STUDY ON THE INFLUENTIAL FACTORS OF SEXUAL AND REPRODUCTIVE HEALTH OF ADOLESCENTS IN THE FIRST YEAR STUDENTS OF THE TWO UNIVERSITIES IN TURKEY
REPORT
ANKARA, 2003
STUDY ON THE INFLUENTIAL FACTORS OF SEXUAL AND REPRODUCTIVE HEALTH OF ADOLESCENTS IN THE FIRST YEAR STUDENTS OF THE TWO UNIVERSITIES IN TURKEY
Principle Investigators
Prof. Dr. Ayşe Akın
Assoc. Prof. Dr. Şevkat Bahar-Özvarış
This study received technical and financial support from the Special Programme of Research, development, and research Training in Human Reproduction, World Health Organization
HacettepeUniversity
Public Health Department-WHO Collaborating Center on RH
Ankara, 2003
STUDY ON THE INFLUENTIAL FACTORS OF SEXUAL AND REPRODUCTIVE HEALTH OF ADOLESCENTS IN THE FIRST YEAR STUDENTS OF THE TWO UNIVERSITIES IN TURKEY
(PROJECT REPORT)
Project Team
Prof. Dr. Ayşe Akın
Assoc. Prof. Dr. Şevkat Bahar-Özvarış
Assoc. Prof. Dr. Melikşah Ertem
Assist. Prof. Dr. Nalan Şahin Hodoğlugil
Assist. Prof. Dr. Günay Saka
Dr. Dilek Aslan
Çiğdem Esin
Kezban Çelik
Report by
Prof. Dr. Ayşe Akın
Assoc. Prof. Dr. Şevkat Bahar-Özvarış
Dr. Dilek Aslan
Çiğdem Esin
Kezban Çelik
Ankara, 2003
Table of Contents
Page
Introduction & Methodology / 8Findings & Discussion / 17
Thoughts/Opinions and Recommendations of Service Providers / 59
Conclusions & Recommendations
References / 78
88
Appendix:
- Informed Consent Form for the Focus Group Discussions Subjects
- Informed Consent Form for Survey Interviews
- Informed Consent Form for Service Providers
- Focus Group Discussions Directory Questions
- Questionnaire Form of Survey
- Questionnaire Form of Service Providers
List of Tables-I
(Findings & Discussion)
PageTable 1. Distribution of Students by Sex and Age / 18
Table 2. Distribution of Some Socio-demographic Characteristics of Students by Sex / 19
Table 3. Percent Distribution of Some Characteristics of Students’ Parents / 21
Table 4. Percent Distribution of Students’ Current Residence / 22
Table 5. Percent Distribution of Some Habits of Students by Sex / 23
Table 6. Percent Distribution of Students’ Free Time Activities By Sex / 24
Table 7. Percent Distribution of Sexual/Reproductive Health Definitions of Students by Sex / 25
Table 8. Percent Distribution of Sources of Information on Sexual/Reproductive Health by Sex of Students
/ 26Table 9. Distribution of Status of Speaking with Parents on Sexual/Reproductive Health and Spoken Issues among Participant Students by Sex / 27
Table 10. Percent Distribution of Status of Speaking with Mothers about S/R Health Issues by Education of s of Mothers of Students / 28
Table 11. Percent Distribution of Status of Speaking with Fathers about S/R Health Issues by Education of Fathers of Students / 28
Table 12. Percent Distribution of Preferred Sources of Information on Sexual/Reproductive Health among Students by Sex / 31
Table 13. Percent Distribution of Receiving Sexual/Reproductive Health Services by
Type of Social Security / 32
Table 14. Percent Distribution of Students’ Status of Ever Receiving Sexual/Reproductive Health Services and Types of Received Services by Sex / 32
Table 15. Distribution of Institutions Where Participant Students Received Sexual/Reproductive Health Services by Sex
/ 33Table 16. Distribution of Reasons of Not Receiving Sexual/Reproductive Health Services by Sex / 34
Table 17. Percent Distribution of Information of Students on the Period in Which Women Have the Highest Possibility to Get Pregnant by Sex / 35
Table 18. Distribution of Information of Students on the Best Age Interval for a Healthy Pregnancy by Sex / 35
Table 19. Percent Distribution of Students’ Ideas on Some Mentioned Sexual/Reproductive Health Issues by Sex
/ 36Table 20. Distribution of Side Effects that Participant Students Think Some Contraceptives May Cause by Sex
