Felt needs and expectations of adolescents regarding sexual and reproductive health from schools and health systems: A descriptive study.

BACKGROUND: Much focus has been given to find ways to overcome the barriers that exist among adolescents in the utilization of sexual and reproductive health (SRH) services. This study attempts to explore the felt needs of adolescents regarding SRH education at schools and their expectations regarding SRH care from a health system.
METHODOLOGY: A cross-sectional study was conducted among 400 1st-year arts and science college students in Puducherry, India. Data collection and analysis were done from January 2015 to February 2015. Data were captured using a self-administered pretested questionnaire.
RESULTS: Seventy percent participants felt that it is necessary to have educational contents on SRH at schools and 33.5% felt that the current SRH education is inadequate. About 28.9% felt uncomfortable to discuss their doubts on SRH with teachers. Almost 90% preferred schools as the source of SRH education in the community. Nearly 42% of adolescents thought that they would consult a doctor in the instance of a sexual illness. Thirty-nine percent preferred specialized SRH clinics. More than half expected privacy and confidentiality and the presence of a same sex doctor as the most important feature of an SRH-care facility. The least preferred SRH-care facility was government clinics (18%), and the major reasons for not preferring government facilities were lack of quality (43%) and overcrowding (43%).
CONCLUSION: It is important to conceive schools as the foundation for providing SRH education among the adolescents supported by a friendly and responsive health system.

INTRODUCTION

Adolescence is defined by the World Health Organization as the period between postchildhood and preadulthood, which is 10–19 years. It is a period which is prone to vulnerabilities, owing to the inability to assess complex concepts and poor decision-making over sexual and reproductive health (SRH) aspects.[12] There are about 243 million adolescents in India constituting one-fourth of the current population.[3] Although they are a major share of the population, wide range of needs related to SRH are still unmet through the existing systems of health care available for the adolescents. The median age of first sexual experience for married women is 17.8 years in India and even lower among the uneducated and poorest economic groups, which is 16.4 years.[4] Still, teenage pregnancies are one among the major causes of poor SRH among adolescents. The risk of maternal deaths, premature delivery, and low birth weight babies are also high among adolescent pregnancies.[5] Although evidence on the prevalence of unintended pregnancies and abortions are limited, a few studies have pointed out that almost 41% of the abortions occur among young women. Many SRH services including safe abortion are still out of reach for women, mostly unmarried women due to social, economic, and health system-related barriers.[6]

Nevertheless, adolescence is the one age group that can have the maximum impact of well-planned and efficient health interventions. Almost all countries that have achieved excellent results in reducing the prevalence of HIV and other sexually transmitted infections have targeted adolescent age groups.[7] Recently, much focus has been given to find ways to overcome the barriers that exist among adolescents in the utilization of SRH services.[8] This study attempts to explore the felt needs of adolescents regarding SRH education at schools and their expectations regarding SRH care from the health system. Such information may thus pave the way for further research on SRH among adolescents and try to build further on this theme.

METHODOLOGY

The study was conducted among students of arts and science colleges in Puducherry, India. Data collection and analysis were done from January 2015 to February 2015. Based on the proportion estimated for the necessity of SRH education from schools as 95%,[9] the sample size was estimated at 253 with an alpha error 5%, absolute precision at 3%, and considering a nonresponse rate of 20%.

From the available list of all arts and science colleges in Puducherry area, four were shortlisted randomly for the purpose of the study. Students from one or two 1st-year batches were selected randomly each from each college. Approximately 400 participants were thus chosen for the study. Data were captured using a self-administered pretested structured questionnaire. Epidata version 3.1 (EpiData - Comprehensive Data Management and Basic Statistical Analysis System. Odense Denmark, EpiData Association, 2010-. Http://www.epidata.dk) and R software version 3.1.2 (R Core Team (2013). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria, http://www.R-project.org/) Frequencies and proportions were used to summarize the data variables in the study.

