Adolescent pregnancy and school health nursing program for adolescent pregnancy prevention: a qualitative study

INTRODUCTION

In 2009, the number of young adult population in South Asia amounted to 335 million, showing the largest population of adolescents followed by the number of teenagers who were in East Asia and the Pacific as much as 329 million, followed by some industrialized countries 118 million and Latin America 108 million, Indonesia is one of the countries within the scope of East Asia and Asia Pacific that the number of teenage population is quite high.

Adolescent population trends in the world continue to increase up to 2050 this trend is also followed by an increase in the adolescent population in developing countries.¹ Adolescence is derived from the Latin word which means growing adolescere.² Teens are also referred to as the social construction period when teens begin a long period enough to learn and practice facing complex social situations that eventually will become an adult who holds responsibility in certain social situations.³

Pregnancy in adolescents and becoming parents during adolescence is not a new issue in developed and developing countries. Socio-economic consequences begin to emerge since unmarried teens begin to become sexually active, pregnant, decide to continue the pregnancy and become a parent. 16 million pregnancies occur in mothers aged 15-19 years old in 2008, the figure represents 11% of all births worldwide. This birth occurred in 95% of countries with medium and low incomes. Globally, teenage birth rate has decreased from 60 per 1,000 in 1990 to 48 per 1,000 in 2007. Although adolescent birth rate is decline, the absolute value of births seems decrease with an increase in the adolescent population.⁴

The incidence of adolescent pregnancy is closely linked to sexual behavior by adolescents. Based on reports from Demographic and Health Surveys (DHS) conducted by UNICEF in collaboration with the World Bank in 33 countries in East Asia and the Asia Pacific region, the results showed that the median age of sexual debut for women aged 25-49 years is between 17.3 to 21, 9 years old and it is the same age with the age of first marriage. Data for Indonesia shows its age of 19.7 years.⁵

Adolescent pregnancy is very risky, 23% of the overall adolescent pregnancy complications gets the disease (may have an impact on lifelong disability) caused by pregnancy and childbirth compared to pregnancy at any age. In low-income and middle countries, adolescent pregnancy complications the highest case causing women death aged 15-19 years.

In addition to unwanted pregnancies associated with increase in induced abortion, because abortion is performed in unsafe conditions that increase the risk of death. In 2008, the estimated 3 million unsafe abortions occur in developing countries at the age of 15-19 years. More than 65% of women with obstetric fistula that developed since they are teenager with terrible consequences on their life both physically and socially.⁴

Teachers and parents are the closest people to teens; teens spend more time with their parents at home and teachers at school. Teachers and parents also have an important role in the supervision of teenagers to avoid the negative behaviors.

Because of so much impact and consequences of adolescent pregnancy, the researcher interested to know the views of teachers, parents and student about adolescent pregnancy and adolescent pregnancy prevention plan through the school health nursing. This study is a qualitative research, part of a large research using qualitative and quantitative methods that entitled models of school health nursing interventions for primary prevention of adolescent pregnancy.

METHODS

This study is a qualitative study, which is already underway in the August-September 2015 in SLTA A and SLTA B Yogyakarta. Both schools were selected from schools that are under the management of Jetis and Tegalrejo health centers, because these two regions in 2013 have a higher adolescent pregnancy rate compared with other areas in the city of Yogyakarta. The samples were teachers, parents and students from the two schools mentioned above. The sample selection of teachers, parents and students in the research is aided by informants- principals and counseling teachers. Selection of the sample group of teachers by considering that these teachers are subject teachers and counseling teacher who have an important role in assisting children every day in schools.

Selection of the sample group of parents with consideration of parents whose children are in those schools, while the samples of students consider the student of grade X and XI. Teachers who were invited to the discussion were 8 people, and all teachers can attend the discussion.

Parents who were invited were 10 people of each school, but they who were present in the activities of the focus group discussion (FGD) were 7 people of SLTA A and 6 people of SLTA B. The students who were invited to the FGD of this study were each of 10 people of each school, but the attendance was 10 people of SLTA A and 9 SLTA B.

FGD is chosen to get richer and more sensitive data, obtained for interaction within the group. The course of the FGD was very lively and had a good interaction among the group of teachers, parents and student in which was assisted by a moderator who was very active. FGDs were conducted in schools outside of teaching hours, with each discussion lasted for approximately 60-90 minutes. The process was recorded with recording equipment in the computer with the consent of all participants.

