Biosocial correlates of adolescent's knowledge on pubertal changes in rural Bangladesh: A structural equation model.

BACKGROUND: The present study aimed to identify factors that are associated with puberty knowledge among school-going rural adolescents in Bangladesh.
METHODS: This cross-sectional study was conducted on 2724 school-going (grades VI-IX) adolescents who were aged between 10-24 years. The adolescents resided only in rural areas of Bangladesh. In this study, relationship between socio-demographic factors and controlling behaviour was assessed considering Bronfenbrenner's bioecological model. Considering the complex nature of Bronfenbrenner's bioecological model the structural equation model to explore factors related to the Adolescents' knowledge of pubertal changes.
RESULTS: The structural equation model result showed a significant association among gender, education, age, and parental limit setting on daily activities with student's knowledge on pubertal changes. peer connection, and peer regulation were associated with adolescent knowledge on puberty directly as well as through the mediator variables year of schooling, academic performance and, parental behavioural control.
CONCLUSION: Adolescents Age, years of schooling, and teachers concerns are positively associated with adolescents' knowledge on puberty. Whereas, parents' and peers' controlling behaviors are negatively associated with adolescents' understanding of pubertal changes. Therefore, there is needed an effective plan to raise the attention of parents and teachers on adolescents' pubertal issues to ensure adolescents' informed pubertal period.

Introduction

The onset of puberty causes physical and physiological, psychological, social, mental, cognitive, and behavioural changes [1-3]. The physical changes during puberty among girls are breast foliage, rapid height and weight rise, pubic and axillary hair development, hip widening and menstrual onset [1, 4–6]. Likewise, boys experience changes in tone, increase in shoulder width, night-time ejaculation, penis enlargement, axillary hair growth, boys’ facial hair [7]. At the same time, adolescents go through a profound psychological transformation, and they experience a wide change in their self-image, attitude, and relationships. Moreover, they also experience a sudden change in social, academic, and other environmental influences [8]. Those multidimensional changes make them confused, insecure, and self-centred [9, 10]. As a result, mental disorders, such as severe depression, anxiety disorders, eating disorders, and substance use disorders, can arise during puberty [11]. More than 50 percent of female adolescents had experienced moderate to severe stress due to changes in puberty [12].

If adolescents can accept themselves and their body functioning during the adolescence period, they may experience a smooth pubertal period and establish a healthy attitude towards sex, marriage, parenthood, and family. Therefore, they need an explanation about the process of puberty that unfolds for everyone and what changes to expect. The lack of adequate knowledge and confusion about their own physical and/or sexual development (i.e., changes in growth) can expose them to depression, anxiety, conduct disorder, and self-harm [13]. Misconceptions, taboos and myths about sex, sexuality, reproduction, and contraception also hinder them from obtaining correct knowledge [14]. Thus, teenagers are getting more fragile along with their distinctive development stage.

The family is responsible for ensuring informed puberty so that adolescents can lead healthy, secure, productive, and enjoyable lives and protect themselves from reproductive health problems. However, in the socio-cultural context of Bangladesh, parents neglect their duty to pass health information to their children because of either shyness or indifference or life obligations and parents left it as a responsibility of teachers who may also overlook it [15]. In such instances, adolescents have no choice other than to go to their peers, siblings, and mass media. These sources offer incomplete and inappropriate sexual and reproductive health knowledge to the adolescents [16]. Therefore, adolescents can get inaccurate or insufficient knowledge about pubertal changes which may rise misconceptions about puberty among them [17]. With the misconceptions, adolescents can create problems for themselves and their parents by putting their physical, emotional, and social well-being at stake [15].

Both the Government of Bangladesh (GOB) and NGOs have undertaken various activities at different times to alleviate the current disparity between the need and prevalence of adequate knowledge and awareness of puberty. Those activities are implemented under the adolescent sexual and reproductive health (ASRH) program initiatives. There were 32 adolescent sexual and reproductive health awareness-raising and service delivery initiatives introduced in Bangladesh between 2005 and 2015 [18]. To make these programs successful, it is essential to identify the factors that are related to adolescent’s knowledge of pubertal changes considering the interrelationship between development and the child circumambient environmental context. Several studies on adolescents’ knowledge have been carried out in Bangladesh [19-23] and other low- and middle-income countries [12, 24–29]. Most of these studies ignore the interrelationship among the child and the surrounding environmental contexts such as the interrelationship among family, community, peer and school. Therefore, to make the awareness-raising program more effective, an empirical study about how family and community relates to adolescents’ knowledge of pubertal changes, is to be carried out.

Therefore, in the situation of minimal evidence, this study sets out to add empirical evidence on the relationship between the environmental context of child development and adolescents’ knowledge of pubertal changes in Bangladesh.

In this study, the effect of socio-demographic factors and controlling behaviour was assessed considering Bronfenbrenner’s bioecological model [30]. According to the bioecological model, environmental setting along with individual characteristics may facilitate the proximal process of adolescent functioning. In this study, the relationship between adolescents’ knowledge on pubertal changes and personal characteristics such as age, sex, religion, and year of schooling was assessed.

Environmental settings and adolescent functioning are linked through social contexts and their interrelations; social context includes family, peers, school, and community [31, 32]. The contextual factors that are used in this study are—mother’s education, parental behavioural control, parental limit-settings on daily activities, peer connection, peer regulation, peer psychological control, community disorganization, academic performance, and teacher concern. The proximal process of the adolescent functioning (acquiring knowledge) provides the conceptual framework (Fig 1) of this study.

Fig 1

Conceptual framework.

Methods

Data

Data for this cross-sectional study was collected by the Department of Statistics of Jagannath University in March 2019 in the rural areas of Bangladesh. Data regarding socio-demographic, psychosocial, and reproductive health knowledge and status-related information were collected from adolescents aged 10–24 years in rural areas of Bangladesh. The survey consisted of two modules of data set named a school module of data sets and household module dataset. The household module was designed to collect information from community adolescents aged 10–24 years. In the survey, 3013 adolescents were successfully interviewed in rural areas of Bangladesh, with 1504 adolescents were in the household module and 1509 adolescents were in the school module.

The survey used a three-stage stratified sampling procedure to select the adolescents. Based on the performance of reproductive health programs, at first 8 upazilas (administrative geographical unit similar to sub-district) of 8 divisions were selected randomly. At the first stage, two unions from each selected upazila were selected randomly. Then at the second stage, from each selected union one secondary school was selected randomly. Then from each secondary school, 47 male and 47 female students of class VI-IX was selected applying simple random sampling.

