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. 2026 Feb 10;26:720. doi: 10.1186/s12889-026-26464-8

Knowledge, attitudes, and perceptions towards premarital screening among undergraduate university students in Chattogram district, Bangladesh: a cross-sectional study

Delwar Hossain 1,#, Mohammed Mohsin 2,3,#, Sadia Tasnuva Jahan 2,#, Bibi Salma 2,4, Nusrat Jahan 2,4, Anupam Barua 2, Mohammed Aktar Sayeed 1, Md Mayin Uddin Hasan 1,2, Mohammad Injamul Hoq 2,5,✉
PMCID: PMC12930697  PMID: 41668059

Abstract

Background

Premarital screening (PMS) programs are a crucial measure to prevent hereditary and sexually transmitted diseases, particularly in communities with high consanguinity levels and genetic disorder prevalence. Premarital training is not well-researched in Bangladesh, where thalassemia and hemoglobinopathies are endemic. This study aimed to assess the knowledge, attitude, and perception (KAP) regarding PMS among undergraduate students in southeastern Bangladesh.

Methods

An analytical cross-sectional study was conducted among 844 undergraduate students from four universities in Chattogram, Bangladesh. A multistage cluster sampling method was used to recruit participants from science, business, and humanities disciplines. Data were collected through face-to-face interviews using a structured questionnaire, which assessed sociodemographic characteristics and KAP towards PMS. Descriptive statistics and multivariate logistic regression analyses were performed using STATA SE 18. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and a p-value < 0.05 was considered statistically significant.

Results

Out of 844 students, only 22.5% students had a good knowledge, while attitudes (89.2%) and perceptions (95.7%) toward PMS were highly positive. In multivariate analysis, science students were significantly more likely to have good knowledge than humanities students (AOR = 1.67; 95% CI: 1.14–2.45; p = 0.009). Conversely, females (AOR = 0.61; 95% CI: 0.43–0.87; p = 0.006) and those with consanguineous parents (AOR = 0.64; 95% CI: 0.42–0.99; p = 0.043) were less likely to demonstrate good knowledge. No significant associations were observed between age group, academic year, family history of hereditary disease, and attitudes after adjustment for factors.

Conclusion

Undergraduate students in southeastern Bangladesh exhibited poor knowledge but positive attitudes and perceptions toward PMS. Incorporation of premarital training modules into university curricula, as well as media- and community-based programs, may increase knowledge and promote preventive health behaviors.

Keywords: Premarital screening, Knowledge, Attitudes, Perceptions, Undergraduate students, Bangladesh

Introduction

Premarital screening (PMS) is a panel of tests for infectious, genetic, and blood-transmitted diseases, administered to couples planning to get married [1]. This screening program identifies carriers of hereditary diseases, such as thalassemia and sickle cell anemia. If both couples are carriers, the usual asymptomatic carriers transmit such diseases to their next generation [2]. It reduced the incidence rate of hereditary blood disorders, including thalassemia, sickle cell anemia, as well as infectious diseases, including HIV/AIDS, Hepatitis B, and C. It reduced the risk of transmitting these diseases to their offspring [3–6].

Mandatory PMS was implemented in several countries. Cyprus was mandated as the first country in 1973 for screening beta thalassemia [7]. Countries in the Middle East also mandated PMS where high rates of consanguinity are found. Iran implemented it in 1997, Saudi Arab in 2004, Bahrain in 2005, and the United Arab Emirates in 2011 [8]. While Saudi Arabia made PMS compulsory for screening thalassemia, sickle cell anemia, HIV, hepatitis B, and C, Egypt made it mandatory to conduct screening for only hemoglobinopathy based on specific disease prevalence [9, 10]. In contrast, Asian countries like China, Taiwan, Malaysia, India, Indonesia, Maldives, Singapore, and Thailand have adopted voluntary premarital screening programs for detecting inherited and sexually transmitted diseases [11].

Despite these global and regional advancements, there are no national records or structured PMS policies in South Asian countries, including Bangladesh, Pakistan, Nepal, Sri Lanka, and Bhutan. In Bangladesh, a few private clinics and hospitals offer PMS packages similar to those in neighboring India [12]. However, the extent of public awareness and understanding of PMS remains largely unknown. Therefore, assessing university students’ knowledge, attitudes, and perceptions regarding PMS is crucial for informing future national health strategies and policy development.

Bangladesh is in the thalassemia zone with an estimated prevalence of 6–12% hemoglobinopathies such as hemoglobin E, beta thalassemia, and the prevalence can reach about 40% [13]. Approximately 3.6 million populations are thalassemia carrier and 4.8 million carry hemoglobin E in Bangladesh, as reported by some published articles [14–16] community knowledge and attitude towards the control and the prevention of genetic diseases. The World Health Organization (WHO) recommends health education to ensure community awareness, improve public understanding, and positively influence attitudes towards genetic screening interventions, which are crucial for preventing and controlling genetic diseases [17, 18].

