POPULATION LITERACY ABOUT REPRODUCTIVE HEALTH AS MEASURED BY THE CARDIFF FERTILITY KNOWLEDGE SCALE (CFKS)

The health and reproductive potential of a nation depend on the literacy of the population. Sexual and reproductive health is a deeply personal issue, so people may find it difficult to find accurate information on this topic. This article identifies and study the factors that influence knowledge about fertility, which will provide an important basis for effective public education. The article analyzes the questionnaires of 738 respondents, including 652 women and 86 men. The literacy rate was low compared to Western countries. Men showed a higher awareness of reproductive health. It was also noted, that the respondents who received knowledge from journals, compared to other sources, showed a significant notable difference compared to other sources (television, Internet).


INTRODUCTION
Reproductive health literacy is an important element of public health. People's knowledge of health allows people to have "the ability to receive, process, and understand the basic health information and services that are needed to decide". [1]]. The higher the level of literacy of the population in matters of reproduction, the lower the behavioral risks of reproductive health of the population.
Sexual and reproductive health is a deeply personal issue, so people may find it difficult to find accurate information on this topic. Perhaps this explains why these problems are still not addressed openly, and services in this area remain poor in some countries, are fragmented and do not target the population [2]. Reproductive literacy is important for the health of people's reproductive systems and influences their fertility choices.
In addition, in recent years, there has been a tendency to postpone childbirth. This trend is becoming more common in developed Western countries, especially in groups with higher education. [3]. Several studies have shown that men and women consider education, job availability, stable income and good housing important to their decision to become parents [4] The age-related impairment of fertility is attributed to both a decrease in conception rates and an increase in miscarriage rates. This impairment begins around the age of 30 and accelerates after the age of 35, so that fertility is close to zero by the time a woman reaches 45 [5]. Currently, there are more and more women seeking help in assisted reproductive technologies (ART) clinics. [6].
As we know, fertility decreases with age, starting in the middle of the third decade. Women who become pregnant at this age are at greater risk of early pregnancy-related complications, including miscarriage, aneuploidy and ectopic pregnancy. [7]. Despite these adverse effects, fertility statistics show a constant increase in women who prefer to postpone childbirth until late in reproductive age, as well as women who do not plan pregnancy [8]. Nevertheless, the availability of ART remains an urgent problem.
In Kazakhstan, the overall fertility rate is 2.7 in 2020, and the average age of the mother at birth was 29.2 years. This increase in the age of the mother is likely to have many causes, including improved educational and professional opportunities for women, an increase in the age of first marriage and improved access to effective contraceptives.
The purpose of the current study is to study literacy in fertility among the general population and to examine related factors that will provide an important basis for effective public education.

MATERIALS AND METHODS
This cross-sectional study was conducted among people of reproductive age. The inclusion criterion was the participation of non-pregnant women and men of reproductive age who are not currently undergoing screening or treatment for infertility. We enrolled 738 people, n = 652 of whom were women and n = 86 men. We sent them a 23-item questionnaire, which included the key questions and questions defining socio-demographic affiliation.
Our version of the Cardiff Fertility Knowledge Scale (CFKS) was developed using a direct translation of the original CFKS into Kazakh and Russian. CFKS comprises of 16 items that measure knowledge about the facts, risks and myths about fertility. The data was collected from February 1, 2021 to April 15, 2021 via an online mailing list. It rated all questions on a three-point scale: "true", "false" or "don't know". For a correct answer a "1" point was assigned, and for an incorrect answer or an answer "I don't know" -"0" points. Points are indicated as a percentage of the highest possible score.
The data were processed using SPSS, version 26. To compare the total scores on the CFKS-K scale between socio-demographic categories, that is: educational level, age, source of information and between categories of marital status, Student's t criteria, analysis of variance (ANOVA) were used. Statistical significance was defined as a two-tailed p-value <0.05; the question's internal consistency index (Cronbach's α) was 0.75 showing sufficient reliability.

