Effectiveness of adolescent health education among secondary and senior secondary school girls in rural Bangalore

INTRODUCTION

Adolescents

Often referred as the “generation of hope”. According to the World Health Organization, adolescence is defined as the period between 10 and 19 years, the second decade of life.¹ It is a phase of transition from childhood to adulthood. It is during this period, that the boy/girl acquires sexual and reproductive maturity. Today 1.2 billion adolescents stand at the crossroads between childhood and the adult world. India is home to more than 243 million adolescents, who account for a quarter of the country’s population.²

Health education

W.H.O defines health education as “Health education is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.”³

Adolescent health education

In rural India, the health education given to these adolescent girls, helps build their knowledge, motivates them to improve and maintain their health, prevent diseases and reduce risky behaviors among them. The health situation of this age group is a key determinant of India’s overall health, mortality, morbidity and population growth scenario.⁴ Issues associated with reproductive health are never discussed openly and the silence surrounding them burdens the young girls by keeping them ignorant of their biological function. Even after the attainment of menarche, very little information is given to these young girls about the physiological processes involved and the hygienic practices to be followed.⁵ They need authentic knowledge that helps them understand the process of growing up in particular reference to their reproductive and sexual health needs. They have to be well equipped to cope with the situations, which they confront during this transitional phase. They need guidance and independence simultaneously education as well as opportunities to explore life for themselves and attain a level of maturity required to make responsible decisions.⁶

Effectiveness of health education

Offering adolescents and young people high-quality reproductive health services and ensuring that they have sound knowledge regarding adolescent changes, menstruation and hygiene, conception and contraception, and STIs, empowers them in their choices and behaviors.⁷ Adolescent reproductive and sexual health education will yield dividends in terms of delaying age at marriage, reducing incidence of teenage pregnancy, meeting unmet contraception need, reducing the maternal mortality, reducing STI incidence and reducing HIV prevalence.⁴

The suddenness and rapid pace in which the changes take place in the body and mind of the adolescents makes them confused and vulnerable although they observe and experience these changes they are unable to completely understand them. Since they don’t have an authentic source available they rely on their peer group which itself is ill-informed or movies/videos which leaves them misunderstood. Teachers are given the task of teaching health education, but they do not have expertise in the field and have vague ideas about reproductive health themselves. This incomplete information can leave a wrong impression on them. The school syllabus and textbooks also limit its content and does not include any information regarding the physical, biological (sexual), psychological and social changes they undergo during this period. The ignorant and conservative outlook of the rural society consider it a taboo to openly discuss such issues, so rarely parents or other family members impart this essential knowledge to them.

The need for this study was felt considering the fact that many studies on reproductive health education had focused on urban population, slums in the cities etc., but not many from rural areas, hence the present study was carried out in Hoskote Taluk which is a part of rural Bangalore and the study population represented the rural adolescent girls.

Objectives

The main objective of the study is to assess the current knowledge of the study participants regarding growth and development during adolescent period, menstruation and menstrual hygiene, conception and contraception, sexually transmitting infections including HIV/AIDS; to improve their knowledge regarding the same through health education; to evaluate the effectiveness of the health education.

METHODS

Study design

Educational interventional study (pre- and post-experimental study design).

Study duration

The present study was conducted for two months from July 2018 to August 2018.

Study participants/source of data

The study was carried out in one secondary school and one senior secondary school in Hoskote Taluk, Rural Bangalore. A total of 150 students (75 secondary school girls and 75 senior secondary school girls) were the study participants.

Selection criteria

Inclusion criteria include secondary and senior secondary school girls in selected schools. Exclusion criteria include students unavailable on the day of study, students who did not agree to participate.

Study process

Study was done in following phases

Phase 1

Semi structured self-administered questionnaire was developed in both English language and local language (Kannada) to assess the baseline knowledge of the secondary and senior secondary school girls. Some modifications were carried out on the translated version of questionnaire to simplify the language and avoid culturally sensitive terms. Both Kannada and English questionnaires were used as per choice of the respondents. Questionnaire contained simple questions to assess knowledge of the girls on adolescent changes, menstruation and menstrual hygiene, pregnancy, contraception and sexually transmitted infections including HIV/AIDS. No information pertaining to personal identity was collected to ensure unbiased response. Materials such as slide presentations, charts, posters, handouts were developed to educate the students.

Phase 2

Questionnaire and materials developed was pilot tested for its content and age appropriateness. Based on the findings of pilot test necessary changes were made to the questionnaire and materials prepared for health education.

Phase 3

The process of data collection included the following.