In the household module, one or two villages within the catchment area of the selected school or madrasa were surveyed. For the household survey, a cluster was comprised of taking 150–200 households within the catchment areas of the selected school. Before the main survey, a household listing was conducted to identify the eligible adolescents. Finally, 95 households were selected within each cluster by systematic random sampling technique. One respondent was chosen in the selected household. Listing operations were done for each and every household with household head name and demographic information. The list recorded the name of household head to select whether eligible respondents were in the household within each cluster. The resulting lists of Households with eligible study populations served as a sampling frame at the final stage.

Finally, two data modules were merged for the analysis. After deleting the missing and incomplete cases, there were 2724 cases which were used for the final analysis.

Ethical consideration

All participants of this study were informed before data collection about the nature and purpose of the study, the procedure, and the right to withdraw their data from the study. Before data collection, verbal consent was taken from all participants, the headmasters of all secondary schools for the school module, and parents or guardians for household module. The study protocol was approved by the Jagannath University, Bangladesh institutional ethical committee (JEC) (Under the project number 37.20.0000.004.033.020.2016.7725).

Outcome variable

The outcome variable was knowledge of pubertal changes. To assess adolescents’ knowledge regarding pubertal changes, students were asked to identify the physical, mental, and behavioural changes during puberty. In the text book of classes VI, VII and VIII, eighteen physical, mental and behavioural changes were mentioned. Adolescents get score 1 for the identification of each change which was in their text book. The total number of changes one had correctly identified was the knowledge on pubertal changes score. Thus, one adolescent can score maximum 18 score and minimum 0. A similar kind of knowledge measuring approach has been used in some studies [12, 29, 33].

The latent construct approach is the most suitable approach for this type of study. However, Field et al. [34] suggested that to construct a latent variable it is essential to remove observed variables if the correlation between variables is very high or is not high-enough. In this study, there are several variables between which correlation is either very high or is not high enough for factor analysis. If those variables were removed from the study, then a considerable amount of information has been lost on adolescents’ knowledge on pubertal changes. Therefore, instead of using the latent construct of knowledge on pubertal changes, knowledge on pubertal changes was measured with constructed score [12, 28, 32].

Control variables

Individual factors

Control variables were year of schooling, age, sex (male and female), religion (Islam and others), and Mother’s education (no education, primary, secondary and higher).

Contextual factors

The contextual factors were measured by utilizing the method from Amoateng and Kalule-Sabiti [35]. They developed this method to find out the bio-social correlates of age at first sexual intercourse among students of South Africa. The method measures various social contextual factors related to family, peers, school, and community that connect the environment with adolescent functioning. For this study, the translation and adoption procedure of the method is done by following the proposed guideline of Beaton et al. [36].

Parental behavioural control (PBC). Parental behavioural control is a composite index. It was measured as a mean score of five questions about how much their parents are conscious about their friends, night stay, and money spending. The responses are taken into a three-point Likert scale categorized as “Does not know”, “know a little”, and “knows a lot”.

Parental limit settings (PLS). To understand the parental limit-setting behaviour respondents are asked four questions about parenting actions. Which are how much did one of your parents or primary caregivers do the following things over the past 30 days: “regulate the period of time you could watch televisions”, “inspect whether or not homework was done”, “help to prepare home assignment, check the exam grade sheet”. The responses are taken on a four-point Likert scale- 1. “Never”, 2. “On rare occasion” 3. “Occasionally” 4. “Frequently”. The average value of these four questions is taken as the child’s parental limit setting.

Community disorganization (CD). The mean score of five questions related to how often they are disrupted in the community is used to assess the community’s disorganization. The questions are- “How often do you see the litter or trash on the sidewalks and streets?”, “How often do you see graffiti on building walls?”, “How often do you see alcoholics or drug sales?”, “How often do you become afraid or worried when you are walking through the empty place?”, “How frequently burglary happened?”. The responses range from 1 to 3. 1 stands for “Often”, 2 for “Sometimes” and 3 for “Never”.

Community psychological control (CPC). The average response of three five-point Likert scale questions is used as community psychological control. The problems are related to is your neighbours always watch what you are doing, interfere with what you are doing, and is noisy.

Peer connection (PeC). The average values of three questions on when and how respondents communicate with the friend via “phone conversation”, “go over to one another residences”, and “go together for a movie/skating/shopping/sports event” is evaluated as connection with friends. The answers are coded as “never”, “once a month”, “once per week”, and “many times a week or everyday”.

Peer psychological control (PePC). Psychological control of peers is quantified by the mean score of the answers to three questions on how often their peers disagree with you, how often they make you feel that your ideas are not as good as theirs, “humiliate or bug you” and “drag you down”. The answers are coded as: “hardly ever”, “once every month”, “once per week”, “a couple of times in a week”, and “every day”.

Peer regulation (PeR). Friend’s regulation focuses on friends’ influence in complying with laws and regulations. It is measured as the mean of two questions about how often the friend “supports you do whatever is correct” and “motivates you to abide by the rules”. “Never”, “once a month”, “once a week”, “a few times a week and everyday” are the replies.

Teacher’s concerns (TC). The teacher’s concern demonstrates teachers’ supportive, friendly relationship with students that supports student’s academic well-being. To measure teachers’ concerns, four questions were asked about teachers’ willingness to assist them with schoolwork and solve personal problems. The average of responses is used as a measure of the teachers’ concerns.

Student’s academic performance (SAP). Since adolescents were interviewed from both household and school, it is difficult to assess academic performance forms the academic year performance. Therefore, students’ academic success is assessed on an ordinary scale by a single question:’ In general, how well are you doing in school? The replies are: 1 “way above average”, 2 “a little above average”, 3 “average”, 4 “at just below average” and 5 “far below average”.

Reliability of dependent variable and contextual factors

Reliability of contextual factors and knowledge on pubertal changes have been measured using Cronbach’s alpha. The value of the Cronbach’s α is 0.646 for knowledge on pubertal changes which is acceptable [37]. Among the contextual factors PBC (Cronbach’s α = .70), CD (Cronbach’s α = .75), CPC (Cronbach’s α = .81), PeR (Cronbach’s α = .79), PePC (Cronbach’s α = .82), and TC (Cronbach’s α = .88) had high reliability. Whereas, PLS (Cronbach’s α = .63), and PeC (Cronbach’s α = .61) had acceptable reliability.

Statistical analysis

Simple descriptive analysis and multivariate statistical analysis were performed in this study. The categorical socio-demographic characteristics were presented by frequency and percentage distribution. The generalized structural equation model was also used to test the hypothetical relational path in which individual level, family level and community level variables correlated adolescents’ knowledge on pubertal changes. There was no latent variable included in the model. Chi-square and t-test were used for the model specification purpose due to the scarcity of previous literature which considered the proximal process of adolescent’s knowledge on puberty as the conceptual framework. Finally, diagonally weighted least squares (DWLS) had been used for estimating regression coefficients of structural equation model since DWLS estimation method provides a more accurate estimate for ordinal data.

