Adolescent sex education in India: Current perspectives

Socio-sexual norms and young people's sexual health in urban Bangladesh, India, Nepal and Pakistan: A qualitative scoping review

In South Asia, young people face myriad challenges and opportunities regarding their sexual lives relating to varied experiences of norms and restrictions; gender norms and socio-sexual taboos limit communication around sexual health which in turn can affect sexual health outcomes. In this article we focus on norms affecting young people's sexual health experiences in urban settings in Bangladesh, India, Nepal, and Pakistan. We conducted a scoping review of peer reviewed empirical studies based on qualitative data pertaining to young people's experiences of sexuality and sexual health in Bangladesh, India, Nepal, and Pakistan. We searched four electronic databases for articles published (2010-2022), using terms relating to sexual health, young people, and South Asia. Sixteen articles met the inclusion criteria with sample size ranging from 9 to 180. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines for the design and analysis of this study. We synthesised the included articles using thematic analysis. The studies covered topics such as sexual health services and contraceptive use; sexuality education and communication; and gender and sexual violence. Recurring findings included: parental and societal expectations around premarital 'sexual purity' through abstinence; limited communication around sexuality between young people and parents/adults; gender norms limiting young women's sexual and reproductive decision making; and an absence of research on experiences of sexual and gender minorities. We identified common themes as well as prominent gaps which must be addressed if we are to capture diverse experiences and build a better evidence base to improve sexual health services for young people in the region. The body of research fails to include experiences of young people with diverse gender, sexual orientation, and sex characteristics.

Unlocking policy synergies, challenges and contradictions influencing implementation of the Comprehensive Sexuality Education Framework in Zambia: a policy analysis

BACKGROUND

Comprehensive sexuality education (CSE) has recently become salient, but adolescent sexual reproductive health and rights (ASRHR) challenges are still a global health problem. Studying policies which have implications for CSE implementation is a crucial but neglected issue, especially in low and middle-income countries (LMICs) like Zambia. We analyzed policy synergies, challenges and contradictions influencing implementation of CSE framework in Zambia.

METHODS

We conducted a document review and qualitative interviews with key stakeholders from Non-Governmental Organizations, as well as health and education ministries at the National and all (10) provincial headquarters. Our methods allowed us to capture valuable insights into the synergies, challenges and contradictions that exist in promoting CSE framework in Zambia.

RESULTS

The study highlighted the synergies between policies that create opportunities for implementation of CSE through the policy window for adoption of sexual reproductive health and rights (SRHR) that opened around the 1990s in Zambia, promotion of inclusive development via education, adoption of an integrated approach in dealing with SRHR problems, and criminalization of gender-based violence (GBV). This analysis also identified the policy challenges and contradictions including restricted delivery of education on contraception in schools; defining childhood: dual legal controversies and implications for children, grey zones on the minimum age to access SRHR services; inadequate disability inclusiveness in SRHR legal frameworks; policy silences/contentious topics: LGBTQI + rights, abortion, and grey zones on the minimum age to access SRHR services.

CONCLUSION

While many policies support the implementation of CSE in schools, the existence of policy silences and challenges are among the barriers affecting CSE implementation. Thus, policy reformulation is required to address policy silences and challenges to enhance effective promotion and integration of the CSE framework.

Perception, practices, and understanding related to teenage pregnancy among the adolescent girls in India: a scoping review

BACKGROUND

Teenage pregnancy is a concerning public health problem in India. Misperception and misunderstanding about pregnancy and its preventive methods lead to pregnancy when adolescents are involved in unsafe sexual intercourse. This scoping review aims to discuss the evidence on the perception, practices, and understanding related to teenage pregnancy among adolescent girls in the Indian context.

METHOD

The Arksey and O'Malley scoping review framework and Joanna Briggs Institute Reviewers' Manual were used for the scoping review. The Population, Concept, and Context strategy (PCC) ensured the review questions, eligibility criteria, and search strategy. The Systematic Review and Meta-analysis: Extension for Scoping Review (PRISMA-ScR) was used. A literature search was done using electronic databases by specific keywords such as "teenage", "adolescences", "pregnancy", "perception", "knowledge", "awareness", etc. Relevant grey literature was identified through further searching. The review included studies that fulfil inclusion criteria having female adolescent groups aged from 10 to 19 years in the Indian context between the years 2000 and 2021.

