Reproductive Health Education Intervention Trial
http://www.100md.com
《美国医学杂志》
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Abstract
Objective: To measure the effectiveness of a reproductive health education package in improving the knowledge of adolescent girls aged 15-19 years in Chandigarh (India). Methods: A reproductive health education package, developed in consultation with parents, teachers and adolescents, was delivered to randomly sampled classes of two senior secondary schools and one school was selected as control. In one school, a nurse conducted 15 sessions for 94 students in three batches using conventional education approach. In another school she conducted sessions for a selected group of 20 adolescents who later disseminated the messages informally to their 84 classmates (peer education). Using a 70-item structured questionnaire the knowledge of 95 adolescents from conventional, 84 from peer, and 94 from control school were assessed before and one month after the last session. Change in the score in intervention and control groups was tested by ANOVA taking age and socio-economic status as covariates. Results : Teachers, parents and students overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education program. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of pre-marital sexual relations. Reproductive health knowledge scores improved significantly after intervention in conventional education (27.28) and peer education group (20.77) in comparison to the controls (3.64). Post-test scores were not significantly different between peer education group and conventional education group (43.65 and 40.52 respectively) though the time consumed in delivering the peer education intervention was almost one third of the time taken to implement conventional education. Conclusion: Peer education and conventional education strategies were effective in improving the reproductive health knowledge of adolescent girls but peer strategy was less time consuming.
Keywords: Adolescence; Health education; Reproductive health; Knowledge; Peer education; Cluster randomized trial
Adolescents are an important resource of any country. They have successfully passed the adversaries of early childhood and are on their way to adulthood. On this way they may face troubles due to lack of right kind of information regarding their own physical and or sexual development. The need of career enhancement forces adolescents and youth to marry late specially those living in urban areas. Consequently, the period between the onset of puberty and marriage has increased predisposing them to risky sexual adventures. On the other hand, among illiterates the age at marriage is quite low particularly in rural areas and urban slums. Thus girls in these communities fall into fertility trap quite early during adolescence. These situations predispose girls to teenage pregnancy that may have more immediate effect on their life than any other problem.[1]
Increasing penetration of international mass media is changing the social values and shifting the standard of societal behaviour from conservatism to liberal interactions between both sexes. Adolescents find themselves sandwitched between a glamorous western influence, which arouses their curiosities and instincts, and a stern conservatism at home, which strictly forbids discussion on sex. This dichotomy aggravates the confusion among adolescents.[2]
Changes in social values may lead to increased premarital sexual activity, pregnancy and possibly child bearing among unmarried girls, apart from the increasing incidence of abortion and STDs.[3],[4]
The need to address these problems through adolescent health education has been recently recognised at various national and international forums. Various government and non-government organisations are trying to develop acceptable and effective reproductive health education packages for adolescents. However, adolescent education programmes in India face many challenges. How much of the reproductive health contents should be taught Whether to include sex education in details or just skip it by a passing reference Whether teachers, health professionals or parents themselves should educate adolescents on these aspects Can there be a positive role of peers in this regard The content and methodology of adolescent reproductive health education remains unclear. Therefore, a study was conducted to develop a reproductive health education package for adolescent girls of Chandigarh (India), and to evaluate its effectiveness in improving their knowledge and perceptions about reproductive health when delivered through different health educational strategies like peer education and conventional education.
Materials and methods
Reproductive Health Education Package
In consultation with parents, teachers and adolescents, contents of the reproductive health education were finalized. The educational package consisted of a guidebook for the educator and self-reading material for the adolescents. 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. An effort was made that it does not reveal unnecessary information and at the same time it provides requisite information using a simple language and culture sensitive terms. The contents of the reproductive health education package consisted of anatomy and physiology of male and female reproductive system, physical and sexual changes during adolescence, menstrual cycle, conception and contraception, nutritional requirements, immunizations, provisions of Child Marriage Restraint Act and Medical Termination of Pregnancy Act, reproductive tract infections and sexually transmitted diseases including HIV/AIDS.
