To assess the effect of advocacy, communication, training and social mobilisation (ACTS) on ‘Adolescent Reproductive and Sexual Health’ (ARSH) among adolescent girls in tribal areas of Panvel Taluka, Dist. Raigad

 

Aalia Thingna¹, Pradeep N Sawardekar^2*, Seema Anjenaya³, Madhavi Mankar⁴, Rupali Gujar⁵,

Sunita Thorat⁶, Shyamal Kamble⁷

 

¹Medical Intern, ²Professor, ³Professor and HOD, ⁴Associate Professor, ⁵MSW, Department of Community Medicine, MGMMC, Navi Mumbai, Maharashtra, INDIA.

⁶MSW, ⁷Medical Intern, CPR Medical College, Kolhapur, Maharashtra, INDIA.

Email: aaliathingna@gmail.com, drpnsk@gmail.com

 

Abstract               Objective: To understand the level of existing knowledge about reproductive and sexual health and the measures required in ameliorating their condition. Furthermore, to further encourage involvement of more people towards the education and awareness of adolescent girls in rural and tribal areas of India. Design: Community based interventional study. Setting: 4 villages namely, Tara, Dolghar, Kalhe and Barapada were identified for the study. The data was collected over a period of 2 months (May-June 2014). Participants: A sample size of 160 was chosen. Any adolescent girls residing in the village during the period of the study were included. They were selected via random sampling technique. Intervention:Sessions regarding male and female anatomy, menstruation and pregnancy, STDs and contraception were conducted, and its impact was assessed with the help of pre and post questionnaires. Outcome Measure: The following null hypothesis (H₀) was formulated prior to data collection, i.e., “there is no significant difference in the pre-test and post-test knowledge scores in all domains.” The pre and post test scores were analysed using paired t test, and the p-values were determined. Results:Data collected in the pre-test showed a mean score of 8.351 out of a possible score of 40. The total percentage increase in the mean after the sessions were conducted was 89.216% (SD=53.172%), which proves the effectiveness of the intervention. This was further confirmed by p-values below 0.05 for most topics. Conclusion: The data obtained in the post-test displayed a considerable percentage increase in the mean scores of the girls, which rejects the null hypothesis (H₀) and illustrates the beneficial effect of the intervention. Also, the low pre-test scores emphasizes the lack of knowledge and the need for such interventions.

Key Words: Adolescent Reproductive and Sexual Health.

 

 

 

 

 

 

INTRODUCTION

The government of India in the National Youth Policy defines youth as the 15-35 age group and adolescents as 13-19 years. They account for one-fifth of the world’s population². In India they constitute 30% of the population, which is around 331 million people³. Female adolescents comprise of 46.9% and male adolescents 53.1% of the total population. In India, considering the predominantly patriarchal setup, ideology of son preference, incidence of early marriage and high rates of maternal morbidity, a strong focus on the needs and awareness of adolescent girls is imperative. Being a fairly conservative society, discussions on reproductive and sexual health are a taboo and therefore the youth is discouraged from actively seeking counsel on their concerns. In tribal areas young girls lack awareness and succumb to societal pressures to get roped into early matrimony. Therefore they lack information concerning the physical changes that occur during adolescence, their implications and how to take care of themselves. Many traditional cultural beliefs and practices, followed even today are not helpful and sometimes even harmful for the adolescent girls. Thus, it is imperative for us as health providers to debunk these myths and enable growing girls to lead healthy and hygienic life. 25% of the adolescent girls in the 15-19 age group in rural areas and 10% in urban areas are illiterate, with the disparity in male and female levels of education further growing especially in rural areas⁴. Due to this disparity, I have limited my study to the female adolescents, as they are currently most vulnerable to a variety of problems stemming from lack of education. Consequently, one of the major causes of mortality and morbidity in adolescents is sexual and reproductive disorders. About 13% of deaths in females under the age of 24 years are attributed to pregnancy and childbirth related complications¹. Lack of education on family planning, use and availability of contraceptives has accelerated rate of pregnancy in adolescents, which often translates to increased morbidity. 50% of Indian women are married before they attain the age of 18 years⁴. In India some demographers have estimated that if marriages were postponed from the age of 16 to 20-21 years, the number of births would decrease by 20-30%.⁵Moreover, it has also been found that a large percentage of HIV infected persons are between 20-40 years and had contracted the virus early in life indicating the importance of education during adolescence. Therefore, reproductive health must be emphasized and the special needs and concerns of adolescents, especially women must be addressed. Adolescents constitute future leaders and guardians of the nations development. The behaviours and lifestyle adopted during adolescence will shape the health of the individual in the present will be further embodied in the future generations. Reducing morbidity, delaying the age of marriage, reducing the incidence of teenage pregnancy, prevention of obstetric complications etc. will preserve adolescent health thus leading to economic benefits such as improved productivity and deterrence of future health costs. The ARSH programme aims at providing health and reproductive education to adolescents all over India. With this background, the present study is proposed to assess the effect of Advocacy, Communication, Training and Social Mobilisation ‘Adolescent Reproductive and Sexual Health’ (ARSH) among adolescent girls in tribal areas of Panvel Taluka, Dist. Raigad.