In Bangladesh, the PMS service is unavailable in all healthcare facility centres and referral hospitals except for some leading private clinics and hospitals. They provide services in the country, covering screening for HIV, syphilis, and thalassemia. No media campaigns and legal outline for screening before marriage for sexually transmitted diseases like HIV or genetic blood disorders like thalassemia are available in Bangladesh. However, a few studies have been conducted to gain an understanding of the current knowledge, attitude, and perception towards PMS in Bangladesh [19, 20]. These studies primarily focused on thalassemia screening and were limited to a single faculty or university. This study systematically targeted undergraduate students from multiple universities in Chattogram, Bangladesh, thereby ensuring broader disciplinary and institutional representation to assess their knowledge, attitudes, and perceptions regarding PMS. Moreover, this study employed multivariate analytical approaches to identify key determinants influencing PMS-related knowledge, attitudes, and perceptions, contributing novel insights to the existing literature.

Methodology

Study design and setting

This was an analytical cross-sectional study to assess knowledge, attitude, and perception (KAP) regarding PMS among undergraduate students at both public and private universities across Chattogram district, Bangladesh. The study was conducted from March 2025 to August 2025.

Inclusion & exclusion criteria

The inclusion criteria were being enrolled in an undergraduate program at a university, aged between 19 and 26 years, and willing to participate in the study. Students unwilling to provide informed consent were excluded from the study.

Sampling technique

A multistage cluster sampling technique was employed to include study participants from the universities in Chattogram. The sampling process included three stages. In the first stage, four universities were randomly selected from a total of 12 recognized universities in Chattogram, as listed by the University Grants Commission of Bangladesh, using the lottery method. In the second stage, three departments (from different faculties, including sciences, business studies, and humanities) were randomly selected from each universities. In the final stage, students from each selected department were selected proportionally to the total number of students in that department, ensuring adequate representation across all 12 departments. The number of students selected from each department was calculated to maintain proportionality based on the department’s student strength.

Sample size determination

The study sample size was calculated based on an expected 50% prevalence of good knowledge and a positive attitude towards premarital screening, as no studies have been conducted in this region. Assuming a 95% confidence level and a 5% margin of error, the sample size was calculated with a design effect of 2, due to the use of a multistage cluster sampling method. Accounting for an anticipated 90% response rate, the final sample size was determined accordingly. The Sample size, n = Z2pq/d2. n = (1.96)2*0.50*0.50/(0.05)2, n = 384. Adjusting with a design effect of 2 and an assumed 10% non-response rate, the final required sample size was 856. We approached 856 students, and 844 participants responded to the questionnaire.

The sampling process proceeded as follows:

  1. Total Students Approached: 856 students were initially approached.

  2. Eligible Students: All 856 students were eligible based on the inclusion criteria.

  3. Students Responding: Out of the 856 students approached, 844 students responded to the questionnaire.

Thus, the final sample comprised 844 participants, corresponding to a response rate of approximately 98.6%.

Data collection tool and procedure

Data were collected through face-to-face interviews using a structured questionnaire. The questionnaire was developed by adapting validated items from previously published studies [21–27]. The questionnaire consisted of four major sections: Sociodemographic characteristics, Knowledge about premarital screening (7 items), Attitude toward premarital screening (12 items), Perception regarding the necessity and importance of premarital screening (10 items). Trained research assistants conducted data collection. The training process lasted three days, focusing on maintaining neutrality, ensuring confidentiality, and avoiding leading questions during interviews. Paper-based data collection was completed over a period of 2 months. All interviews were conducted in private settings within university premises to encourage honest responses. Participants were assured of anonymity and informed that there were no right or wrong answers. The questionnaire was self-administered in the presence of trained interviewers who provided clarification only when requested, thereby reducing interviewer influence on participant responses.

Variable definitions

Each item was evaluated on a scoring system, and composite scores were calculated. An overall score of < 50% was categorized as poor knowledge, negative attitude, or incorrect perception, whereas a score of ≥ 50% was categorized as good knowledge, positive attitude, or positive perception [28]. Each domain was treated as a categorical variable with two levels: knowledge (good vs. poor), attitude (good vs. poor), and perception (good vs. poor). According to the scoring criteria, knowledge was considered good when the score was ≥ 4 (out of 7). Similarly, attitude was considered good when the score was ≥ 24 (out of 48), and perception was considered good when the score was ≥ 10 (out of 20) [24, 26, 29].

Data analysis

Descriptive statistics (frequencies and percentages) were used for categorical variables. Means and standard deviations were calculated for continuous variables. Bivariate analysis was conducted using the chi-square test to explore associations between sociodemographic factors and the KAP outcomes. A p-value < 0.05 was considered statistically significant. Univariate logistic regression models were constructed to assess the individual effect of predictors on each KAP outcome. Multiple logistic regression analyses were also performed to evaluate the combined effect of independent variables. A univariate p-value ≤ 0.05 was entered into the multivariate analysis. Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs) were reported for all predictors in the final models. P-values of < 0.05 were considered significant. All statistical analyses were conducted using STATA SE 18 (StataCorp, College Station, TX, USA), and data visualization was performed with R Programming software (version 4.3.4).

