Original article
Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements Maya M Kumar MD1, Rodrick Lim MD1,2,3, Cindy Langford RN2,3, Jamie A Seabrook MA1,3, Kathy N Speechley PhD1,3,4, Timothy Lynch MD1,2,3 MM Kumar, R Lim, C Langford, JA Seabrook, KN Speechley, T Lynch. Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements. Paediatr Child Health 2013;18(2):74-80. bACKgRouNd: Formal sexual education is a mandatory component
of the high school curriculum in most Canadian provinces. The present study was a preliminary assessment of sexual knowledge among a sample of Ontario adolescents who had completed their high school sexual education requirements. MeTHodS: A questionnaire, testing understanding of the learning objectives of Ontario’s minimally required high school sexual education course, was distributed in a paediatric emergency department to 200 adolescent patients who had completed the course. ReSuLTS: Respondents demonstrated good understanding of pregnancy physiology and sexually transmitted infections, but poor understanding of concepts related to reproductive physiology, contraception, HIV/AIDS and sexual assault. Most respondents could not identify Canada’s age of sexual consent. CoNCLuSioNS: Respondents demonstrated concerning gaps in sexual knowledge despite completion of their sexual education requirements. Further studies must determine whether a representative, population-based student sample would exhibit similar findings. Sexual education currently offered in Ontario may require investigation. Key Words: Adolescent; Canada; Health; Sex education
A
dolescence is a crucial period for learning about healthy sexuality (1,2). As teenagers struggle to complete the developmental tasks of adolescence, such as accepting their changing bodies and defining their sexual identities, they are at risk for negative sexual consequences (3). Sexually active Canadian teenagers commonly engage in risky sexual behaviours, including unprotected sex, multiple sexual partners and intercourse, before 15 years of age (4). Canadians 15 to 24 years of age also have the country’s highest incidences of chlamydia and gonorrhea infections (5). Such statistics raise concerns about whether young Canadians have sufficient knowledge to make responsible sexual decisions. Comprehensive sexual education for adolescents effectively reduces the incidence of negative sexual outcomes (6,7). The Canadian Paediatric Society and the American Academy of Pediatrics (8,9) recommend that paediatricians participate in the development and implementation of comprehensive sexual education programs in schools. In Canada, education is under provincial jurisdiction and almost every province’s high school curriculum contains formal sexual
Les connaissances des adolescents canadiens en matière de sexualité après la fin du cours d’éducation sexuelle au secondaire HiSToRiQue : L’éducation sexuelle est un élément obligatoire du programme d’études secondaires de la plupart des provinces canadiennes. La présente étude visait à obtenir une évaluation préliminaire des connaissances en matière de sexualité d’un échantillon d’adolescents ontariens qui avaient terminé leur cours d’éducation sexuelle au secondaire. MÉTHodoLogie : Lors de leur visite au département d’urgence pédiatrique, 200 patients adolescents qui avaient terminé leur cours d’éducation sexuelle ont reçu un questionnaire afin de vérifier leur compréhension des objectifs d’apprentissage du cours d’éducation sexuelle de base offert dans les écoles secondaires de l’Ontario. RÉSuLTATS : Les répondants ont démontré une bonne compréhension de la physiologie de la grossesse et des infections transmises sexuellement, mais une mauvaise compréhension des concepts liés à la physiologie de la reproduction, à la contraception, au VIH-sida et aux agressions sexuelles. La plupart des répondants ne pouvaient pas préciser l’âge du consentement sexuel au Canada. CoNCLuSioNS : Les répondants ont démontré des lacunes préoccupantes en matière de connaissances sexuelles, même s’ils avaient terminé leur cours d’éducation sexuelle obligatoire. D’autres études devront déterminer si un échantillon d’étudiants représentatifs en population donnerait des résultats similaires. Les cours d’éducation sexuelle actuellement offerts en Ontario méritent peut-être d’être évalués.
education. Within the province of Ontario, sexual education is a subcomponent of health and physical education courses; each course is comprised of approximately 110 h of instruction. However, only a fraction of course time, determined by each school, is dedicated to sexual education; consequently, there is potential for significant variability among schools. Ontario’s Ministry of Education has outlined six course expectations (Table 1) for its Grade 9/10 Healthy Growth and Sexuality unit (10). Completion of this unit is the minimum sexual education required for a high school diploma or certificate in Ontario. There are currently no standardized examinations or evaluation processes to assess the knowledge of students who have completed their sexual education requirements and no other standardized assessments of sexual education quality. Several studies have attempted to assess the sexual knowledge of Canadian adolescents. The majority of these studies, however, limited the scope of their assessment to knowledge of HIV/sexually transmitted infections (STI) alone (11-16) or HIV/STI, contraception and limited reproductive physiology (17).