RESULT

We found 40 eligible studies; more than half of these were from southern (35%) and northern (27.5%) regions, and studies from the rest of India were very sporadically distributed. Most studies (72.5%) were published in the last 10 years. The relevant extracted data from individual studies were synthesized and presented in the two major sections, perception, practices, and the second one, understanding and experiences among teenage girls. The understanding of pregnancy and teenage pregnancy-related preventive methods was detailed analysis in about 72% of papers whereas other aspects, such as perception (22.5%), practices (25%), and experiences (7.5%) were discussed in the remaining papers related to pregnancy among adolescent girls.

CONCLUSION

Evidence in the selected studies shows that understanding and practices are the major areas that were primarily explored, where perception, practices and experiences are the topics that are relatively less investigated. Literature synthesis derives misconception, lack of understanding, and practices without knowing the consequences are the key factors responsible for early pregnancies. Future interventions like increasing awareness, providing comprehensive reproductive knowledge, convenient health care aids, and proper counselling are adequate measures for minimalising the problem. The present analysis showed that studies are limited in their scope concerning various aspects of teenage pregnancy in India, so this scoping review gives essential perspectives on future research and implementation plans and policies in this field.

Emotional distress among adolescents living with perinatal HIV in India: examining predictors and their mediating and moderating effects

BACKGROUND

Development of emotional distress (ED) among adolescents living with perinatally acquired HIV (ALPHIV) affects their adherence behaviour and social and psychological functioning. Data on stressors among ALPHIV demonstrates the gap on the predictors of ED experienced by 'perinatally infected ALHIV' in the Indian socio-cultural milieu. This study aimed to identify the predictors of ED and examine their mediating and moderating role in the development of ED among Indian ALPHIV.

METHODS

Utilizing the sequential exploratory mixed-methods design, 43 qualitative interviews were conducted with ALPHIV, parents/guardians, and health care providers, followed by the cross-sectional survey among 100 ALPHIV (10-19 years). The distress subscale of the Weinberger Adjustment Inventory was used to measure ED. Qualitative data, analyzed using grounded theory were utilized to develop a survey tool. Bivariate and regression analyses were conducted to identify predictors of ED. Mediation and moderation models were tested to examine underlying mechanisms associated with ED. The study was approved by the institutional ethics committee.

RESULTS

Strong parental control, compulsive asexuality, perceived negatively different from peers, and anger toward parents were the major themes emerging from the qualitative component which eventually led to survey tool domains viz., HIV awareness, parental control, hypervigilance, adolescent-parent relationship, adolescent-parent communication, body image and perceived negatively different from peers (PNDP). Quantitative analysis indicated high ED among ALPHIV and ED was significantly associated with PNDP, anger, body image, and hypervigilance. The relationship between PNDP and ED was significantly mediated by anger, and moderated by body image and hypervigilance.

CONCLUSIONS

The study stresses the need for early mental health interventions for Indian ALPHIV before an ALPHIV develops ED. Focused counseling on anger assessment, body image issues, and self-perception is critical for leading a 'normal' life by ALPHIV. Besides, skill building of primary caregivers is recommended to draw a line between protection and overprotection.

How to make services adolescent friendly? A cross-sectional study on awareness of adolescent friendly health clinics in Central India

Background

India's flagship program on adolescent health - Rashtriya Kishor Swasthya Karyakram (RKSK) emphasises the importance of strengthening Adolescent Friendly Health Clinics (AFHCs) under its facility-based approach for improving the health of adolescents. AFHCs are intended to provide targeted intervention in six domains - nutrition, injuries & violence (including gender-based violence), mental health, sexual & reproductive health, substance abuse and noncommunicable diseases.

Objective

The current study was conducted to assess the determinants of awareness and utilisation of AFHC services in districts with RKSK services in Madhya Pradesh.

Subjects

In total, 1605 adolescents (both males and females) within the age group of 10-19 years were included in the study.

Methods

Multistage stratified random sampling was employed to enrol participants from three districts of Madhya Pradesh, where AFHC services have been launched.