Study Design
An experimental design was adopted to carry out the study among female students of class X, XI and XII in three randomly selected Government Girls Senior Secondary Schools of Chandigarh, India. For sample size estimation, it was assumed that knowledge would increase by 20% after reproductive health education intervention, i.e., from 20% to 40% in the intervention groups. At 95% confidence interval, power of 80%, ratio of control to intervention 1:1, sample size was estimated to be 100 for each of the intervention groups and 100 for the control group.
A two stage-sampling scheme was followed. In the first stage, schools were selected randomly and in the second stage classes from the selected schools were sampled randomly. One school was taken as control and two of the schools were assigned to one of the experimental group, i.e., (a) Conventional Approach: education to a group of students directly by the educator, (b) Peer Approach: education of peer educators directly by the educator, later peer educators communicated the messages actively to their classmates. Using a 70-item structured questionnaire the knowledge and perceptions of the students was assessed before and one month after the last reproductive health education session in each experimental school and at the beginning and at the end of the study period in the control school. In addition, parents and teachers of the schools were also interviewed to find out their attitude to reproductive health education of adolescents.
Health Education Strategy
Before initiating the intervention, consent of teachers, parents and students was taken. In the conventional education school, a total of 95 students were divided into three groups, each having 30-35 students. A public health nurse conducted health education sessions twice a week. Average duration of each session was 45 minutes. After each session, self-reading material was given to the students. Fifteen education sessions were conducted to cover all aspects of the reproductive health. It took 9 months to implement the intervention to the three groups in the conventional education school. In the peer education school, investigator delivered the reproductive health education to only a group of 20 students identified by the teachers as peer educators on the basis of their communication and leadership skills. They were also trained by the investigator to disseminate message to others in their class. Reproductive health education of the peer educators was done in the same way as in the conventional education group. For them the education sessions were also arranged twice a week so that they had enough time to educate their peers. It took three months to complete their education. To minimize the anxiety and to answer queries of the students, if any, individual and group counselling was done in both the schools after the sessions.
Data Analysis
To assess the knowledge, correct responses in the pre-test and post-test were assigned scores. All correct responses were given equal weightage. The minimum score was zero and maximum was seventy. The scores were also computed separately for the section on puberty changes including menstruation, MCH and family planning, and RTIs/STDs/ HIV/AIDS. Chi-square test was used to test the significance of difference in proportions. Paired t-test was also used to test the statistical significance of change in score at pre-test and post-test in each of the intervention and control groups. Unpaired t-test was applied to test the statistical significance of difference in pre-test and post-test score of each group with that of control group. Analysis of variance was done taking change in score in the intervention groups as dependent variable and age and socio-economic status as covariates. The p value of < 0.05 was considered to be significant.
Results
Socio-demographic characteristics of the study population are presented in table1. The mean age of the adolescents was 16.47 years (SD 0.83; range 15-20 years). Adolescents in the control school were significantly younger than in the intervention schools (p<0.01), however, mean age in both the intervention groups was not significantly different (p=0.1). Forty percent of the adolescents belonged to middle class, 22.5% were from upper middle class and 20% were from lower middle class families. Twenty two percent of the respondents in the control group belonged to higher social status compared to 6% to 12% in the intervention groups (p<0.01).
Teachers, parents and adolescents overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education. Regarding timing of such education, 22% adolescents were of the view that it may be imparted after marriage, however, 75% felt the need for it before the onset of menarche, and 13% opined that it should be done after menarche.
Mothers were quoted as the most important source for providing information on menstruation (70%) followed by sister or sister-in-law (41%) and friends (39%). Teachers and health professionals did not play an important role in this regard. For providing information on reproductive system, parents (38%) ranked at number one followed by teachers (26%) and sister/sister-in-law (23%). When asked who should impart reproductive health education to them, 64% preferred teachers, 48% chose doctors, 50% favoured nurses, and 14% selected parents. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of sexual relations before marriage.