Pre intervention survey

The schools were visited on a particular day, the study participants were gathered in a hall and were made to sit at a fair distance from one another to avoid copying and discussing. They were explained about the purpose of the study. A baseline survey was conducted to assess their knowledge regarding the various aspects of adolescent health using the pretested questionnaire. They were instructed on how to fill the questionnaire. Adequate time was given to fill up the questionnaire. Difficulties faced while answering the questionnaire were sorted out immediately.

Intervention

Health education was conducted the next day after evaluating the answers of the questionnaire and noting the areas which need to be stressed upon during the lecture. Audio-visual aids such as slide presentations, charts, posters, handouts were used along with the lecture. The education was followed by an interactive session with the students to clarify doubts. Students were divided into groups containing not more than 30 students per session of health education for better effectiveness. A total of 6 sessions were conducted in the secondary (3 sessions) and senior secondary school (3 sessions).

Post intervention survey

Was conducted immediately after the health education session to assess the improvement in the knowledge regarding adolescent health using the questionnaire.

Phase 4

The data was analyzed using Statistical Package for Social Sciences (SPSS) version 21.

Statistical analysis

Data was entered into Computer using Microsoft Excel sheet and analyzed using SPSS version 21. Descriptive statistics was used as basis for statistical analysis. Frequency and percentage was used for categorized variables. Mean and standard deviation was used for continuous data. Chi-square test was used to compare the pre and post-test improvement of knowledge among study participants. The statistical significance was evaluated at 5% level of significance.

RESULTS

A total of 150 study subjects participated in the study out of which 75 were secondary school girls and 75 were senior secondary school girls. Participants belonged to the age group of 13-18 years, with the mean age of 15.5 years. Around 140 girls had attained menarche with minimum and maximum age of menarche being 10 and 16 years respectively and the mean age of menarche being 13.26 years. Ten girls had not yet attained menarche.

Table 1 show that the girls’ knowledge about puberty changes and menstruation improved significantly after intervention. Students had a good knowledge regarding age at first menses, reason for menstruation and ideal absorbents to be used during menstruation at pre-test. However knowledge regarding number of ovaries and number of eggs released per menstrual cycle was 35.5% and 33.3% which improved to 74% and 76.7% post educational intervention respectively and it was found to be highly statistically significant (p<0.001).

Around 107 (71.3%) subjects knew that menstruation is a physiological process but only around 70 (46.7%) subjects knew that menstrual blood comes from the uterus. Only 63 (42.0%) knew the normal menstrual cycle duration and 84 (56.0%) the normal number of days flow occurs per cycle but on intervention the knowledge increased to a significantly high value of 90.0% and 95.3% respectively.

Menstrual hygiene practices with regard to usage of sanitary pads such as the minimum number of times pads should be changed per day and proper method of disposal of sanitary pads improved from 50.7% to 80.0% and from 50.7% to 87.3% respectively which was found to be highly statistically significant.

Initial knowledge regarding how pregnancy occurs and the ideal child bearing age was 61.3% and 70% after intervention their knowledge increased significantly to 96.0% and 97.3% respectively. Only 55 (36.7%) knew that missed period is the first sign of pregnancy and 56 (37.3%) knew pregnancy occurs in the mid phase of menstrual cycle on fertilization. On intervention their knowledge improved significantly to 87.3% and 78.7% respectively (p value <0.001) and the knowledge regarding the good practices during pregnancy was fairly good (Table 2).

Contraceptive methods were a topic regarding which the study participants had a very poor knowledge, especially towards injectable hormone, male and female sterilization procedures as contraceptives. In pre-survey as high as 67 (44.7%) had not heard of any contraceptive methods before but after intervention their knowledge regarding the contraceptive methods and their advantages improved significantly (p value <0.001) (Table 3). In Table 4, it is seen that among sexually transmitted infections, AIDS emerged as the popular choice among the subjects followed by Hepatitis B (43.3%). Around 118 (78.9%) of the students knew that AIDS was a Sexually Transmitted Infection (STI) and only 55.3% knew it is not completely cured by medicine, but their knowledge regarding the symptoms of STIs, transmission and prevention of HIV/AIDS was poor. Only 24.7%, 21% and 22% knew that AIDS does not spread by shaking hands, sharing of food, utensils, objects and clothes and by mosquito bite pre intervention which was increased to 93%, 92% and 96% respectively post intervention. After intervention their knowledge regarding various STIs, symptoms of STIs, Transmission and prevention of HIV/AIDS improved significantly (p value <0.001). Regarding using condoms while sexual intercourse for prevention of AIDS pre-test only 26% knew which was increased to 86% post intervention which was statistically highly significant.