1Department
of Pediatrics, Schulich School of Medicine and Dentistry; 2Pediatric Emergency Medicine, London Health Sciences Centre; 3Children’s Health Research Institute, University of Western Ontario; 4Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario Correspondence: Dr Timothy Lynch, Department of Pediatrics, Room E1-110, Children’s Hospital, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario N6A 5W9. Telephone 519-685-8129, fax 519-685-8156, e-mail [email protected] Accepted for publication June 26, 2012
74
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 2 February 2013
Sexual knowledge of Canadian adolescents
The present study will expand on previous Canadian work in two ways. First, it will assess student knowledge in multiple domains using an assessment questionnaire addressing all major topics included in Ontario’s high school human sexuality curriculum, including reproductive physiology throughout life (not just adolescence), HIV/STI, contraception and responsible sexuality including sexual consent. Second, unlike most previous Canadian studies, participants will be recruited from many different schools. The objective of the present study was to conduct a preliminary assessment of sexual knowledge related to the learning objectives of Ontario’s minimally required high school sexual education course, among a sample of adolescents presenting to an emergency department who had completed their provincial high school sexual education requirements.
Table 1 Course expectations for Ontario’s Grade 9/10 Healthy Growth and Sexuality course (10) 1. Identify the developmental stages of sexuality throughout life 2. Describe the factors that lead to responsible sexual relationships 3. Describe the relative effectiveness of methods of preventing pregnancies and sexually transmitted diseases (eg, abstinence, condoms, oral contraceptives) 4. Demonstrate understanding of how to use decision-making and assertiveness skills effectively to promote healthy sexuality (eg, healthy human relationships, avoiding unwanted pregnancies and sexually transmitted infections such as HIV/AIDS) 5. Demonstrate understanding of the pressures on teens to be sexually active 6. Identify community support services related to sexual health concerns
MeTHodS
The present descriptive study used a convenience sample of adolescent patients (see patient eligibility below), from the paediatric emergency department of the London Health Sciences Centre, a tertiary care facility located in London, Ontario, whose catchment is two million people and which treats 37,500 patients annually. Ethics approval was obtained from the Health Sciences Research Ethics Board at the University of Western Ontario (London, Ontario) and the Clinical Research Impact Committee at the Lawson Health Research Institute (London, Ontario).
completed; the number of high school health courses completed; whether the school in which these courses were taken was private or public, religious or secular; municipality in which the school was located; household structure (eg, two-parent, single-parent or alternative arrangement); and reason for presenting to the emergency department. The questionnaire was piloted among a convenience sample of adolescents before distribution. Feedback was obtained about readability, time required to complete the survey, printed layout of the questionnaire, subject matter covered by the questions and whether any questions were perceived as invasive; further revisions were consequently made. The questionnaire took 10 min to 15 min to complete. Its Flesch Reading Ease score was 68% and its Flesch-Kincaid Grade level was 6.8.