The distribution of reproductive health knowledge score of the adolescents at pre-test and post-test is presented in Figure1 and table2. The mean scores improved significantly in all the groups. However, highest increase in mean scores occurred in conventional education group followed closely by peer education group. The change in knowledge scores in both the intervention groups were significantly higher in comparison to the controls even after accounting for the differences in age and socio-economic status in various groups by ANOVA test.
The post-test scores of conventional education group were similar to post-test scores of peer education group. Thus, it can be concluded that peer education was equally effective in achieving knowledge levels similar to that in the conventional education group. It is interesting to observe that the time consumed in educating adolescents in peer education was one third of the time taken to implement the conventional education approach.
Comparison of knowledge on various aspects of reproductive health revealed significant increase in each aspect except that for some specific aspects there were differences in the effectiveness of conventional education and peer education strategies table3. For example, the knowledge ' swapan dosh' , i.e., emission of semen during sleep increased from 3% to 93% in conventional education group, whereas it increased from 7% to 38% in peer education group.
Discussion
Introduction of reproductive health education through a public health nurse was found to be feasible. The package was effective in improving the knowledge level of adolescent girls on various issues related to reproductive health table3, Figure1. It was observed that peer education strategy was equally effective in achieving similar level of knowledge about reproductive health compared to the conventional education table2. However, peer education strategy was found to be more cost effective compared to conventional education. Average time spent on educating in conventional education group was three times more than that in peer education group as less number of adolescents (only peer educators) were imparted education directly in peer education group. Other studies have also reported successful implementation of reproductive and sexual health education through various health education approaches including the peer education approach.[5]-[8]
On some aspects of reproductive health for example knowledge related to HIV transmission and prevention was quite high even in control school table3. This is because during the intervention period a lecture was delivered in this school by state AIDS control program. An earlier and later evaluation with concurrent control design thus helps in revealing the true change due to intervention. In the absence of control it is not possible to ascertain the effect of intervention.
A comprehensive adolescent reproductive health programme can provide biomedical information through didactic education methods like lecture, films, charts, planned graph, exhibits and splash etc, and influence the attitudes and behaviour through participatory approach like group teaching.[9] Print and audio-visual mass media can also influence adolescents' behaviour. However, these sources are not proving to be effective in providing the right information at right age. Teachers 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 textbook. They are often unable to break the barrier of hesitation and feel incompetent to deal with topics related to sexuality. Only 26% respondents had acquired information from teachers although 64% think that teachers are the best source of information on reproductive health issues. Parents' position is more sensitive. They also lack the confidence and skills to address the psychosocial and sexuality related problems of the adolescents. Interface of schools with health professionals is usually not very strong in India. Thus peers remain the only choice from where adolescents learn, who in turn learn from mass media, pornography, magazines etc.
Reproductive health education by a health professional was acceptable for school going adolescent girls in urban area, however, acceptability in rural areas, urban slums and non-school going adolescents need to be ascertained before universal application of the proposed reproductive health education package. Peer education strategy is effective and less time consuming compared to conventional education, therefore, in resource restrained situations like the one in India where health professionals are overburdened with curative care, peer education strategy should be adopted rather than conventional education. A review recently has concluded that primary prevention strategies are not successful in delaying the initiation of sexual intercourse.[10] This review has focussed on studies from developed countries, as good quality professional studies on this issue are not available from developing countries where socio-cultural conditions are quite different and level of sexual activity is low compared to many developed countries. In Chandigarh schools traditional adolescents had lower level of sexual activity (OR 0.8; 95% CI 0.6-0.9) compared to their westernized counterparts.[11] Though 11% boys in 11th class have experienced kissing, 5% had hugged a female but only 4% had sexual intercourse whereas among females 4% have experienced kissing, 1% had hugging and only 1% had sexual intercourse. Mean age at sexual debut was 15 years among both males and females. Efficacy of reproductive health education in changing the behaviour of adolescents should also be ascertained in developing countries by follow-up study of the adolescents for few years after the intervention.