Results

The mean age of the participants was 15.07 ± 2.32 years. Only 153 (9.5%) adolescents were aware of AFHC services. On multivariate logistic regression, awareness of AFHC was seen to be associated with being aware of RKSK, being a part of the peer educator-led peer group, having had adolescent health days organised in the village and belonging from one of the financially better off districts. Utilisation rate of AFHC services was lower still - at 2.74%.

Conclusion

Both awareness and utilisation of AFHC services remain very low among adolescents. There is a pressing need to focus on awareness generation campaigns - via mass media, but more importantly, through community health workers and peer educators - in order to sensitise target beneficiaries about the available services.

HPV vaccination and factors influencing vaccine uptake among people of Indian ancestry living in the United States

Approximately one-quarter of annual global cervical cancer deaths occur in India, possibly due to cultural norms promoting vaccine hesitancy. We sought to determine whether people of Indian ancestry (POIA) in the USA exhibit disproportionately lower human papilloma virus (HPV) vaccination rates than the rest of the US population. We utilised the 2018 National Health Interview Survey to compare HPV vaccine initiation and completion rates between POIA and the general US population and determined factors correlating with HPV vaccine uptake among POIA. Compared to other racial groups, POIA had a significantly lower rate of HPV vaccination (8.18% vs. 12.16%, 14.70%, 16.07% and 12.41%, in White, Black, Other Asian and those of other/mixed ancestry, respectively, P = 0.003), but no statistically significant difference in vaccine series completion among those who received at least one injection (3.17% vs. 4.27%, 3.51%, 4.31% and 5.04%, P = 0.465). Among POIA, younger individuals (vs. older), single individuals (vs. married), those with high English proficiency (vs. low English proficiency), those with health insurance and those born in the USA (vs. those born outside the USA) were more likely to obtain HPV vaccination (P = 0.018, P = 0.006, P = 0.029, P = 0.020 and P = 0.019, respectively). Public health measures promoting HPV vaccination among POIA immigrants may substantially improve vaccination rates among this population.

Prevalence of Sexual Dysfunction in Women With Depression: Need for Psychosexual Health Promotion Approach

Introduction:

Depression-associated sexual dysfunction (SD) is a pervasive and ignorant problem among the general population. The antidepressant used to treat depression may further alter the sexual response cycle in one way or another. This study aims to assess the prevalence of SD in females with major depressive disorders and the effects of antidepressant therapy after 4 weeks of follow-ups.

Material and Methods:

In a prospective observational survey, 94 women diagnosed with depression and on antidepressant therapy were purposively enrolled. Female Sexual Functioning Index (FSFI) and Montgomery-Asberg Depression Rating Scale (MADRS) are administered at baseline and 4 weeks of treatment to measure sexual function and depression changes. Relevant descriptive and inferential statistics are applied to compute the results.

Results:

The mean age of the participants was 35.87 (±5.10) years. A total of 95.7% of participants showed SD at baseline assessment. There was a significant difference (31.87 vs 18.51, P < .001) in depression from baselines to 4 weeks after antidepressant therapy. Further, a significant negative correlation was reported between the MADRS scores and the scores of arousals (r = −0.396, P < .001), lubrication (r = −0.453, P < .001), orgasm (r = −0.342, P < .001), satisfaction (r = −0.407, P < .001), pain (r = −0.362, P < .001), and total domains of FSFI (r = −0.412, P < .001) after 4 weeks. Using cut-off scores of different areas, decreased sexual desire was reported in 97.9%, poor vaginal lubrication (100%), a problem with arousal (100%), reduced satisfaction (96.8%), reduced ability to achieve orgasm (100%), and pain during sexual intercourse in 100% of the participants.

Conclusions:

There is a high prevalence of SD in women with depression. There is a marked improvement in depression at the end of 4 weeks. However, sexual function status remains unchanged and indicates the need for time to improve, suggesting different study designs.