/ 37Table 21. Percent Distribution of Sexual/Reproductive Health Knowledge Scores of Students by Sex / 38
Table 22. Percent Distribution of Sexual/Reproductive Health Knowledge Scores of Students by Age Groups / 38
Table 23. Percent Distribution of Sexual/Reproductive Health Knowledge Scores of
Participant Students by Mother’s Education / 39
Table 24. Percent Distribution of Sexual/Reproductive Health Knowledge Scores of
Students by Father’s Education / 39
Table 25. Percent Distribution of Sexual/Reproductive Health Knowledge Scores of
Students by Their Current Residence / 39
Table 26. Percent Distribution of Status of Knowing, Using, and Knowing Where to Get Contraceptive Methods among Students by Sex / 41
Page
Table 27. Percent Distribution of Status of Contraceptive Use among Participant Students by Sexual Experience / 43
Table 28. Percent Distribution of Students’ Ever Use of Any Contraceptive Method by Sexual/Reproductive Health Knowledge Score / 43
Table 29. Percent Distribution of Status of Knowing Where to Get Contraceptive Methods Among Participant Students by Sex / 44
Table 30.1. Percent Distribution of Agreement Status of Students to Some Statements by Sex / 45
Table 30.2 Percent Distribution of Agreement Status of Students to Some Statements by Sex / 45
Table 31. Percent Distribution of Students’ Ever Having a Partner by Sex / 47
Table 32. Distribution of Ideas of Students on What Sexuality May Include in Dating by Sex / 47
Table 33. Percent Distribution of Ideas of Participant Students on “Pre-marital Sex is Natural Part of Dating” by Sex / 48
Table 34. Percent Distribution of Previous Sex Experience of Participant Students by Sex / 50
Table 35. Percent Distribution of Students’ Definitions of Safe Sex by Sex / 50
Table 36. Percent Distribution of Students’ Ideas on the Risks in Sexual Intercourse by Sex / 51
Table 37. Percent Distribution of Students’ Ideas on “What Should be Done in Case of Unwanted-Premarital Pregnancy?” by Sex / 51
Table 38. Percent Distribution of Students/Their Partners’ Pregnancy Experience by Sex / 52
Table 39. Percent Distribution of Ways of Termination of Pregnancy among Students by Sex / 52
Table 40. Percent Distribution of Ideas on the Responsibility of Protection from Pregnancy by Sex. / 53
Table 41. Percent Distribution of Ideas on the Responsibility of Protection from STIs by Sex. / 53
Table 42. Percent Distribution of Students’ Definitions of Sexual Violence Behavior by Sex / 54
Table 43. Percent Distribution of Students’ Ideas on “Where Should Sexual/Reproductive Health Services Specific to Young People be Provided?” by Sex / 55
Table 44. Percent Distribution of Students’ Ideas on the Expected Qualifications of Sexual/Reproductive Health Services Specific to Young People by Sex / 56
Table 45. Distribution of Ideas of Students on the Qualifications of Service Providers by Sex / 57
List of Tables-II
(Ideas and Recommendations of Service Providers)
PageTable 1. Age Distribution of Interviewed Service Providers / 61
Table 2. Sex Distribution of Interviewed Service Providers / 61
Table 3. Percent Distribution of Marital Status of Interviewed Service Providers / 61
Table 4. Percent Distribution of Interviewed Service Providers by Having Children / 62
Table 5. Percent Distribution of Interviewed Service Providers by the Last Attended School / 62
Table 6. Percent Distribution of Interviewed Service Providers by Occupation / 62
Table 7. Percent Distribution of Work Duration of Interviewed Service Providers / 63
Table 8. Percent Distribution of Service Provided By Interviewed Providers / 63
Table 9. Percent Distribution of Interviewed Service Providers by Their Status of Having Training Specific to Young People / 64
Table 10. Percent Distribution of Interviewed Service Providers’ Evaluation of Sufficiency of Their Education Specific to Young People / 64
