Int J Adolesc Med Health 2015; 27(1): 57–63
Zohreh Shahhosseini and Zeinab Hamzehgardeshi*
Female adolescents’ perspective about reproductive health education needs: a mixed methods study with explanatory sequential design Abstract Background: One of the most important and basic needs of adolescent girls is reproductive health services and education, which is different from that required by adults. Objectives: The aim of this study was to determine reproductive health education needs from the perspective of adolescent girls living in urban and rural areas, as well as to explore adolescents’ understanding of reproductive health needs. Subjects: The first phase was a cross-sectional study conducted on 1274 female adolescents. In the second phase, 77 girls in the form of 11 groups participated in focused group discussions. Methods: This sequential explanatory mixed methods study using follow-up variants was conducted in two phases. Questionnaires, including items on socio-demographic characteristics and reproductive health needs from adolescents’ perspectives, were completed using the self-administered method. Results: The quantitative results of the study revealed city and village girls’ perspectives on reproductive health education needs. These results showed that village adolescents were nearly 1.5–2 times more in favor of a same sex counselor, reproductive health group education, and the need for sexual health education than city adolescents. A review of the transcripts of the qualitative phase led to the extraction of two themes including the characteristics of the reproductive health educator and priorities of *Corresponding author: Zeinab Hamzehgardeshi, Department of Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences, Vesal Street, Amir Mazandarani Boulevard, PO Box 4816715793, Sari, Mazandaran Province, Iran, Phone: +98-151-22673425, Fax: +98-151-2268915, E-mail: [email protected]; and Traditional and Complementary Medicine Research Centre, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran, Zohreh Shahhosseini: Department of Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
reproductive health education, which explains the adolescent girls’ understanding of reproductive health education needs. Conclusion: The findings of this study confirm the importance of determining reproductive health education needs from the perspective of adolescent girls. The present study shows how a sequential mixed design can be used for a better understanding of reproductive health needs of adolescent girls. The results of this study can be used in health research, education, policy making, and planning associated with adolescent health. Keywords: adolescent; girls; mixed methods; reproductive needs. DOI 10.1515/ijamh-2014-0008 Received February 10, 2014; accepted April 17, 2014; previously published online May 24, 2014
Introduction A young population is one of the most striking features of the population of Eastern Mediterranean countries, members of the World Health Organization, including Iran. According to a report by the Statistics Organization in Iran, the population of 10- to 19-year-old age groups in Iran is 15.4 million, which is 21.8% of the country’s population (1, 2). Given the peculiarities of maturity in girls, with physical and mental conditions of this period, and the essential reproductive role of girls, it can be argued that reproductive health education of adolescent girls is of special importance. Adolescence in girls is a decisive foundation and beginning for their future stages of life and will have a direct impact on their family and children (3). Providing adolescent health is a requirement for the sustainable development of any country. Adoption of appropriate strategies for assessment of adolescents’ health needs, determining priorities, and attempts to meet Brought to you by | Lund University Libraries Authenticated Download Date | 10/18/16 9:06 PM
58 Shahhosseini and Hamzehgardeshi: Female adolescents’ perspective about reproductive health education needs these needs, given the evaluations and existing resources, in line with national development goals, and taking into account views of principal recipients of this service can ensure the health of future generations (4). In recent years, healthcare policy makers of the country have felt the need for designing programs that would include adolescents’ needs more than ever before, and in their policies seek ways to meet these needs in an acceptable and sensitive manner that is culturally compatible. However, the development of these activities and programs will require sufficient information on adolescents’ reproductive health education. Adolescents’ reproductive health education at a global level has also been considered at the International Conference on Population and Development. In the Declaration of the International Conference on Population and Development, which is a milestone in reproductive health services, unique requirements of adolescents have been emphasized, as compared to adults, and requires committed countries to this declaration to identify these requirements and to strive to meet them (5). One of the most important and basic needs of adolescent girls is the need for reproductive health services and education, which is different from that required by adults. Reproductive health services include all influential elements and components in total physical, mental, and social health of the reproductive system (5). At a content level, the provision and management of these services is important. The added importance of reproductive health services in adolescents is thus considered because this age group is less equipped with