Ethical considerations

Ethical approval was obtained from the Institutional Review Board (IRB) of the University of Creative Technology Chittagong (UCTC) (Ref. No.: UCTC/IRB/2025/0025). All participants provided informed consent before their participation. Anonymity and confidentiality of the respondents were strictly maintained throughout the research process.

Results

A total of 844 undergraduate students from four universities in southeastern Bangladesh participated in this study, with a mean age of 22.2 years (SD = 1.47). Among the participants, 114 (13.5%) were aged 19–20 years, 366 (43.4%) were aged 21–22 years, 322 (38.2%) were aged 23–24 years, and 42 (5.0%) were aged 25–26 years. The sample consisted of 417 (49.4%) males and 427 (50.6%) females, with 803 (95.1%) unmarried and 41 (4.9%) married students. The majority were Muslim (813, 96.3%), with 31 (3.7%) identifying as other religions. Participants were recruited from the University of Chittagong (CU) (202, 23.9%), International Islamic University Chittagong (IIUC) (214, 25.4%), University of Science and Technology Chittagong (USTC) (214, 25.4%), and BGC Trust University Bangladesh (BGC) (214, 25.4%). Regarding academic standing, 206 (24.4%) were in their first year, 165 (19.6%) in their second year, 293 (34.7%) in their third year, and 180 (21.3%) in their fourth year. In terms of academic disciplines, 274 (32.5%) studied science, 208 (24.6%) business, and 362 (42.9%) humanities.

Family income per month ranged from BDT 20,000–40,000 for 391 (46.3%) participants, BDT 40,001–60,000 for 259 (30.7%), and above BDT 60,000 for 194 (23.0%). Additionally, 197 (23.3%) students reported parental consanguinity, 82 (9.7%) had a personal hereditary disease, and 197 (23.3%) had a family history of hereditary disorders (Table 1).

Table 1.

Sociodemographic characteristics of respondents

Variable Category Freq. Percent(%)
Age Mean ± SD (22.2 ± 1.47)
Age group 19–20 years 114 13.51%
21–22 years 366 43.36%
23–24 years 322 38.15%
25–26 years 42 4.98%
Total 844 100%
Gender Male 417 49.41%
Female 427 50.59%
Total 844 100%
Marital Status Married 41 4.86%
Unmarried 803 95.14%
Total 844 100%
Religion Muslim 813 96.33%
others 31 3.67%
Total 844 100%
University CU 202 23.93%
IIUC 214 25.36%
USTC 214 25.36%
BGCTUB 214 25.36%
Total 844 100%
Academic Year First 206 24.41%
Second 165 19.55%
Third 293 34.72%
Fourth 180 21.33%
Total 844 100%
Field of study Science 274 32.46%
Business 208 24.64%
Humanities 362 42.90%
Total 844 100%
Family Income (BDT) 20,000–40,000 BDT 391 46.33%
40,001–60,000 BDT 259 30.69%
More than 60,000 BDT 194 22.99%
Total 844 100%
Parental Consanguinity No 647 76.66%
Yes 197 23.34%
Total 844 100%
Personal Hereditary Disease No 762 90.28%
Yes 82 9.72%
Total 844 100%
Family Hereditary Disease No 647 76.66%
Yes 197 23.34%
Total 844 100%
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Figure 1 illustrates the distribution of knowledge, attitude, and perception categories related to premarital screening (PMS) among undergraduate students. Most participants demonstrated poor knowledge, with 654 (77.5%) classified in this category, while only 190 (22.5%) had good knowledge. Conversely, positive attitudes were highly prevalent, with 753 (89.2%) students exhibiting good attitudes toward PMS compared to 91 (10.8%) with poor attitudes. Similarly, perception was overwhelmingly favorable, as 808 (95.7%) respondents had a good perception of PMS, and only 36 (4.3%) had a poor perception Fig. 1.

Fig. 1.

Fig. 1

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Distribution of knowledge, attitude, and perception categories regarding premarital screening (PMS) among undergraduate students (N = 844)

Table 2 shows considerable deficiencies in knowledge of premarital screening (PMS) among undergraduate students. Less than half of the respondents, 396 (46.9%), reported awareness of PMS. Even fewer participants were knowledgeable about the meaning of 323 (38.3%) and the objectives of 259 (30.7%) of PMS. Awareness of its focus on infectious 173 (20.5%) and hereditary diseases 211 (25.0%) was limited. Moreover, only a small proportion of students knew where PMS could be performed 71, 8.4%) or the specific tests involved 57, 6.8%), Table 2.