Research tools used are the researchers assisted with FGD guidelines that were prepared. Analysis of the research was carried out by the steps of qualitative research manually, first: did a transcript of the data obtained from the FGD, records during data retrieval and data associated with the informant; the second: reconfirmed the correctness of the data to the participants and triangulate the data to the nurses in health centers who are in charge of UKS in high school; the third: read all the data or the transcript to find a general idea presented by informants and other information that is required; the fourth, started coding; the fifth, used the results of coding process to develop a theme for later analysis; the sixth: presented the description and themes into a qualitative narrative; the seventh: made an interpretation of the data.⁶

RESULTS

Participant’s characteristics of the study

The Figure of participants’ characteristics can be seen completely in Table 1. Based on Table 1, the characteristics of the teachers involved in FGD were 9 of SLTA A and 8 of SLTA B, the average was 38 years and teachers have been employed for about 11 years. For parents, there were 13 people attending the FGD; 7 parents of SLTA A and 6 of SLTA B. The average of parents’ age was 47.46 years old and most of them had high school education-84.61%, while the other was only Elementary School. As for student, there were 9 people of SLTA A and 10 people of SLTA B.

The average of participants’ age was 16.10 years and now they are in grade X and XI.

The views of teachers about adolescent pregnancy and school health nursing for the prevention of adolescent pregnancy

Based on the analysis, it was determined six major themes; five themes illustrated the teachers about adolescent pregnancy:

• • The incidence of adolescent pregnancy is concern of the teachers, viewed from the perspective of culture, religion and past experiences,
• • The occurrence of adolescent pregnancy due to complex causes,
• • Adolescent pregnancy prevention efforts require a special approach and teachers play an important role to direct a positive intercourse behavior,
• • Adolescent pregnancy has negative effects for adolescents, parents and the fetus, and
• • There are barriers to discuss and provide sexuality education. There is one theme that describes the views of teachers to the school health nursing for adolescent pregnancy prevention:
• • School health nursing can be made under terms and conditions that apply in school. Table 2 shows them completely.

Based on Table 2, it showed that the incidence of adolescent pregnancy turns to be the concern of teachers, viewed from the perspective of culture, religion and past experiences. Teachers connect the incidence of adolescent pregnancy with the presence of Yogyakarta as a cultural city. In addition, teachers also found the city of Yogyakarta is a religious basis in which teenage behavioral expectations are also cultured, but the cause to experience adolescent pregnancy can be seen in the following quotation:

P7: "Adolescent pregnancy is very alarming, the first is that because the Special Region of Yogyakarta (DIY) is cultural city, it must be all cultured, cultured in the sense of good." "Especially here ...... is included the basis of religious organizations."

Teachers also looked at the incidence of adolescent pregnancy from the experience of the past, at which time the incidence of adolescent pregnancy is a very embarrassing incident, making the family's name tarnished, so that pregnant teenagers will be evacuated.

P8: "At past, pregnant teenager in the school age should be evacuated to somewhere .., or do not want to be together or stay in the same, do rare communication." "The term, being lost." (Already considered as not a child anymore)

P9: "At past, person knew if some children were pregnant, it was that taboo, now is also taboo but it’s another taboo."

According to the teacher, adolescent pregnancy prevention efforts require a special approach such as increasing cooperation between parents and teachers as seen in this quote.

P13: "Establish communication between school and home, do not surrender completely to the school, moral education is got in the home, then teacher continues at school."

P15: "The approach to the parents; do not busy by themselves, these events occur outside of school." In addition, according to the teachers to prevent adolescent pregnancy, mental and religious approach are needed in the school. Mental approach is required to make child uneasily affected by their negative behavior and the religious approach gives filter and self-control of children before doing anything.

The last category on the theme 3 is to provide assistance to the child's behavior firmly but patiently, it can be seen in the following quotation:

P8: "Today children are difficult to control, the parents must set loose and tight, too tight is not good, too loose is not good, so they should be combined hardly but also assist with patience. "

Teachers feel that there are obstacles to discuss and provide sexuality education because they think that talking about sex is a difficult thing, taboo, and afraid of misuse by teenagers. It makes teachers reluctant to provide sexuality education for children in school.

The last scene is the teacher's views about the plan of school health nursing, teachers found that the school health nursing can be made under terms and conditions that apply in school. Conditions prevailing in schools, for examples: it needs to socialize, does not interrupt the learning process and needs cooperation with health centers for implementation.