Table 11. Percent Distribution of Services Specific To Young People Provided by Interviewed Service Providers / 65
Table 12. Percent Distribution of Interviewed Service Providers’ Evaluation of Sufficiency of The Services Specific to Young People / 65
Table 13. Percent Distribution of Young People’s Reasons for Application According to Interviewed Service Providers / 65
Table 14. Percent Distribution of Issues Out of Clinical Complaints that Young People Ask for Information According to Interviewed Service Providers / 66
Table 15. Percent Distribution of Opinions of Interviewed Service Providers on Status of Being Comfortable of Young People While Talking About Their Complaints / 66
Table 16. Percent Distribution of The Things To Be Done By Young People In The Application Process To Receive Sexual/Reproductive Health Services / 67
Table 17. Percent Distribution of Opinions of Interviewed Service Providers on Positive and Negative Aspects of Application Process / 68
Table 18. Percent Distribution of Opinions of Interviewed Service Providers on The Necessity of Sexual/Reproductive Health Services Specific To Young Age / 68
Table 19. Percent Distribution of Opinions of Interviewed Service Providers on Issues on Which Young People Necessitated To Get Information / 68
Table 20. Percent Distribution of Interviewed Service Providers’ Opinions on Areas of Services Necessary To Be Provided for Young People / 69
Table 21. Percent Distribution of Important Matters in Which Service Providers Should Be Careful During Service Provision / 69
Table 22. Percent Distribution of the Issues on which Service Providers Necessitate Further Training / 70
Table 23. Percent Distribution of the Influence of Service Providers’ Attitudes on the Decisions of Youth to Utilize the SRH Services / 71
Table 24. Percent Distribution of Interviewed Service Providers’ Opinions on Stratas/Regions of Young Persons Receiving SRH Services / 71
Table 25. Percent Distribution of Interviewed Service Providers’ Opinions on the Sex Distribution of Applicant Young Persons for SRH Services / 71
Table 26. Percent Distribution of Interviewed Service Providers’ Opinions on Provision of Contraceptive Methods to Unmarried Women / 72
Table 27. Percent Distribution of Interviewed Service Providers’ Opinions on Making Gender Differentiation in Provision of Services / 72
Page
Table 28. Percent Distribution of Interviewed Service Providers’ Opinions on Providing Information about Sexual/Reproductive Health / 73
Table 29. Percent Distribution of Interviewed Service Providers’ Opinions on
Informing Families Before Provision of Information on Sexual/Reproductive Health to Adolescents / 74
Table 30. Percent Distribution of Interviewed Service Providers’ Opinions on Providing Information about Sexually Transmitted Infections to Unmarried Adolescents / 74
Table 31. Percent Distribution of Interviewed Service Providers’ Opinions on Tools of Information Services about Sexual/Reproductive Health Specific to Adolescents/Young People / 74
Table 32. Percent Distribution of Interviewed Service Providers’ Opinions on the Qualities of an Ideal Sexual/Reproductive Health Service for Adolescents/Young People / 75
INTRODUCTION
METHODOLOGY
RATIONALE AND OBJECTIVES OF THE STUDY
Rationale
Sexual and reproductive health of adolescents has been a major international concern and it had been very clearly indicated in the 1994 International Conference on Population and Development (ICPD) in Cairo. In the Programme of Action, in paragraphs 7.7. and 7.8 it is stated that “reproductive health programmes should be designed to serve the needs of women, including adolescents”, and that innovative programmes should be developed to “ensure information, counseling and services for reproductive health accessible for adolescents and adult men” (UN, 1996).
