2024) concluded that education based on the transtheoretical model improved women's attitudes toward childbearing(27). Furthermore, Rahimi et al. (2025) explored the effects of motivational interviewing on attitudes and intentions to have children in women providing health services, and reported that attitudes toward having children (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and intentions to have children (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were significantly greater in the intervention group than in the control group immediately and one month after the intervention.(28)\u003c/p\u003e\u003cp\u003eFertility knowledge is the process by which men and women become aware of their potential for reproduction(29). The general public's knowledge of fertility is lacking, according to earlier research. They also concluded that household income, age, and university education all have an impact on fertility knowledge.(30\u0026ndash;33) Additionally, Mena et al. (2023) explored whether fertility awareness training improves knowledge of the reproductive cycle and may reduce the time to pregnancy in infertile women and reported that after women receive fertility awareness training, the score on frequently asked questions increases after training compared with the score on frequently asked questions before training.(34) Carla Concei\u0026ccedil;\u0026atilde;o et al. (2017) demonstrated the effectiveness of a video intervention on fertility knowledge among university students and concluded that participants in the intervention group significantly increased their knowledge about fertility issues, infertility risk factors, and the definition of infertility. As a result, a short video intervention is effective in increasing short-term knowledge about reproductive health and infertility.(35)Furthermore, Garcia et al. (2016) conducted tailored education to increase knowledge and awareness about fertility. They concluded that only the tailored group showed a significant increase in fertility knowledge scores with education. Information regarding a woman's most fertile age and childbearing restrictions was the most useful information. Therefore, tailored oral education increases fertility knowledge in young women, especially in relation to their reproductive lifespan.(36) We believe that \" face-to-face training\" played a crucial role in this outcome for two reasons: first, the random nature of our study ensured that the groups were initially balanced; second, the information provided to the intervention and control groups differed. In the intervention group, information was delivered orally in a face-to-face manner along with an educational booklet, which helped attract women\u0026rsquo;s attention to their incorrect responses. In contrast, the control group received no intervention. Therefore, we conclude that the observed increase was primarily due to the method of information delivery. While there was a trend toward higher attitudes and knowledge in the intervention group, without the booklet accompanying personalized information, sufficient interest and retention are less likely to occur. Overall, delayed childbearing has changed due to economic and social factors such as job opportunities for educated people, access to higher education, and education itself, which can enable women to make informed reproductive decisions in the future. In recent years, one of the keys to changing couples' attitudes toward childbearing has been through various means.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and strengths\u003c/h2\u003e\u003cp\u003eA major strength is its focus on an under researched yet influential group of working women in the medical field along with the use of a structured, evidence-based educational program. Follow-up assessments were conducted immediately after the intervention and one month later, allowing short-term impact evaluation. However, the study faced limitations such as participants\u0026rsquo; limited cooperation due to demanding work schedules, which may have affected engagement and response rates. Additionally, the findings may not be generalizable to nonacademic or culturally different populations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOn the basis of the results of this study, educational intervention based on reproductive health literacy can effectively improve attitudes toward childbearing and fertility knowledge. Attitudes toward fertility and childbearing are key determinants of fertility behaviors; the more favorable these attitudes are, the stronger individuals\u0026rsquo; intentions are to have children, which may also lead to an increase in the number of children they decide to have. Considering the importance of addressing population decline in the country, this educational approach can serve as an effective means of preparing individuals for behavioral change and motivating them to consider having more children. In light of the declining population, education on reproductive health literacy and awareness of the consequences of delayed pregnancy are crucial. A lack of knowledge can lead to infertility and a reduction in birth rates. Therefore, the findings of this study could significantly contribute to the development of policies and counseling programs aimed at supporting families and increasing fertility rates. According to the findings of this study, future research should focus on implementing additional behavioral strategies aimed at enhancing attitudes toward having children. Moreover, it is advisable for future studies to include extended follow-up periods to better understand the lasting impact of these approaches from fertility-related perspectives, which can ultimately aid in addressing demographic issues.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Ethics Committee of Shiraz University of Medical Sciences with the code number of REC1403.009. Moreover, the study is also registered on the clinicaltrials.gov website under the registry number 20240507061690N1. The date of the first trial registration was 2024.05.19. Participants were informed about confidentiality and signed a written informed consent before participating in the study, also the ethical approval and consent to participate were obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of the article\u0026apos;s contents in articles or any other scientific writing is permitted, provided that the source is cited and in compliance with the publishing regulations of Shiraz University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare to the journal that this article has no Competing of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research has no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCopying (by any method) of the full text or of the findings is only possible with the coordination of the supervisor and the registered author and according to the instructions provided by the Central Library of Shiraz University of Medical Sciences (details are available through the relevant faculty library).