The views of parents on adolescent pregnancy and school health nursing for the prevention of adolescent pregnancy

Based on the analysis, it is determined six major themes, five themes describe parents' opinions about adolescent pregnancy:

• • Having daughters improve parental concern on the incidence of adolescent pregnancy,
• • The occurrence of adolescent pregnancy due to complex causes,
• • All efforts made by parents is to reduce risky behavior in children and as early prevention of adolescent pregnancy,
• • adolescent pregnancy has negative effects for adolescents, parents and the fetus, and
• • Insecurity inhibits parents to provide sexuality education to children. There is one theme that describes the views of parents to school health nursing for the prevention of adolescent pregnancy:
• • school health nursing addresses the needs of parents on reproductive health information for adolescents through this program that can provide reproductive health education, provide education health that adapts to individual needs and work with the government and related agencies.

It can be observed completely in Table 3.

Based on Table 3, according to the parents, having daughter increases parental concern on the incidence of teenage pregnancies.

Parents who attended the FGDs expressed their worries of the risk of adolescent pregnancy. Increase in worries is if have a daughter. All efforts is made by the parents to reduce risky behavior in children and early prevention of adolescent pregnancy is important to be implemented in all environments where adolescents grow, as it is raised on the theme 3. The works done by parents include: maintaining the manners of Javanese culture, restricting access to negative information from media information, and improving behavioral education at home and at school.

P10: "Adolescents do not know manners today, whereas if they understand the manners, it would bring the child gets more orderly life."

P11: "If children sleep, control their mobile phones, what picture do you find? There are pictures that are less appropriate. "

P5: "Restricting information through television, the internet also advertisements that do not educate, especially for children."

Insecurity inhibits parents to provide sexuality education to children, a statement indicating the parents' insecurity in providing sexuality education, as quoted below:

P10: "If the child is 17 years old, she should already know about it, the teacher should notify, inform with limits."

P6: "Parents may be able to provide guidance, but not necessarily true."

P7: "If parents convey, the children give more questions, parents do not know the answer."

P7: "We recommend that the person who conveys is an expert of health, so that they already know how to convey to the child."

P8: "Pupils are also more confident."

The view of the student about adolescent pregnancy and school health nursing for the prevention of adolescent pregnancy

Based on the analysis, it is determined 7 main themes, 6 themes illustrated the student about adolescent pregnancy:

• • The incidence of adolescent pregnancy is something negative and contrary to the teachings of religion,
• • The occurrence of adolescent pregnancy due to complex causes,
• • Parents play the most important role in preventing adolescent pregnancy,
• • incidence of adolescent pregnancy have negative effects for adolescents, parents and the fetus, and
• • Looking at porn video is a common, easily accessible and intriguing to try. There is one theme that describes students' view to the program of school health nursing for adolescent pregnancy prevention:
• • The school health nursing addresses the needs of students for health services in schools. It can be observed fully in Table 4.

According to the student, parents play an important role in preventing adolescent pregnancy, what parents can do is to guide and supervise children, and be more stringent for girls, direct children to spend leisure time with positive activities, and direct dating behavior.

Another interesting phenomenon is about seeing pornographic videos, according to the students, viewing pornographic videos is common, easily accessible and intriguing to try.

Based on the statements of participants, most of participants in FGD ever see porn videos, evidenced by some of the following quotations:

P3: "I ever see, ever see before, once or twice, it because of friends."

P6: "Disgusting, disgusting , maam, sure."

P7: "At this, our level of curiosity is very high, you know ma'am." "We will be more curious want to see, so far we want to try, finally conceive something like this .... "

P4: "Yesterday when I was with my friends, there a re a lot of porn videos within, really."

Based on the views of teachers, parents and student on adolescent pregnancy, there are two themes that almost similar as submitted by the three groups of participants:

1) The occurrence of adolescent pregnancy due to complex causes, and

2) Adolescent pregnancy gives bad effect for adolescents, parents and the fetus. For the theme of the occurrence of adolescent pregnancy due to complex causes, participants in all three groups said that the complex causes are divided into internal causes include: normal psychological changes in teenagers, curiousity and uncontrolled emotion also for their promiscuity, while external causes, including: advances in technology and information, adolescents' freedom to access information about pornography, and lack of parental supervision or family background is not good, for example, a broken home.

The theme of adolescent pregnancy leaves a negative impact on teenagers, parents and the fetus.