References
1. Benson MD, Perlman C, Sciarra JJ. Sex education in the inner setting: Learning and retention. J Amer Med Association 1986; 255: 43-47.
2. Sharma V, Sharma A. The letter box approach - A model for sex education in an orthodox society. J Fam Welfare 1995; 41: 31-33.
3. Gupta RB, Khan ME. Teenage fertility. Some results from a baseline survey in Uttar Pradesh. J Fam Welfare 1996; 42: 14 -20
4. Kothari P. The need of sex education for adolescents in India. Report of the National Seminar. New Delhi: National Council of Education Research and Training, 1994
5. Siegel DM, Aten MJ, Roghmann KJ, Enaharo M. Early effects of a school-based human immunodeficiency virus infection and sexual risk prevention intervention. Arch Pediat Adolsc Med 1998; 152: 961-970.
6. Mbizvo MT, Kasule J, Gupta V et al. Effects of a randomized health education intervention on aspects of reproductive health knowledge and reported behaviour among adolescents in Zimbabwe. Soc Sc Med 1997; 44 : 573-577.
7. Boyer CB, Shafer MA, Tschann JM. Evaluation of knowledge and cognitive behavioural skills building intervention to prevent STDs and HIV infection in high school students. Adolescence 1997; 32 (125): 25-42.
8. Agha S. An evaluation of the effectiveness of a peer sexual health intervention among secondary school students in Zambia. AIDS Educ and Prevention 2002; 14: 269-281.
9. World Health Organisation. School health education to prevent AIDS and sexually transmitted diseases. Geneva, World Health Organisation, 1992.
10. DiCenso A, Guyatt G, Griffith WL. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomized controlled trials. Br Med Journal 2002; 324; 1426-1450.
11. Lakshmi PVM. Sexual behaviour in adolescence: psychosocial correlation. Doctor of Medicine Thesis. Post Graduate Institute of Medical Education and Research, Chandigarh, India, 2002.(Parwej Saroj, Kumar Rajes)
Abstract
Objective: To measure the effectiveness of a reproductive health education package in improving the knowledge of adolescent girls aged 15-19 years in Chandigarh (India). Methods: A reproductive health education package, developed in consultation with parents, teachers and adolescents, was delivered to randomly sampled classes of two senior secondary schools and one school was selected as control. In one school, a nurse conducted 15 sessions for 94 students in three batches using conventional education approach. In another school she conducted sessions for a selected group of 20 adolescents who later disseminated the messages informally to their 84 classmates (peer education). Using a 70-item structured questionnaire the knowledge of 95 adolescents from conventional, 84 from peer, and 94 from control school were assessed before and one month after the last session. Change in the score in intervention and control groups was tested by ANOVA taking age and socio-economic status as covariates. Results : Teachers, parents and students overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education program. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of pre-marital sexual relations. Reproductive health knowledge scores improved significantly after intervention in conventional education (27.28) and peer education group (20.77) in comparison to the controls (3.64). Post-test scores were not significantly different between peer education group and conventional education group (43.65 and 40.52 respectively) though the time consumed in delivering the peer education intervention was almost one third of the time taken to implement conventional education. Conclusion: Peer education and conventional education strategies were effective in improving the reproductive health knowledge of adolescent girls but peer strategy was less time consuming.