Understanding Adolescent Sexuality: A Developmental Perspective

Adolescence is a period of transition from childhood to adulthood, during which the individual undergoes significant biological, psychological, and social changes. The development of sexuality, though begins at conception, gets shaped during this period. The changes occurring differ in males and females not just in terms of biopsychosocial organization but sexual behavior and functioning as well. Adolescent sexuality is although highly acknowledged but is quite complex and needs in-depth understanding. Challenges faced by adolescents include being vulnerable to risky sexual behaviors, unprotected sex, nonconsensual sexual interactions, sexually transmitted infections, stigmatization from society, and so on. In developing countries such as India, adolescents deal with additional challenges with higher risk associated with early marriages, unplanned pregnancies, sexual abuse, patriarchy, and insufficient information regarding sexual behavior and risks. This article is an attempt to review the nuances of adolescent sexuality, particularly in developing countries, to ensure appropriate culturally sensitive yet scientifically sound intervention programs.

Men, The Missing Link In Gender-equitable Family Planning: A Scoping Review

Background: Across societies, gender norms often allow men to hold key decision-making power within relationships, households and communities. This extends to almost all domains, consisting of family planning (FP) as well.  FP programs have largely engaged men as clients and rarely as equal partners or influencers although across lower- and middle-income countries (LMICs), and especially in South Asia, men hold key decision-making power on the domain of family planning. The objective of this article is to explore couple dynamics through the lens of spousal communication and decision-making and unpack male engagement and spousal dynamics in family planning. Methods: This review presents a synthesis of evidence from two peer-reviewed databases, PubMed and Jstor, and and insights from programmatic documents to shed light on gender equitable engagement of young married men in family planning. Inclusion and exclusion criteria for both these databases was set and search strategies were finalized. This was followed by title and abstract screening, data extraction, synthesis and analysis. Results: Study participants included unmarried men (16%, n=8), married men (19%, n=9), married women (19%, n=9), married couples (25%, n=12) or more than two respondent categories (21%, n=10). Almost three quarters (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacy (n=12, 22%). Conclusions: The evidence presented provides sufficient impetus to expand on gender-equitable male engagement, viewing men as equal and supportive partners for informed, equitable and collaborative contraceptive uptake and FP choices by couples.

Enabling Young People from Informal Urban Communities to Exercise Their Right to Sexual and Reproductive Health: A Practice-Based Study

This qualitative study explores how comprehensive sexuality education located within a broader positive youth development approach informed transformations among young people from informal urban communities in India. A thematic analysis of data obtained from the young people, their parents, and frontline workers revealed that securing the cooperation of families was possible for the program because sexual and reproductive health education was not a stand-alone intervention, but a part of a larger approach seeking to build capacities of young people. The strategic introduction of sexual and reproductive health communication helped the participants to overcome inhibitions about the topic. Enhanced awareness of gender, pubertal changes, gender-based violence, and child sexual abuse was evidenced post participation. Improved agency was manifest through decision making, critical thinking, confidence, mobility, and articulation, especially among girls. Program interventions to enhance sexual and reproductive health awareness of parents and communities and to improve health services and facilities were bolstered through youth engagement. Such contribution by the young reinforced their knowledge and skills, strengthened agency, and cemented family and community support. A holistic program situated within the positive youth development approach thus seemed a pragmatic vehicle to promote comprehensive sexuality education for young people in vulnerable urban communities.

School-Based Interventions for Promoting Sexual and Reproductive Health of Adolescents in India: A Review

In India, the prevalent stigma and taboos regarding sexuality prevent adolescents from acquiring information about sexual and reproductive health. This review assessed the school-based interventions for adolescents designed to enhance their sexual health knowledge, attitudes, and behaviors. Studies were gathered from 4 online databases: PubMed, DOAJ, Google Scholar, and ScienceDirect. Relevant studies conducted in India among adolescents, published in peer-reviewed journals between 2000 and 2020, available in the public domain and written in English, were considered for the review. 14 studies were selected through database searches that fulfilled the eligibility criteria. Findings highlighted that school-based sexuality education positively influences adolescents to develop their knowledge, attitude, and behavior related to sexual and reproductive health outcomes. Sexual and reproductive health (SRH) programs and interventions are limited to small-scale experiments conducted in a few schools. The researchers recommend educating adolescents about pregnancy prevention, sexually transmitted infections (STIs), sexual hygiene, and reproductive health. Comprehensive reproductive health education programs should be implemented in every school setting to ensure that all school-going adolescents are convinced of the importance of sexual and reproductive health.