Questionnaire development A questionnaire (Appendix A) designed to test expectations 1 through 4 outlined in the Ontario Ministry of Education’s Grade 9/10 Healthy Growth and Sexuality course (Table 1) was developed (achievement of expectations 5 and 6 was not considered objectively testable by the authors.) Specific questions pertaining to each objective were developed using the Guidelines for Comprehensive Sexuality Education, 3rd Edition published by the Sexuality Information and Education Council of the United States (SIECUS) (18). This guideline, created by a national task force of health care professionals, educators and experts in adolescent development, contains recommendations for subject matter to be included in a comprehensive sexual education curriculum. Questions were also created using Canadian laws relevant to responsible sexuality (19-21) and Canadian health guidelines (22-25). Questions were arranged into six categories: pregnancy; reproductive physiology and puberty; STI; contraception; HIV/AIDS; and sexuality and the law. Questions were true/false/unsure or multiple-choice. Participants were not asked about their personal experiences or values related to sexuality. Additionally, participants used a seven-point Likert scale to rate the usefulness of various sources of sexual information (Table 2), in which 1 = not at all helpful, 4 = somewhat helpful and 7 = extremely helpful. Baseline characteristics were assessed, including age and sex; whether currently in school, and current/highest grade successfully
Patient eligibility Adolescent patients attending London Health Sciences Centre’s paediatric emergency department were considered eligible if they had completed at least one credit of health education in an Ontario high school (minimum provincial requirement), and triage scores upon presenting to the emergency department were neither resuscitative nor emergent (ie, Canadian Pediatric Triage and Acuity Scale score of 3 [urgent], 4 [less urgent] or 5 [nonurgent]). No age minimum was set as long as the educational requirement was met, but all participants were younger than 18 years of age (maximum patient age accepted by the paediatric emergency department). Exclusion criteria included incapacity to provide one’s own consent (assessed by the attending physician); insufficient fluency in written English (as self-reported by patient after inquiry); and acute pain, psychiatric or psychosocial crisis of such severity that recruitment was deemed inappropriate (assessed by the attending physician). Questionnaire distribution Once deemed eligible, the patient received the questionnaire with an accompanying letter of information. Completion of
Table 2 Frequencies of respondents’ ratings of usefulness for six common sources of sexual information on a seven-point likert scale Not at all helpful Source
Somewhat helpful
extremely helpful
1
2
3
4
5
6
7
4 (2.0)
7 (3.5)
16 (8.0)
58 (29.0)
48 (24.0)
48 (24.0)
16 (8.0)
Sexual education classes received before high school
22 (11.0)
32 (16.0)
48 (24.0)
53 (26.5)
25 (12.5)
13 (6.5)
3 (1.5)
Parents
34 (17.0)
35 (17.5)
22 (11.0)
39 (19.5)
19 (9.5)
19 (9.5)
29 (14.5)
Friends
20 (10.0)
26 (13.0)
31 (15.5)
33 (16.5)
37 (18.5)
28 (14.0)
22 (11.0)
Popular media (television, movies, magazines)
41 (20.5)
35 (17.5)
29 (14.5)
40 (20.0)
29 (14.5)
13 (6.5)
10 (5.0)
Internet
38 (19.0)
29 (14.5)
34 (17.0)
35 (17.5)
28 (14.0)
14 (7.0)
20 (10.0)
Sexual education classes received in high school
Data presented as n (%)
Paediatr Child Health Vol 18 No 2 February 2013
75
Kumar et al
Table 3 baseline characteristics of participants (n=200) Characteristic
Table 4 Mean scores within each question category Value
Age, years, mean ± SD
16.0±0.9
Male participants
88 (44)
Currently enrolled in school
193 (96.5)
Current grade or highest grade completed, mean ± SD
10.6±1.8
Completed health and physical education courses (maximum available courses = 5)
Category
Total questions per category, n
Correctly answered questions, mean (%)
Reproductive physiology and puberty
6
3.7 (61.6)
Pregnancy
9
7.2 (79.6)
Sexually transmitted infections
7
5.5 (79.1)
HIV/AIDS
2
1.0 (51.4)
1
94 (47)
Contraception
3
1.3 (43.1)
2
44 (22)
Sexuality and the law
6
4.0 (66.3)
3
26 (13)
4
7 (3.5)
5
2 (1)
Type of school attended Public
170 (85)
Private
7 (3.5)
Religiously based
58 (29)
Secular
129 (64.5)
Urban
149 (74.5)
Rural
39 (19.5)
Living situation With both parents
129 (64.5)
With one parent
43 (21.5)
Divides time between both parents Other
9 (4.5) 19 (9.5)
Data presented as n (%) unless otherwise indicated
the questionnaire implied informed consent. Participants could complete the questionnaire in the presence of parents/guardians but were asked to refrain from discussion while completing it. However, respondents and parents/guardians were informed that upon return of the questionnaire, they would receive an answer key with explanations for each question that they could review together and take home. This allowed parents/guardians to let their child complete the questionnaire privately, knowing that the answer key would be available shortly for review and discussion. If an eligible patient did not wish to participate, their reason for declining was documented. Statistical analysis Because this was a descriptive study without primary or secondary end points, a sample size calculation was not performed. It was decided that a sample size of 200 would obtain a sufficient crosssection of adolescents from different socioeconomic backgrounds and types of schools, while acknowledging that the convenience sample of emergency department patients may not be representative of the general adolescent population. Mean (± SD) scores were calculated for each question category and each question. Categorical variables were reported as percentages. A χ2 test was used to assess associations between categorical variables; P
Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements Maya M Kumar MD1, Rodrick Lim MD1,2,3, Cindy Langford RN2,3, Jamie A Seabrook MA1,3, Kathy N Speechley PhD1,3,4, Timothy Lynch MD1,2,3 MM Kumar, R Lim, C Langford, JA Seabrook, KN Speechley, T Lynch. Sexual knowledge of Canadian adolescents after completion of high school sexual education requirements. Paediatr Child Health 2013;18(2):74-80. bACKgRouNd: Formal sexual education is a mandatory component
of the high school curriculum in most Canadian provinces. The present study was a preliminary assessment of sexual knowledge among a sample of Ontario adolescents who had completed their high school sexual education requirements. MeTHodS: A questionnaire, testing understanding of the learning objectives of Ontario’s minimally required high school sexual education course, was distributed in a paediatric emergency department to 200 adolescent patients who had completed the course. ReSuLTS: Respondents demonstrated good understanding of pregnancy physiology and sexually transmitted infections, but poor understanding of concepts related to reproductive physiology, contraception, HIV/AIDS and sexual assault. Most respondents could not identify Canada’s age of sexual consent. CoNCLuSioNS: Respondents demonstrated concerning gaps in sexual knowledge despite completion of their sexual education requirements. Further studies must determine whether a representative, population-based student sample would exhibit similar findings. Sexual education currently offered in Ontario may require investigation. Key Words: Adolescent; Canada; Health; Sex education
A
dolescence is a crucial period for learning about healthy sexuality (1,2). As teenagers struggle to complete the developmental tasks of adolescence, such as accepting their changing bodies and defining their sexual identities, they are at risk for negative sexual consequences (3). Sexually active Canadian teenagers commonly engage in risky sexual behaviours, including unprotected sex, multiple sexual partners and intercourse, before 15 years of age (4). Canadians 15 to 24 years of age also have the country’s highest incidences of chlamydia and gonorrhea infections (5). Such statistics raise concerns about whether young Canadians have sufficient knowledge to make responsible sexual decisions. Comprehensive sexual education for adolescents effectively reduces the incidence of negative sexual outcomes (6,7). The Canadian Paediatric Society and the American Academy of Pediatrics (8,9) recommend that paediatricians participate in the development and implementation of comprehensive sexual education programs in schools. In Canada, education is under provincial jurisdiction and almost every province’s high school curriculum contains formal sexual
Les connaissances des adolescents canadiens en matière de sexualité après la fin du cours d’éducation sexuelle au secondaire HiSToRiQue : L’éducation sexuelle est un élément obligatoire du programme d’études secondaires de la plupart des provinces canadiennes. La présente étude visait à obtenir une évaluation préliminaire des connaissances en matière de sexualité d’un échantillon d’adolescents ontariens qui avaient terminé leur cours d’éducation sexuelle au secondaire. MÉTHodoLogie : Lors de leur visite au département d’urgence pédiatrique, 200 patients adolescents qui avaient terminé leur cours d’éducation sexuelle ont reçu un questionnaire afin de vérifier leur compréhension des objectifs d’apprentissage du cours d’éducation sexuelle de base offert dans les écoles secondaires de l’Ontario. RÉSuLTATS : Les répondants ont démontré une bonne compréhension de la physiologie de la grossesse et des infections transmises sexuellement, mais une mauvaise compréhension des concepts liés à la physiologie de la reproduction, à la contraception, au VIH-sida et aux agressions sexuelles. La plupart des répondants ne pouvaient pas préciser l’âge du consentement sexuel au Canada. CoNCLuSioNS : Les répondants ont démontré des lacunes préoccupantes en matière de connaissances sexuelles, même s’ils avaient terminé leur cours d’éducation sexuelle obligatoire. D’autres études devront déterminer si un échantillon d’étudiants représentatifs en population donnerait des résultats similaires. Les cours d’éducation sexuelle actuellement offerts en Ontario méritent peut-être d’être évalués.
education. Within the province of Ontario, sexual education is a subcomponent of health and physical education courses; each course is comprised of approximately 110 h of instruction. However, only a fraction of course time, determined by each school, is dedicated to sexual education; consequently, there is potential for significant variability among schools. Ontario’s Ministry of Education has outlined six course expectations (Table 1) for its Grade 9/10 Healthy Growth and Sexuality unit (10). Completion of this unit is the minimum sexual education required for a high school diploma or certificate in Ontario. There are currently no standardized examinations or evaluation processes to assess the knowledge of students who have completed their sexual education requirements and no other standardized assessments of sexual education quality. Several studies have attempted to assess the sexual knowledge of Canadian adolescents. The majority of these studies, however, limited the scope of their assessment to knowledge of HIV/sexually transmitted infections (STI) alone (11-16) or HIV/STI, contraception and limited reproductive physiology (17).