Keywords: Adolescence; Health education; Reproductive health; Knowledge; Peer education; Cluster randomized trial
Adolescents are an important resource of any country. They have successfully passed the adversaries of early childhood and are on their way to adulthood. On this way they may face troubles due to lack of right kind of information regarding their own physical and or sexual development. The need of career enhancement forces adolescents and youth to marry late specially those living in urban areas. Consequently, the period between the onset of puberty and marriage has increased predisposing them to risky sexual adventures. On the other hand, among illiterates the age at marriage is quite low particularly in rural areas and urban slums. Thus girls in these communities fall into fertility trap quite early during adolescence. These situations predispose girls to teenage pregnancy that may have more immediate effect on their life than any other problem.[1]
Increasing penetration of international mass media is changing the social values and shifting the standard of societal behaviour from conservatism to liberal interactions between both sexes. Adolescents find themselves sandwitched between a glamorous western influence, which arouses their curiosities and instincts, and a stern conservatism at home, which strictly forbids discussion on sex. This dichotomy aggravates the confusion among adolescents.[2]
Changes in social values may lead to increased premarital sexual activity, pregnancy and possibly child bearing among unmarried girls, apart from the increasing incidence of abortion and STDs.[3],[4]
The need to address these problems through adolescent health education has been recently recognised at various national and international forums. Various government and non-government organisations are trying to develop acceptable and effective reproductive health education packages for adolescents. However, adolescent education programmes in India face many challenges. How much of the reproductive health contents should be taught Whether to include sex education in details or just skip it by a passing reference Whether teachers, health professionals or parents themselves should educate adolescents on these aspects Can there be a positive role of peers in this regard The content and methodology of adolescent reproductive health education remains unclear. Therefore, a study was conducted to develop a reproductive health education package for adolescent girls of Chandigarh (India), and to evaluate its effectiveness in improving their knowledge and perceptions about reproductive health when delivered through different health educational strategies like peer education and conventional education.
Materials and methods
Reproductive Health Education Package
In consultation with parents, teachers and adolescents, contents of the reproductive health education were finalized. The educational package consisted of a guidebook for the educator and self-reading material for the adolescents. 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. An effort was made that it does not reveal unnecessary information and at the same time it provides requisite information using a simple language and culture sensitive terms. The contents of the reproductive health education package consisted of anatomy and physiology of male and female reproductive system, physical and sexual changes during adolescence, menstrual cycle, conception and contraception, nutritional requirements, immunizations, provisions of Child Marriage Restraint Act and Medical Termination of Pregnancy Act, reproductive tract infections and sexually transmitted diseases including HIV/AIDS.
Study Design
An experimental design was adopted to carry out the study among female students of class X, XI and XII in three randomly selected Government Girls Senior Secondary Schools of Chandigarh, India. For sample size estimation, it was assumed that knowledge would increase by 20% after reproductive health education intervention, i.e., from 20% to 40% in the intervention groups. At 95% confidence interval, power of 80%, ratio of control to intervention 1:1, sample size was estimated to be 100 for each of the intervention groups and 100 for the control group.
A two stage-sampling scheme was followed. In the first stage, schools were selected randomly and in the second stage classes from the selected schools were sampled randomly. One school was taken as control and two of the schools were assigned to one of the experimental group, i.e., (a) Conventional Approach: education to a group of students directly by the educator, (b) Peer Approach: education of peer educators directly by the educator, later peer educators communicated the messages actively to their classmates. Using a 70-item structured questionnaire the knowledge and perceptions of the students was assessed before and one month after the last reproductive health education session in each experimental school and at the beginning and at the end of the study period in the control school. In addition, parents and teachers of the schools were also interviewed to find out their attitude to reproductive health education of adolescents.
Health Education Strategy
Before initiating the intervention, consent of teachers, parents and students was taken. In the conventional education school, a total of 95 students were divided into three groups, each having 30-35 students. A public health nurse conducted health education sessions twice a week. Average duration of each session was 45 minutes. After each session, self-reading material was given to the students. Fifteen education sessions were conducted to cover all aspects of the reproductive health. It took 9 months to implement the intervention to the three groups in the conventional education school. In the peer education school, investigator delivered the reproductive health education to only a group of 20 students identified by the teachers as peer educators on the basis of their communication and leadership skills. They were also trained by the investigator to disseminate message to others in their class. Reproductive health education of the peer educators was done in the same way as in the conventional education group. For them the education sessions were also arranged twice a week so that they had enough time to educate their peers. It took three months to complete their education. To minimize the anxiety and to answer queries of the students, if any, individual and group counselling was done in both the schools after the sessions.