Love, sex, and commitment: relationship choices and trajectories among unmarried youth in India

There is limited research in India to understand young people's decision-making processes about intimate relationships before marriage. This paper, adopting a life course perspective, explains relationship choices and diachronic trajectories of relationships from adolescence to young adulthood. Retrospective data were collected from 1240 never married 20-29-year-old men and women living in Pune using a relationships history calendar. All the relationships from 10 years of age onwards were plotted on the calendar, and information on predictor variables was collected through structured questionnaires. Data were analysed using descriptive statistics. Sequence analysis approach was used to identify different typologies. Overall, 76% of the participants reported having at least one relationship. More women compared to men (84% vs 70%) ever had a relationship. The median age of starting the first relationship was 17 years for women and 18 for men. Different relationship types were reported, such as "serious", casual, "friends with benefit", and "exploring". The level of emotional involvement, commitment, and physical intimacy significantly differed in different relationship types with significant gender differences. Four typologies of relationships were observed, labelled as (1) Commitment-No sex (N = 187); (2) Commitment-Sex-Some exploration (N = 189); (3) No commitment-Exploration (N = 281), and (4) No relationship (N = 583). Compared to men, women were more likely to follow the trajectory of "Commitment-No sex" (RR 2.13, CI 1.5-3.03). Family environment was significantly related to young people's relationship choices. The findings strongly suggest the need to adopt a developmental perspective towards intimate relationships to understand and address the vulnerabilities of young people across the life course.

Experiences of Getting Reproductive Health Information from Friends as the Most Influenced Factor on Human Immunodeficiency Virus (HIV) Risk Behavior in Adolescents

BACKGROUND: Adolescents are a vulnerable group to reproductive health and sexuality problems. The problem of drug use and premarital sexual behavior is the focus of attention for adolescents because it can be a risk of HIV transmission. Providing information from various parties regarding reproductive health is expected to reduce adolescents risk of carrying out HIV risk behaviors. AIM: This study purpose was to analyze the experience of obtaining reproductive health information (from friends, parents, community, community leaders, social media, and organizations) that most influence HIV risk behavior in adolescents. METHODS: This cross-sectional study was conducted on adolescents aged 15–19 years living with their parents in Surakarta. The research sample was 450 teenagers. The sampling used convenience sampling technique and data collection using a questionnaire. Data analysis was performed using Chi-square and Fisher’s exact test in bivariate analysis and logistic regression in multivariate analysis. RESULTS: Information from friends is the most influential factor on HIV risk behavior in adolescents (OR = 0.314, CI = 0.090–1.102). Teenagers who get information from friends tend to carry out HIV risk behaviors because the information is not credible and comprehensive and is more toward the negative, namely, pornography. CONCLUSION: Reproductive health information from friends is not necessarily correct. Efforts to improve the skills of adolescents to find credible sources of information on reproductive health and sexuality are needed to reduce the risk of HIV transmission.

Community-based point-of-care testing to identify new HIV infections: A cross-sectional study from Pune, India

ABSTRACT

The World Health Organization recommends point-of-care testing (POCT) to detect human immunodeficiency virus (HIV) infected individuals in the community. This will help improve treatment coverage through detection of HIV infection among those who are unaware of their status.This study was planned with an objective to investigate the feasibility and acceptability of POCT for HIV in the community.A community-based cross-sectional study was conducted in rural and peri-urban areas of Pune, India. These sites were selected based on the distance from the nearest HIV testing center. Testing locations were identified in consultation with the local stakeholders and grass-root health workers to identify and capture the priority population. The POCT was performed on blood samples collected by the finger-prick method.The proportion of participants seeking HIV tests for the first time was 79.6% that signifies the feasibility of POCT. The acceptability in the peri-urban and rural areas was 70.2% and 69.7%, respectively. POCT was performed at construction sites (24.9%), nearby industries (16.1%) and parking areas of long-distance trucks (8.1%) in the peri-urban area. Three newly diagnosed HIV-infected participants (0.1%) were detected from the peri-urban areas but none from the rural areas. Two of the newly diagnosed participants and their spouses were linked to care.There was a high acceptability of POCT and wider coverage of priority population with a strategy of testing at places preferable to the study population. Therefore, we believe that community-based POCT is a promising tool for improving HIV testing coverage even in low prevalence settings with the concentrated HIV epidemic.