All the analysis was conducted using the software R version 3.6.0. A Simultaneous equation model was fitted using the “lavaan” package [38].

Results

Socio-demographic characteristics of sampled adolescents

Table 1 demonstrates descriptive statistics of socio-demographic variables. There was almost an equal number of representatives of both sexes in the survey data (male 50.8% and female 49.2%). The mean age of adolescents and their years of schooling was 14.7 and 8.1,respectively. More than half of the adolescent’s parents (father and mother) had achieved a secondary level education (51.2% for father and 57.3% for mother), whereas only 7.5 percent of adolescent’s fathers had higher education and only a small portion of adolescent’s mother completed higher education (2.7%).

Table 1

Descriptive statistics of socio-demographic characteristics.

Variable	Group	Frequency/Mean±SD	Percentage
Year of Schooling		8.08±1.02
Age		14.67±1.32
Sex	Male	1384	50.8
	Female	1340	49.2
Religion	Islam	2556	93.8
	Others	168	6.2
Father’s education	No education	500	18.3
	Primary	623	22.9
	Secondary	1397	51.3
	Higher	204	7.5
Mother’s education	No education	412	15.1
	Primary	677	24.9
	Secondary	1560	57.3
	Higher	75	2.7

Contextual factors of adolescents

Descriptive statistics of contextual factors, Table 2, showed that parental behavioural control and community disorganization ranges from 1 to 3, and the remaining variables’ values ranging from 1 to 4 except parental limit setting which can take value from 1 to 4. Family level variables parental behavioural control and Parental limit setting had median values 2.67 and 2.75 respectively. The median of parental behavioural control was close to the maximum value indicates high parental behavioural control for the adolescents. The median value of peer psychological control was 1.25 which was very close to the lower limit of the range indicating adolescents who are merely psychologically controlled by the peer. But the peer regulation had median value 4 and for peer connection was 3.

Table 2

Descriptive statistics of contextual factors.

Factors	Median	Minimum	Maximum
Student’s academic performance	0.67	1	5.00
Parental behavioural control	2.67	1	3.00
Parental limit setting	2.75	1	4.00
Peer connection	3.00	1	5.00
Peer psychological control	1.25	1	5.00
Peer regulation	4.00	1	5.00
Community disorganization	1.67	1	3.00
Community psychological control	2.67	1	5.00
Teacher’s concern	4.00	1	5.00

Findings from generalized structural equation model analysis

Model generating approach [39] had been used for the model specification. Initially based on Bronfenbrenner’s bioecological model [30] all possible paths are included in our model. Then we went through a process of deleting and adding paths in the model based on the modification indices to arrive at a final best-fitting model that also fit well with substantive theoretical and practical meaning. Finally, the fitted structural equation model was over-identified as the model’s degrees of freedom are 73, indicating that the number of free parameters to be estimated is less than the number of distinct values in the sample variance and covariance matrix. The model fit test statistic (χ2) was with p-value less than 0.001. The Goodness of fit index value (GFI = 0.89) and values of error-of-approximation based fit indices (RMSEA = 0.07, RMR = 0.02) indicated that the model was reasonably fit to the data.

The path coefficient of the structural equation model showed in Table 3. The result of structural equation model showed that gender (β = 0.754, P<0.001), education (β = 0.578, P<0.001), age (β = 0.29, P<0.001), and parental limit setting (β = 0.398, P<0.001) had significant effect on student’s knowledge on pubertal changes.

Table 3

Result of simultaneous equation model of contextual factors with knowledge about puberty.

Path	Estimate (Standardised)	P-value	Path	Estimate (Standardised)	P-value
KAP ←Female	0.754	<0.001	EOS ←PLS	-0.053	0.011
KAP ←Education	0.578	<0.001	EOS ←PPC	-0.005	0.889
KAP ←Age	0.29	<0.001	SAP←ME1	0.139	0.001
KAP ←Islam	-0.278	0.10	SAP← ME2	0.108	0.006
KAP ←SAP	-0.534	0.03	SAP← ME3	0.094	0.010
KAP ←PBC	0.119	0.703	SAP ←PBC	-0.054	<0.001
KAP ←PLS	-0.398	<0.001	SAP ←PLS	-0.030	<0.001
KAP ←PePC	-0.155	0.009	SAP ←PPC	0.006	0.592
KAP ←PeC	-0.286	<0.001	PBC ←PeR	0.073	<0.001
KAP ←PeR	0.134	0.01	PBC ←PePC	-0.064	<0.001
KAP ←TC	0.069	0.102	PBC ←CD	-0.064	<0.001
KAP ← ME1	-0.872	0.04	PBC ←TC	0.074	<0.001
KAP ← ME2	-0.483	0.200	PLS ←PeC	0.063	<0.001
KAP ← ME3	-0.328	0.437	PLS ←PeR	0.007	0.603
EOS ← ME1	0.078	0.518	PLS ←CD	-0.048	0.052
EOS ← ME2	0.047	0.137	PLS ←CPC	-0.033	0.017
EOS ← ME3	0.104	0.413	PLS ←TC	0.124	<0.001
EOS ←FWS	0.016	0.755	PPC ←PePC	0.082	<0.001
EOS ←PBC	0.016	0.634	PPC ←CD	0.10	0.561

KAP = Knowledge about Puberty; EOS = Year of Schooling; ME = Mother’s Education; FE = Father’s Education; SAP = Student’ s Academic performance; PBC = Parental behavioural control; PLS = Parental limit setting; PePC = Peer psychological control; PeC = Peer connection; PeR = Peer regulation; TC = Teacher’s concern.

There were several instances of mediation effect in the model. Student’s academic performance act as a mediating variable for PPC→SAP→KAP, PLS→SAP→KAP, and PBC→SAP→KAP. Whereas, student’s educational aspiration was the mediator for the indirect effect of the father’s education (FE→SEA→KAP), mother’s education (ME→SEA→KAP), and parental behavioural control (PBC→SEA→KAP) on knowledge about pubertal changes. The community-level variable, community disorganization showed an indirect impact on knowledge about pubertal changes through the mediating variable parental limit setting (CD→PLS→KAP). Adolescents’ peer connection, regulation, and psychological control also demonstrated secondary effects on knowledge about pubertal changes through the mediating variables of parental limit settings and parental psychological control (PePC→PLS→KAP, PeR→PLS→KAP, and PePC→PBC→KAP).