FGD results in three groups explained that the negative impact on teenagers are teenagers who dropped out of school, the future became unclear, adolescents get risk of problems during pregnancy and childbirth can even cause death. The negative impact on the parent, that parent will be under pressure from the public, be considered unable to educate children, be a shame.

The latter is a negative impact on the fetus is born, according to these three groups, fetus will be in risk of miscarriage, premature birth, or died. After successfully born, child is likely to experience less affection, neglect, and in less favourable conditions, as both his parents are unready for a family.

DISCUSSION

The views of teachers, parents and student about adolescent pregnancy

The results showed that teachers view adolescent pregnancy as a negative thing from the perspective of culture, religion and past experiences. Teenage pregnancies should not occur in civilized cities and towns of the basis of religion. Teachers and teens also assume that adolescent pregnancy is the result of negative behavior, the religious order violation. Parents also strengthen their worries about adolescent pregnancy, it is necessary to provide special supervision for girls. In Indonesia the majority of the population is Muslim, it affects the perception of the public in response to a behavior.

Islam considers that sexual relations done before the couple married as a very bad behavior and violates the religious orders, sexual relations are only allowed for legalized marriage, while for sexual relations outside of marriage is prohibited and is not socially acceptable.⁷

This is also consistent with the results of the research that was presented by Smerecnik that is based on interviews with Muslim participants, sexual intercourse before marriage is haram (something forbidden) in Islam, the consequences as a Muslim should be virgin until they are married is the standard, this standard applies to men and women.⁸

These results indicate that adolescents perceive that the incidence of adolescent pregnancy is something negative and surprising. The surprised response of the teens also shows teens' unpreparedness to face the consequences of sexual behavior. Teens unpreparedness is also shown in the study Kennedy et al. which states that teens who have never seen or heard messages about family planning in the media (radio, TV, newspapers / magazines and posters or pamphlets), is from 10.9 to 84.8% and the majority of teens do not use contraception and do not discuss about family plan with health care staff in the last 12 months.

Lack of knowledge about sex and family plan and lack of access to teenage contraception service encourage teenagers to not plan the pregnancy well.⁵

The surprised response of teenagers can also be supported by low motivation of young people in the prevention of pregnancy and HIV/AIDS disease as shown in studies Cai et al., which states that 12,313 participants (high school students in China) or 4.5% (95% CI: 4.2 -5.0) have done premarital sex and 25.0% (95% CI: 21.2-29.1) of them had used a condom during their first sexual intercourse. However, only 1 of 9 people among those who consistently used condoms.⁹

These results indicate that teachers assume that adolescent pregnancy is a taboo issue. Sexuality and pregnancy is taboo for the people of Indonesia as well as for the people of Malaysia. According to Muttalib & Mohamed, the notion of sexuality as a taboo subject does not make decreasing of risky behaviors in adolescent sexuality in Malaysia. Most respondents agreed that sexuality education can help young people to avoid risky sexual behavior. The study also proved that assumption taboo does not mean that this topic needs to be avoided, so that it can provide positive benefits for teens.¹⁰

The study states that teachers, parents and student consider the occurrence of adolescent pregnancy is caused by the complex causes. Starting from teen's internal causes such as psychologically normal changes, increase of curiosity and uncontrolled emotion. This was followed by promiscuity, bad at choosing friends, participation with friends who have poor behavior. Based on the theory of adolescent development, sexual orientation has been around since early childhood, but for young people sexual orientation is a pressing issue. Not all adolescent has sexual activity, some are deciding not to engage in sexual activity altogether (abstinence).³

External causes are that technological progress makes teens to easily access information about the pornography. Teenagers easily get videos of pornography from friend's mobile phone. Based on research Tanton of et al., on the pattern and trend of sex resources among teenagers in Britain: evidence from three national surveys of sexual behavior and lifestyle, the results showed 80% of teenagers get information about sex from school, only a few teenagers who get information from pornography media, consisting of 23.9% of boys and only 2.2% of girls.

They get sources of information from pornography sites on the internet and pornographic magazines. Actually teens crave information about sexuality from schools, parents and health professionals.¹¹ The other cause of adolescent pregnancy is less parental attention. According to teenagers, they feel less affection, still less attention and freedom for the teenagers from their parents. Opinions of adolescents on the need parental supervision are supported by the opinion of Buhi & Goodson that the good quality of relationships with parents provides protective effects.