RESULTS

As cited in Table 1, more than half of the students in the study were female and around 45% were male. Table 2 shows that almost 275 (70%) participants out of the 393 responses felt that it is necessary to have proper educational contents on SRH at schools. However, among these 275 adolescents only 54.2% felt that the current education available through schools as adequate. Among the total study population, only 48.6% felt that the present educational content on SRH is sufficient and 33.5% adolescents felt the current system as inadequate. Only 37.7% of the adolescents in the current study felt that it was comfortable for them to discuss their doubts on SRH with their teachers, whereas 28.9% felt uncomfortable to do so. Table 3 shows that schools were the most preferred source of education for SRH (89.8) among the adolescents in the present study.

Table 1

Gender distribution among the study participants

Gender	Frequency (%)
Males	179 (45.1)
Females	218 (54.9)
Total	397 (100)

Table 2

Felt needs, perception on adequacy of educational content, and comfort level with teachers among adolescents regarding sexual and reproductive health education at schools

	Gender
	Males (n=179), n (%)	Females (n=218), n (%)
Felt needs on SRH education (n=393)
Necessary	119 (66.5)	156 (71.6)
Not necessary	35 (19.6)	24 (11.0)
Adequacy of present SRH education in schools (n=397)
Sufficient	81 (45.3)	112 (51.4)
Insufficient	70 (39.1)	63 (28.9)
Comfort level in discussing doubts on SRH with teachers (n=397)
Comfortable	68 (37.9)	82 (37.6)
Uncomfortable	50 (27.9)	65 (29.8)

SRH=Sexual and reproductive health

Table 3

Preferred mode of education on sexual and reproductive health among adolescents

Mode of education	Frequency (n=365), n (%)
Through schools by teachers and experts	328 (89.8)
Through one-to-one counseling	131 (35.8)
Through TV and radio	120 (32.8)
Through family members	83 (22.7)
Through posters and banners	50 (13.7)

As observed in Table 4, almost 37% responded that they may either self-treat or ignore or were unsure regarding what to do in a situation of SRH illness. Furthermore, 39% responded that they prefer a facility which is exclusively providing SRH care and the least preferred type of facility was a public health-care facility. Privacy and confidentiality (56.2) and doctor of the same gender (54.3) were the most expected features from an SRH health-care facility by the adolescents in the study.

Table 4

Participants perception on how to respond for sexual and reproductive health illnesses, preferences regarding type of facility for care, expectations from sexual and reproductive health facilities, and reasons for not preferring public facility

	Frequency (%)
Perception on how to respond (n=298)
Consult a doctor	163 (42.5)
Seek the advice from family	79 (20.6)
Search Internet and self-treat	59 (15.4)
Do not know what to do	56 (14.6)
Ignore it	26 (6.8)
Preferred type of facility (n=337)
Special clinic for SRH	131 (38.8)
No particular preferences	75 (22.3)
Private clinic	71 (21.1)
Government hospital	60 (17.8)
	Multiple options (%)
Expected features from an SRH facility (n=368)
Privacy and confidentiality	207 (56.2)
Doctor of the same gender	200 (54.3)
Can go with my partner	87 (23.6)
Should not ask family details	73 (19.8)
Can go alone	71 (19.2)
Anonymous phone consultation	70 (19.0)
Reasons for not preferring government facility (n=353)
Lack of quality	154 (43.6)
Overcrowding	152 (43.1)
No same gender doctor	129 (36.5)
Lack of confidentiality	112 (31.7)
Lack of access	66 (18.7)
Others	15 (4.2)

SRH=Sexual and reproductive health

DISCUSSION

It was encouraging to note that, most of the adolescents in the study (70%) felt that it was important to have sexual education at schools. The results from the present study were found to be consistent with other studies on similar subject. A study among school students in Mumbai observed that 99% of adolescents perceived that education on SRH was necessary at schools for them.[10] A similar study among college students in Punjab also observed similar findings, where 95% study participants favored SRH education through schools.[9] However, when probed about their perception of adequacy of SRH education available from schools, only 49% felt that it was adequate. A similar study by Tripathi and Sekher also found that, considerable amounts of educational needs on SRH are unmet among Indian youth, as there were considerable gap in the proportion of individuals desiring education and actually receiving it in their study.[11]