Effect of bio-social factors on knowledge on puberty (direct effects, indirect effects, and total effect)

Table 4 showed that sex, age, years of schooling and academic performances significantly influenced adolescents’ knowledge of pubertal changes. The gender (β = 0.753, p<0.001) of adolescents directly correlated adolescents’ understanding of puberty, which means that female adolescents have a higher understanding of puberty than their male counterparts. Adolescents’ age (β = 0.293, p<0.001) had a significant positive impact on knowledge about pubertal changes, Table 4. The knowledge about pubertal changes increased by 0.293 for every year increase in the adolescents’ age. Adolescents’ years of schooling (β = 0.578, p<0.001) also showed a direct positive effect on their knowledge of pubertal changes. This means that as the adolescents spend one year more time at school, their knowledge of pubertal changes significantly increased by 0.578. However, students’ academic performances (β = - 0.534, p<0.001) had a negative effect on knowledge about pubertal changes, which indicates that adolescents who were good at school had less knowledge on pubertal changes.

Table 4

Direct effect, indirect effect and total effect of bio-social factors on Knowledge on puberty.

Variable	Direct effect β (95% CI)	Indirect effect		Total effect (95% CI)
		β (95% CI)	Mediator Variable
Sex
Female	0.754*** [0.74, 0.768]	NA	NA	0.754*** [0.74, 0.768]
Male	Ref.	Ref.		Ref.
Age	0.29*** [0.284, 0.296]	NA	NA	0.29*** [0.284, 0.296]
Religion
Islam	-0.278 [-0.273, -0.283]	NA	NA	-0.278 [-0.273, -0.283]
Others	Ref.	Ref.		Ref.
Year of Schooling	0.578*** [0.567, 0.589]	NA	NA	0.578*** [0.567, 0.589]
Student’ s Academic performance	-0.534*** [-0.524, -0.544]	NA	NA	-0.534*** [-0.524, -0.544]
Mother’s education
No education	-0.872* [-0.855, -0.889]	-0.076 [-0.075, -0.077]	Year of schooling, and Academic Performance	-0.949* [-0.931, -0.967]
Primary education	-0.483 [-0.474, -0.492]	-0.059 [-0.058, -0.06]	Year of schooling, and Academic Performance	-0.541 [-0.531, -0.551]
Secondary education	-0.328 [-0.322, -0.334]	-0.052 [-0.051, -0.053]	Year of schooling, and Academic Performance	-0.38 [-0.373, -0.387]
Higher education	Ref.	Ref.		Ref.
Parental behavioural control	0.119 [0.117, 0.121]	0.029* [0.028, 0.03]	Academic Performance	0.149 [0.146, 0.152]
Parental limit setting	-0.398*** [-0.39, -0.406]	-0.022 [-0.022, -0.022]	Year of schooling, and Academic Performance	-0.42*** [-0.412, -0.428]
Peer connection	-0.286*** [-0.28, -0.292]	-0.001 [-0.001, -0.001]	Parental limit setting	-0.287*** [-0.281, -0.293]
Peer regulation	0.134* [0.131, 0.137]	0.002 [0.002, 0.002]	Parental behavioural control	0.134* [0.131, 0.137]
Peer psychological control	-0.155*** [-0.152, -0.158]	-0.002 [-0.002, -0.002]	Parental behavioural control	-0.156*** [-0.153, -0.159]
Community psychological control	NA	0.001 [0.001, 0.001]	Parental limit setting	0.001 [0.001, 0.001]
Community disorganization	NA	-0.001 [-0.001, -0.001]	Parental behavioural control and Parental limit setting	-0.001 [-0.001, -0.001]
Teacher’s concern	0.069*** [0.068, 0.07]	-0.001 [-0.001, -0.001]	Parental behavioural control and Parental limit setting	0.068*** [0.067, 0.069]

At the family level, the mother’s education and parental limit-setting directly correlated adolescents’ knowledge on pubertal changes. While parental behavioural control possessed an indirect effect on knowledge on pubertal changes. Mothers with no education had a direct (β = -0.872, p< 0.05) negative impact on adolescents’ puberty knowledge than mothers with higher education. The analysis indicated that children with higher educated mothers had more pubertal knowledge. Similarly, parents’ limitation setting on their child was directly (β = -0.398, p< 0.001), impeding the acquisition of the child’s knowledge on pubertal changes. Unlike the above two-variable parental behavioural control (β = 0.029, p< 0.05) indirectly enhanced adolescents’ knowledge on pubertal changes.

Among the community level variables, peer connection, peer regulation and teacher’s concern demonstrated a significant effect on adolescent’s knowledge of pubertal changes. Peer psychological control, community disorganization, and community psychological control failed to significantly impact adolescents’ knowledge of pubertal changes. Among the significant variables, peer connection (-0.286, p< 0.001) negatively influenced adolescent’s knowledge of pubertal changes more strongly than the other two significant variables. However, peer regulation (β = 0.134, p< 0.05) and teacher’s concern (0.069, p< 0.05) produces positive impact on adolescent’s knowledge on pubertal changes.

Discussion

The analysis of the study showed that adolescents’ knowledge of pubertal changes is influenced significantly by various individual level, family level, and community-level factors. Sex, age, year of schooling, and academic performance were the individual level of factors that displayed a significant effect on adolescent’s knowledge of pubertal changes. This current study revealed that knowledge of pubertal changes is positively influenced by age and years of schooling. A similar type of positive impact of age and year of schooling was also founded by Uddin and Choudhury [22]. As adolescents get older and complete more academic years, they are exposed more to the source of knowledge on pubertal changes and experience those pubertal changes as result they acquire higher knowledge on puberty with the increase in age and year of schooling. An interesting finding of our analysis showed that female adolescents had more knowledge on puberty than males. This evidence is supported by an earlier study conducted in Bangladesh and the study observed that male adolescents had poor knowledge of pubertal changes than female adolescents [40]. Separate studies from India on school-going adolescents [41] and Portugal on college students [42] found the same findings. The higher presence of consciousness regarding the pubertal changes among female adolescents may be related to the early onset of puberty among female adolescents, extensive focus to the female adolescents of adolescents sexual and reproductive health awareness-raising program, and the variation in the main source from which they get the information regarding the pubertal changes.

This study revealed that religion plays an important role in the knowledge of pubertal changes. Muslim students had lower pubertal change knowledge than students of other religions. This dissimilarity between different religions may be due to the different views towards human sexuality among different religions. In socio-economic context in south Asian countries, discussion about human sexuality is often recognized as taboo and the socio-religious context refrains adults from discussing with adolescents [43]. A previous study found that Hindu students had 1.76 times more likely to have better communication with mothers regarding sexual and reproductive health (SRH) [1].