information, experience, and means compared to adults, in maintaining their reproductive health, and in an attempt to obtain reproductive health services, including reproductive health education, and may face resistance or impediments of adults (6). Thus, this group is exposed to risks that may affect their health in adulthood (7, 8). Despite an emphasis by the World Health Organization to meet reproductive health services required by adolescents and to enhance youth friendly services, these requirements have not truly been materialized in many parts of the world (7). Studies conducted in Iran indicate that the majority of existing reproductive health service centers for adolescents provide their service during school hours or when they are at work. A lack of proper access in addition to poor provision of information are among some of the important factors in the lack of adolescent referrals to these centers (9). A study by Mohammadi et al. indicates that despite high-risk behaviors among Tehran adolescents, they do not consider themselves exposed to pregnancy or sexually transmitted diseases, their in-depth awareness of reproductive and sexual health and sexually transmitted
diseases is limited, and incorrect beliefs about risks of unsafe sexual acts and their consequences have widely been observed. Furthermore, owing to gender-based double standards in sexual and reproductive attitudes and behaviors, adolescents, especially girls, are particularly vulnerable (10). Reproductive health services include all services that influence the physical, mental, and social health parts of the adolescent reproductive system (5). This group of services can be expressed and prioritized in different ways in different cultural, social, and economic settings in various societies (11, 12). To the best of our knowledge, little has been done regarding a deep understanding of reproductive health education needs, from the perspective of Iranian adolescent girls, and existing studies are mainly concerned with investigating girls’ awareness, attitude, and performance regarding puberty and menstrual hygiene (13). Thus, a more in-depth examination of whatever is experienced and understood by Iranian adolescents as reproductive health education needs is necessary. This lack of information, adolescents’ importance and multitude in the country’s population age pyramid, and serious vulnerabilities of Iranian adolescents in relation to behaviors associated with reproductive health (9, 13) are among the reasons for conducting this study. Moreover, a variety of ecosystems and social-cultural diversity in towns and villages on the one hand, and the different status of health indicators in various regions on the other hand, require health needs to be assessed regionally and locally, and accordingly health plans, allocation of resources, and budget and research priorities can be determined regionally. Mazandaran, as a northern province of the country, has a 10- to 19-year-old population of approximately 580,000, and similar to the country’s population composition, nearly one-fifth are adolescents; girls comprise half this population (2).
Materials and methods Study design To answer the study questions, researchers used the mixed methods research method, which uses a qualitative and quantitative method within a single project, which tends towards a holistic explanation of a subject or a phenomenon. The present study uses an explanatory sequential design approach with follow-up variants. An explanatory sequential design is a two-stage research-combination method. The overall aim in this method is that qualitative data help in the explanation or expansion of quantitative results. The explanatory follow-up model is used when the researcher requires qualitative data to explain or
Brought to you by | Lund University Libraries Authenticated Download Date | 10/18/16 9:06 PM
Shahhosseini and Hamzehgardeshi: Female adolescents’ perspective about reproductive health education needs 59
interpret quantitative results. In this model, the researcher identifies specific quantitative results that need explanation (e.g., statistical differences between groups, people that score highly, or unexpected results). Then, the researcher collects qualitative data from participants that can best explain the findings. In this model, the main emphasis is usually on quantitative aspects. In the present study, the rationale for use of the combination explanatory sequential design of the follow-up type was the complexity of the subject of reproductive health needs of girls, for which the researcher required qualitative data to explain or expand quantitative data. In this model, the researcher identified specific quantitative results that required further explanation. For example, significant statistical differences between reproductive health education needs were identified according to their demographic and social characteristics. Then, the researcher collected qualitative data from participants with best explanations. In this study, the quantitative phase was more prominent and larger than the qualitative phase. Finally, in the conclusion stage, analysis of qualitative data, with a deeper understanding of participants’ perspectives, explained the statistical results (14). In the first phase of the study, perspectives of adolescent girls on reproductive health education needs were examined in towns or villages separately. Then, statistical differences between the two groups of girls from towns and villages were found, and in the qualitative stage, the researcher attempted to explain these differences, arriving at a better understanding of these differences in the conclusion stage.
