Sexual and reproductive health needs of adolescent girls from conservative and low-income families in Erzurum, Turkey

doi:10.4236/health.2011.36063

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Vol.3, No.6, 370-377 (2011)

doi:10.4236/health.2011.36063

Health

Sexual and reproductive health needs of adolescent

girls from conservative and low-income families in

Erzurum, Turkey

Nesrin Reis1, Dilek Kilic2*, Raziye Engin2, Ozlem Karabulutlu2

1Bezmialem University, Health Sciences Faculty, Department of Nursing, Istanbul, Turkey;

2Ataturk University, Health Sciences Faculty, Department of Nursing, Erzurum, Turkey; *Corresponding Author: [email protected]

Received 3 February 2011; revised 28 April 2011; accepted 5 May 2011.

ABSTRACT

The objective of this survey was to determine

the sexual and reproductive health needs of

conservative and/or economically challenged

adolescent girls. A total of 310 subjects (16.5 ±

2.2 years old), attending three private institutes

teaching Islamic matter and the holy Quran and

two private institutes teaching carpet-weaving

in Erzurum, Turkey, were interviewed between

November 2004 and February 2005. The ques-

tionnaire covered knowledge on reproductive

health and s exua l ma tter s to attain their feelings

prior to their first menarche, their practices

during menstruation, and their awareness of

gynecological and sexually transmitted dis-

eases as well as their attitudes toward and re-

sponsiveness to domestic violence. Their re-

sponses showed that these issues were con-

sidered taboo and/or embarrassing to share.

Also, a considerable percentage of the girls had

no or limited knowledge on reproductive health

and sexual matters and mismanaged gyneco-

logical problems and domestic violence. More-

over, those had knowledge revealed that their

sources were non-scientific information from

unprofessional individuals. In conclusion, the

conservative and/or economically challenged

adolescent girls who are not attending regular

high schools need professional lectures on re-

productive health and sexual matters.

Keywords: Reproductive Health; Sexual Health;

Adolescent Gi rls

1. INTRODUCTION

Of the world population in 2000, over one billion

people were adolescents (10 - 19 years old) and 85% of

them lived in developing countries, mainly Asian coun-

tries [1]. They will contribute to population growth in

next decades, suggesting that their education on sexual

and reproductive health and their needs are extremely

critical [2]. Moreover, they may be vulnerable to several

diseases and problems, such as HIV and sexually trans-

mitted diseases (STD) as well as experiencing unin-

tended pregnancies and maternal complications, if they

receive inaccurate or incomplete information on repro-

ductive h ealth. A survey conducted by Polish researchers

ascertained that adolescent girls were sexually active and

41.1% of them were referred to ineffective methods,

which led to withdrawal during sexual intercourse, re-

sulting in a higher rate of unwanted pregnancy, STD,

and other sexual and reproductive health problems [3].

In fact, it was reported that 70% of the people STDs

were at age ranging from 15 to 24 years [4]. Adolescent

sexual and reproductive health education is still a ne-

glected issue in many countries [5]. Especially the ado-

lescents from the rural part of the developing countries

are disadvantageous due to unavailability and/or inade-

quacy of reproductive health care services and trainings

[6-10]. While the reproductive and sexual health of ado-

lescents is acknowledged as good from developed coun-

tries to Western Europe cou ntries [11,12], there ar e stud-

ies reporting that the reproductive and sexual health of

adolescents in some European countries [13,14], Canada

[12,15], and America [15-17] are poor. Worldwide, so-

cietal shifts and behavioural patterns exacerbated by

unique developmental vuln erabilities create a confluen ce

of factors that place today’s adolescents at heightened

risks for poor health outcomes [16]. Therefore, World-

wide, all adolescents need sexual and reproductive

health education and legal acts [13,16]. International

Conference on Population and Development held in

Cairo in 1994 recognized the reproductive rights as fun-

damental human rights [9]. These rights cover that all

adolescents should receive health care services and that

N. Reis et al. / Health 3 (2011) 370-377

371371

they should be given a h igh-quality sexu al and reproduc-

tive health education . However, before provision of su ch

service, field surveys must be performed to determine

knowledge on and attitudes toward reproductive health

and sexual matters, which may vary the culture, relig ion,

economical and educational statues, and environmental

factors. Therefore, in this preliminary study, we con-

ducted a survey involving adolescent girls from conser-

vative and/or economically challenged families to de-

termine their knowledge on and attitudes toward repro-

ductive health and sexual matters and explore their

needs.

2. METHODS

2.1. Participants and Their Characteristics

This descriptive study included 220 adolescent girls

attending three private institutes teaching the Quran as

well as some Islamic issues and 90 adolescent girls at-

tending two private institutes teaching carpet-weaving in

Erzurum, Turkey. The subjects voluntarily participated

in this study from November 2004 to February 2005.