Table 2.

Knowledge of premarital screening (PMS) among undergraduate students (N = 844)

Question Yes n (%) No n (%) Total n (%)
Have you heard about PMS? 396 (46.92%) 448 (53.08%) 844 (100%)
Do you know the meaning of PMS? 323 (38.27%) 521 (61.73%) 844 (100%)
Do you know the objectives of PMS? 259 (30.69%) 585 (69.31%) 844 (100%)
Does PMS focus on infectious diseases? 173 (20.50%) 671 (79.50%) 844 (100%)
Does PMS focus on hereditary diseases? 211 (25.00%) 633 (75.00%) 844 (100%)
Do you know where to perform PMS? 71 (8.41%) 773 (91.59%) 844 (100%)
Do you know the tests included in PMS? 57 (6.75%) 787 (93.25%) 844 (100%)
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Figure 2 illustrates the distribution of undergraduate students’ responses to key attitude statements about premarital screening (PMS). Most participants agreed or strongly agreed on the importance of PMS, with 699 (82.8%) students responding positively. Similarly, 732 (86.7%) supported raising awareness about PMS, and 650 (77.0%) believed that PMS reduces the risk of genetic or sexually transmitted diseases. A majority also favored religious leaders discussing PMS 516 (61.2%) and agreed that PMS should be conducted just before marriage (710 [84.1%]). Conversely, 533 (63.2%) disagreed that PMS is against religious rules, and 376 (44.5%) disagreed that it breaches privacy. Furthermore, 498 (59.0%) acknowledged consanguinity as a risk factor for hereditary diseases, and 609 (72.1%) preferred not to marry relatives. Lastly, 584 (69.2%) intended to undergo PMS themselves, and 616 (73.0%) would advise others to do so. These findings indicate generally positive attitudes toward PMS among the surveyed students, as shown in Fig. 2.

Fig. 2.

Fig. 2

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Attitudes toward premarital screening (PMS) among undergraduate students assessed using a Likert scale (N = 844)

Figure 3 presents undergraduate students’ responses to statements about the importance and perceptions of premarital screening (PMS). A majority agreed that PMS is important for couples, 600 (71.1%), and beneficial for Bangladesh, 634 (75.1%). Most participants also felt that increased awareness about PMS is necessary, 715 (84.7%), and that PMS awareness before marriage is essential, 722 (85.6%). Over half were willing to pay for PMS 451 (53.4%) and believed PMS helps reduce genetic diseases 505 (59.8%), as well as sexually transmitted diseases 447 (53.0%).

Fig. 3.

Fig. 3

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Students’ responses to statements about the perceptions of premarital screening (PMS)

Regarding consanguinity, 456 (54.0%) agreed that marrying within relatives increases the risk of hereditary diseases. Half of the respondents, 425 (50.4%), agreed that PMS results should be confidential. Approximately one-quarter 196 (23.2%) believed PMS might cause psychological distress, though the majority were either unsure 469 (55.6%) or disagreed 179 (21.2%) with this statement.

Figure 4 presents the distribution of information sources about premarital screening (PMS) among undergraduate students. Media platforms, including television, radio, and the internet, were the most frequently reported sources, with 284 (33.6%) respondents citing them. 93 (11.0%) students identified health educators; friends accounted for 78 (9.2%). Health workers and schools were less frequently reported sources, with 65 (7.7%) and 54 (6.4%), respectively. Periodicals and notes were the least common source, reported by only 10 (1.2%) participants (Fig. 4).

Fig. 4.

Fig. 4

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Sources of information about premarital screening (PMS) among undergraduate students

Among the 844 participants, 190 (22.5%) demonstrated good knowledge regarding premarital screening, while 654 (77.5%) exhibited poor knowledge. Knowledge levels varied significantly across several socio-demographic factors. The age group was associated with knowledge (χ² = 11.47, p = 0.009), with good knowledge more prevalent among those aged 23–24 years (88, 46.3%) compared to those aged 19–20 years (14, 7.4%). Gender differences were observed (χ² = 4.68, p = 0.03), as males, 107 (56.3%), were more likely to report good knowledge than females, 83 (43.7%). The academic year showed a significant association (χ² = 14.25, p = 0.003), with good knowledge being highest among third-year students (68, 35.8%) and fourth-year students (56, 29.5%). The field of study was strongly associated with knowledge (χ² = 17.65, p < 0.001), as science students (85, 44.7%) were more knowledgeable compared to those in business (34, 17.9%) and humanities (71, 37.4%).

Parental consanguinity was also associated with knowledge (χ² = 4.89, p = 0.027), as those without consanguinity, 157 (82.6%), demonstrated higher good knowledge. A family history of hereditary disease showed a significant association (χ² = 5.15, p = 0.023), with good knowledge being more frequent among those reporting such a history, at 56 (29.5%). In contrast, no significant associations were observed for marital status, religion, university, family income, or personal history of hereditary disease (p > 0.05). Attitude toward premarital screening correlated significantly with knowledge (χ² = 5.08, p = 0.024), with 178 (93.7%) of those demonstrating good attitudes also showing good knowledge. Perception did not show a statistically significant association with knowledge (χ² = 2.8, p = 0.094), Table 3.