Among family-level factors, Mother’s education shows a positive impact on adolescent’s pubertal knowledge. These findings are also consistent with the study of Uddin and Choudhury [21] on adolescent girls in rural areas in Bangladesh and another study in India [15]. This is because daughters also have a trustworthy relationship with their mother as a primary source of SRH information [15]. Though mothers are uncomfortable discussing SRH-related problems in our social structure, educated mothers do not hesitate to talk about SRH issues [44]. However, parental limit setting on children significantly reduces adolescents’ pubertal knowledge in this analysis. This finding depicts our country’s tradition, where parents think that pubertal changes are a natural human development phenomenon that needs to remain secret [45]. Parental behavioural control showed an indirect positive effect on adolescent’s knowledge on pubertal changes. This indicates that parents by imposing restrictions on adolescents’ behaviour increase their knowledge of pubertal changes through the mediating variable of years of schooling and academic performance.

Peers and community are two important social components that have a great impact on adolescent functioning. This analysis found that despite being a major source of knowledge regarding puberty, peer connection significantly reduces adolescents’ pubertal knowledge. It might have occurred due to incomplete and misleading information. The findings of Das and Roy [17]- peer almost always supplies incomplete and fantasy-oriented sexual and reproductive knowledge, also supports the findings of this study regarding the role of peer connection. On the other hand, peer regulation showed a direct positive impact on adolescents’ pubertal knowledge.

Adolescents spend a significant portion of their daily life in school. Therefore, school-level factors are essential for shaping their knowledge. Among other school-level factors, students’ academic performance negatively impacts adolescent’s knowledge of puberty. This contrary result can be due to the ignorance of students to the topics related to reproductive health issues as there was no exam taken on physical education and health in Bangladesh. On the other hand, the teacher’s concern demonstrates an overall positive impact on adolescent’s pubertal knowledge. Furthermore, the findings demonstrated that teacher concern had a significant positive impact on adolescent’s pubertal knowledge. This evidence coincided with other studies and observed that when teachers exhibit care towards students, the adolescents are motivated to learn and eliminate and correct disruptive behaviour [46, 47].

Conclusions

In summary, we could conclude that sex, years of schooling, age, parental limit-setting, peer concern, and peer regulation were the significant determinants on adolescent’s knowledge of pubertal changes. Male and Muslim adolescents had less understanding regarding the pubertal changes. Whereas, academic performance also demonstrated a negative relationship with knowledge on puberty. Though, the social context parents and peers were negatively associated with adolescent’s knowledge on puberty, Teachers are positively associated with knowledge on puberty. This research establishes a new framework for policy research to develop appropriate strategies to improve SRH conditions through cultural relevance. This study also recommended that policymakers and development strategies need to formulate appropriate strategies that can change parents and peers’ roles to ensure adolescent’s informed puberty. Furthermore, there is a need to evaluate the effectiveness of the awareness raising program considering the conceptual framework used in this study.

Limitations

There are several limitations in this study. The study sample was taken from only rural schools which limits the generalization of the findings. The academic performance was assessed using participants self-response. Adolescents’ responses may vary by school, but any random effect of the school had not been included in this study.

24 Jun 2021

PONE-D-21-15883

Impact of School-based Sexual and Reproductive Health Education among Secondary Student’s Knowledge on Pubertal Changes in Rural Bangladesh

PLOS ONE

Dear Dr. Haq,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The study raised important and sensitive topic; focusing on the ``Impact of School-based Sexual and Reproductive Health Education among Secondary Student’s Knowledge on Pubertal Changes in Rural Bangladesh``. However, fundamental issues are indicated to be provided mainly for the methodology section and the statistical analysis.  The manuscript could be greatly strengthened by aggressive editing for most of the study sections. Consider revising the spelling and grammar throughout the manuscript for increased clarity.

Please note that your manuscript was reviewed by 4 experts in the field. There is consensus agreement that the idea of the article is interesting but also the majority detected sections that required additional work. The reviewers identified many important problems and provided copious comments (enclosed).

The manuscript could be greatly strengthened by considering editing according to the specific Reviewers’ comments.

Please submit your revised manuscript by July 30, 2021, 11:59 PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

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2. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

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5. Please include a copy of Table 5 which you refer to in your text on page 11.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript is technically sound and the statistical analysis has been performed appropriately but they have mentioned that data cannot be shared publicly because of the restriction of data authority. However, they can add data course link. The manuscript needs major revisions as sentences are not very clear.

Reviewer #2: The authors have touched a very sensitive issue related to Adolescent in a school setting. Few of the comments below can be considered to make the paper more useful for the readers and other users.

1. The justification given as a rational for the study- "No specific research has been done so far on how parents and our society hinder adolescent's knowledge of pubertal changes."- seems a bit odd. There are several published studies done in rural Bangladesh and several Asian countries and probably specific research might not be done in the specific study area in the past, and it should not be generalized.

2. I am not clear if there was a parental consent since the mean age in this study was 14.67 Years. Did the researchers used other mechanisms to ensure parental consent?

3. One of the variables relate to Student's academic performance by directly asking the student. It might have been better if the actual performance form the academic year was assessed.

4. The discussion tried to compare results with other studies but the why part of the results are not included in the discussion part. As an example the female adolescent's understanding of puberty was higher that male, which might be related to having the onset menses (Menstrual period) during that age under study. So such justifications are important to give the reader in knowing what reasons are linked to the findings of the study.

5. I don't see any limitation of the study included to justify some of the drawbacks which might be very useful for the reader to understand those factors which hinder the researchers.

6. Part of the recommendation can include possible future studies to be done based on the findings of the study.

7. The title of the study relates to impact of school based SRH education, but this is not clearly seen in the study and it might be good to modify the title to represent the study methodology and findings.

Reviewer #3: The paper "Impact of School-based Sexual and Reproductive Health Education among Secondary Student’s Knowledge on Pubertal Changes in Rural Bangladesh" undertakes an interesting topic. It seems like the study has certain potential. The results are interesting and it seems that authors were able to put their findings within the general literature context. However, the study lacks considerably in terms of readability and academic rigor of presentation. Below I present my more specific remarks but I encourage you to thoroughly proof read the manuscript.

Abstract

"parental limit setting" should be explained more thoroughly.

Please refrain from using causal language (e.g., influencing) in your cross-sectional study.

Your claim that some of your variables were "influencing" knowledge on puberty both directly and indirectly suggests that you were using some mediation analysis. The article would benefit if you were more explicit about that fact and also, if you could state the reasons for running mediation analysis.

