Knowledge, Attitude, and Practice of Family Planning Among Saudi Primary Health Care Attendees in Al-Ahsa, Kingdom of Saudi Arabia

Background: Assessing community awareness and practice of the significance and methods of family planning is critical for improving the effectiveness and quality of services, policies, and planning, which has a positive impact on the health and quality of life of women, children, families, and communities. Objective: This study aims to determine Saudi population's knowledge, attitude, and practice of family planning in Al-Ahsa, Kingdom of Saudi Arabia. Methodology: A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia. The study included randomly selected participants (male and female Saudi primary health care attendees). All adult Saudi individuals of both genders attending primary health care centers were eligible for inclusion in this study. Data were analyzed using IBM SPSS Statistics for Windows, Version 15 (Released 2006; IBM Corp., Armonk, New York, United States). Descriptive statistics for the prevalence and quantitative variables was used. Results: The study included 672 participants; 78.6% of them were females and 21.4% were males. 23.8% of participants aged between 20 and 30 years old. 73.8% of participants heard of family planning before. The source of information about family planning was reported as 36.9% from the Internet, 27.4% from relatives, 21.4% from the doctor, and 14.3% from books. 21.4% think that long-term contraceptive use led to permanent infertility. 81.0% of the participants said that they tend to use family planning methods. 78.6% of the participants have used a family planning method before, where 25.8% of the participants used natural contraception methods, 21.2% used surgical contraception, 27.3% used condoms, and 12.1% used hormonal tablets, while 13.6% used nothing. However, 65.2% currently use contraceptives. 31.8% use the natural method of family planning currently, 21.2% use surgical methods, and 6.1% use condoms. Conclusion: In comparison to many studies previously mentioned, the rate of family planning utilization was average, as was the level of knowledge and attitude toward family planning. However, there were some mistaken beliefs among participants regarding contraceptives. Age, gender, the duration of a marriage, education level, working status, and monthly income were all found to be significantly associated with knowledge of family planning.


Introduction
According to the World Health Organization (WHO), family planning is defined as "the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is accomplished via the use of contraception and the therapeutic interventions of unplanned infertility" [1].
One of the ten greatest public health achievements of the 20th century is family planning. Family planning meets three key necessities: it tends to help couples minimize unplanned pregnancies; it decreases the risk of sexually transmitted diseases (STDs); and it significantly reduces rates of infertility by acknowledging the STD problem [2].
Every year, one-third of unplanned pregnancies are caused by improper or failed contraceptive use. In developing countries, obstacles include a lack of knowledge about methods of contraception, a lack of supply, high costs, and limited accessibility.
Individuals' ability to choose their family size, as well as the timing and spacing of their children, has led to substantial improvements in health and social and economic well-being. Inability to plan childbirth can harm the health of the entire family. Low birth rates and increased child spacing have contributed to lower participants were aged between 20 and 30 years old, 38.1% were aged between 31 and 40 years old and 14.3% were aged between 51 and 60 years. The duration of marriage was reported more than three years in 79.8% of participants. 81% of participants were university educated. 50% were employed. Half of the studied samples had low family income (less than 5000 SAR/Month). As for co-morbid diseases, 3.6% had diabetes, 1.2% had hypertension, and 1.2% had liver disease, as in Table 1    As shown in Table 4, 81.0% of the participants said that they tend to use family planning methods. Figure  1 shows that the source of information for family planning was reported as 36.9% from the Internet, 27.4% from relatives, 21.4% from the doctor, and 14.3% from books.     Table 6 shows that sociodemographic factors such as age, gender, the duration of a marriage, education level, working status, and monthly income were all found to be significantly associated with knowledge of family planning (p=0.001).

