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Biomedical Research

Knowledge and attitude about reproductive health among rural adolescent girls in Kuppam mandal: An intervention study

Author(s): K. Malleshappa, Shivaram Krishna, Nandini C

Vol. 22, No. 3 (2011-07 - 2011-09)

K. Malleshappa1, Shivaram Krishna2, Nandini C1

(1) Department of physiology, P.E.S.Institute of Medical Sciences and research, Kuppam, chittoor dt, Andhra pradesh-517425, India
(2) Department of Community Medicine, P.E.S Institute of Medical Sciences and Research, Kuppam, chittoor dt , Andhra Pradesh, India

Abstract

Adolescents in rural areas may face troubles due to lack of right kind of information regard-ing their own physical and or sexual developments. The need to address this problem through health education by health professionals needs to be ascertained. The objective is to determine the effectiveness of a reproductive health education intervention programme in improving the knowledge of adolescent girls aged between 14-19 years in Kuppam mandal, chittoor dt, Andhra Pradesh. The study was carried out over a period of 8 months. A total of 656 girls in the age group of 14-19 years were randomly selected from 3 high schools (class X) and 3 intermediate colleges(class XI and XII) in kuppam mandal, chittoor dt, Andhra Pradesh. The reproductive health education package developed in consultation with par-ents, teachers and adolescents was used to educate the girls. A 50 item structured question-naire was used to test the knowledge of all the participants about the reproductive health be-fore and after the education session. The data was tabulated and analyzed using SPSS version 11.0 for windows .Findings were described in terms of proportions and percentages, chi square test was used to test the effect of intervention. Reproductive health Knowledge score improved significantly after intervention. A significant increase in overall knowledge re-garding menstrual cycle, ovulation, fertilization and pregnancy by 44.5% was noted (95%CI=42.5,46.5;P<0.001); knowledge regarding contraception improved remarkably from 33.7% to 97.4%(P<0.0001);A significant improvement in the knowledge about trans-mission and prevention of STDs was noted after intervention (P<0.0001). A reproductive health education intervention programme improves the knowledge and attitude among rural adolescent girls regarding reproductive health.

Keywords: Knowledge, adolescent girls, rural area, reproductive health education, intervention
Accepted February 23 2011

Introduction

Adolescents are an important resource of any country. According to the WHO expert committee, adolescence is defined as the period between 10-19yrs, the 2nd decade of life[1]. Adolescents comprise 20% of the world’s total population[2].out of 1.2 billion adolescents world-wide,about 85% live in developing countries[3].In India there are 190 million adolescents comprising 21% of In-dia’s total population[4].Adolescent pregnancies consti-tute 10-15% of total pregnancies in India.This is largely attributed to early marriage,a culture widely prevalent in the whole of Indian subcontinent,besides Africa[5]. The age at marriage is quite low in rural areas and adolescent girls in these communities fall into fertility trap quite ear-ly. These situations predispose girls to teenage pregnancy that may have more immediate effect on their life than any other problem[6].The changing moral and social val-ues and shift in the standard of societal behavior from conservatism to liberal interaction between both sexes is attributed largely to exposure to the media especially tele-vision and movies. Adolescents find themselves sand-wiched between a glamorous western influence and a stern conservatism at home, which strictly forbids discus-sion on sex. This dichotomy aggravates the confusion among adolescents [7]. This has led to increase in pre-marital sexual activity, pregnancy among unmarried girls apart from the increasing incidence of abortion and STDs [8,9]. Among adolescents, girls are particularly vulner-able, not only because they are more likely to be coerced invariably for unprotected sex than Boys, but also they are more susceptible biologically to STDs including HIV infection [10].

In order to lead a healthy, responsible and fulfilling lives and protect themselves from reproductive health problems youngsters need to be knowledgeable about themselves and need adequate information about the physical, psycho-logical changes that take place during puberty, menstrua-tion, pregnancy and child birth [11]. The need to address these problems through reproductive health education has been recognized at various national and international fo-rums. Among the several options available, creating awareness among adolescents appears to be an important tool[13]. However adolescent education programmes in India face many challenges. A lot of debate is going on about how much of the reproductive health contents should be taught? Whether teachers should impart this knowledge or should it be imparted by health profession-als[9,10].

The study was taken up keeping in mind that Kuppam being a small town comprising predominantly of rural population,the study population represents rural adoles-cent girls from southern India.The knowledge and aware-ness levels about reproductive health among rural adoles-cent girls may not be similar to that of their counterparts from urban areas. The need for this study was felt consid-ering the fact that many studies on reproductive health education intervention had focused on urban popula-tion,slums in cities etc.,but none from a rural area.In addi-tion to this,Andhra Pradesh has the second highest num-ber of HIV cases in the country,with a prevalence of 0.90%[14,15] and the prevalence is high in the 15-45 years age group(88.7% of all cases) indicating that assessment of knowledge and awareness levels about reproductive health among adolescents is an important issue based on which the education intervention program can be decided.