Quantitative phase The first stage began with the aim to investigate reproductive health education needs from the perspective of adolescent girls living in urban and rural areas of Sari town. Two questionnaires comprised the data collection tool; first, the health needs of Iranian female adolescents, and in this study, questions related to reproductive health needs from adolescents’ perspectives. The second was a socio-demographic questionnaire, developed by the research team. Both face validity and content validity were used for questionnaire validity. Twelve specialists commented on the necessity items. To assess the reliability of the test retest, 20 female adolescents completed the two questionnaires within a 2-week interval. Cronbach’s α was calculated to evaluate the reliability of the questionnaire with regard to internal consistency. The mean content validity index of the “health needs of Iranian female adolescents” questionnaire was reported to be 0.92, with Cronbach’s α coefficient at 0.9 and an intraclass consistency coefficient (with a 2-week interval) of 0.984 (p
Zohreh Shahhosseini and Zeinab Hamzehgardeshi*
Female adolescents’ perspective about reproductive health education needs: a mixed methods study with explanatory sequential design Abstract Background: One of the most important and basic needs of adolescent girls is reproductive health services and education, which is different from that required by adults. Objectives: The aim of this study was to determine reproductive health education needs from the perspective of adolescent girls living in urban and rural areas, as well as to explore adolescents’ understanding of reproductive health needs. Subjects: The first phase was a cross-sectional study conducted on 1274 female adolescents. In the second phase, 77 girls in the form of 11 groups participated in focused group discussions. Methods: This sequential explanatory mixed methods study using follow-up variants was conducted in two phases. Questionnaires, including items on socio-demographic characteristics and reproductive health needs from adolescents’ perspectives, were completed using the self-administered method. Results: The quantitative results of the study revealed city and village girls’ perspectives on reproductive health education needs. These results showed that village adolescents were nearly 1.5–2 times more in favor of a same sex counselor, reproductive health group education, and the need for sexual health education than city adolescents. A review of the transcripts of the qualitative phase led to the extraction of two themes including the characteristics of the reproductive health educator and priorities of *Corresponding author: Zeinab Hamzehgardeshi, Department of Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences, Vesal Street, Amir Mazandarani Boulevard, PO Box 4816715793, Sari, Mazandaran Province, Iran, Phone: +98-151-22673425, Fax: +98-151-2268915, E-mail: [email protected]; and Traditional and Complementary Medicine Research Centre, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran, Zohreh Shahhosseini: Department of Midwifery, Nasibeh Nursing and Midwifery Faculty, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
reproductive health education, which explains the adolescent girls’ understanding of reproductive health education needs. Conclusion: The findings of this study confirm the importance of determining reproductive health education needs from the perspective of adolescent girls. The present study shows how a sequential mixed design can be used for a better understanding of reproductive health needs of adolescent girls. The results of this study can be used in health research, education, policy making, and planning associated with adolescent health. Keywords: adolescent; girls; mixed methods; reproductive needs. DOI 10.1515/ijamh-2014-0008 Received February 10, 2014; accepted April 17, 2014; previously published online May 24, 2014
Introduction A young population is one of the most striking features of the population of Eastern Mediterranean countries, members of the World Health Organization, including Iran. According to a report by the Statistics Organization in Iran, the population of 10- to 19-year-old age groups in Iran is 15.4 million, which is 21.8% of the country’s population (1, 2). Given the peculiarities of maturity in girls, with physical and mental conditions of this period, and the essential reproductive role of girls, it can be argued that reproductive health education of adolescent girls is of special importance. Adolescence in girls is a decisive foundation and beginning for their future stages of life and will have a direct impact on their family and children (3). Providing adolescent health is a requirement for the sustainable development of any country. Adoption of appropriate strategies for assessment of adolescents’ health needs, determining priorities, and attempts to meet Brought to you by | Lund University Libraries Authenticated Download Date | 10/18/16 9:06 PM
58 Shahhosseini and Hamzehgardeshi: Female adolescents’ perspective about reproductive health education needs these needs, given the evaluations and existing resources, in line with national development goals, and taking into account views of principal recipients of this service can ensure the health of future generations (4). In recent years, healthcare policy makers of the country have felt the need for designing programs that would include adolescents’ needs more than ever before, and in their policies seek ways to meet these needs in an acceptable and sensitive manner that is culturally compatible. However, the development of these activities and programs will require sufficient information on adolescents’ reproductive health education. Adolescents’ reproductive health education at a global level has also been considered at the International Conference on Population and Development. In the Declaration of the International Conference on Population and Development, which is a milestone in reproductive health services, unique requirements of adolescents have been emphasized, as compared to adults, and requires committed countries to this declaration to identify these requirements and to strive to meet them (5). One of the most important and basic needs of adolescent girls is the need for reproductive health services and education, which is different from that required by adults. Reproductive health services include all influential elements and components in total physical, mental, and social health of the reproductive system (5). At a content level, the provision and management of these services is important. The added importance of reproductive health services in adolescents is thus considered because this age group is less equipped with