Discussion
If all prospective families, especially eligible women, lack sufficient understanding for a positive attitude and fail to correctly and regularly practice as per their needs, expanding program coverage and access to family planning will not be enough. It is highly advised that eligible women increase their awareness, knowledge, and favorable attitudes toward using family planning methods at all levels, and it is crucial that health care professionals, especially primary care doctors, have solid knowledge and a positive attitude and engage in family planning [10]. Additionally, family planning is regarded as a societal development phase [11]. Regarding knowledge and actual use of contraceptives during the reproductive phase, a gap was discovered among Saudi participants in different studies. Additionally, the majority of them use contraceptives to increase the time between births rather than to reduce the size of their families [7,12].
However, over the past few decades, Saudi society has undergone a profound transformation. Changes in fertility beliefs and habits were brought about by socioeconomic development, urbanization, and women's education and employment. The findings of this study provide information about Al-Ahsa, Saudi Arabia. It examines the opinions, behaviors, and preferences of women in the reproductive stage with regard to family planning, fertility choices, and health-seeking behavior. Al-Ahsa is the largest governorate in Saudi Arabia's Eastern Province [13,14]. Our study unleashes an encouraging fact that most of the participants are not aware of the disadvantages of family misplanning, as 89.3% of the participants said there is no defect in having more than four children, though most of the participants (73.8%) were aware and have heard of family planning. A study conducted in Abha, Saudi Arabia, in 2019 by Al-Musa revealed that 80.6% of the participants were aware of the term family planning [5]. According to a number of other studies, the majority of women in Saudi Arabia were found to be aware of contraceptives but to know little about the particulars [7,15] [16]. Likely, a prior survey conducted in the Aseer region found that 99.2% of women were aware of how to use contraception [17]. The participant education level was higher in both of these surveys, and prior research has shown that as education levels rise, understanding of family planning considerably rises [18]. Another study conducted in Kashmir, India revealed that 100.0% of the participants were aware of family planning and 78.8% of them had their information from trainings [1]. In Pakistan, a study in a rural region found that just (81.0%) of women were aware of contraception [19], compared to (97.4%) and (99.0%) in studies done in metropolitan Pakistan (Lahore, Islamabad) [16,20]. Another Indian study indicated that 82.2% of participants were aware of family planning [21], and a Bangladeshi one found that 87.7% of participants were aware [22]. Also in a survey conducted in Sudan, 87.0% of participants had knowledge of family planning [23].
According to our study results, 21.4% of the participants said that long-term contraceptive use leads to permanent infertility, while 21.4% said no, and 57.1% did not know. The fear of using contraceptive because of the possible and widely known side effects was identified clearly in our study with a 33.3% rate and in other studies. In a study conducted in Abha, due to their concern over side effects, 11.8% of people had a bad attitude toward contraceptives [5]. This is comparable to a study from Madinah, Saudi Arabia, where 19.5% of the participants displayed negative attitude due to fear of side effects [16], although just 6% of the participants in a prior study from the same region demonstrated such worry [17]. A cross-sectional study conducted among Rohingya women living in refugee camps in Bangladesh revealed that 21.57% of women did not use contraceptives because of worries about potential side effects [24].
In our study, 79.8% of participants recognized condoms as a family planning method, 56.0% recognized hormonal tablets as a family planning method, 56.0% recognized hormonal injections as a family planning method, and 82.1% considered external ejaculation as a family planning method. Similarly, a study in Abha showed that in contrast to other treatments, which were only identified by a small number of participants, hormonal pills were recognized by 53.2% of participants, followed by intrauterine devices [5]. This may be attributed to the fact that the oral contraceptive pill was the most widely used form of contraception which is supported by other studies carried out in Saudi Arabia [7,15]. In addition, another study in Saudi Arabia showed that 88.0% recognized hormonal pills or injections as the known type of contraceptives, 90.7% knew condoms as a contraceptive, and 61.4% knew IUD as a contraceptive [16]. Likewise, a survey conducted in Qatar found that the majority of women were aware of IUDs (89.1%) and oral contraceptive pills (90.0%) [18]. The oral contraceptive pill and IUD are also the most often used forms of birth control in the Gulf region, according to a review [25].
Discussing the source of information for the participants, our study revealed that 36.9% got their information from the Internet, 27.4% from relatives, 21.4% from the doctor, and 14.3% from books. In our opinion, there are misconceptions among the participants regarding family planning, contraceptives and their use because of the unreliability of the source of information, as only 21.4% got their information from the doctor and the rest got it from untrusted sources. This result is comparable to that of other previous studies carried out across Saudi Arabia, which similarly indicated that friends and family were the main information sources [26,27]. Similarly, the study conducted in Abha showed that family members were the most often cited source of information for participants' family planning knowledge, followed by the Internet and health care providers, with books and newspapers ranking last in importance [5]. A study conducted in Bangladesh showed that 34.85% of the participants got their information from the health care personnel, 15.71% from radio/TV, 11.71% from family planning centers, and 10.0% from relatives and friends [22].
Concerning attitude toward family planning, 81.0% of the participants said that they tend to use family planning methods. Similarly, a study in Saudi Arabia showed that 96.0% of the participants favored family planning, and 70.5% said that their husbands are supporting them in family planning [8]. Another study conducted in Saudi Arabia showed that 89.2% of the participants tend to perform family planning, and 87.6% of the participants think that their spouse would agree [5]. Differently, a study conducted in Ethiopia showed that 58.8% of the participants had a favorable attitude towards family planning, whereas 41.2% did not [2].
Regarding practice and usage of contraceptives, in our study 78.6% of the participants have used a family planning method before, where 25.8% of the participants used natural contraception methods, 21.2% used surgical contraception, 27.3% used condoms, and 12.1% used hormonal tablets, while 13.6% used nothing. A study conducted in Abha showed that 53.5% of the participants had used family planning before [5].
Another study in Saudi Arabia showed that for family planning, 58.6% of the individuals were currently using contraceptives [16]. A study conducted in Bangladesh showed that in terms of contemporary family planning methods, 20% of the respondents utilized tablets, 10% used injections, 3.14% used implants, and 3.43% used IUCDs [22]. Another study in Kenya showed that 62.0% of the participants approved the use of modern family planning methods, while only 32.3% were currently using any family planning method [28].
Sociodemographic factors such as age, gender, the duration of a marriage, education level, working status, and monthly income were all found to be significantly associated with knowledge of family planning (p=0.001). There was also significant association between the use of family planning by participants with some of the sociodemographic characteristics such as age, duration of marriage, education level, and monthly income (p-value=0.001). Participants aged 20-40 years tended to use family planning methods more than participants aged 41-60 years. Also participants who were married for more than three years tended to use family planning methods than who were married for a duration of 1-3 years. Another interesting but not surprising finding was that participants who received university degrees tended to use family planning methods more than those who were high school graduates. Participants also tended to use less family planning methods as their monthly income rises.