 MATERIALS AND METHODS

Study Design: Community based Interventional stud

Study Period: May - June 2014 (2 months)

Study Area: Four tribal villages namely Tara, Dolghar, Kalhe and Barapada were identified for this study. They comprise of the field practice areas of Rural Health Training Centre (RHTC) under the Department of Community Medicine of a tertiary care medical college and hospital in Raigad District.

Selection of Subjects: The subjects were made aware of the purpose of the study, type of data required from them, and its outcome. Participation was entirely voluntary and no subject was pressurized in doing so. Confidentiality of the data was maintained. The total number of houses in these four villages is approximately 664. The subjects were selected using systematic random sample technique. In this method, starting from one end of the village, every 4^th house was approached to assemble study subjects and collect data. If a subject was not found, the next 4^th house was selected, thus following a specific pattern. If 2 or more girls were present in 1 house, 1 of them was selected via random sampling. The sample size obtained was 160 adolescent girls. The adolescent girls were interviewed personally with the pretested, pre-structured questionnaire. The questionnaire and consent form was translated in Marathi, so as to enable the subjects to understand and answer the questions appropriately. Thereafter, 10 sessions on family life and reproductive health were undertaken. The sessions were conducted with the assistance of an expert who was deeply involved in community developmental activities in those villages and thus enjoyed a good rapport with the villagers. In the counselling sessions, we first discussed the physical and psychological changes of adolescence and the anatomy of the male and female bodies. As our focus was adolescent girls, we explored in detail menstruation with relevant hygiene alsoeradicating certain myths prevalent in these areas. We also taught them the importance and various methods of contraception including the merits and de-merits associated with each method. We discussed various sexually transmitted diseases, with a special emphasis on HIV/AIDS. We stressed on modes of transmission and the symptoms to enable them to avoid as well as to be able to identify when to seek medical assistance. After conducting the health education sessions the girls were interviewed again using the same questionnaire and to assess the change in knowledge among the subjects.

Research Tools

These include

• Personal interviews using questionnaire
• Training programme for adolescent girls using manual developed on the male and female reproductive system, contraception and STDs including HIV/AIDS (for intervention).

Inclusion Criteria

Adolescent girls native to that village and residing there during the period of the study.

Exclusion Criteria

• Any guest who was temporarily staying in the village or who would not be present throughout the length of the study
• Adolescents who were unwilling to participate.

Statistics: Data is analysed using SPSS 20.0 software and presented using frequencies, percentages and descriptive statistics. The normality of the data was tested using kolmogorov-smirnov (KS) test. Pre-test and post-test scores were compared using paired t-test. The level of significance was set at 5%, with 159 degrees of freedom, therefore all p-values below 0.05 were considered significant. The null hypothesis was that the difference between the post-test and pre-test means was 0 and so the intervention made no significant difference on the mean scores obtained. In order to show that the data was in fact significant, the null hypothesis would need to be rejected. A paired t-test was conducted which yielded the values shown in the table III. The p-values corresponding to the different t-statistics obtained show that the teaching made a significant increase (p<0.05) in the mean scores obtained for all topics.
RESULTS

The data was found to be normally distributed (p<0.05). The results are presented below.

Table no. 1: Shows the distribution of the subjects involved in the study according to age. Most of the subjects belong to the 11-14 age group (92%), while the least subjects belong to the 15-19 age group (5.6%). The mean age of subjects involved in the study was 12.76 years (n=160, SD=1.64 years).

Table No. 2: Shows a comparison of pre-test and post-test scores in all the domains, which are:

• Changes during Adolescence: The mean pre-test score was 3.431 (SD=1.573), while the post-test score was 4.663 (SD=1.822), with the mean difference being 1.232. The p-value was 0.000.
• Male Reproductive System: The mean pre-test score was 0.838 (SD=0.831), while the post-test score was 1.644 (SD=1.118), with the mean difference being 0.806. Thep-value was 0.000.
• Female Reproductive System: The mean pre-test score was 3.633 (SD=2.508), while the post-test score was 7.413 (SD=3.920), with the mean difference being 3.78. The p-value was 0.000.
• Contraception: The mean pre-test score was 0.125 (SD=0.332), while the post-test score was 0.325 (SD=0.887), with the mean difference being 0.2.The p-value was 0.004.
• HIV and STD’s: The mean pre-test score was 0.638 (SD=0.843), while the post-test score was 2.406 (SD=1.575), with the mean difference being 1.768.The p-value was 0.000.
• The total difference between pre-test and post-test scores is 7.756, which indicates that there was a major increase in the scores after the sessions. Thep-value was 0.000.

According to Table No. III: The total percentage increase in the mean after the sessions were conducted was 89.216% (SD=53.172%). The maximum percentage change in mean is found in the topic of HIV and STD’s (277.451%), while the least percentage change in mean was seen in the topic of changes during adolescence (35.883%). The data obtained through the post-test indicates that the standard deviation and the mean both increase.