Internet
TV Magazine My doctor Family or friend Don't know

Right answers' mean
When analyzing literacy by family status, there were significant differences between the groups (p<0.001). A posteriori analysis was also conducted, which revealed differences between married respondents from those who are in a stable relationship and are single. Married respondents had an average of 6.98 (±3.3), which is significantly lower than the group of respondents in stable relationships of 8.19 (±4.04) and single respondents of 8.27 (±3.6) (p1-2= 0.01, p1-3<0.01). There are no differences in literacy between single and in relationships (p2-3= 0,98).
According to our research, the source of information directly influenced the indicators of literacy in matters of reproductive health of the respondents (p <0.001). For example, people who received information from magazines (newspapers, educational brochures) showed the highest literacy 10.69 (± 2.21) in comparison with the respondents who answered that they "know nothing about it" 4.48 (± 2.7) who received information from the Internet 7.9 (± 3.32), from family and friends 7.65 (± 3.4), from the media 6.61 (± 6.61) with a significant difference p1-3 = 0.04, p2-3 = 0.005, p3-5 = 0.02, p3-6 <0.001, except for respondents who received information from "their doctor" 8.03 (±3,7) (p3-4= 0,07). The group of respondents who had previously received advice on reproductive issues from their doctor showed a good level of literacy, a significant difference was noted only with the group who answered "I know nothing about it" (p4-6 < 0,001*). In the rest of the intergroups, the differences were insignificant.
The analysis using the ANOVA method did not reveal any differences between the age groups (p=0,6).

DISCUSSION
This study determines the level of knowledge about the fertility of the population of reproductive age. To date, the Cardiff Fertility Knowledge Scale is a confirmed scale, although many other scales focus on more extensive knowledge, including misconceptions about infertility treatment [9]. In addition, including men and people of older reproductive age also provides new information, since previous studies have mainly focused on women [9][8] or students [10].
Our findings are consistent with previous studies that examined the relationship between fertility knowledge and

MAIN SOURCE OF INFORMATION
The woman who ran out of menstruation is still fertile.  [10]. Although there is a difference in that knowledge of fertility was significantly better in men than in women. Other previous studies have shown higher knowledge in women, persons with higher education [11], which is consistent with our study.
The indicators of knowledge about fertility are related to education(= 0.001), so the level of knowledge about fertility in the population we studied is low and does not depend on age (p=0.6). This finding is consistent with the findings of previous studies.
This study highlighted the issues of sources of information, as this is an important element in the development of society. According to our research, they mainly received knowledge from non-formal sources as the Internet (52.98%). To improve reproductive health, it is necessary to consider more formal sources of education. The most correctly answered were in the group that studied, learned about this topic from magazines. This may be because high-quality information is published in journals that refer to evidence sources. This can explain the low literacy of the group "family and friends" in which information is transmitted orally, with no evidence base.
In particular, we note that the percentage of respondents who correctly answered the question about the age-related impairment of female fertility was significantly higher in this study 462 (62,5 %).
In the present results, the percentage of participants who correctly answered questions about overweight was low -358 (48.4%), possibly reflecting the fact that media reports about the effect of overweight on fertility are very rare. And the percentage of correctly answered questions about the impact of smoking on human reproductive health was significantly higher -525 (71%), this may be the result of educational work in recent years, which very well covered the harm of smoking to the human body. The question of which pair will be considered infertile was correctly answered by 320 respondents, which is 43.3%. And illiteracy in this matter can entail the late call of couples for help from a doctor, which can extend the deadlines for achieving the goal. Also, the question of the spread of infertility in the population remains little studied, so the percentage of correctly answered respondents to this question is 315 (42,6 %) The results of this study also showed that the majority of participants have an incorrect understanding of male fertility In general, we found that the respondents were quite familiar with the risk of advanced maternal infertility and about the complications of pregnancy in old age, such as the spread of cesarean section and the risk of genetic complications in the child were less informed. At the same time, they are less well versed in the complexities of assisted reproductive technologies. Therefore, it is necessary to improve health education on fertility issues. Targeted promotion of fertility knowledge can raise awareness, improve the use of more effective methods and improve fertility decision-making in some populations.
It should develop strategies to improve reproductive health knowledge, given that teachers and primary health care professionals may be suitable candidates to provide health information on fertility, they should be educated with additional information and resources. The forms and channels of fertility information dissemination and standardization of information should also be expanded. Given these issues, future research should focus on designing and evaluating interventions to improve fertility health knowledge and exploring barriers and opportunities for fertility health education.

CONCLUSIONS
The knowledge of the population of the Republic of Kazakhstan about reproductive health leaves much to be desired, as it is lower than the average in developed countries. It is important to note that many people received knowledge through the media or the Internet. The respondents were quite familiar with the risk of infertility in older maternal age and less informed about complications of pregnancy in old age, such as the spread of caesarean section and the risk of genetic complications in a child. To prevent infertility and improve people's choices regarding childbearing, it may require educational activities both in schools and in society.