This study was conducted to assess the knowledge and awareness levels of adolescent girls about reproductive health and to develop a reproductive health education pack-age for adolescent girls of Kuppam mandal, chittoor dt (Andhra pradesh, India), and to evaluate the effectiveness of reproductive health education by health professionals in improving the knowledge, perceptions and attitude of adolescent girls about reproductive health.

Materials and Methods

This was an intervention study and the study population included girls from 3 intermediate colleges (class XI and XII) and 3 high schools (Class X) of Kuppam mandal in Chittoor district(Andhra pradesh).The demographic pat-tern according to census 2001,shows that females consti-tute about 49% of the total population with agriculture as the main occupation.The female literacy rate is about 58% and that of males is about 75%. Kuppam mandal(taluka) consists of several villages and majority of the students travel to kuppam for schools and colleges. The sampling design was a stratified cluster sampling. The students were stratified on the basis of the year (class X, XI, XII). Each division in a stratum was taken as a cluster. A clus-ter of 40 to 50 students was found to be feasible for inter-vention. Of the 22 clusters, 15 clusters were randomly selected and considering a dropout rate of 10% and design effect of 2, a total of 656 students were included in the study. Willingness to participate in the study was obtained by a verbal consent from the students after taking written consent and requisite permission from school and college principals after explaining the objective of the study. To ensure confidentiality students were asked not to furnish their names.

Reproductive health education package

In consultation with parents, teachers and adolescents, contents of the reproductive health education were final-ized. It was designed to cover the gaps in the knowledge of the adolescents keeping in view the age group of the adolescents and the cultural sensitivities of parents and teachers. The contents included anatomy and physiology of male and female reproductive system, physical and psychological changes during puberty, adolescence, con-ception and contraception, STDs including HIV/AIDS, using a simple language and culture sensitive terms.

Pre test

A total of 656 adolescent girls participated in the pre-test assessment. A pre tested 50 item structured questionnaire was administered, which tested the knowledge and per-ceptions of the study population on puberty changes, menstruation, maintaining hygiene during menstruation, regarding ovulation and fertilization, conception, changes during pregnancy, antenatal care, and also on contracep-tion and STDs.

Intervention

A health education programme was organized in 6 ses-sions, each session lasting for two hours on 6 consecutive days. Programme included a didactic lecture by one of the educators followed by interactive sessions. Audio visual aids such as power point presentation using LCD projec-tor, video films, charts, posters were used. The topics in-cluded were on anatomy and physiology of male and fe-male reproductive system, physical changes during and after puberty, menstrual cycle, pregnancy, antenatal care, various methods of contraception. The lectures were fol-lowed by interactive session with the students.

Post Test

The effect of education program was evaluated immedi-ately following intervention with a post test questionnaire.

The data was analyzed using the statistical package for social sciences (SPSS) version 11. The data was analyzed using proportions and percentages and chi-square test was used to test the effect of intervention.

Results

Table 1 shows the demographic profile of the study popu-lation of the 656 students 554 students were in the age group of 16-17 years with a mean of 16.68 years .Table 2 shows that the students’ knowledge about puberty changes improved significantly after intervention (P<0.005). Students had a good knowledge regarding age at first menses and maintaining hygiene during menses at pre-test. About 49.5% of the students were not aware about ovulation. Their knowledge about ovulation im-proved from 49.5% to 96.1% (P<0.001), and regarding menstruation and menstrual hygiene, improved signifi-cantly from 78.3% to 96.4% and from 92.5% to 98.9% respectively after intervention (P<0.005). Table 3 shows that only about 74.2% of participants were aware about missed period as the first sign of pregnancy.The interven-tion significantly improved participants’ knowledge (P<0.001).

Table 4 shows that awareness of students regarding dif-ferent contraceptive methods. It was observed that their knowledge was poor during per-test and remarkable im-provement was noted following intervention (P<0.0001)

Table 5 shows the knowledge of the participants regard-ing STDs especially HIV/AIDS and its prevention. Their knowledge improved remarkably following intervention (P<0.0001)

Table 1. Demographic profile of study population

Demographic variable (n-656)
  No %
Age group(yrs)
15.15.9 56 8.5
16-16.9 224 34.1
17-17.9 330 50.3
18-18.9 42 6.4
19-19.9 4 0.6
Socio-economic status
Lower 338 51.52
Middle 212 32.31
Upper 106 16.15
Education
Class 10th 113 17.22
Class 11th 355 54.11
Class 12th 188 28.65

Table 2. Knowledge related to puberty,menstruation and menstrual hygiene

  Pre-test
(n-656)
Post-test
(n-656)
‘p’
No. % No. %
Usual age of first menses(9-16yrs) 625 95.2 656 100 <0.05
Usual interval between 2 Menstrual cycles (1 month) 514 78.3 633 96.4 <0.05
Ovulation is release of matured Egg from the ovary 325 49.5 631 96.1 <0.001
Sanitary napkin/clean cloth should be used during menses,& also changed regularly 642 97.8 656 100 <0.05
breasts enlarge in puberty 608 92.6 656 100 <0.05
hips broaden in puberty 572 572 651 99.2 <0.05
pubic hair grow in puberty 593 90.3 654 99.6 <0.05