1Department
of Pediatrics, Schulich School of Medicine and Dentistry; 2Pediatric Emergency Medicine, London Health Sciences Centre; 3Children’s Health Research Institute, University of Western Ontario; 4Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario Correspondence: Dr Timothy Lynch, Department of Pediatrics, Room E1-110, Children’s Hospital, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario N6A 5W9. Telephone 519-685-8129, fax 519-685-8156, e-mail [email protected] Accepted for publication June 26, 2012
74
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 2 February 2013
Sexual knowledge of Canadian adolescents
The present study will expand on previous Canadian work in two ways. First, it will assess student knowledge in multiple domains using an assessment questionnaire addressing all major topics included in Ontario’s high school human sexuality curriculum, including reproductive physiology throughout life (not just adolescence), HIV/STI, contraception and responsible sexuality including sexual consent. Second, unlike most previous Canadian studies, participants will be recruited from many different schools. The objective of the present study was to conduct a preliminary assessment of sexual knowledge related to the learning objectives of Ontario’s minimally required high school sexual education course, among a sample of adolescents presenting to an emergency department who had completed their provincial high school sexual education requirements.
Table 1 Course expectations for Ontario’s Grade 9/10 Healthy Growth and Sexuality course (10) 1. Identify the developmental stages of sexuality throughout life 2. Describe the factors that lead to responsible sexual relationships 3. Describe the relative effectiveness of methods of preventing pregnancies and sexually transmitted diseases (eg, abstinence, condoms, oral contraceptives) 4. Demonstrate understanding of how to use decision-making and assertiveness skills effectively to promote healthy sexuality (eg, healthy human relationships, avoiding unwanted pregnancies and sexually transmitted infections such as HIV/AIDS) 5. Demonstrate understanding of the pressures on teens to be sexually active 6. Identify community support services related to sexual health concerns
MeTHodS
The present descriptive study used a convenience sample of adolescent patients (see patient eligibility below), from the paediatric emergency department of the London Health Sciences Centre, a tertiary care facility located in London, Ontario, whose catchment is two million people and which treats 37,500 patients annually. Ethics approval was obtained from the Health Sciences Research Ethics Board at the University of Western Ontario (London, Ontario) and the Clinical Research Impact Committee at the Lawson Health Research Institute (London, Ontario).
completed; the number of high school health courses completed; whether the school in which these courses were taken was private or public, religious or secular; municipality in which the school was located; household structure (eg, two-parent, single-parent or alternative arrangement); and reason for presenting to the emergency department. The questionnaire was piloted among a convenience sample of adolescents before distribution. Feedback was obtained about readability, time required to complete the survey, printed layout of the questionnaire, subject matter covered by the questions and whether any questions were perceived as invasive; further revisions were consequently made. The questionnaire took 10 min to 15 min to complete. Its Flesch Reading Ease score was 68% and its Flesch-Kincaid Grade level was 6.8.