Knitting Thread Devices: Detecting Candida albicans Using Napkins and Tampons

Reproducible and in situ microbial detection, particularly of microbes significant in urinary tract infections (UTIs) such as Candida albicans, provides a unique opportunity to bring equity in the healthcare outcomes of disenfranchised groups like women in low-resource settings. Here, we demonstrate a system to potentially detect vulvovaginal candidiasis by leveraging the properties of multifilament cotton threads in the form of microfluidic-thread-based analytical devices (μTADs) to develop a frugal microbial identification assay. A facile mercerization method using heptane wash to boost reagent absorption and penetration is also performed and is shown to be robust compared to other existing conventional mercerization methods. Furthermore, the twisted mercerized fibers are drop-cast with media consisting of l-proline β-naphthylamide, which undergoes hydrolysis by the enzyme l-proline aminopeptidase secreted by C. albicans, hence signaling the presence of the pathogen via simple color change with a limit of detection of 0.58 × 106 cfu/mL. The flexible and easily disposable thread-based detection device when integrated with menstrual hygiene products showed a detection time of 10 min using spiked vaginal discharge. The developed method boasts a long shelf life and high stability, making it a discreet detection device for testing, which provides new vistas for self-testing multiple diseases that are considered taboo in certain societies.

Even Mists Have Silver Linings: Promoting LGBTQ+ Acceptance and Solidarity through Community-Based Theatre in India

OBJECTIVES

This project aimed to assess the effectiveness of a community-based theatre intervention to improve attitudes towards and increase knowledge about LGBTQ+ communities among audiences in Mumbai, India.

STUDY DESIGN

This study was a program evaluation using pre- and post-show surveys that incorporated an adapted version of The Riddle Scale: Attitudes Towards Difference and questions assessing self-reported knowledge about LGBTQ+-related issues to assess changes in attitudes and knowledge after viewing the theatre intervention.

METHODS

An original 90-min devised play was created by a company of Indian, American, and Canadian theatre artists using Participatory Action Research methods and was designed to bring audiences to a deeper understanding of LGBTQ+ identity. The show was performed four times in Mumbai, India, and pre-/post-show surveys were collected at each performance. Audience survey responses were analysed using parametric and non-parametric descriptive statistics as appropriate, and Likert scale questions were compared using Wilcoxon Signed Rank for non-parametric data.

RESULTS

A total 184 surveys were completed across four performances between March 7 and 14, 2020. Significant increases in audiences' self-reported knowledge of LGBTQ+ identity, impacts of discrimination, and struggles faced by LGBTQ+ communities were reported after viewing the show. Furthermore, attitudes towards LGBTQ+ rights, understanding of the challenges of being LGBTQ+ in India, and recognition of the contributions LGBTQ+ individuals make to society improved significantly among our audiences after test. The play further fostered increased acceptance of prosocial behaviours towards LGBTQ+ individuals with higher percentages of audiences recognizing the importance of standing up to homophobia and anti-gay attitudes. While these observations were seen across audiences, they were particularly pronounced among cisgender heterosexual men and audiences ages 18-24.

CONCLUSION

Community-based theatre intervention is highly acceptable and effective as a medium for informing positive attitudes, improving knowledge, and promoting acceptance of and solidarity towards LGBTQ+ communities among young adult heterosexual audiences.

Exploring young women's menstruation-related challenges in Uttar Pradesh, India, using the socio-ecological framework

Menstruation frequently poses psychological, social, and health challenges for young women living in low- and middle-income countries. In countries such as India, where menstruation is stigmatised, it can be particularly difficult. This paper examines challenges related to menstruation for young women living in slums in Lucknow, Uttar Pradesh, India. The research was informed by the socio-ecological model. Life course interviews were conducted with 70 young women ages 15–24 living in the slums of Lucknow. Thematic analysis was used to identify salient themes regarding individual, social, and systemic challenges related to menstruation. On the individual level, young women lack knowledge about menstruation. In the social sphere, young women experience stigma around menstruation, lack opportunities to discuss menstruation, and experience limitations around mobility and other activities during menstruation. At the institutional level, for example in school, there are few resources to support menstruating young women as toilets are dirty and doors are broken. Therefore, menstruating adolescents and young women in Lucknow, Uttar Pradesh, India, face an array of challenges at multiple levels. These findings suggest that multi-level interventions are warranted to create a supportive context for menstruation.