Table 3. knowledge related to pregnancy and antenatal care

  Pre-test
(n-656)
Post-test
(n-656)
‘p’
No. % No. %
Usual age of first menses(9-16yrs) 625 95.2 656 100 <0.05
Usual interval between 2 Menstrual cycles (1 month) 514 78.3 633 96.4 <0.05
Ovulation is release of matured Egg from the ovary 325 49.5 631 96.1 <0.001
Sanitary napkin/clean cloth should be used during menses,& also changed regularly 642 97.8 656 100 <0.05
breasts enlarge in puberty 608 92.6 656 100 <0.05
hips broaden in puberty 572 572 651 99.2 <0.05
pubic hair grow in puberty 593 90.3 654 99.6 <0.05

Table 4. Knowledge about various contraceptive methods

  pre-test
(n-656)
post-test
(n-656)
‘p’
Questions no % no %
Do not know 435 66.3 4 0.6 <0.0001
Oral contraceptives 228 34.7 639 97.4 <0.0001
Condoms 184 28.0 613 93.4 <0.0001
IUCD/copper T 96 14.6 598 99.1 <0.0001
Tubectomy 102 15.5 587 89.4 <0.0001
Vasectomy 54 8.2 78 11.8 <0.05
Small family norm means Family with 2 children (agree) 644 98.1 656 100 >0.05

Table 5. Kknowledge about STDs

  pre-test
(n-656)
post-test
(n-656)
‘p’
Questions no % no %
Do not know 435 66.3 4 0.6 <0.0001
Oral contraceptives 228 34.7 639 97.4 <0.0001
Condoms 184 28.0 613 93.4 <0.0001
IUCD/copper T 96 14.6 598 99.1 <0.0001
Tubectomy 102 15.5 587 89.4 <0.0001
Vasectomy 54 8.2 78 11.8 <0.05
Small family norm means Family with 2 children (agree) 644 98.1 656 100 >0.05

Table 5. Kknowledge about STDs

  pre-test
(n-656)
post-test
(n-656
‘p’
Questions No % No %
Sex with multiple partners
Can cause STDs(agree)
32 4.8 610 92.9 <0.0001
Sex with condom is safe sex
(agree)
49 7.4 626 95.4 <0.0001
AIDS can be prevented by
Condom (agree)
105 16.0 641 97.7 <0.0001
AIDS can be prevented by
Single sex partner(agree)
92 14.0 639 97.4 <0.0001
AIDS can be prevented by
Safe blood(agree)
140 21.3 634 96.6 <0.0001
AIDS can be prevented by Sterile needles & syringes(agree) 178 27.1 651 99.2 <0.0001

Discussion

This study evaluated the effect of health education by health professionals on adolescent girls’ knowledge and attitudes towards reproductive health. Remarkable im-provement was seen with relation to knowledge of par-ticipants about puberty, menstrual cycle, pregnancy, con-traception and also transmission and prevention of STDs. Various studies have shown the effectiveness of interven-tion in increasing the knowledge of reproductive health [12,13,16,17]. Studies conducted in developed countries have also shown that girls have good knowledge and use contraceptives to prevent unwanted pregnancies[22]. The present study indicates that the adolescent girls in rural areas are still ignorant about many aspects of reproductive health especially regarding contraceptive methods. The findings of this study regarding awareness of girls about contraception concur with findings of some of the other Indian studies [19,20,21]. Similar findings have been noted in other developing countries as well [18,22,23]

A comprehensive adolescent reproductive health program can provide right information at right age. Teachers in schools and colleges often find it difficult to discuss the topics related with reproduction. It is commonly observed that they ask students to read these topics on their own from the text book. They are often unable to break the barrier of hesitation. Parents’ position in this regard is more sensitive. They also lack the confidence and skills to address the psychosocial and sexuality related prob-lems of adolescents. Reproductive health education by a health professional has become acceptable for adolescent girls in urban areas, however acceptability in rural areas and among non school-going adolescents need to be as-certained before universal application of the proposed reproductive health education package [16]. Intervention in the form of health education increases the awareness level among adolescent girls especially in rural areas like Kuppam where majority of them belong to low socio eco-nomic status, thus empowering them to take care of their own health as well as protect themselves from possible health problems like unwanted pregnancies, risk of STDs in their future life

Conclusion

This study suggest that reproductive health education by health professionals can improve the knowledge and per-ceptions of adolescent girls especially in rural areas. Such educational intervention programs must be given due im-portance, which will help the adolescent girls to take care of their own health and protect themselves from the risk of STDs etc.

Acknowledgment

The authors thank all the teachers and students involved in the study for their cooperation

Limitations of the study:

The study has certain limitations in terms of sample size. There is need for more such studies particularly from ru-ral areas, as the assessment of knowledge and awareness is crucial before initiating educational intervention pro-grams,especially in states like Andhra Pradesh where the prevalence of HIV cases is quite high, to educate the peo-ple from an early age.

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Correspondence to:
K. Malleshappa

Department of Physiology
P.E.S.Institute of medical Sciences and Research
Kuppam, Chittoor District
Andhra Pradesh 517425 India

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