Instead of simple conclusions, you could provide some policy implications to improve knowledge about pubertal changes in Bangladesh.

Introduction

What do you mean by "To make healthy adults from childhood, ..."? This sentence is very unclear. I would suggest to omit first three sentences in your introduction.

You claim that "society is responsible for ensuring informed puberty" but probably even more responsibility lies in the family and in the schooling system.

Please refrain from using "condition" in relation to puberty. It is rather a developmental stage.

Again, in stating your objectives please refrain from causal language (e.g., affect).

It would be worth describing which elements of bioecological model of Bronfenbrenner were included in your framework and what is the conceptual novelty of your approach. In the current version it is not clear.

The section on data is not clear. Individuals between 10 and 18 or 10 and 24 were sampled? 3014 or 3000 were surveyed? 1504+1509 is not equal to 3014. "VI to IX" or "6-9"?

It is not clear while "outcome variable" is under the heading of "study population". Please explain.

Knowledge of pubertal changes scale should be somehow described. Questionnaire should be put in the appendix. If the scale is used, its psychometric properties should be checked - at least reliability of the scale.

The scales used in the study (PBC, PLS, CD, CPC, PeC, PePC, PeR, TC) should have their psychometric properties checked. Reader should also have access to detailed wording of the items comprising each scale.

Statistical Analysis

Again, please refrain from causal language.

Please elaborate more on specification and estimation of your structural equation model.

Why you have not decided to use latent constructs in your model? Your data is perfectly fit to such an approach.

Results

In the analysis of contextual factors why do you use median when for the socio-economic characteristics you were using mean?

Table 3 contains variable KAP, it is not clear what it means?

Lack of reference categories for variables like "Gender", "Religion" precludes understanding of the results in Table 3.

When presenting indirect effects in Table 4, I would suggest to include mediating variable. It is difficult to understand to which indirect paths the results refer.

Discussion

What is the meaning of SRH? The acronym has not been introduced.

Reviewer #4: Question 1: The Sexual and Reproductive Health Education variable was not included in the questionnaire and in data analysis. The conclusion is based on this intervention variable which was not part of the analysis

Question 3: Some restriction applied on data availability

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Nikita Bhattarai

Reviewer #2: Yes: Mengistu Asnake Kibret

Reviewer #3: No

Reviewer #4: Yes: Tekachew Wana

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: 4.PONE-D-21-15883_reviewer.pdf

Click here for additional data file.

Submitted filename: manuscript paper review.docx

Click here for additional data file.

30 Jul 2021

Response to the editors remarks:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have followed the instruction of PLOS ONE style

2. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Response: In method section we have clearly stated the consent which are taken before data collections.

[line 162 -163]

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Response: ORCID id have been attached.

4. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure.

5. Please include a copy of Table 5 which you refer to in your text on page 11.

Response: There was mistake, actually it was Table -4. We have amended the Table number.

Responses to the reviewers’ remarks:

The manuscript is technically sound and the statistical analysis has been performed appropriately but they have mentioned that data cannot be shared publicly because of the restriction of data authority. However, they can add data course link. The manuscript needs major revisions as sentences are not very clear.

Response: We revised the manuscript. We revised the manuscript.

Reviewer-2

1. The justification given as a rational for the study- "No specific research has been done so far on how parents and our society hinder adolescent's knowledge of pubertal changes."- seems a bit odd. There are several published studies done in rural Bangladesh and several Asian countries and probably specific research might not be done in the specific study area in the past, and it should not be generalized.

Response: We have amended the justification. [Line: 104-107] We have amended the justification. [Line: 104-107]

2. I am not clear if there was a parental consent since the mean age in this study was 14.67 Years. Did the researchers used other mechanisms to ensure parental consent?

Response: Parental consent was taken. We have made an attempt to clarify this issue in line 161-163. Parental consent was taken. We have made an attempt to clarify this issue in line 161-163.

3. One of the variables relate to Student's academic performance by directly asking the student. It might have been better if the actual performance forms the academic year was assessed.

Response: Since adolescents were interviewed from both household and school, it is difficult to assess academic performance forms the academic year performance. Therefore, Student's academic performance by directly asking the student. [Line: 234 – 237] Since adolescents were interviewed from both household and school, it is difficult to assess academic performance forms the academic year performance. Therefore, Student's academic performance by directly asking the student. [Line: 234 – 237]

4. The discussion tried to compare results with other studies but the why part of the results are not included in the discussion part. As an example, the female adolescent's understanding of puberty was higher that male, which might be related to having the onset menses (Menstrual period) during that age under study. So such justifications are important to give the reader in knowing what reasons are linked to the findings of the study.

Response: We have revised the discussion section of the manuscript. We have revised the discussion section of the manuscript.

5. I don't see any limitation of the study included to justify some of the drawbacks which might be very useful for the reader to understand those factors which hinder the researchers.

Response: We have added limitations of the study.

We have added limitations of the study.

6. Part of the recommendation can include possible future studies to be done based on the findings of the study.

Response: We have revised the recommendation section. We have revised the recommendation section.

7. The title of the study relates to impact of school based SRH education, but this is not clearly seen in the study and it might be good to modify the title to represent the study methodology and findings.

Response: We have modified the title as “Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model”

We have modified the title as “Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model”

Reviewer-3

1. The paper "Impact of School-based Sexual and Reproductive Health Education among Secondary Student’s Knowledge on Pubertal Changes in Rural Bangladesh" undertakes an interesting topic. It seems like the study has certain potential. The results are interesting and it seems that authors were able to put their findings within the general literature context. However, the study lacks considerably in terms of readability and academic rigor of presentation. Below I present my more specific remarks but I encourage you to thoroughly proof read the manuscript.

Response: We have revised our manuscript to improve the readability of the manuscript. We have revised our manuscript to improve the readability of the manuscript.

We have replaced "parental limit setting" with “parental limit setting on daily activities ” in the result of the abstract. [ line 22-23]. Moreover, the explanation of “parental limit setting is given in contextual factors under methodology [line: 197 to 203] We have replaced "parental limit setting" with “parental limit setting on daily activities ” in the result of the abstract. [ line 22-23]. Moreover, the explanation of “parental limit setting is given in contextual factors under methodology [line: 197 to 203]

2. Please refrain from using causal language (e.g., influencing) in your cross-sectional study.

Response: We have revised our manuscript and replace the causal language. [line no. 53,55] We have revised our manuscript and replace the causal language. [line no. 53,55]

3. Your claim that some of your variables were "influencing" knowledge on puberty both directly and indirectly suggests that you were using some mediation analysis. The article would benefit if you were more explicit about that fact and also, if you could state the reasons for running mediation analysis.