The majority adolescent girls attending these courses

had completed current the 8-year compulsory education

(elementary and intermediate school) imposed by law of

the state (n = 151, 82.9%). Some of them had only an

earlier the 5-year mandatory elementary school educa-

tion (n = 106, 34.2%). However, there also 16 subjects

who had no education (Ta b l e 1 ). Institutes teaching the

Quran and religious rheoretics were boarding institutes

where education, food, and shelter are provided. The

girls attending these courses were mostly from families

with low-income and/or had many children. Because

both kinds of institutes are regulated by the government,

families intend to take advantage of learning and prac-

ticing Islam in a proper environment and of making liv-

ing with their skills.

The mean age was 16.5 ± 2.2 years. All of them were

single and 82.9% of them had compulsory elementary

education. Majority were urban residents (78.7%) and

economically dependents (67.4%). Almost half the sub-

jects relied on the state social security system (SSS) due

to their parent’s employment in the government (37.7%)

and insurance system due to their parents’ private small

businesses (17.8%). The majority of the other half was

supported by the go vernment (33.5%) (Table 1).

2.2. Ethics

Written permission was taken from the related institu-

tions before the research. The aim of the research was

explained to the adolescent girls, and they were in-

formed that if they prefer not to continue, they could

withdraw from the study any time they wish. Further-

more, they were informed that their decision to partici-

pate into the research would not affect their attendance

to the course. They were assured that their names and

the names of their institu tions were confiden tial and th ey

were free to respond to whichever question(s) they

wanted.

Table 1. Socio-demographic characteristics of the adolescent girls.

N %

Educational status

Illiterate 27 8.7

Literate 16 5.2

Elementary school (5 years) 106 34.2

Intermediary sc hool (3 years) 151 48.7

High school (3 - 4 years) and university ( 2 - 6 yea rs) 10 3.2

Birth place

Urban 189 61.0

Rural 121 39.0

Current address

City centre 244 78.7

Suburb 66 21.3

Income status

Lower than outcome 209 67.4

Equal to outcome 85 27.4

Higher than outcome 16 5.2

Health insurance

SSS 117 37.7

Individual membership to the state insura nce system 55 17.8

Green card 104 33.5

No health insurance 34 11.0

N. Reis et al. / Health 3 (2011) 370-377

372

2.3. Procedure and Data Collection

Prior to the research, the researchers visited the insti-

tutes to evaluate facilities for pre-interviews with the

adolescent girls about the nature of the study. In this

meeting, the researchers focused upon sexuality, to a

large extent, the first menarche/pubertal changes, gyne-

cologic diseases, familial violence such as restric-

tions/prohibitions and verbal abuse.

The relevant literature was reviewed for the estab-

lishment of semi-structured questionnaire. Th e da ta were

collected with face-to-face interviews and included

demographic characteristics and sexual and reproductive

health needs of the adolescent girls. Each interview

lasted approximately 30 - 40 minutes.

2.4. Data Analysis

The PROC MEANS and UNIVARIATE procedures

were employed to determine descriptive statistics of

demographic characteristics and sexual and reproductive

health needs (SPSS, Version 10.0, Chicago, IL, USA).

Mean, standard deviation, range and frequency of re-

sponse variables were reported.

3. RESULTS

3.1. Knowledge and Management of

Menarche and Menstruation

One-third of the subjects had no knowledge prior to

their first menarche (Ta b le 2 ). Half of the subjects who

had knowledge about menarche (n = 209) received in-

formation from their family members, whereas only re-

ceived information from health professionals (n = 20, 9,

6). Moreover, majority of these girls had no knowledge

on menstruation physiology (79.7%). Feeling after ex-

periencing the first menarche was mix; 43% of the sub-

jects had uncomfortable feelings, such as anxiousness,

nervousness, and feeling dirty; 20% of them were happy

about considering them blooming; and 35.5% of them

had both feelings. Menstruation management practices

were hot application (38.7%), taking painkiller (16.1%),

and having more frequent bath (11.9%). While one-fifth

of the subjects practiced all these, almost other one-fifth

did not take any action to cope with menstruation.

3.2. Knowledge on Reproductive Health

Dysmenorrhea (23.9%) and irregular menses (18.1%)

were two most common gynecologic problems that

study subjects experienced (Tab le 3 ). Only one subject

(0.3%) had not experience their first menarche at time of

survey. More than one-third of the girls did not prefer to

share their gynecologic health status. Overall, 62.9% of

the girls acknowledged presence of gynecologic prob-

lems. However, majority of the adolescent girls (87.4%)

reported that they did not consider health unit for solu-

tion (87.4%) and preferred female doctor if they would

have to visit health unit (91.3%).

Table 2. Knowledge and management of menarche and menstruation of the adolescent girls.