 

Table 1: Distribution of study subjects according to age

Mean Age= 12.76 Yrs, SD = 1.64 Yrs

Table 2: Comparison of pre-test and post-test scores in all the domains

 

Figure 1:

Table 3: Domain wise percentage change in the pre-test and post-test scores of all subjects in each domain

 

Figure 2:

DISCUSSION

The data collected through this study has helped reject the null hypothesis and thus proved the effectiveness of the interventional sessions. The studies involved subjects mainly between the age group of 12-14 years, which is the peak adolescent age group. The total percentage increase in the mean test scores after the sessions were conducted was 89.216% (SD=53.172%), which represents the effectiveness of the interventional lectures. The p-values corresponding to the different t-statistics obtained through the paired t-test established that the teaching made a significant difference (p<0.05),as the p-values obtained for all the domains were 0.000, except for contraception (0.004) (p<0.05). It suggests that as a result of the sessions there was a substantial increase in the knowledge and awareness as a whole, in all the topics collectively, in all the adolescent girls. The counselling sessions focussed on the female reproductive system including menstruation and the male reproductive system. The total percentage increase in the mean scores after the sessions in the topic of the male reproductive system is 96.269% while the increase in the topic of the female reproductive system is 102.389%. The major percentage increase in these topics proves the effectiveness of the sessions in covering these particular aspects. The least percentage change in mean was seen in the topic of changes during adolescence (35.883%), which is because most of the girls already possessed information regarding physical and psychological maturation, and hence an immense difference wasn’t noted in the post-test and pre-test scores. Not many subjects were found in older age groups (16-19 years) (5.6% of total subjects), because in the target villages of Tara, Dolghar, Kalhe and Barapada, child marriages continue to take place and hence most of the girls are married in early adolescence before completing their basic education. This study was mainly restricted to school-going girls and did not account for the married adolescents; hence most of the subjects were in the younger age bracket. Since the study deals with issues pertinent to young married adolescents the study should have extended to include this population. Standard deviation measures the amount of variation or dispersion from the average. The increased SD in the post-test could be because each student has a different level of intelligence, ability to recall and capacity to pay attention. So each student was able to grasp varying amounts of data, which could result in the variability of the post-test scores. The male adolescent population was excluded from this study, however such an intervention can be equally beneficial in that group as well. Due to time constraints certain topics were covered more extensively both in the sessions and the questionnaire, which may cause some bias in the results obtained. For instance although contraception was covered in detail during the sessions, the questionnaires however didn’t cover this topic extensively, hence making it difficult to accurately assess the significance of the intervention in this particular topic. The standard deviation was highest in the topic of contraception (167.368%), which is again due to few questions in the questionnaire covering this topic. Different methods of data delivery could have been added to the study, to determine the most effective medium of providing this information. Data obtained from a study carried out in Chandigarh India by Parwej et al, aimed to measure the effectiveness of a reproductive health education package, procured similar results. It was found that the 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)⁷.Thus this study, while utilizing different methods tested the same hypothesis of the effect of intervention in knowledge on reproductive health in adolescents. The results obtained in our study were analogous to the data obtained in this study, proving the requirements and benefits of educational intervention in adolescent girls. Another study carried out by Kushwah K. and Anuj Mittal, in rural areas of Satna and Rewa found that with regard to menstruation, 29.97% of adolescents were aware of its cause, while 57.49% were not. Only 17.77% were cognizant about the concept of ovulation; 31.01% of adolescents were aware of the average age of menarche. Approximately 72% of adolescents agreed that they gained sufficient information with regard to the mental and physical changes associated with adolescence from this program. Of all adolescents, 73.87% did not have any genital problems, while 26.12% had some problems, mainly, abnormal menstrual cycle and itching and pain during urination⁸.The data obtained from this study is corresponding to the data obtained in the pre-test scores regarding these topics, of our study. The extremely low mean score of the pre-test is indicative of the lack of basic awareness and knowledge. According to a study carried out in South Delhi by Alexandra McManus more than one third of students involved in the study had no accurate understanding about the signs and symptoms of STDs other than HIV/AIDS. About 30% of respondents considered HIV/AIDS could be cured, 41% were confused about whether the contraceptive pill could protect against HIV infection and 32% thought it should only be taken by married women⁹.In our study the mean score regarding HIV and STD’s was 0.638 out of a possible score of 6. This score was exceptionally low, even though most of the girls get married early and are thus sexually active at a much younger age. Despite this, they lack fundamental education on sexual transmitted diseases and AIDs, thus leaving them highly vulnerable and unprepared, leading to maternal morbidity and mortality. In conclusion, the data obtained through the study successfully demonstrates the effectiveness of the intervention on the level of knowledge and awareness among the adolescent girls considered for the study. The p-values obtained help reject the null hypothesis. Itascertains the paucity of education on reproductive and sexual health of girls in tribal areas and the vital need for assistance. It also illustrates the beneficial effect of intervention and further encourages involvement of more people towards the education and awareness of adolescent girls in rural and tribal areas of India.

 

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