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article was extracted from the research proposal approved by Shiraz University of Medical Sciences (IRCTID: IRCT20240507061690N1). The authors would like to thank Shiraz University of Medical Sciences for financially support and Center for Development of Clinical Research of Namazi Hospital for statistical assistance also the authors wish to thank all participants for their cooperation\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHosseini H A-SJ. Proximate determinants of fertility of women between the Kurd and Turk populations in Orumieh District: An application of Bongaarts decomposition method. Journal of Iranian Social Studies. 2011;4(2):23-48.\u003c/li\u003e\n\u003cli\u003eAbbasi-Shavazi MJ, Razeghi-Nasrabad HB, Hosseini-Chavoshi M. Socio-economic security and fertility intention in Tehran City. Journal of Population Association of Iran. 2020;15(29):211-38.\u003c/li\u003e\n\u003cli\u003eMoeini B, Erfani A, Barati M, Doosti-Irani A, Hosseini H, Soheylizad M. 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Investigating the Effect of Educational Intervention Based on the Stages of Change on the Attitude and Behavior of Married Women to Have Children. Iranian Journal of Health Education and Health Promotion. 2024;12(2):219-28.\u003c/li\u003e\n\u003cli\u003eMoridi M, Damghanian M, Keshaverz S. An integrated theory based-educational intervention to change intention to have a child: study protocol of a cluster randomized controlled trial. Reproductive Health. 2024;21(1):30.\u003c/li\u003e\n\u003cli\u003eRahimi A, Taheri M, Dafei M, ZareMobini F. The effect of motivational interviewing on attitude and intention for childbearing in healthcare provider women. BMC psychology. 2025;13(1):1-11.\u003c/li\u003e\n\u003cli\u003eBodin M, K\u0026auml;ll L, Tyd\u0026eacute;n T, Stern J, Drevin J, Larsson M. Exploring men\u0026rsquo;s pregnancy-planning behaviour and fertility knowledge: a survey among fathers in Sweden. Upsala journal of medical sciences. 2017;122(2):127-35.\u003c/li\u003e\n\u003cli\u003eAlmeida-Santos T, Melo C, Macedo A, Moura-Ramos M. Are women and men well informed about fertility? Childbearing intentions, fertility knowledge and information-gathering sources in Portugal. Reproductive health. 2017;14(1):1-9.\u003c/li\u003e\n\u003cli\u003eHeywood W, Pitts MK, Patrick K, Mitchell A. Fertility knowledge and intentions to have children in a national study of Australian secondary school students. Australian and New Zealand Journal of Public Health. 2016;40(5):462-7.\u003c/li\u003e\n\u003cli\u003eMaeda E, Sugimori H, Nakamura F, Kobayashi Y, Green J, Suka M, et al. A cross sectional study on fertility knowledge in Japan, measured with the Japanese version of Cardiff Fertility Knowledge Scale (CFKS-J). Reproductive health. 2015;12(1):1-12.\u003c/li\u003e\n\u003cli\u003eMbugua SM, Karonjo JM. Reproductive health knowledge among college students in Kenya. BMC public health. 2018;18:1-7.\u003c/li\u003e\n\u003cli\u003eMena GP, and McLindon LA. Fertility awareness education improves fertility cycle knowledge and may reduce time-to-pregnancy in subfertile women. Human Fertility. 2023;26(2):405-12.\u003c/li\u003e\n\u003cli\u003eConcei\u0026ccedil;\u0026atilde;o C, Pedro J, Martins MV. Effectiveness of a video intervention on fertility knowledge among university students: a randomised pre-test/post-test study. The European Journal of Contraception \u0026amp; Reproductive Health Care. 2017;22(2):107-13.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a D, Vassena R, Prat A, Vernaeve V. Increasing fertility knowledge and awareness by tailored education: a randomized controlled trial. Reproductive biomedicine online. 2016;32(1):113-20.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 2 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Attitude toward childbearing, Fertility knowledge, Reproductive health literacy","lastPublishedDoi":"10.21203/rs.3.rs-7447612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7447612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003eFertility rates have sharply declined worldwide, especially in developing countries. Many reproductive-age individuals lack reproductive health literacy, including knowledge about optimal fertility timing and infertility risks. This study evaluated the effects of reproductive health literacy education on fertility knowledge and childbearing attitudes.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eIn this clinical trial study eligible participants were randomly assigned to (intervention, n\u0026thinsp;=\u0026thinsp;45; control, n\u0026thinsp;=\u0026thinsp;45) using simple randomization with a 1:1 allocation ratio. The randomization sequence was generated in advance using a random number table. The intervention group received five training sessions, each lasting 45\u0026ndash;60 minutes, which were conducted twice weekly. For all 3 assessments, two questionnaires were used at all three time points (before, immediately after and one month after the intervention), participants completed two validated questionnaires: the Attitudes Toward Fertility and Childbearing Scale and the Cardiff Fertility Knowledge Scale. Data analysis was performed using independent t-test and chi-square tests, and SPSS version 22 statistical software was used to analyze the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThere were no significant differences in demographic characteristics between the two groups. Prior to the intervention, there was no significant difference in the mean attitudes toward childbearing scores between the groups. However, immediately after and one month after the intervention, the intervention group had a significantly greater mean attitude score toward childbearing than did the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although a significant difference was observed in the before fertility knowledge scores between the groups, the analyses were adjusted accordingly. Following the intervention, at both the immediate and one-month follow-ups, the intervention group demonstrated significantly greater fertility knowledge than did the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study shows that reproductive health literacy education improves attitudes toward childbearing and fertility knowledge, and that higher knowledge is linked to more favorable attitudes. It supports targeted educational programs to boost reproductive health literacy and inform decision-making.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eIran Randomized Clinical Trial Center registration IRCT20240507061690N1, Date of first trial registration: 2024.05.19.\u003c/p\u003e","manuscriptTitle":"Impact of Reproductive Health Literacy Education on Fertility Knowledge and Childbearing Attitudes among Employed Married Women at Shiraz University of Medical Sciences (2024)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:14:52","doi":"10.21203/rs.3.rs-7447612/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46749d85-2810-4034-ab1d-12d734ff3d6e","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-07T07:40:36+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T07:57:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:14:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7447612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7447612","identity":"rs-7447612","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}