Response: We have included the reasons of running mediation analysis in the methodology section of the abstract [line 40 to 43] We have included the reasons of running mediation analysis in the methodology section of the abstract [line 40 to 43]

4. Instead of simple conclusions, you could provide some policy implications to improve knowledge about pubertal changes in Bangladesh.

Response: We have revised the conclusion section of the manuscript We have revised the conclusion section of the manuscript.

Introduction

5. What do you mean by "To make healthy dults from childhood, ..."? This sentence is very unclear. I would suggest to omit first three sentences in your introduction.

Response: We have omitted the first three line of the introduction. We have omitted the first three line of the introduction.

6. You claim that "society is responsible for ensuring informed puberty" but probably even more responsibility lies in the family and in the schooling system.

Response: Replacing Society with family.

[line: 87] Replacing Society with family.

[line: 87]

7. Please refrain from using "condition" in relation to puberty. It is rather a developmental stage.

Response: We have made an amendment to refrain from using causal language. We have made an amendment to refrain from using causal language.

8. Again, in stating your objectives please refrain from causal language (e.g., affect).

Response: We have made an amendment to refrain from using causal language We have made an amendment to refrain from using causal language

10. Conceptual Framework

It would be worth describing which elements of bioecological model of Bronfenbrenner were included in your framework and what is the conceptual novelty of your approach. In the current version it is not clear.

Response: We have elaborately described the Conceptual framework section. We have elaborately described the Conceptual framework section.

11.The section on data is not clear. Individuals between 10 and 18 or 10 and 24 were sampled? 3014 or 3000 were surveyed? 1504+1509 is not equal to 3014. "VI to IX" or "6-9"?

Response: Individual between 10-24 were sampled. 3013 were surveyed. We have revised our manuscript with VI-IX. Individual between 10-24 were sampled. 3013 were surveyed. We have revised our manuscript with VI-IX.

12. It is not clear while "outcome variable" is under the heading of "study population". Please explain.

Response: The manuscript is rewritten to increase the clarity of the manuscript. The manuscript is rewritten to increase the clarity of the manuscript.

13. Knowledge of pubertal changes scale should be somehow described. Questionnaire should be put in the appendix. If the scale is used, its psychometric properties should be checked - at least reliability of the scale.

Response: We included the reliability. [ line: 241-247] We included the reliability. [ line: 241-247]

14. The scales used in the study (PBC, PLS, CD, CPC, PeC, PePC, PeR, TC) should have their psychometric properties checked. Reader should also have access to detailed wording of the items comprising each scale.

Response: We included the reliability. [ line: 241-247] We included the reliability. [ line: 241-247]

Statistical Analysis

15. Again, please refrain from causal language.

Response: We have made an amendment to refrain from using causal language. We have made an amendment to refrain from using causal language.

16. Please elaborate more on specification and estimation of your structural equation model.

Response: The statistical analysis section have been rewritten with an elaboration of specification and estimation of structural equation model. [ Line: 256-261] The statistical analysis section have been rewritten with an elaboration of specification and estimation of structural equation model. [ Line: 256-261]

17. Why you have not decided to use latent constructs in your model? Your data is perfectly fit to such an approach.

Response: We have included the explanation of not using latent construct between line 176 to 183. We have included the explanation of not using latent construct between line 176 to 183.

Results

18. In the analysis of contextual factors why do you use median when for the socio-economic characteristics you were using mean?

Response: For continuous socio-economic characteristics, mean have been used and for ordinal contextual factors median have been used. We have included the explanation between line 2513 to 253. For continuous socio-economic characteristics, mean have been used and for ordinal contextual factors median have been used. We have included the explanation between line 2513 to 253.

19.Table 3 contains variable KAP, it is not clear what it means?

Response: We made an attempt to clarify the meaning the variable We made an attempt to clarify the meaning the variable

20. Lack of reference categories for variables like "Gender", "Religion" precludes understanding of the results in Table 3.

Response: We made an amendment of Table 3 with the reference categories. We made an amendment of Table 3 with the reference categories.

21. When presenting indirect effects in Table 4, I would suggest to include mediating variable. It is difficult to understand to which indirect paths the results refer.

Response: We have included a column of mediator variables in Table 4. We have included a column of mediator variables in Table 4.

22. Discussion

What is the meaning of SRH? The acronym has not been introduced.

Response: We have amended the discussion section. [line 374] We have amended the discussion section. [line 374]

Reviewer-4

Question 1: The Sexual and Reproductive Health Education variable was not included in the questionnaire and in data analysis. The conclusion is based on this intervention variable which was not part of the analysis

Response: We have revised our manuscript. We have revised our manuscript.

Question 3: Some restriction applied on data availability

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

3 Sep 2021

PONE-D-21-15883R1

Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model

PLOS ONE

Dear Dr. Methun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Great effort was made by the authors to utilize the feedback that was provided for them to correct. I find it interesting and improved with respect to the original submission. However, there are few minor things to adjust and one major.  Discussion about the specification of the structural equation model (which is vital) is still missing. Please elaborate on your understanding on structural relationships, especially for the part of the model where you.

Please consider reviewers’ comments for more details

Please submit your revised manuscript by Oct 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: All the comments have been addressed, the datas were all available and it has been corrected. The manuscript had been written in standard English.

Reviewer #2: The authors have addressed all the comments and queries provided from my side and don't have additional comments.

Reviewer #3: At first I would like to thank the Authors for addressing the comments raised during the first stage of review. I have a number of minor remarks and one major concern. As for my major reservation, I am still hesitant about the structural model. Authors do not present the initial specification of the structural model and additionally they do not properly justify the links between variables. It is especially concerning for the mediation effects, which should be thoroughly discussed before being implemented in the analysis.

I would suggest revising the statements in lines 175-177 "Latent construct approach is the most suitable approach for measuring. However, to construct a latent variable it is essential to remove observed variables if the correlations between variables is very high or is not high-enough." It is not clear what is the intention behind the statement.

Could you provide a bit more elaborate description of the Kalule-Sabiti method. 2-3 additional sentences could help better understand the approach.

In line 287 you mention that "The structural equation model was over-identified," but it is unclear what kind of specification you suggest for the model. I would suggest that you draw your model with all potential covariates to show your starting specification.

Minor:

"pubertal period" sounds a bit artificial - please change this.

Line 84: should be "prevent"

Line 90 "think" sounds a bit strange in this context.

Line 91: Maybe instead of "mass media", current teenagers refer more to social media.

Line 101: Replace "find out" with "identify"

Line 130: Replace "carried out" with "provided"

Line 139: Revise the sentence.