The students reported that their major source of information regarding reproductive and sexual issues were their mothers (71.3%) followed by their friends (66.0%). Barriers they faced to seek information was either they hesitated (56.0%) or feared (50.7%) to ask questions or some felt there was no ideal source (45.3%). Majority (73.3%) of the girls reacted worried to their first menstruation. The girls also faced restrictions during menstruation such as they were not allowed to attend religious functions (79.3%) and were not allowed to do routine work (56%). The students wanted to learn more about these topics and preferred to hear about them from doctors or health personnel (85.3%), followed by school or college lecturers (72.7%).

DISCUSSION

The present study was carried out among secondary and senior secondary school girls to evaluate the effectiveness of health education in improving their knowledge regarding growth and development during adolescent period, menstruation and menstrual hygiene, conception and contraception, sexually transmitting infections including HIV/AIDS.

In the present study the age of the study participants ranged from 13 to 18 years with the mean age being 15.5 years. The mean age of menarche of study participants was 13.26 years which was comparable with studies conducted by Ghongdemath JS et al and Mittal et al.^8,9 During the initial pretest gross inadequacy was found for most of the aspects of reproductive health especially for contraceptive methods and STIs this was in consistent with various other studies conducted on reproductive health.^10-13

In the present study majority of the students preferred to learn more about these topics from doctors/ health personnel (85.3%) but only 40% from mother. This is in contrast to the study findings of the studies conducted by Vanusha et al where 75% preferred their mothers as source of information.¹³ Differing observations may be accounted for due to regional variations in views and attitude. When asked about the barriers they faced in seeking information regarding reproductive health hesitation, fear, shame were the main reasons cited which confers with the study findings of Vanusha et al.¹³

Studies done in rural areas of East Delhi, Guntur and Vadodara district have reported that 80% of girls were forbidden from worshipping and had restrictions on many day to day activities during menstruation which was similar to the findings of our study.^14-16

In the present study only 36.7% of girls answered missing periods as the first sign of pregnancy during pre-test however following health education 87.3% of the girls were aware that missing period is the first sign of pregnancy which is comparable to the intervention study conducted by Vanusha et al, Rao et al, but the study conducted by Malleshappa et al showed only 74% had answered correctly following intervention.^13,17,18

In the present study around 38% and 28.7% of the girls were aware of condom and contraceptive pills respectively as method of contraceptives during the initial phase. This was in concordance with the study done by Malleshappa et al where it was 28% and 34.7% respectively.¹⁸ However statistically significant improvement in knowledge regarding contraceptives were found following health education.

In the present study majority (78%) of the girls knew that HIV/AIDS is a STI and around 42% and 46% of the students were able to expand HIV and AIDS respectively during pre-test survey which was comparable with the study done Mittal et al in Haryana where around 50% were able to expand HIV/AIDS.⁹ Majority of them were unaware about other modes of transmission of AIDS.

As seen in our study, few studies in the recent years too have shown the effectiveness of such educational interventions which increased the knowledge of reproductive health.^10-13

The studies conducted in developing countries also prove the efficacy of such intervention in improving their knowledge in various aspects of reproductive health.^19-23

This study has certain limitations that need to be taken into account when considering the study and its findings. This study focused on Adolescent Health, a subject too vast to cover all relevant issues in a single questionnaire. Because of time constraints, the number of questions was limited and some adolescent health issues such as suicides, mental health, violence and substance abuses were not included.

But without doubt, it is clear that adolescent health education can have a great impact on the reproductive and sexual health of the rural adolescent girls. It will build good attitudes and practices in them to lead a healthy and long life. Repetitive health education should be provided from the school level to help them retain this knowledge in the long run as they grow older and have families of their own one day. Educating the mothers of the adolescent girls will also help in this regard. As the American leader Brigham Young rightly said – “You educate a man; you educate a man. You educate a woman; you educate a generation”.

CONCLUSION

The results of the present study successfully proved that adolescent health education was successful in improving the knowledge among adolescent girls in rural area. It helped clear the myths and misconceptions related to reproductive health by providing them authentic knowledge. It strived to empower the rural girls to take care of their own health and protect themselves from the risks of unwanted conceptions, STIs etc., in their future life.

Further research is necessary on whether adolescent health education is effective on the long run and periodic health education should be provided from school level to help them retain this information.