The importance of adolescent sexual and reproductive health had been neglected in reproductive health and population programs and studies due to the sensitivity of the issue for a long time. By the strong emphasize on adolescent sexual and reproductive health in 1994 International Conference on Population and Development in Cairo, and in Beijing Platform for Action (Fourth World Conference on Women, 1995), where a comprehensive and holistic approach towards sexuality, sexual and reproductive health was developed as part of basic human rights. The programs of action developed in these conferences state that the characteristics and necessities of adolescent/young people sexual and reproductive health should be included into the programs designed to improve the health conditions all over the world (MSI, 1998).
The study on sexual/reproductive health of adolescents/young people requires specific focus and perspective. Their reproductive health needs are rapidly increasing in a world where the number of adolescents is increasing. While sexual activity is being initiated earlier, due to lack of adequate information on sexuality and contraceptives, adolescents are exposed to increased risk of unwanted pregnancy and sexually transmitted infections (STI). Under the current circumstances in the world, adolescents can face serious physical, economic and psycho-social consequences from pregnancy and STI (WHO/FRH/FPP, 1997).
Although great variation is observed in the incidence of adolescent pregnancies among countries, this is more frequently a problem of more developed countries. Adolescent pregnancies increase the morbidity and mortality of young mothers. Additionally, having children at an early age is a barrier for many women for educational, psycho-social and economical development. Early motherhood also causes increased morbidity and mortality for their children as well as for themselves (WHO, 1998).
Married or unmarried, 15 millions of adolescents experience pregnancy each year. Since most of these pregnancies are unwanted, young women tend to have induced abortions, whether legal or not. Adolescent pregnancy and induced abortions are important problems in several countries (UN Population Fund, WHO, Ministry of Health (MoH) of Ukraine, Ukrainian FP Association, 1999; WHO, MoH of Bulgaria, 1998) and according to WHO projections, nearly half of the induced abortions occur under unsafe conditions. Unsafe abortions cause a serious morbidity and mortality burden for women, and in the case of adolescents, the risk is even magnified (WHO, 1998). Also, even in countries where abortion is legal, unmarried adolescents, when compared to married adolescents more often recourse to unsafe abortion partially due to moral and cultural values and concerns.
Studies about STIs in adolescents show that the incidence is increasing. Today, each year, one in 20 adolescents suffer from an STI other than HIV/AIDS. Moreover, half of new HIV cases are observed in the 15-24 age group. When factors such as lack of knowledge, frequent changing of partners, or having multiple partners are combined, the risk of adolescents to contract the diseases increases (WHO, 1998). Adolescents also lack sufficient information about contraceptives and an important proportion does not know how to prevent pregnancy or prevent transmission of STIs (Serbanescu F and Morris L, 1997).
It is necessary to develop plans and programs for adolescents / young people to easily access sexual/reproductive health information and services within reproductive health programs in order to solve the problems of sexual/reproductive health faced by adolescents/young people.
One of the prior precautions to be taken within this context is the provision of services specific to adolescent age. These services should be provided by highly qualified health personnel with specific training on sexual/reproductive health of adolescents. However, the studies conducted with service providers show that they do not assess themselves “adequate” in provision of services to adolescents/young people. A study on attitudes and practices of physicians toward adolescent health care show that they have limited experience and perceive themselves to be underskilled in dealing with adolescent health issues (Hardoff D, Tamir A and Paltı H, 1999). Training programs on adolescent health need to be developed to meet the needs of health personnel.
