Low fertility knowledge
The current study found that young college students in China (mainland) had a modest level of fertility knowledge. This finding was consistent with the findings of previous studies [8, 13]. The IFDMS reported that the average score was 56.9% correct in 79 countries but less than 44.9% in China, and the average score was 59.7% in the university-educated population [8]. In this study, although all participants were college students, the average score was only 49.9%, higher than the previous study in China, lower than the sample of university education population in 79 countries [8] and in Japan [13]. In general, greater fertility knowledge was associated with higher education [8-9, 21, 31]. It follows that fertility knowledge remains low in China.
The findings of the present study also indicated that most of the participants had misconceptions about fertility and the basic facts of infertility. Table 2 reveals that college students underestimate the incidence of infertility and the influence of mumps and overestimate the importance of a healthy lifestyle to fertility. In fact, more than half of participants had misperceptions about fertility, although 89.6% reported that they were educated about fertility issues. This may have led to delayed childbearing and to neglecting some risk factors for reduced fertility. In regard to health issues, based on explanatory models for behaviour change, lack of knowledge is the core reason why people do not behave optimally [8].
All participants with medicine discipline had increased fertility knowledge, as did those who were female, born in a city, those with non-single status, those being in year 4 or above of study, and those with an intention to have children. These findings are consistent with previous studies, which reported that greater fertility knowledge was associated with female gender [8, 13, 22], socioeconomic status [8, 13] and with medical consultation for infertility [8]. These may be caused by the persistent lag in fertility health education and by cultural differences. Many people are aware of the necessity of sex education, but they feel embarrassed when discussing sex or fertility issues; this is especially true in unmarried populations [21, 22]. Moreover, a positive relationship between education and health literacy has been recorded in hypertension, diabetes, and HIV health contexts [32-35]. Therefore, it is urgent to improve fertility health education in China, and it is particularly important to consider those items and populations that had low scores. Targeted promotion of fertility knowledge may raise awareness, improve uptake of more effective methods and improve fertility decision-making in certain population groups [36].
Low intention to have children
Approximately one-fifth (18.2%) of the respondents stated that they did not want to have children, which was higher than previous studies in the US (14.2%) and Sweden (4.1%) [15, 23] and slightly lower than the sample in Hong Kong (19.1%) [31]. When indicating how important childbearing was to them, both male and female college students rated it as highly important (mean=6.3, SD=2.7), and the score was lower than those found in Denmark (male: mean=8.2, SD=3.1; female: mean=9.7, SD=2.3) [11] and the US (male: mean=8.3, SD=2.5; female: mean=8.5, SD=2.9) [23] but higher than in Hong Kong (mean=6.2, SD=3.0) [37]. These findings are in line with the fertility rate in China. This phenomenon may result from the country’s fertility policy of the last 30 years. The two-child policy has been implemented for four years in China; however, an increasing number of newlyweds put off having children or decide not to have children at all to pursue higher education or career development. A previous study demonstrated that providing fertility-related information contributes to greater reproductive knowledge and may affect childbearing intention [38]. Furthermore, males had significantly higher scores than females, a finding that was contrary to other results [12, 15, 23, 37]. Explanations for this may be that women – especially highly educated women – must balance childbearing with education, career aspirations, health and partner selection. Previously, published literature found that delaying childbearing has steadily increased in recent decades[39, 40]. Modern women are independent and pay more attention to their development and freedom than did women of earlier generations; having children means more effort and burden[41]. Furthermore, an increasing number of women identify with feminism[42].
Moreover, this study found a small positive relationship between CFKS-C and the importance of childbearing. Therefore, improving fertility knowledge may be beneficial for increasing the fertility rate.
Lack of corrected fertility health education
Overall, more than three-quarters of participants self-reported that they had some education about fertility-related knowledge, and more than half discussed fertility issues with family, but their rate of correct fertility knowledge was actually low. Furthermore, the findings showed that more than half of college students obtained knowledge from media and the internet (41.4%) instead of school and the health department. However, in the US, the main modes of acquiring fertility knowledge were school (46.0%) and family (20.0%) [23]. These findings may reveal that young people have an incomplete understanding of fertility issues, and they seek fertility information in a haphazard way from less formal sources. The World Health Organization (WHO) recently established the goal of supporting sexual and reproductive health, including fertility care [43]. Hence, fertility health promotion strategies should be developed. First, public health initiatives should set up a special organization to be responsible for fertility education. For example, in 2011, a government-funded fertility health promotion programme was established in Australia to increase fertility awareness[1]. Second, education about fertility should be strengthened in the school and primary health care setting [45, 46]. Considering that teachers and primary health care professionals may be suitable candidates to deliver health information about fertility, they should be educated with additional information and resources [10, 47]. Third, the forms and channels of publicity about fertility should be broadened, and information should be standardized, especially on the internet. Internet education is a double-edged sword, and both accurate and inaccurate knowledge can be spread quickly. However, given that information from the internet can be obtained easily and conveniently, web-based approaches can be applied to fertility education. Previously, published literature has demonstrated that a short educational intervention (including online education) was effective in increasing knowledge about reproductive health and fertility, thus supporting family planning decisions [31,48-50]. But, fertility information may increase infertility threats and feelings of anxiety [50,51]. Given these issues, future research should focus on developing and evaluating interventions to improve knowledge about fertility health and to investigate the barriers and enablers of fertility health education.
Limitations
First, the cross-sectional design of the present study had self-selection bias, which was inherent in using the convenience sampling method.
Second, the response rate and the characteristics of the non-respondents could not be ascertained because the participants were recruited by posters at the university.
Third, the population in three universities in Hunan province may not reflect the fertility knowledge level in other universities of Hunan province or other parts of China when generalizing the findings.
In addition, to collect more credible and comprehensive information, both quantitative and qualitative methods could be used in the future.