ACKNOWLEDGEMENTS

The Authors offer their sincere thanks to Indian Council of Medical Research (ICMR) for funding this project under Short Term Studentship (STS) 2018.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. WHO Adolescence Health. Available at: https://www.who.int/topics/adolescent_health/en/. Accessed on 5 August 2018.
2. 2. UNICEF, 2011. Adolescence- an age of opportunity. Available at: http://unicef.in/PressReleases/87/Adolescence-An-Age-of-Opportunity. Accessed on 20 August 2018.
3. 3. WHO definition of health education. Available at: http://www.who.int/topics/health_education/en/. Accessed on 18 August 2018.
4. 4. Ministry of Health and Family Welfare. Implementation guide on RCH II Adolescent Reproductive Sexual Health strategy. National Rural Health Mission. May 2006. Available at: http://www.jknhm.com/ARSH%20Guidelines.pdf. Accessed on 21 August 2018.
5. 5. UNICEF (2008). Sharing simple facts, useful information about menstrual health and hygiene. UNICEF India. Available at: https://www.susana.org/_resources/documents/default/2-1151mhmbook.pdf. Accessed on 18 August 2018.
6. 6. National AIDS Control Programme. Youth and Adolescent: Working Group Report. May 2011.
7. 7. National Aids Control Organisation. Adolescence education programme, life skills dvelopment-Facilitators guide. New Delhi. Available at: http://164.100.130.11:8091/webarsh/Resources%20on%20ARSH/Adolescent%20Education%20Programme%20Facilitators%20Guide.pdf. Accessed on 18 August 2018.
8. 8. Ghongdemath JS, Sidhmalswamy A, Mallapur AA, Shindholimath VV. Impact of adolescent health education on adolescent girls in rural schools and colleges. Int J Reprod Contracept Obstet Gynecol. 2016;5:53-7.
9. 9. Mittal K, Goel MK. Knowledge regarding reproductive health among urban adolescent girls of Haryana. Indian J Community Med. 2010;35:529-30.
10. 10. Tawfik MM, El-Sharkawy OG, Abdelbaqy MA, Hanafy SA, Shehata SF, Malek A, et al. Reproductive Health Education Among Adolescent Girls in Alexandria, Egypt. Population Reference Bureau, MENA Working Paper Series. March 2013. Available at: https://assets.prb.org/pdf13/girls-education-egypt-mena-workingpaper.pdf. Accessed on 18 August 2018.
11. 11. Tork HMM, Al hosis KF. Effects of Reproductive Health Education on Knowledge and Attitudes Among Female Adolescents in Saudi Arabia. J Nurs Res. 2015;23(3):236–42.
12. 12. Parwej S, Kumar R, Walia I, Aggarwal AK. Reproductive health education intervention trial. Indian J Pediatr. 2005;72(4):287–91.
13. 13. Vanusha A, Parvathavarthini K. Assessment of present awareness on reproductive health and evaluation of a tool designed for reproductive health education among school going adolescent girls. Int J Reprod Contracept Obstet Gynecol. 2018;7:2381-7.
14. 14. Gandhi AB, Raval. The role of audio visual programme in creating awareness about reproductive health in adolescent girls. J Obstet Gynaecol India. 1993;43:257-61.
15. 15. Malathy S. Menstrual and gynecological disorders in 500 school girls in Madras city. J Obstet Gynaecol India. 1993;43:940-5.
16. 16. Grover NP. Awareness and practices of menstruation and pubertal changes amongst unmarried female adolescents in a rural area of East Delhi. Indian J Community Med. 2007;32:156-7.
17. 17. Rao RSP, Lena A, Nair NS, Kamath V, Kamath A. Effectiveness of reproductive health education among rural adolescent girls: a school based intervention study in Udupi Taluk, Karnataka. Indian J Med Sci. 2008;62(11):439–43.
18. 18. Malleshappa K, Krishna S. Knowledge and attitude about reproductive health among rural adolescent girls in Kuppam mandal: An intervention study. Biomed Res. 2011;22(223):305–10.
19. 19. Lawan UM, Yusuf NW, Musa AB. Menstruation and menstrual hygiene amongst adolescent school girls in Kano, Northwestern Nigeria. Afr J Reprod Health. 2010;14(3):201-7.
20. 20. Nwankwo TO, Aniebue UU, Aniebue PN. Menstrual disorders in adolescent school girls in Enugu, Nigeria. J Pediatr Adol Gynecol. 2010;23(6):358-63.
21. 21. Werven IV. Health and hygiene school program initiative for adolescents in Dhaka, Bangladesh. J Gender Water. 2012;1(1):34-6.
22. 22. Sapkota D, Sharma D, Budhathoki SS, Khanal VK, Pokharel HP. Knowledge and practices regarding menstruation among school going adolescents of rural Nepal. J Kathmandu Med Coll. 2013;2(5):122-7.
23. 23. Haque SE, Rahman M, Itsuko K, Mutahara M, Sakisaka K. The effect of a school-based educational intervention on menstrual health: an intervention study among adolescent girls in Bangladesh. BMJ Open. 2014;4:e004607.