Questionnaire development A questionnaire (Appendix A) designed to test expectations 1 through 4 outlined in the Ontario Ministry of Education’s Grade 9/10 Healthy Growth and Sexuality course (Table 1) was developed (achievement of expectations 5 and 6 was not considered objectively testable by the authors.) Specific questions pertaining to each objective were developed using the Guidelines for Comprehensive Sexuality Education, 3rd Edition published by the Sexuality Information and Education Council of the United States (SIECUS) (18). This guideline, created by a national task force of health care professionals, educators and experts in adolescent development, contains recommendations for subject matter to be included in a comprehensive sexual education curriculum. Questions were also created using Canadian laws relevant to responsible sexuality (19-21) and Canadian health guidelines (22-25). Questions were arranged into six categories: pregnancy; reproductive physiology and puberty; STI; contraception; HIV/AIDS; and sexuality and the law. Questions were true/false/unsure or multiple-choice. Participants were not asked about their personal experiences or values related to sexuality. Additionally, participants used a seven-point Likert scale to rate the usefulness of various sources of sexual information (Table 2), in which 1 = not at all helpful, 4 = somewhat helpful and 7 = extremely helpful. Baseline characteristics were assessed, including age and sex; whether currently in school, and current/highest grade successfully
Patient eligibility Adolescent patients attending London Health Sciences Centre’s paediatric emergency department were considered eligible if they had completed at least one credit of health education in an Ontario high school (minimum provincial requirement), and triage scores upon presenting to the emergency department were neither resuscitative nor emergent (ie, Canadian Pediatric Triage and Acuity Scale score of 3 [urgent], 4 [less urgent] or 5 [nonurgent]). No age minimum was set as long as the educational requirement was met, but all participants were younger than 18 years of age (maximum patient age accepted by the paediatric emergency department). Exclusion criteria included incapacity to provide one’s own consent (assessed by the attending physician); insufficient fluency in written English (as self-reported by patient after inquiry); and acute pain, psychiatric or psychosocial crisis of such severity that recruitment was deemed inappropriate (assessed by the attending physician). Questionnaire distribution Once deemed eligible, the patient received the questionnaire with an accompanying letter of information. Completion of
Table 2 Frequencies of respondents’ ratings of usefulness for six common sources of sexual information on a seven-point likert scale Not at all helpful Source
Somewhat helpful
extremely helpful
1
2
3
4
5
6
7
4 (2.0)
7 (3.5)
16 (8.0)
58 (29.0)
48 (24.0)
48 (24.0)
16 (8.0)
Sexual education classes received before high school
22 (11.0)
32 (16.0)
48 (24.0)
53 (26.5)
25 (12.5)
13 (6.5)
3 (1.5)
Parents
34 (17.0)
35 (17.5)
22 (11.0)
39 (19.5)
19 (9.5)
19 (9.5)
29 (14.5)
Friends
20 (10.0)
26 (13.0)
31 (15.5)
33 (16.5)
37 (18.5)
28 (14.0)
22 (11.0)
Popular media (television, movies, magazines)
41 (20.5)
35 (17.5)
29 (14.5)
40 (20.0)
29 (14.5)
13 (6.5)
10 (5.0)
Internet
38 (19.0)
29 (14.5)
34 (17.0)
35 (17.5)
28 (14.0)
14 (7.0)
20 (10.0)
Sexual education classes received in high school
Data presented as n (%)
Paediatr Child Health Vol 18 No 2 February 2013
75
Kumar et al
Table 3 baseline characteristics of participants (n=200) Characteristic
Table 4 Mean scores within each question category Value
Age, years, mean ± SD
16.0±0.9
Male participants
88 (44)
Currently enrolled in school
193 (96.5)
Current grade or highest grade completed, mean ± SD
10.6±1.8
Completed health and physical education courses (maximum available courses = 5)
Category
Total questions per category, n
Correctly answered questions, mean (%)
Reproductive physiology and puberty
6
3.7 (61.6)
Pregnancy
9
7.2 (79.6)
Sexually transmitted infections
7
5.5 (79.1)
HIV/AIDS
2
1.0 (51.4)
1
94 (47)
Contraception
3
1.3 (43.1)
2
44 (22)
Sexuality and the law
6
4.0 (66.3)
3
26 (13)
4
7 (3.5)
5
2 (1)
Type of school attended Public
170 (85)
Private
7 (3.5)
Religiously based
58 (29)
Secular
129 (64.5)
Urban
149 (74.5)
Rural
39 (19.5)
Living situation With both parents
129 (64.5)
With one parent
43 (21.5)
Divides time between both parents Other
9 (4.5) 19 (9.5)
Data presented as n (%) unless otherwise indicated
the questionnaire implied informed consent. Participants could complete the questionnaire in the presence of parents/guardians but were asked to refrain from discussion while completing it. However, respondents and parents/guardians were informed that upon return of the questionnaire, they would receive an answer key with explanations for each question that they could review together and take home. This allowed parents/guardians to let their child complete the questionnaire privately, knowing that the answer key would be available shortly for review and discussion. If an eligible patient did not wish to participate, their reason for declining was documented. Statistical analysis Because this was a descriptive study without primary or secondary end points, a sample size calculation was not performed. It was decided that a sample size of 200 would obtain a sufficient crosssection of adolescents from different socioeconomic backgrounds and types of schools, while acknowledging that the convenience sample of emergency department patients may not be representative of the general adolescent population. Mean (± SD) scores were calculated for each question category and each question. Categorical variables were reported as percentages. A χ2 test was used to assess associations between categorical variables; P