Outcomes assessment pitfalls: challenges to quantifying knowledge gain in a sex education game

Background: The use of videogames as a public health tool is rapidly expanding. Accurate assessment of the efficacy of such games is complicated by many factors. We describe challenges associated with measuring the impact of playing a videogame with information about human sexual anatomy and reproduction and discuss motivations for, and solutions to, these challenges. Methods: The My Future Family Game (MFF) is a validated tool for collecting data about family planning intentions which includes information about human anatomy and sexual reproduction. We sought to assess the efficacy of the game as a tool for teaching sexual education using a pre-post model which was deployed in three schools in and around Chennai, India in summer of 2018. Results: The MFF game was successfully modified to collect data about players' pre-gameplay knowledge of sexual anatomy and processes. The post gameplay assessment process we used did not effectively assess knowledge gain. Designing assessments for games dealing with sexuality presents challenges including: effectively communicating about biological parts and processes, designing usable and intuitive interfaces with minimal text, ensuring that all parts of the process are fun, and integrating assessments into the game in a way that makes them invisible. Conclusion: Games can be an effective means of gathering data about knowledge of sex and reproduction that it is difficult to obtain through other means. Assessing knowledge about human sexual reproduction is complicated by cultural norms and taboos, and technical hurdles which can be addressed through careful design. This study adds to the sparse literature in the field by providing information about pitfalls to avoid and best practices in this evolving area.

Sexual and reproductive health self-care: a theory-based intervention

Purpose

This study, a theory-based interventional study, aims to promote self-care behaviors regarding sexual and reproductive health in adolescents (female) in Karaj, Iran.

Design/methodology/approach

This study was conducted on 90 female students of the Alborz University of Medical Sciences in Iran. For selecting subjects, the researchers went to two girls' dormitories on working days and tried to observe the proportion of students with different fields. Initially, 200 eligible female students were identified in the dormitories of Alborz University of Medical Sciences. Based on the sample size estimation, 100 research units were divided into two groups of receiving counseling (intervention group) and not receiving counseling (control group) by four-digit block randomization. Sexual and reproductive health self-care questionnaire was used as a tool for data collection before, after and one month after intervention. Data were analyzed by using X2 and ANOVA tests using SPSS (16).

Findings

Both groups were homogeneous in terms of demographic characteristics before the intervention. The results of the study indicated that after education, sexual and reproductive knowledge (p < 0.001), self-care of sexual health (p < 0.001), self-care of menstrual and genital health (p < 0.001) increased significantly. But, regarding parents' communications (p = 0.11), conversation barriers with parents (p = 0.83), interaction with (p = 0.79) and the perceptions of sexual risk behaviors relationships (p = 0.61) differences are not significant.

Research limitations/implications

Failure of parents to participate in this study and the implementation of this study only on the female sex were main limitations of the present study.

Practical implications

Theory-based education can improve sexual and reproductive health in adolescents' girls.

Originality/value

All Authors declare the manuscript entitled “Sexual and reproductive health self-care: a theory-based intervention” is original work of the author. All data, tables, figures, etc. used in the manuscript are prepared originally by authors; otherwise, the sources are cited and reprint permission is attached.

Social and economic marginalisation and sexual and reproductive health and rights of urban poor young women: a qualitative study from Vadodara, Gujarat, India

In this paper, we present the results of a qualitative study by a non-profit organisation implementing a community-based urban adolescent development programme. The study highlights the sexual and reproductive health and rights (SRHR) situation of marginalised young women in a developed state of India. Our findings, based on in-depth interviews with young women and frontline health providers, show that structural factors, such as economic and social stratifiers, gender norms and cultural beliefs, result in further marginalisation of young women. In turn, marginalisation adversely affects the realisation of SRHR through discriminatory practices around menstruation and lack of control in matters related to sexuality, contraception, pregnancy and safe abortion. Rights to the highest standards of sexual and reproductive health (SRH) care are compromised. Health system factors like providers’ attitudes and knowledge, commodity supplies, and indifference to ensuring delivery of contraceptives and other services often result in unplanned pregnancies and affect the quality of young women’s SRH care. Whatever information and support adolescents and young women get is from local community-based organisations. We conclude that structural determinants and violations of fundamental rights to education, equal opportunities and participation constitute a significant barrier to the enjoyment of SRHR by the marginalised young women in the study. Unless these are addressed, government policies and programmes to promote young people’s SRHR will not benefit young women from disadvantaged communities. Partnership and complementarity between government programmes, adolescents and health rights civil society organisations are recommended to promote rights-based, equitable adolescent and youth-friendly services to this vulnerable population.