About 90% of participants in the study reported that their preferred source of education on SRH topics was through schools, either by teachers or by experts in the field. These results also help in further substantiating the felt needs of the adolescents regarding education on SRH. It was also observed that only 38% of the adolescents in the study were comfortable in discussing SRH topics with their school teachers. A study among male adults in Mysore, India, could also point out the existing gaps in SRH pedagogy at schools. However, in general, teachers too are usually uncomfortable to teach about SRH that most of them either skip the topic or teach it at a superficial level, leaving much in doubt.[12] Such discomfort among teachers could invariably lead to the inability of the students to approach them for doubts related to SRH, even if they wanted to.

These responses from adolescents portray the abysmal lack of ability within the existing education system to address the needs of its children. A system which is expected to provide the necessary foundation for cultivating healthy habits and a healthy generation lags behind fulfilling its responsibilities. Sex and related subjects has largely remained a taboo subject among Indian communities, thus, it is a concern that, the educational system which should act as a change agent also deals with this subject quite rigidly. These culturally rigid norms have also reflected politically too, like the government ban on sex education in schools among different states in India. A ban which was implemented citing the reason that sex education in schools can be a provocation for increased sexual activities among the adolescents.[13] This topic holds its relevance in a time when the country is shaken by events like the Nirbhaya case which involved a juvenile among the main convicts.[14] There should be a proactive approach on the part of the society, and a considerable amount of political will to address these concerns.

The present study also observed that almost 37% of adolescents in the study felt that in the instance of a sexual illness, they may either self-treat, ignore, or were unsure as to what may be done. A similar study among adolescents also observed that 66% of participants were unaware regarding sexually transmitted diseases (STDs) and other related issues.[15] Evidence also suggest that a common barrier in utilizing SRH services by adolescence is lack of seriousness about the problem they face.[16] These evidence points out to the existing gaps in the awareness and knowledge among adolescents regarding the seriousness of SRH.

A majority of the adolescents (39%) preferred special clinics for SRH care in the study. Furthermore, around 56% of the participants reported that the primary factors they consider in selecting a facility for SRH care were privacy and confidentiality in the current study. Higher preference for specialized SRH clinics also further substantiates and reflects the expectation of an SRH care that values personal information. The least preferred source of SRH care (18%) was government facilities. The four major reasons observed for not preferring a public facility were a perceived lack of quality (44%), overcrowding (43%), lack of same sex doctor (36.5%), and lack of confidentiality (32%). These results were consistent with the findings of yet another study conducted in India, where the adolescents felt that private facilities were chosen due to the quality of facility.[17] The importance given toward the care provider's sex was also further evidenced from the results, as 54% expected this feature from an SRH facility and was also one among the major reason for not availing a government SRH facility. Evidence also suggests some of the barriers in utilizing SRH services were negative attitudes of health workers, stigmatization, and lack of same sex staff among others.[18] These findings thus echo the major priorities that adolescents have while receiving care from facilities providing SRH care. However, it is encouraging to note that 63% of adolescents preferred to consult a doctor or seek advice from family in case of a sexual illness [Table 4]. This reflected the readiness of adolescents to respond positively to such situations, which may be considered as a window of opportunity to act and convert them to positive utilizers of services through suitable interventions.

CONCLUSION

The major themes that can be derived from these findings are cultural proscriptions, social stigma associated with these illnesses, importance of adolescent-friendly services in the community, and a general lack of awareness among the adolescents regarding SRH. Thus, it is important to conceive schools as the foundation for providing SRH education and awareness among the adolescents. There needs to be age-appropriate education through schools on topics related to SRH including safe and unsafe touches, STDs, and healthy sexual habits. This should be supported by a friendly and responsive health system combined with a conducive environment for personalized care which can thus go a long way in achieving better SRH among the adolescents in the community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.