The good quality of the relationship between mother and teenage inhibit the beginning of sexual relations, particularly for girls. Parents support also has a protective effect. The reduced monitoring and supervision of the parents have a significant relationship with the beginning of sexual intercourse, increase frequency of sexual intercourse, increase the number of sexual partners, risky sexual behavior, and early sexual relations of boys.¹² According to Pilgrim & Blum the quality of relationships between adolescents and parents are included in micro system factor for the occurrence of adolescent pregnancy.¹³

The results of the study explained that the negative impacts on teenagers are dropped out of school, unclear future, at risk of problems during pregnancy and childbirth death. Adolescent pregnancy leaves a negative impact on teenagers, parents and the fetus. All results accordance with the opinion of the WHO which states that unwanted pregnancies associated with increased induced abortion, because abortion is performed in unsafe conditions, further it increases the risk of death. More than 65% of women with obstetric fistula that developed since adolescence.⁴

Bad effects on pregnancy, childbirth, and result in death are also described in WHO which states that adolescent pregnancy is closely linked to maternal morbidity and mortality. Pregnancy in adolescents is also more likely to be painful to the mother, miscarriage, stillbirth and neonatal death. Based on a study in Latin America, the death rate for young women less than 16 years old are four times higher than women aged 20 years. In Ethiopia and Nigeria, 25% of the fistula at age less than 15 years old and 50% of fistula cases occurred at the age of 18 years.¹⁴

The negative impacts on parents are that parents get under pressure from the public, they are considered unable to educate children, there will be a shame. Besides these teenagers and born children will be the burden on parents, as long as they are not independent yet.

Last impact on the results of this study is the impact on the born fetus. According to the three groups of participants, the fetus will be at risk of miscarriage, premature birth, or also died. After successfully born, children are also likely to experience less affection, neglect, and in conditions less favorably because their parents are unready for a family. Based on research conducted by the University of Indonesia in 2000, it's estimated that 2 million abortions occurred in Indonesia and 30% of them is committed by teenagers.¹⁵

Adolescent pregnancy also has an impact on the social lives of teenagers. Many pregnant teenagers do not want or are not allowed to enter the school during their pregnancy or they are fear of ridicule of friends and the community.¹⁶ The number of suicide may also arise due to the occurrence of pregnancy in adolescents. Pregnancy in adolescents who are not married towards a culture becomes the background of the Homicide in order to protect the family honor.¹⁷ Hewageegana et al. also said that teens who experienced pregnancy are vulnerable and pregnant in an unhappy condition, because they were pregnant after their first sexual intercourse. All of these consequences must be paid by girls; the reason is to make parents more concerned about girls as compared to boys.¹⁸

These results indicate that the necessary of prevention and treatment of adolescent pregnancy, according to the teacher, needs to be done with a particular approach, and by teens and parents, and needs the important role of parents. Interesting efforts to be learned is that the current approach to youth mentoring is firmly but patiently. Teenagers will be easier to tell the secret to a parent if the parent is overt, loving and not to blame as well as adolescents get the best solution of the problem.¹⁹

The best support that is most expected of the teenager is from parents. In a systematic review of randomized controlled trials (RCTs) conducted by Disenco et al., quite a lot of interventions in research RCTs are given to adolescents with the aim of increasing positive activity in adolescents. These activities include: Summer training and education program (STEP), Teen incentive program, Self-efficacy training, Safer choices. These positive activities last from two weeks to several months by trainers who have been trained previously. Similar activities need to be organized, especially in Indonesia in encouraging teens to be more active, have a positive activity and did not have a chance to think about negative things.²⁰

Communication between parents and children is very important, especially on sexual and reproductive health, according to a study Wamoyi et al. in rural Tanzania shows that a majority, parent-child communication is still a warning, threats and physical discipline.²¹ The same opinion was also expressed by Tesso et al. that communication between parents and teenagers has rare frequency, and is still in the form of warnings and threats.²²

Most teens become sexually active at the age of early adolescence and when they do not know how to avoid unwanted pregnancies and also do not understand how to prevent sexual transmitted diseases. It needs sexual education based curriculum.²³ The most effective program to prevent adolescent pregnancy in U.S is combining accurate medical information about sexuality, abstinence, contraception, safe sex, the risk for unprotected sexual intercourse and how to avoid them. In addition, also with building communication, negotiation and ability in rejecting premarital sex.²⁴