Table 3.

Association between sociodemographic variables, attitude, and perception with the knowledge level of premarital screening (PMS) among undergraduate students (N = 844)

Variable Knowledge level (n = 844) aχ² bp-value
Good (n, %) Poor (n, %) Total (n)
Age group (years)
19–20 years 14 (7.37%) 100 (15.29%) 114 11.47 0.009*
21–22 years 78 (41.05%) 288 (44.04%) 366
23–24 years 88 (46.32%) 234 (35.78%) 322
25–26 years 10 (5.26%) 32 (4.89%) 42
Total 190 (100.0%) 654 (100.0%) 844
Gender
Male 107 (56.32%) 310 (47.40%) 417 4.681 0.03*
Female 83 (43.68%) 344 (52.60%) 427
Total 190 (100%) 654 (100%) 844
Marital Status
Married 7 (3.68%) 34 (5.20%) 41 0.731 0.393
Unmarried 183 (96.32%) 620 (94.80%) 803
Total 190 (100%) 654 (100%) 844
Religion
Muslim 183 (96.32%) 630 (96.33%) 813 0.0001 0.993
Others 7 (3.68%) 24 (3.67%) 31
Total 190 (100.0%) 654 (100.0%) 844
University
CU 46 (24.21%) 156 (23.85%) 202 1.993 0.574
IIUC 44 (23.16%) 170 (25.99%) 214
USTC 45 (23.68%) 169 (25.84%) 214
BGC 55 (28.95%) 159 (24.31%) 214
Total 190 (100%) 654 (100%) 844
Academic Year
First Year 42 (22.11%) 164 (25.08%) 206 14.247 0.003*
Second Year 24 (12.63%) 141 (21.56%) 165
Third Year 68 (35.79%) 225 (34.40%) 293
Fourth Year 56 (29.47%) 124 (18.96%) 180
Total 190 (100%) 654 (100%) 844
Field of Study
Science 85 (44.74%) 189 (28.90%) 274 17.65 < 0.001*
Business 34 (17.89%) 174 (26.61%) 208
Humanities 71 (37.37%) 291 (44.50%) 362
Total 190 (100.0%) 654 (100.0%) 844
Family Income (BDT)
20,000–40,000 BDT 90 (47.37%) 301 (46.02%) 391 3.561 0.169
40,001–60,000 BDT 49 (25.79%) 210 (32.11%) 259
More than 60,000 BDT 51 (26.84%) 143 (21.87%) 194
Total 190 (100%) 654 (100%) 844
Parental Consanguinity
No 157 (82.63%) 490 (74.92%) 647 4.889 0.027*
Yes 33 (17.37%) 164 (25.08%) 197
Total 190 (100%) 654 (100%) 844
Personal Hereditary Disease
No 167 (87.89%) 595 (90.98%) 762 1.596 0.206
Yes 23 (12.11%) 59 (9.02%) 82
Total 190 (100%) 654 (100%) 844
Family Hereditary Disease
No 134 (70.53%) 513 (78.44%) 647 5.154 0.023*
Yes 56 (29.47%) 141 (21.56%) 197
Total 190 (100%) 654 (100%) 844
Attitude
Poor 12 (6.32%) 79 (12.08%) 91 5.08 0.024*
Good 178 (93.68%) 575 (87.92%) 753
Total 190 (100%) 654 (100%) 844
Perception
Poor 4 (2.11%) 32 (4.89%) 36 2.8 0.094
Good 186 (97.89%) 622 (95.11%) 808
Total 190 (100%) 654 (100%) 844
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a Chi‑square (χ²) test was used to assess the association between socio‑demographic variables, attitude, perception and knowledge level of premarital screening (PMS) among undergraduate students

b *p < 0.05

In univariate analysis, age group, gender, field of study, parental consanguinity, family history of hereditary disease, and attitude were significantly associated with knowledge levels (all p < 0.05). Students aged 23–24 years were more likely to have good knowledge than those aged 18–20 years (OR = 2.69, 95% CI: 1.46–4.95; p = 0.002). Female students had lower odds of good knowledge than males (OR = 0.70, 95% CI: 0.50–0.97; p = 0.031). Students enrolled in science disciplines had significantly higher odds of demonstrating good knowledge regarding premarital screening (OR = 1.84, 95% CI: 1.28–2.65; p = 0.001). Participants with parental consanguinity had reduced odds compared to those without (OR = 0.63, 95% CI: 0.41–0.95; p = 0.028). Those with a good attitude toward the topic were more likely to have good knowledge than those with a poor attitude (OR = 0.49, 95% CI: 0.26–0.92; p = 0.027) (Table 4).