Data Analysis
To assess the knowledge, correct responses in the pre-test and post-test were assigned scores. All correct responses were given equal weightage. The minimum score was zero and maximum was seventy. The scores were also computed separately for the section on puberty changes including menstruation, MCH and family planning, and RTIs/STDs/ HIV/AIDS. Chi-square test was used to test the significance of difference in proportions. Paired t-test was also used to test the statistical significance of change in score at pre-test and post-test in each of the intervention and control groups. Unpaired t-test was applied to test the statistical significance of difference in pre-test and post-test score of each group with that of control group. Analysis of variance was done taking change in score in the intervention groups as dependent variable and age and socio-economic status as covariates. The p value of < 0.05 was considered to be significant.
Results
Socio-demographic characteristics of the study population are presented in table1. The mean age of the adolescents was 16.47 years (SD 0.83; range 15-20 years). Adolescents in the control school were significantly younger than in the intervention schools (p<0.01), however, mean age in both the intervention groups was not significantly different (p=0.1). Forty percent of the adolescents belonged to middle class, 22.5% were from upper middle class and 20% were from lower middle class families. Twenty two percent of the respondents in the control group belonged to higher social status compared to 6% to 12% in the intervention groups (p<0.01).
Teachers, parents and adolescents overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education. Regarding timing of such education, 22% adolescents were of the view that it may be imparted after marriage, however, 75% felt the need for it before the onset of menarche, and 13% opined that it should be done after menarche.
Mothers were quoted as the most important source for providing information on menstruation (70%) followed by sister or sister-in-law (41%) and friends (39%). Teachers and health professionals did not play an important role in this regard. For providing information on reproductive system, parents (38%) ranked at number one followed by teachers (26%) and sister/sister-in-law (23%). When asked who should impart reproductive health education to them, 64% preferred teachers, 48% chose doctors, 50% favoured nurses, and 14% selected parents. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of sexual relations before marriage.
The distribution of reproductive health knowledge score of the adolescents at pre-test and post-test is presented in Figure1 and table2. The mean scores improved significantly in all the groups. However, highest increase in mean scores occurred in conventional education group followed closely by peer education group. The change in knowledge scores in both the intervention groups were significantly higher in comparison to the controls even after accounting for the differences in age and socio-economic status in various groups by ANOVA test.
The post-test scores of conventional education group were similar to post-test scores of peer education group. Thus, it can be concluded that peer education was equally effective in achieving knowledge levels similar to that in the conventional education group. It is interesting to observe that the time consumed in educating adolescents in peer education was one third of the time taken to implement the conventional education approach.
Comparison of knowledge on various aspects of reproductive health revealed significant increase in each aspect except that for some specific aspects there were differences in the effectiveness of conventional education and peer education strategies table3. For example, the knowledge ' swapan dosh' , i.e., emission of semen during sleep increased from 3% to 93% in conventional education group, whereas it increased from 7% to 38% in peer education group.
Discussion
Introduction of reproductive health education through a public health nurse was found to be feasible. The package was effective in improving the knowledge level of adolescent girls on various issues related to reproductive health table3, Figure1. It was observed that peer education strategy was equally effective in achieving similar level of knowledge about reproductive health compared to the conventional education table2. However, peer education strategy was found to be more cost effective compared to conventional education. Average time spent on educating in conventional education group was three times more than that in peer education group as less number of adolescents (only peer educators) were imparted education directly in peer education group. Other studies have also reported successful implementation of reproductive and sexual health education through various health education approaches including the peer education approach.[5]-[8]
On some aspects of reproductive health for example knowledge related to HIV transmission and prevention was quite high even in control school table3. This is because during the intervention period a lecture was delivered in this school by state AIDS control program. An earlier and later evaluation with concurrent control design thus helps in revealing the true change due to intervention. In the absence of control it is not possible to ascertain the effect of intervention.