The results of related research about education on sexuality, teachers stated that they have problems in providing education about sexuality, such barriers include: taboo to talk about sex, find difficulty to provide sex education and misuse of sexuality education by teenagers. On the other hand, parents also feel confident in providing sexuality education; they also assume that children over the age of 17 years already know about sex. Barriers in providing sexuality education and reproductive also are faced by the parents in rural Tanzania, according to parents, it because of lack of knowledge and cultural norms that forbids.²¹ According to the results of a study in the Southeastern United State at a secondary school, that adolescents in this study are mostly women who often communicate with parents, partners and friends about sexual problems. In detail, more than the majority of participants (54%) do not discuss sex with their boyfriends, 29% of participants did not discuss with parents and 25% did not discuss with close friends. This study also shows that sexual decision making is influenced by intervention of sexual communication.²⁵

The views of teachers, parents and students of school health nursing

The results of research on school health nursing, the three groups of participants have expressed support for a plan of school health nursing for the prevention of adolescent pregnancy. Parents and student said that this program will address the needs of adolescents to get information about reproductive health. School health nursing is one part of the school to engage interventions for the prevention of pregnancy in adolescents.

School health nursing in developed countries like America has a crucial role in providing comprehensive health cares for children and adolescents in school. Council on School health defines a school nurse as a practitioner of nursing professionals in charge of facilitating the positive response to the development of children or adolescents, promoting health and safety, providing the actual and potential intervention health issues in adolescents, providing management services for particular case, doing active collaboration with other health cares to build the capacity of children or adolescents and families to adapt, self-management, self advocacy and learning.²⁶

Teachers also expressed their support for this program with the terms and conditions applicable in schools, for example, this program should not interfere with the learning process, be socialized to all citizens of the school in cooperation with health care centers. The role of school nurses in reproductive health education can be seen in the following study, based on research conducted by Borawski et al., on the effectiveness of health education on the prevention of sexually transmitted diseases (STDs) that health education conducted by teachers and school nurses could significantly increase the knowledge of STD prevention by using condoms.²⁷

In addition, 12 months after the intervention, there are behavioral changes, adolescents' self-efficacy and beliefs28. According to Inman et al., health education conducted in schools largely effectively improves health and prevents the risk of health issues including inhibit the beginning of sexual intercourse, increase condom use, decrease sexual intercourse unsafe, and reduce the transmission of sexually transmitted disease and increase contraceptive use among adolescents. However, interventions involving schools need sufficient time and consistency in the application, so it requires a lot of human resources and funds.²⁷ Students suggestions for school health nursing in line with the suggestion Hall that the role of the school nurse is: screening routine health to students, updating our services according to the needs of students, strengthening the role of school health nursing by involving the government and conduct further research to improve the quality of school health nursing.²⁹

Also in accordance with the opinion of the National Association of School Nurses on the role of nurses: providing health services directly to students, providing screening services and providing health promotion services.²⁶

CONCLUSION

Based on the three groups of discussion, there are six major themes for each. Four common themes that emerged in each group were: 1) views on adolescent pregnancy as something negative, 2) the occurrence of adolescent pregnancy due to complex causes, 3) adolescent pregnancy has a negative impact, and 4) school health nursing addresses the needs of parents and adolescent reproductive health cares.

For the different themes in each group were: 1 by teachers and parents) the necessary of a special approach to address adolescent pregnancy, 2) obstacles in delivering sexuality education to adolescents. According to the teen and parent 1) the role of parents is important in preventing adolescent pregnancy.

Suggestion

For teachers, parents and students, they need to change the notion that sexuality is taboo, so that sexuality education can be implemented in schools and provides positive benefits for teens. Sexuality education is needed for teachers and parents to make them more confident in providing sexuality education for adolescents. The parents need to give more supervision in using technology and information for teens to access information according to their age. Plan for school health nursing is expected to provide reproductive health education and aimed at preventing adolescent pregnancy.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