Table 4.

Univariate and multivariate analyses of factors associated with knowledge on PMS (n = 844)

Variable Knowledge Level (n=844) aUnivariate OR (95% CI) cp-value bMultivariate AOR (95% CI) cp-value
 Good n=190 (%)  Poor n=654 (%)  Total N=844(%)
Age group (years)
19–20 years (ref) 14 (7.37) 100 (15.29) 114(13.51) Reference — Reference —
21–22 years 78 (41.05) 288 (44.04) 366(43.36) 1.93 (1.05–3.57) 0.035 1.59 (0.81–3.13) 0.178
23–24 years 88 (46.32) 234 (35.78) 322(38.15) 2.69 (1.46–4.95) 0.002 1.63 (0.78–3.39) 0.195
25–26 years 10 (5.26) 32 (4.89) 42(4.98) 2.23 (0.90–5.51) 0.082 1.36 (0.50–3.69) 0.548
Gender
Male (ref) 107 (56.32) 310 (47.40) 417(49.41) Reference — Reference —
Female 83 (43.68) 344 (52.60) 427(50.59) 0.70 (0.50–0.97) 0.031 0.61 (0.43–0.87) 0.006*
Academic year
1st year (ref) 42 (22.11) 164 (25.08) 206(24.41) Reference — Reference —
2nd year 24 (12.63) 141 (21.56) 165(19.55) 0.66 (0.38–1.15) 0.145 0.58 (0.33–1.04) 0.068
3rd year 68 (35.79) 225 (34.40) 293(34.72) 1.18 (0.76–1.82) 0.455 0.93 (0.57–1.53) 0.782
4th year 56 (29.47) 124 (18.96) 180(21.33) 1.76 (1.11–2.80) 0.016 1.37 (0.78–2.39) 0.27
Field of study
Humanities (ref) 71 (37.37) 291 (44.50) 362(42.89) Reference — Reference —
Business 34 (17.89) 174 (26.61) 208(24.64) 0.80 (0.51–1.26) 0.333 0.76 (0.47–1.22) 0.259
Science 85 (44.74) 189 (28.90) 274(32.46) 1.84 (1.28–2.65) 0.001 1.67 (1.14–2.45) 0.009*
Parental consanguinity
No (ref) 157 (82.63) 490 (74.92) 647(76.66) Reference — Reference —
Yes 33 (17.37) 164 (25.08) 197(23.34) 0.63 (0.41–0.95) 0.028 0.64 (0.42–0.99) 0.043*
Family history of hereditary disease
No (ref) 134 (70.53) 513 (78.44) 647(76.66) Reference — Reference —
Yes 56 (29.47) 141 (21.56) 197(23.34) 1.52 (1.06–2.19) 0.024 1.41 (0.96–2.06) 0.079
Attitude
Poor (ref) 12 (6.32) 79 (12.08) 91(10.78) Reference — Reference —
Good 178 (93.68) 575 (87.92) 753() 0.49 (0.26–0.92) 0.027 0.53 (0.27–1.01) 0.052
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a Univariate logistic regression provides unadjusted odds ratios (OR) with 95 % confidence interval (CI)

b Multivariate logistic regression provides adjusted odds ratios (AOR) with 95 % CI

c *p < 0.05

In the multivariate logistic regression model, gender, field of study, and parental consanguinity remained significantly associated with knowledge levels. Females were less likely than males to have good knowledge (AOR = 0.61; 95% CI: 0.43–0.87; p = 0.006). Students in the science field were more likely to have good knowledge than those in the humanities (AOR = 1.67; 95% CI: 1.14–2.45; p = 0.009). Participants reporting parental consanguinity were less likely to have good knowledge compared to those without consanguinity (AOR = 0.64; 95% CI: 0.42–0.99; p = 0.043). Attitude showed a borderline association with knowledge (AOR = 0.53; 95% CI: 0.27–1.01; p = 0.052). No statistically significant associations were observed for age group, academic year, or family history of hereditary disease in the adjusted model (p > 0.05) (Table 4).

Discussion

This is the first-ever study in Bangladesh to determine the knowledge, attitude, and perception towards PMS among university students. The study explored low levels of PMS knowledge among undergraduate university students, while high levels of attitude and perception were observed among the respondents. In our study, only 22.5% of the respondents had good knowledge about PMS. This finding is aligned with the findings from other regions of the world. In Iraq, a recent university-based study revealed that only 24.7% of the students had good knowledge of PMS [24]. Studies in Saudi Arabia reported that only 20–25% of the students had fair or satisfactory knowledge of PMS [30, 31]. We attempted to identify studies from developed countries, such as the USA, the UK, and European regions, that assessed knowledge or attitudes toward premarital screening. However, little to no empirical evidence was found, as premarital screening programs are not routinely practiced in these settings. Instead, public health initiatives in developed countries tend to focus on preconception care and genetic carrier screening [32–34]. This difference in policy and programmatic focus may explain the limited availability of comparable data, underscoring the importance of studies like ours in contributing to the global understanding of premarital screening awareness. Such a finding emphasizes the need for a health literacy program to elevate health awareness and promotion about PMS. This initiative aims to reduce the burden of sexually transmitted diseases and certain genetic conditions. A study in Saudi Arabian University found educational program was successful in improving knowledge of students on PMS and recommended application of similar educational programs among other university students and those studying secondary level [30].