Figure 1: "framework" instead of "frame work"

Line 222-223: The inverted commas system is not clear.

Line 242: "using" instead of "sing"

Line 163: Shouldn't it be "approved by" instead of "taken from"?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Nikita Bhattarai

Reviewer #2: Yes: Mengistu Asnake Kibret

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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6 Nov 2021

Responses to the remarks of reviewers:

1.I would suggest revising the statements in lines 175-177 "Latent construct approach is the most suitable approach for measuring. However, to construct a latent variable it is essential to remove observed variables if the correlations between variables is very high or is not high-enough." It is not clear what is the intention behind the statement.

Response: We have revised the lines 175-177.

2.Could you provide a bit more elaborate description of the Kalule-Sabiti method. 2-3 additional sentences could help better understand the approach.

Response: We have a brief description of Kalule-Sabiti method in lines 191 to 196.

3. In line 287 you mention that "The structural equation model was over-identified," but it is unclear what kind of specification you suggest for the model. I would suggest that you draw your model with all potential covariates to show your starting specification.

Response: We have explained the specification procedure in lines 293 – 297.

Minor:

"pubertal period" sounds a bit artificial - please change this.

Response: In line 78 and 62, we replace “pubertal period” with “puberty”.

In line 78 changes with puberty. In line 62 changes with puberty

Line 84: should be "prevent"

Response: Replaced.

Line 90 "think" sounds a bit strange in this context.

Response: In line 90, we replace “think” with “Parents left”.

Line 91: Maybe instead of "mass media", current teenagers refer more to social media.

Response: Yes, we have amended the line.

Line 101: Replace "find out" with "identify"

Response: Replaced with identify

Line 130: Replace "carried out" with "provided"

Response: Replaced with “provided”.

Line 139: Revise the sentence.

Figure 1: "framework" instead of "frame work"

Response: Replaced with “framework”

Line 222-223: The inverted commas system is not clear.

Response: The inverted commas system is rearranged.

Line 242: "using" instead of "sing"

Response: Replaced with “using”.

Line 163: Shouldn't it be "approved by" instead of "taken from"?

Response: Replaced with “approved by”.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

9 Dec 2021

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Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: All the comments have been addressed and the manuscript has been written in an intelligible fashion.

Reviewer #3: Dear Authors,

Thank you for your work. I still feel that there are some issues (even if small) that should be addressed before the article is published.

Please be more specific in your statement "parents and peers are negatively associated with adolescent’s understanding of pubertal changes". It is not clear what you mean.

Line 68 "in girls" seems redundant.

Line 77 - "recognize" is not a correct word here (maybe "accept" or "endorse" would be better)

Line 82 - "expose" needs a pronoun here

Line 84 - "prevents" is not correct

Lines 92-94 - the sentences are not clear

"upzila"'s meaning should be explained

Line 182 - still not clear what you mean when you say "using above approach"

Line 186 - instead of saying "independent variables" I would suggest "control variables"

Please read carefully your description of "Contextual factors". It requires a through proof reading.

Line 281 - what do you mean by saying "parental limit setting ranging from 1 to 4 and the upper limit for the remaining variables is 5"?

Line 300 - what is the "model fit test statistic" that you are referring to?

The values of model fit (GFI, RMSEA) are rather acceptable and not good.

In notes for Table 3, please describe the abbreviations used.

Table 3 - please comment whether the coefficients are standardized or unstandardized.

Please avoid causal language in your analysis. Your sample is cross-sectional and words like "affected" should not be used. Replace with "correlated", for example. Check the whole manuscript and eliminate causal language.

I see discrepancies between the coefficients presented in Table 3 and in the description provided in "Direct effects, indirect effects, and total effect". Please correct it.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Nikita Bhattarai

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

24 Jan 2022

Thank you for giving us the opportunity to submit a revised draft of my manuscript titled “Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model” to Plos One. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on my manuscript. We are grateful to the reviewers for their insightful comments on my paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. Here is a point-by-point response to the reviewers’ comments and concerns.

Responses to the remarks of reviewers:

1.Please be more specific in your statement "parents and peers are negatively associated with adolescent’s understanding of pubertal changes". It is not clear what you mean.

Response: We have revised the line. (Line 50 and 51)

2. Line 68 "in girls" seems redundant.

Response: line 60: we deleted "in girls".

3. Line 77 - "recognize" is not a correct word here (maybe "accept" or "endorse" would be better)

Response: line 69 – “recognize’ replaced with “accept”.

4. Line 82 - "expose" needs a pronoun here

Response: line 74- We have added pronoun.

5. Line 84 - "prevents" is not correct

Response: line 76 – we replaced “prevents”.

6. Lines 92-94 - the sentences are not clear

Response: line 84 – 88 – we have amended the sentences.

7. "upzila"'s meaning should be explained

Response: We added the meaning of “upazila” in line 135.

8. Line 182 - still not clear what you mean when you say "using above approach"

Response: line 176-177 – We have revised the sentence.

9. Line 186 - instead of saying "independent variables" I would suggest "control variables"

Response: line 179 - "independent variables" replaced with "control variables".

10. Please read carefully your description of "Contextual factors". It requires a through proof reading.

Response: We have revised contextual factors.

11. Line 281 - what do you mean by saying "parental limit setting ranging from 1 to 4 and the upper limit for the remaining variables is 5"?

Response: The line is revised. (Line 277-278.)

12. Line 300 - what is the "model fit test statistic" that you are referring to?

Response: We have included in line 296.

13. The values of model fit (GFI, RMSEA) are rather acceptable and not good.

Response: We have made amendment the statement. (Line 297 -299).

14. In notes for Table 3, please describe the abbreviations used.

Response: We have added the abbreviations.

15. Table 3 - please comment whether the coefficients are standardized or unstandardized.

Response: standardized

16. Please avoid causal language in your analysis. Your sample is cross-sectional and words like "affected" should not be used. Replace with "correlated", for example. Check the whole manuscript and eliminate causal language.

Response: we made an amendment

17. I see discrepancies between the coefficients presented in Table 3 and in the description provided in "Direct effects, indirect effects, and total effect". Please correct it.

Response: we revised the manuscript.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Feb 2022

Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model

PONE-D-21-15883R3

Dear Dr. Methun,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Thank you for your hard work. My only concern regards the figure 1. In its current form, it suggests that indirect path can run from "community level factors" to "mother's education", which seems pretty unlikely and the causal path is probably not set in a right direction. I would also suggest a proof editing before the final publication. In line 277 something is missing.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

9 Mar 2022

PONE-D-21-15883R3

Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: a structural Equation model

Dear Dr. Methun:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Ammal Mokhtar Metwally

Academic Editor

PLOS ONE