1. 1. UNICEF. Adolescence an age of opportunity. New York: Division of Communication. UNICEF. 2011.
2. 2. Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, Ezeh AC, et al. Adolescence: a foundation for future health. Lancet. 2012;379:1630-40.
3. 3. Papalia DE, Olds SW, Feldman RD. Human Development. Ninthed. RH H, editor. New York: McGraw-Hill. 2003.
4. 4. WHO. Early marriages, adolescent and young pregnancies Geneva: WHO. 2012.
5. 5. Kennedy E, Gray N, Azzopardi P, Creati M. Adolescent fertility and family planning in East Asia and the Pacific: a review of DHS reports. Reprod Health. 2011;8:11.
6. 6. Creswell JW, Vicki LPC. Design and conducting mix methods research. second edition ed. California: Sage publication, Inc. 2011.
7. 7. Gerholm L. Overcoming temptation: on masculinity and sexuality among muslims in Stockholm. Global Networks. 2003; 3:401-16.
8. 8. Smerecnik C, Schaalma H, Gerjo K, Meijer S, Poelman J. An exploratory study of Muslim adolescents’ views on sexuality: Implications for sex education and prevention. BMC Public Health. 2010;10(533):1-10.
9. 9. Cai Y, Ye X, Shi R, Xu G, Shen L, Ren J, et al. Predictors of consistent condom use based on the information-motivation-behavior skill (IMB) model among senior high school students in three coastal cities in China. BMC Infectious Diseases. 2013;13:262.
10. 10. Mutalip SS, Mohamed R. Sexual Education In Malaysia: Accepted Or Rejected? Iran J Public Health. 2012;41(7):34-9.
11. 11. Tanton C, Jones KG, Macdowall, Clifton S, Mitchell KR, Datta J, et al. Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles. BMJ Open. 2015;5(e007834).
12. 12. Buhi ER, Goodson P. Predictors of Adolescent Sexual Behavior and Intention: A Theory-Guided Systematic Review. J Adolesc Health. 2007;40(1):4-21.
13. 13. Pilgrim NA, Blum RW. Protective and risk factors associated with adolescent sexual and reproductive health in the english-speaking caribbean: A literature review. J Adolesc Health. 2012;50(1):5-23.
14. 14. WHO. WHO Guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. Geneva: WHO Press. 2011.
15. 15. Situmorang A. Adolescent reproductive health in Indonesia. 2003.
16. 16. Madondo TT. Adolescence Pregnancies and Their Impact on Communities. One 2013. 2013. Available at: http://www.popline.org/node/571831.
17. 17. WHO. Social determinants of health and well-being among young people. 2012.
18. 18. Rajapaksa-Hewageegana N, Salway SM, Piercy H, Samarage S. A quantitative exploration of the sociocultural context of teenage pregnancy in Sri Lanka. BMC Pregnancy Childbirth. 2014;5;14:394.
19. 19. Ipas. Adolescents unwanted pregnancy and abortion. In: Bruyn, Maria, Packer, Sarah, editors. Polices, counceling and clinical care. United states of America: Ipas; 2004.
20. 20. DiCenso A, Guyyat G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. BMJ. 2002;324(Primary Care):1-9.
21. 21. Wamoyi J, Fenwick A, Urassa M, Zaba B, Stones W. Parent-child communication about sexual and reproductive health in rural Tanzania: Implications for young people's sexual health interventions. Reproductive Health. 2010;7(6):1-18.
22. 22. Tesso DW, Fantahun MA, Enquselassie F. Parent-young people communication about sexual and reproductive health in E/Wollega zone, West Ethiophia: implication for intervention. Reproductive Health. 2012;9(13):1-13.
23. 23. Chandra-Mouli V, Camacho AV, Michaud PA. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. J Adolesc Health. 2013;52(5):517-22.
24. 24. Kohler PK, Manhart LE, Lafferty WE. Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen Pregnancy. J Adolesc Health. 2008;42:344-51.
25. 25. Widman L, Choukas-Bradley S, Helms SW, Golin CE, Prinstein MJ. Sexual communication between early adolescents and their dating partners, parents, and best friends. J Sex Res. 2014;51(7):731-41.
26. 26. Council on School Health. Role of the school nurse in providing school health services. American academy of Pediatrics. 2008;121(5):1052-6.
27. 27. Inman DD, Bakergem KM, LaRosa AC, Garr DR. Evidence-Based Health Promotion Program for Schools and Communities. Am J Prev Med. 2011;40(2):207-19.
28. 28. Borawski EA, Tufts KA, Trapl FS, Hayman LL, Yoder LD, Lovegreen LD. Effectiveness of Health Education Teachers and School Nurses Teaching Sexually Transmitted Infections/Human Immunodeficiency Virus Prevention Knowledge and Skills in High School. J Sch Health. 2015;85(3):189-96.
29. 29. Hall DMB. School Nursing : Past, Present and Future. Arc Dis Child. 1999;81:181-4.