Females were less likely to be aware of premarital screening than males, according to our study findings. This pattern is also observed in Omani adult males, who have more knowledge regarding PMS than females [23]. However, studies from Saudi Arabia and Syria demonstrated that females had good knowledge of PMS rather than males [29, 35]. Another study in Qatar also found females had significantly higher knowledge scores than males [21]. However, no gender difference was found in another Qatari study [36]. This variation may be due to cultural, educational, and socioeconomic factors specific to the respondents. Moreover, students from a science background had higher odds of good knowledge than students with a non-science background. This finding aligns with studies conducted in Saudi Arabia [37, 38].

This result is expected because science students are likely to learn more about PMS through their academic curriculum than students from non-science fields. Compared to those with unrelated parents, respondents with related parents (consanguinity), were less likely to have good knowledge. Consistent with this finding, a study in Kuwait showed that respondents having unrelated spouses had a better understanding of PMS. This might be due to parents’ high level of education, which results in improved knowledge among children [29]. In addition, though univariable regression analysis displayed that participant with a good attitude toward PMS were significantly less likely to have good knowledge compared to those with a poor attitude but in multivariate analysis the relationship between knowledge and attitude weakened to a borderline level of significance (AOR = 0.53, 95% CI: 0.27–1.01; p = 0.052), although the evidence is not conclusive after adjusting with other factors. Similarly, a Qatari study also showed good knowledge but poor attitude and perception among the participants [24].In contrast, a positive association between attitude and PMS knowledge was observed in another Qatari study [21]. The inverse relationship we found in our study may reflect that attitude is shaped more by socio-cultural norms rather than by factual understanding. In our study, respondents may support the screening concept without being fully aware of its effectiveness. This highlights the necessity of interventions that address both the attitude and knowledge through PMS awareness campaigns.

Despite lacking knowledge, almost 90% of the participants showed a good attitude regarding PMS. The observed mismatch, characterized by a relatively high attitude but low factual knowledge about premarital screening, is consistent with prior KAP research in South Asia. Respondents frequently express a favorable stance toward screening due to social norms and broad awareness campaigns, yet they often lack a detailed understanding of screening procedures, target conditions, and follow-up actions. This gap may reflect limited curricular coverage, dependence on general media or informal sources that emphasize the value rather than the mechanics of screening, and the different natures of attitude versus knowledge measurements. Similar findings have been reported among university students and young adults in the region (e.g., Pakistan and Bangladesh), where positive attitudes toward premarital screening coexist with limited background knowledge [19, 39].In line with this observation, 70% of university students in Saudi Arabia had positive attitudes [37]. A recent study in Ghana also showed that participants had a lack of knowledge about PMS, but had a positive attitude of 67% [40]. A national study in Saudi Arabia also displayed that 83.8% of the participants showed positive attitudes towards the importance of PMS [41].

The positive attitudes we found in our current study could support the clinicians during consultations with couples who might have a positive result in screening test. Future studies should further investigate the relationship between attitudes and factors influencing decision-making and behavior change. More specifically, in our study, 82.8% of students responded positively towards the importance of PMS, 77.0% believed PMS reduces the risk of genetic or sexually transmitted diseases, and 72.1% preferred not to marry relatives. These results are consistent with studies conducted in Iraq and Saudi Arabia [24, 41]. However, 36.8% had either agreed or provided a neutral opinion that PMS is against religious rules. Therefore, it is vital to engage religious scholars to promote the effectiveness of PMS through their discussions and speeches. A Saudi Arabian study showed that almost 90% of respondents agreed on the importance of religious scholars in promoting the effectiveness of PMS [30].

Likewise, attitudes, in our study, more than 95% respondents had a good perception towards PMS. Similarly, around 90% respondents showed positive perception towards PMS for thalassemia prevention in Bangladesh [42]. In addition, the study findings showed that 84.7% of respondents felt that increased awareness about PMS is necessary, 85.6% believed that PMS awareness before marriage is essential, 59.8% believed that PMS helps reduce the risk of genetic diseases, and 54.0% agreed that marrying within relatives increases the risk of hereditary diseases. The results align with a Qatari study that demonstrated that around 80% of respondents believed PMS is essential before marriage, and 65% believed PMS reduces the risk of genetic diseases [24].Further, no statistically significant association was found between perception and knowledge in our study. The finding indicates that favourable perceptions are not associated with a higher level of knowledge. However, an Egyptian study showed perception is positively and significantly correlated with high knowledge scores of future couples [26]. More studies should be conducted to explore the association and related factors with the perception of PMS.