N %

Getting inform a t i on before the f i r s t menarche

Yes 209 67.4

No 101 32.6

The source of informa tion

Friend 39 18.7

Mother 58 27.7

Sister 41 19.6

Health staff 20 9.6

Other (book, media, etc.) 15 7.2

Multiple (friend, sister and medi a) 36 17.2

Knowledge on menstruation

Yes 63 20.3

Not knowing 247 79.7

Feelings at the first menarche

Unfavorable feelings (anxiousness, n e rvousness, fear, dirtiness, etc.) 136 43.9

Favorable feelings (to be on the verge of becoming a young girl, etc.) 64 20.6

Mix feeling 110 35.5

Menstruation man agement

Showering 37 11.9

Taking painkillers 50 16.1

Hot application 120 38.7

Others (more than one application) 61 19.7

No action 42 13.6

N. Reis et al. / Health 3 (2011) 370-377

373373

Table 3. Gynecologic health needs of the adolescent girls.

N %

Gynecologic problems

Irregularity of menses 56 18.1

Dysmenorrhea 74 23.9

Over bleeding 10 3.2

No menses 1 0.3

Genital infections 17 5.5

Two or more problems 37 11.9

No response 115 37.1

Reference to a health unit for the problems

Yes 39 12.6

No 271 87.4

Preference of doctor’s gender

Female 283 91.3

Male 2 0.6

Either 25 8.1

Almost half of the subject had no know ledge on sexu-

ality and almost another half did not want to share their

knowledge on sexuality (Table 4). Information source

was highly variable; being elder sister and/or close

friend the major source. Likewise, more than half of the

subjects were not willing to share their information

source (55.1%) preferred to keep silent and did not an-

swer the question, whereas the other half (18.7%,

14.5%). Frequency of subjects that were aware of sexu-

ally transmitted diseases (STD) was similar to frequency

of the subjects who had general knowledge on sexual

matters. Only 13.2% of the subjects had knowledge on

STD’s and almost half of them did no t want to talk about

this issue. More than half of the subjects were not will-

ing to express their opinion on birth control (52.6%).

Other half had knowledge on contraceptive methods.

One percent of the subjects were aware of traditional

methods such as coitus interruptus and vaginal douching.

3.3. Experience of and Attitude toward

Domestic Violence

Three quarters of the subjects did not want to talk

about familial violence (Table 5). Others we re witness to

verbal abuse (12.9%), social abuse (9.4%), physical as-

sault (2.9%), and sexual violence (1.0%) between their

parents. Half of the subjects did not prefer to express

their feeling about domestic violence. Those expressed

their feeling were approval (6.1%), disapproval (hatred,

fear, fury) (24.2%), and ignorance (20.0%). Interestingly,

none of the subjects shared domestic violence with

health or security personnel and 15.1% of them did not

share it with anybody. Other family members (17.4%)

and friends (12.6%) were the primary contacts to men-

tion domestic violence. Again, more than half of the

subjects did not want to answer who was the person to

share domestic violence.

4. DISCUSSION

The Turkish education system is secular and “health

science” is a mandatory in high school curriculum.

However, conservative and low-income family or fami-

lies living in rural may prefer especially their daughters

to continue on their education in some institutes offering

religious program or skills. We assumed that these

groups of adolescent girls might need more assistance to

improve their know ledge and awareness on reproductiv e

health and sexual matters because their current curricu-

lum does not cover these issues. Ta b le 1 indicated that

our study gro up was not on ly conserva tive but also were

educationally deficient and from low-income families.

The majority were either hesitant to talk about their first

menarche experience and menstruation cycle or not in-

formed at all/improperly informed before the first men-

arche and during menstruation and did not know how to

manage their menstruation cycle. Instead of perceiving

these as a result of a health physical and physiological

development, they were swamped with depression signs

(Table 2). Similar information source and feelings at

pubertal age by the girls were also reported in other sur-

veys conducted in India [18] and Pakistan [6]. These

suggest that such education should be emphasized in

schooling adolescents effectively by teachers and com-

pensated in nonschooling adolescents through regular

workshops by local health care providers.

Despite presence of gynecological discomforts and

needs for professional assistance, our study subjects

were not willing to consult health unit. In case they

wanted to visit a doctor, female doctor was preferred

N. Reis et al. / Health 3 (2011) 370-377

374

(Ta b le 3). This could be due to considering clinics dis-

turbing and non-confidential [6], unavailability of such

service [19], not knowing to get help from health cabi-

nets [8]. Young people need access to quality clinical

services that offer effective treatments and vaccines as

well as proper sexual education. Mbonye reported that

the adolescents with gynecological problems were free

of these problems and learned how to manage these

problems upon consulting health units in Uganda [20].

These findings emphasize the necessity of the youth

development programs covering health education and

care to economically challenged adolescents.