Conclusions
In comparison to many studies previously mentioned, the rate of family planning utilization was average, as was the level of knowledge and attitude toward family planning. However, there were some mistaken beliefs among participants regarding contraceptives. Therefore, it is crucial to create proper campaigns and create compelling communication tools in order to change this misinformed community's perceptions.

Appendices
Sociodemographic characters of participants  Adding of new member(s) to the team will require justification and clarification of the roles. 4. If the research is not completed within the validation period, the PI will be required to apply for an extension from the IRB, two months before the expiry of the approval. 5. Abide by the rules and regulations of the Government of Saudi Arabia, NCBE, MOH and the IHC-GCP guidelines. 6. The research team should follow the IRB approved study documents, unless amendment(s) are requested and approved by the IRB. 7. All researchers are required to have a valid research ethics certificate on protecting human research participants. 8. The research team is not allowed to disclose personally identifiable data of the participants to any other party. 9. The PI is required to keep the study data securely for at least three years after the completion of the study. 10. The collected data should only be used for this research. 11. It is required to collect three copies of informed consent forms (unless waived) as follows: I. One copy to be kept with the PI. II. One copy to be kept with the study participant. III. One copy for the IRB committee OR to be kept in the participant file in case of clinical research. 12. The PI is required to submit a progress report every six months. 13. The PI must ensure adequate close-out of the study. 14. Publication by any means is not allowed except after getting an approval letter from the IRB and MOH research department. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.