Among the total participants, most of the participants mentioned media (33.6%) as the source of information on PMS in our study. In addition, 11%, 9.2% and 6.4% addressed health educators, friends, and school, respectively, as the source of information. Several studies underscored the role of media platforms, NGOs, healthcare professionals, and social media for providing clear information to young adults on the effectiveness of PMS [40, 43, 44]. The implementation of simple prevention strategy PMS has reduced the incidence of thalassemia major among newborns [45]. The successful implementation of a mandatory PMS program has been observed in Cyprus, Turkey, and Greece, enabling the detection of carriers of various genetic diseases and reducing the incidence of thalassemia and hemoglobinopathies [46–48]. Thalassemia has become a major concern for public health in Bangladesh. Several recent articles have recommended mandatory PMS, along with the promotion of public health education, to raise awareness among people about the effectiveness of PMS in Bangladesh [49, 50].

The Ministry of Health is recommended to develop standardized PMS guidelines and pilot initiatives for premarital screening services for specific diseases, such as thalassemia. Moreover, the government of Bangladesh should plan on the promotion of PMS effectiveness by engaging educational institutes, media platforms, and community leaders to reduce sexually transmitted diseases and genetically hereditary diseases. Educational institute-based programs, such as workshops and webinars, could utilise data and information to highlight the gaps between awareness and practice. In addition, culturally sensitive social media posts, short videos on PMS on TV, and articles in newspapers can play a vital role in educating the people. Furthermore, inclusion of community leaders (e.g., religious leaders) can be crucial in promoting the effectiveness of PMS through their discussions and speeches.

Strengths & Limitations: This study was the first conducted in the south-eastern part of Bangladesh among university students, utilising a large sample. The study could serve as a baseline for future research and is key to public health education and literacy programs for PMS. However, the current study also has some limitations. Firstly, this study cannot be generalized to the entire country’s population, as it was conducted among university students. Secondly, as the study design was cross-sectional, causal inferences should not be made. Lastly, all data from the participants were collected through face-to-face interviews; therefore, due to socially preferable attitudes and behaviors, there may be a reporting bias.

Conclusion

This study highlights a significant gap in knowledge regarding PMS among undergraduate students in southeastern Bangladesh, despite positive attitudes and perceptions. Key predictors of good knowledge include academic discipline, with science students demonstrating better knowledge than humanities students, and gender, with females showing lower knowledge levels. The presence of consanguinity in the family was also negatively associated with PMS knowledge. To address these disparities, future research should further explore the underlying reasons for the differences in knowledge, particularly in relation to gender and family structure. These findings suggest that interventions, such as incorporating premarital training into university curricula, as well as media and community-based education programs, could significantly enhance knowledge and promote preventive health behaviors. Broader awareness can be developed through collaborations with student organisations to conduct peer-led seminars and health fairs, as well as media campaigns through social media, radio, and television in local languages. NGOs, religious leaders, healthcare providers, community-based programs, mobile health units, and mandatory screening services with counseling at public health centers are central to inclusivity and compliance.

Acknowledgements

We acknowledge the logistic support provided by the Drug Insides and Disease Epidemiology (DIDE) Organization.

Transparency statement

The corresponding author, Mohammad Injamul Hoq, assures that all authors have read and approved the final version of the manuscript; he had full access to all of the data in this study and takes complete responsibility for the data’s integrity and the accuracy of the data analysis.

Authors’ contributions

Delwar Hossain, Mohammed Mohsin, Sadia Tasnuva Jahan ($) : Conceived and designed the study, developed the research strategy, and drafted the manuscript. These authors contributed equally to the study.Bibi Salma, Nusrat Jahan, Anupam Barua : Provided logistical support, assisted in data collection, drafted the manuscript and contributed to data curation.Md. Mayin Uddin Hasan : Conducted statistical analyses, interpreted the data, and prepared figures and tables.Mohammed Aktar Sayeed, Mohammad Injamul Hoq *: Oversaw overall study planning, critically revised it for intellectual content, and supervised the study.

Funding

No funding was received to support the study’s conduct.

Data availability

The dataset used and/or analyzed during the current study are available from the corresponding author.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of the University of Creative Technology Chittagong (UCTC) (Ref. No.: UCTC/IRB/2025/0025). All participants were informed about the purpose of the study, its voluntary nature, and the confidentiality of their responses. Written informed consent to participate was obtained from every participant prior to data collection. No minors were involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Delwar Hossain, Mohammed Mohsin and Sadia Tasnuva Jahan contributed equally to this work.

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Associated Data

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Data Availability Statement

The dataset used and/or analyzed during the current study are available from the corresponding author.

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