Sexual/Reproductive Health of Adolescents/Young People in Turkey
Sexual/reproductive health of adolescents/young people is an area of study that has been gaining importance especially in developed countries. On the other hand, although the adolescent sexual and reproductive health is a primary concern in terms of reproductive health issues, early marriages, and fertility in developing countries (Koc & Unalan, 2000), the comprehensive studies including Information-Education and Counseling (IEC) training phases have been accelerated only in the last decade. Similarly, it is still an under-investigated area in Turkey. Especially, the knowledge, perception, and attitude of adolescents on sexual/reproductive health are ignored research subjects.
According to the 1995 census, the population of 10-19 age group is 13 331 000 and constitute 21.8% of the general population in Turkey. The 1998 Turkish Demographic and Health Survey (TDHS) results show that women aged 15-19 constitute 20.1% of the female population (HUIPS and DHS+, 1999).
The legal age of marriage was equalized to 17 for women and men in Turkey by a Law enacted in 2001. According to 1998 TDHS, currently 15.5% of women aged 15-19 are married. The percentage of women with the age 15-19 at first marriage is 33.7%. In Turkey, the age at first marriage and women’s educational status are generally lower in especially eastern and rural areas (HUIPS and DHS+, 1999). Early marriage and adolescent pregnancies are to be an important and known health problem of adolescent/young women in particular regions of Turkey. The existing data on young women at these ages is mostly classified under the headings of age at first marriage, pregnancy and becoming mother. According to 1998 TDHS, 1.8% of the women at the age of 15; 9% of the women at the age of 17; and 23.1% of the women at the age of 19 are married and have children (HUIPS and DHS+, 1999).
According to the 1998 TDHS, 3.7% of young women at the age group of 15-19 have no idea about any type of contraceptive method. While 55.5% of married women at this age group are using any traditional and/or modern contraceptive method, 44.5% of them do not use any method (HUIPS and DHS+, 1999). According to the Results of Further Analysis of 1998 TDHS (2002), the percentage of women in this age group with at least one induced abortion is 5.5%. This figure increases to 7.3% in the age group of 20-24.
The limited number of studies on sexual/reproductive health of young people have not focused on perceptions of sexual/reproductive health, attitudes and behaviors related to sexual/reproductive health. Rather, most studies have investigated the knowledge of adolescents on reproductive health. The findings of major studies conducted in Turkey are summarized below:
A survey conducted in Ankara in 1992 among 13 665 female students aged 13-18 attending to 32 High Schools found the average age of menarche as 13.3. In this study, 85% of female students had previous information about menarche, and while 34% indicated that they know how menstruation occurred, only 22% knew it correctly. The study also reported that girl friends, books, newspapers and magazines were the major sources of information on sexual issues and those parents or health staff did not have a major role in acquiring knowledge. The same study also indicated that 90% of all students wanted to have an education at schools about sexuality (Vicdan, 1993).
Another study conducted in a high school in Gulveren, which is a slum area of Ankara, aimed to identify the knowledge of students on sexual health and sexuality. Among the 170 senior high school students, the level of knowledge was low, and only 1% was classified as having sufficient knowledge. Combined oral contraceptives were mentioned most frequently as the known method of contraception (60%) by both males and females. Also, male students seemed to have more information on STD than female students (Ozvaris et al., 1995).
In a survey, which was conducted in slum areas of five big provinces by the collaboration of the Turkish Ministry of Health and Hacettepe University Institute of Population Studies, knowledge of STIs among adolescents was examined. In the 15-19 age groups, 21.8% of males and 34.6% of females could not even say the name of any sexually transmitted disease (HUIPS and DHS+, 1999).
Another study aimed to find out the sexual health knowledge of teacher nominees. The study was conducted in three Faculties of Education in Istanbul. For this study, 494 candidates were surveyed and one focus group was conducted in each faculty. According to the results, 24.1% of the candidates found their knowledge about STD, physiology, anatomy and fertility regulation insufficient, while 55.7% rated themselves as average and 15.4% as having sufficient knowledge. Overall, the knowledge scores were very low, however, prospective female teachers had relatively higher scores (Ozyurek and Nalbant, 1998).