The half of our study subjects was no t willing to share

their knowledge, knowledge source on sexual matters

and STD as well as birth control methods. The other half

were either not knowledgeable or had limited knowledge

(Table 4). Naturally, it is the duty of families to give

information to adolescents on sexuality, STD’s and con-

traception, but families of our study group perhaps did

not know or were not aware of these issues. Surprisingly,

other studies also show that children/adolescents rarely

receive information on their sexual matters from their

parents [21,22], which may be account for performing

risky behavior due to possible variation of accuracy in

knowledge from various sources [23]. Girls with a

longer period of training were shown to conduct less

risky sexual behavior than those with a shorter period of

training [24]. In another study, it was shown that Nige-

rian girls lacking sexual education at school and home

tended to perform malicious sexual behaviors such as

involuntary pregnancy and injuries and infections in

genital system [10]. In Turkey, pre-marriage sex is not

acceptable adolescent girls. Upon marriage, some rela-

tives or honored friends inform the couple about sexual

matters including pregnancy and birth control. In case of

extra-marital pregnancy, criminal act of honor killin gs or

committing suicide may be encountered, especially in

communities where feudalism is still exits. Such percep -

tion, sometimes may lead improper places or methods to

abort in case of unauthorized marriages. In Kenya and

Zambia [7], it was reported that referred unmarried

pregnant girls to abortion. De Jong et al (2005) have

shown that in Arabic and Iranian communities, it is a

taboo to discuss sexuality and the young are unable to

receive knowledge concerning these subjects at a satis-

fying and adequate level. Overall, these studies suggest

that cultural and religious factors, inadequate informa-

tion, limited usage of services of reproductive health

usually appear to make the adolescent girls prone to

some diseases including STD’s and HIV-AIDS and so-

cially unacceptable cases including unwanted and un-

planned pregnancy, personal sexual and reproductive

health problems [20,26]. Disadvantaged groups exists

among adolescents in terms of sexual and reproductive

health despite presence of the sexual and reproductive

health services and training programmes directed at

adolescents in developed countries [11,12,16]. It is re-

ported that the age of their first sexual experience, the

Table 4. Reproductive health needs of the adolescent girls.

N %

Knowledge on sexual matters

Yes 41 13.2

No 138 44.5

No response 131 42.3

Information on sexual matters

Elder sister/Female friend 58 18.7

Various books 45 14.5

Magazine and journals 9 2.9

Television 21 6.8

Multiple communication resources (Friends, journals, TV, etc.) 6 2.0

No response 171 55.1

Knowledge on sexually transmitted diseases

Yes 41 13.2

No 138 44.5

No response 131 42.3

Awareness of contraceptive method s

At least 1 effective method 72 23.2

Two or more effective methods 72 23.2

Traditional methods 3 1.0

No response 163 52.6

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375375

Table 5. Experience of and attitude toward domestic violence of the adolescent girls.

N %

Types of familial violence

Verbal violence 40 12.9

Physical violence 9 2.9

Imposition of restrictions 29 9.4

Sexual violence 3 1.0

No response 229 73.8

Feelings towards the one who conducts violence

Love 19 6.1

Hatred 39 12.6

Fear 11 3.5

Fury 25 8.1

Nothing 62 20.0

No response 154 49.7

Person choice to talk about violence

Fami ly membe r 39 12.6

Friend 54 17.4

Relative 3 1.0

Professional (health and/or security) 0 00.0

Nobody 47 15.1

No response 167 53.9

pregnancy rate, the use of contraception, HIV knowledge,

and STI rate from one population to another in these

groups, as well as adolescents portray high risk repro-

ductive health behaviour [11,12]. Therefore, it is impera-

tive to provide optimal sexual and reproductive health

education. It is recommended to apply a peer-based ap-

proach in reproductive health and sex education to the

adolescents [17,27,28]. Strategies should consider de-

velopmental needs of age of the adolescents and their

social context [29,30].

Our study population did not want to share domestic

violence and majo rity did not notify this to authorities in

case it happened (Ta ble 5). Domestic violence can ad-

versely affect adolescents’ attitudes on sexual matters

and mental and behavioral health as well as destroys the

development of self-concept and body image [31-34].

Information and counseling service should be provided

to parents especially when their girls become adolescent,

to facilitate establishment for their happy and health

marriages in future.

In conclusion, our survey revealed that conservative

and/or economically challenged adolescent girls with up

to intermediate education were in need of accurate and

professional education on sexuality and reproductive

health. However, at this point, we were unable to indi-

cate what characteristics of these adolescents (religion,

low education, or low-income) could be attributed to

their responses. Teachers and health professionals should

be facilitated by authorities to provide proper reproduc-

tive health and sex education to adolescents attending

institutes whose curriculum does not cover this topic.

Cross-cultural studies involving adolescents from dif-

ferent economic and education background should be

performed to determine factors underlying different atti-

tudes toward sexu a lity.

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