information, experience, and means compared to adults, in maintaining their reproductive health, and in an attempt to obtain reproductive health services, including reproductive health education, and may face resistance or impediments of adults (6). Thus, this group is exposed to risks that may affect their health in adulthood (7, 8). Despite an emphasis by the World Health Organization to meet reproductive health services required by adolescents and to enhance youth friendly services, these requirements have not truly been materialized in many parts of the world (7). Studies conducted in Iran indicate that the majority of existing reproductive health service centers for adolescents provide their service during school hours or when they are at work. A lack of proper access in addition to poor provision of information are among some of the important factors in the lack of adolescent referrals to these centers (9). A study by Mohammadi et al. indicates that despite high-risk behaviors among Tehran adolescents, they do not consider themselves exposed to pregnancy or sexually transmitted diseases, their in-depth awareness of reproductive and sexual health and sexually transmitted
diseases is limited, and incorrect beliefs about risks of unsafe sexual acts and their consequences have widely been observed. Furthermore, owing to gender-based double standards in sexual and reproductive attitudes and behaviors, adolescents, especially girls, are particularly vulnerable (10). Reproductive health services include all services that influence the physical, mental, and social health parts of the adolescent reproductive system (5). This group of services can be expressed and prioritized in different ways in different cultural, social, and economic settings in various societies (11, 12). To the best of our knowledge, little has been done regarding a deep understanding of reproductive health education needs, from the perspective of Iranian adolescent girls, and existing studies are mainly concerned with investigating girls’ awareness, attitude, and performance regarding puberty and menstrual hygiene (13). Thus, a more in-depth examination of whatever is experienced and understood by Iranian adolescents as reproductive health education needs is necessary. This lack of information, adolescents’ importance and multitude in the country’s population age pyramid, and serious vulnerabilities of Iranian adolescents in relation to behaviors associated with reproductive health (9, 13) are among the reasons for conducting this study. Moreover, a variety of ecosystems and social-cultural diversity in towns and villages on the one hand, and the different status of health indicators in various regions on the other hand, require health needs to be assessed regionally and locally, and accordingly health plans, allocation of resources, and budget and research priorities can be determined regionally. Mazandaran, as a northern province of the country, has a 10- to 19-year-old population of approximately 580,000, and similar to the country’s population composition, nearly one-fifth are adolescents; girls comprise half this population (2).
Materials and methods Study design To answer the study questions, researchers used the mixed methods research method, which uses a qualitative and quantitative method within a single project, which tends towards a holistic explanation of a subject or a phenomenon. The present study uses an explanatory sequential design approach with follow-up variants. An explanatory sequential design is a two-stage research-combination method. The overall aim in this method is that qualitative data help in the explanation or expansion of quantitative results. The explanatory follow-up model is used when the researcher requires qualitative data to explain or
Brought to you by | Lund University Libraries Authenticated Download Date | 10/18/16 9:06 PM
Shahhosseini and Hamzehgardeshi: Female adolescents’ perspective about reproductive health education needs 59
interpret quantitative results. In this model, the researcher identifies specific quantitative results that need explanation (e.g., statistical differences between groups, people that score highly, or unexpected results). Then, the researcher collects qualitative data from participants that can best explain the findings. In this model, the main emphasis is usually on quantitative aspects. In the present study, the rationale for use of the combination explanatory sequential design of the follow-up type was the complexity of the subject of reproductive health needs of girls, for which the researcher required qualitative data to explain or expand quantitative data. In this model, the researcher identified specific quantitative results that required further explanation. For example, significant statistical differences between reproductive health education needs were identified according to their demographic and social characteristics. Then, the researcher collected qualitative data from participants with best explanations. In this study, the quantitative phase was more prominent and larger than the qualitative phase. Finally, in the conclusion stage, analysis of qualitative data, with a deeper understanding of participants’ perspectives, explained the statistical results (14). In the first phase of the study, perspectives of adolescent girls on reproductive health education needs were examined in towns or villages separately. Then, statistical differences between the two groups of girls from towns and villages were found, and in the qualitative stage, the researcher attempted to explain these differences, arriving at a better understanding of these differences in the conclusion stage.
Quantitative phase The first stage began with the aim to investigate reproductive health education needs from the perspective of adolescent girls living in urban and rural areas of Sari town. Two questionnaires comprised the data collection tool; first, the health needs of Iranian female adolescents, and in this study, questions related to reproductive health needs from adolescents’ perspectives. The second was a socio-demographic questionnaire, developed by the research team. Both face validity and content validity were used for questionnaire validity. Twelve specialists commented on the necessity items. To assess the reliability of the test retest, 20 female adolescents completed the two questionnaires within a 2-week interval. Cronbach’s α was calculated to evaluate the reliability of the questionnaire with regard to internal consistency. The mean content validity index of the “health needs of Iranian female adolescents” questionnaire was reported to be 0.92, with Cronbach’s α coefficient at 0.9 and an intraclass consistency coefficient (with a 2-week interval) of 0.984 (p