A comprehensive adolescent reproductive health programme can provide biomedical information through didactic education methods like lecture, films, charts, planned graph, exhibits and splash etc, and influence the attitudes and behaviour through participatory approach like group teaching.[9] Print and audio-visual mass media can also influence adolescents' behaviour. However, these sources are not proving to be effective in providing the right information at right age. Teachers 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 textbook. They are often unable to break the barrier of hesitation and feel incompetent to deal with topics related to sexuality. Only 26% respondents had acquired information from teachers although 64% think that teachers are the best source of information on reproductive health issues. Parents' position is more sensitive. They also lack the confidence and skills to address the psychosocial and sexuality related problems of the adolescents. Interface of schools with health professionals is usually not very strong in India. Thus peers remain the only choice from where adolescents learn, who in turn learn from mass media, pornography, magazines etc.
Reproductive health education by a health professional was acceptable for school going adolescent girls in urban area, however, acceptability in rural areas, urban slums and non-school going adolescents need to be ascertained before universal application of the proposed reproductive health education package. Peer education strategy is effective and less time consuming compared to conventional education, therefore, in resource restrained situations like the one in India where health professionals are overburdened with curative care, peer education strategy should be adopted rather than conventional education. A review recently has concluded that primary prevention strategies are not successful in delaying the initiation of sexual intercourse.[10] This review has focussed on studies from developed countries, as good quality professional studies on this issue are not available from developing countries where socio-cultural conditions are quite different and level of sexual activity is low compared to many developed countries. In Chandigarh schools traditional adolescents had lower level of sexual activity (OR 0.8; 95% CI 0.6-0.9) compared to their westernized counterparts.[11] Though 11% boys in 11th class have experienced kissing, 5% had hugged a female but only 4% had sexual intercourse whereas among females 4% have experienced kissing, 1% had hugging and only 1% had sexual intercourse. Mean age at sexual debut was 15 years among both males and females. Efficacy of reproductive health education in changing the behaviour of adolescents should also be ascertained in developing countries by follow-up study of the adolescents for few years after the intervention.
References
1. Benson MD, Perlman C, Sciarra JJ. Sex education in the inner setting: Learning and retention. J Amer Med Association 1986; 255: 43-47.
2. Sharma V, Sharma A. The letter box approach - A model for sex education in an orthodox society. J Fam Welfare 1995; 41: 31-33.
3. Gupta RB, Khan ME. Teenage fertility. Some results from a baseline survey in Uttar Pradesh. J Fam Welfare 1996; 42: 14 -20
4. Kothari P. The need of sex education for adolescents in India. Report of the National Seminar. New Delhi: National Council of Education Research and Training, 1994
5. Siegel DM, Aten MJ, Roghmann KJ, Enaharo M. Early effects of a school-based human immunodeficiency virus infection and sexual risk prevention intervention. Arch Pediat Adolsc Med 1998; 152: 961-970.
6. Mbizvo MT, Kasule J, Gupta V et al. Effects of a randomized health education intervention on aspects of reproductive health knowledge and reported behaviour among adolescents in Zimbabwe. Soc Sc Med 1997; 44 : 573-577.
7. Boyer CB, Shafer MA, Tschann JM. Evaluation of knowledge and cognitive behavioural skills building intervention to prevent STDs and HIV infection in high school students. Adolescence 1997; 32 (125): 25-42.
8. Agha S. An evaluation of the effectiveness of a peer sexual health intervention among secondary school students in Zambia. AIDS Educ and Prevention 2002; 14: 269-281.
9. World Health Organisation. School health education to prevent AIDS and sexually transmitted diseases. Geneva, World Health Organisation, 1992.
10. DiCenso A, Guyatt G, Griffith WL. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomized controlled trials. Br Med Journal 2002; 324; 1426-1450.
11. Lakshmi PVM. Sexual behaviour in adolescence: psychosocial correlation. Doctor of Medicine Thesis. Post Graduate Institute of Medical Education and Research, Chandigarh, India, 2002.(Parwej Saroj, Kumar Rajes)