Outcomes assessment pitfalls: challenges to quantifying knowledge gain in a sex education game

Background: The use of videogames as a public health tool is rapidly expanding. Accurate assessment of the efficacy of such games is complicated by many factors. We describe challenges associated with measuring the impact of playing a videogame with information about human sexual anatomy and reproduction and discuss motivations for, and solutions to, these challenges. Methods: The My Future Family Game (MFF) is a validated tool for collecting data about family planning intentions which includes information about human anatomy and sexual reproduction. We sought to assess the efficacy of the game as a tool for teaching sexual education using a pre-post model which was deployed in three schools in and around Chennai, India in summer of 2018. Results: The MFF game was successfully modified to collect data about players' pre-gameplay knowledge of sexual anatomy and processes. The post gameplay assessment process we used did not effectively assess knowledge gain. Designing assessments for games dealing with sexuality presents challenges including: effectively communicating about biological parts and processes, designing usable and intuitive interfaces with minimal text, ensuring that all parts of the process are fun, and integrating assessments into the game in a way that makes them invisible. Conclusion: Games can be an effective means of gathering data about knowledge of sex and reproduction that it is difficult to obtain through other means. Assessing knowledge about human sexual reproduction is complicated by cultural norms and taboos, and technical hurdles which can be addressed through careful design. This study adds to the sparse literature in the field by providing information about pitfalls to avoid and best practices in this evolving area.

Facilitators of Sexual Health Education for Male Adolescents in Iran: A Qualitative Study

Background:

Adolescence is a period of rapid physical, social, emotional, cognitive, and sexual development. The widening gap between biological maturity and social transition to adulthood highlights the importance of adolescents' need for education, especially in sexual health. The main objective of this study was to explore the facilitators of Sexual Health Education (SHE) for male adolescents in Iran.

Materials and Methods:

In this qualitative content analysis, a total number of 45 participants were investigated from June 2018 to July 2019 through individual, semi-structured, in-depth interviews in the city of Mashhad, Iran, until data saturated. The participants were selected using a purposive sampling method. The data were analyzed using a conventional content analysis method based on the approach developed by Graneheim and Lundman (2004) using MAXQDA software.

Results:

In data analysis, 2 main categories and 9 subcategories emerged. The main categories included extrapersonal facilitators and intrapersonal facilitators. The category of extrapersonal facilitators included the 7 subcategories of appropriate policy-making, use of religious capacities, consideration of native culture, supportive family environment, school empowerment, inter-sectoral integration and collaboration, and reinforcement of parent-teacher interaction. The category of intrapersonal facilitators comprised of the 2 subcategories of supporting adolescent socialization and using distraction techniques in adolescents.

Conclusions:

The study revealed that having an action plan with a scientific, ethical, legal, religious, and cultural background, establishing a suitable home, school, and community environment, strengthening inter-sectoral integration, collaboration, and interpersonal coordination, and utilizing the capabilities and potentials of adolescents can provide an appropriate SHE for adolescent boys.

Outcomes assessment pitfalls: challenges to quantifying knowledge gain in a sex education game

Background: We describe challenges associated with incorporating knowledge assessment into an educational game on a sensitive topic and discuss possible motivations for, and solutions to, these challenges. Methods: The My Future Family Game (MFF) is a tool for collecting data about family planning intentions. The game was expanded to include information about human anatomy and sexual reproduction. To assess the efficacy of the game as a tool for teaching sexual education, we designed a pre-post study with assessments before and after the game which was deployed in three schools in and around Chennai, India in summer of 2018. Results: The pre-post process did not effectively assess knowledge gain and made the game less enjoyable. Although all participants completed the pre-test because it was required to access the main game, many did not complete the post test. As a result, the post-test scores are of limited use in assessing the efficacy of the intervention as an educational tool. This deployment demonstrated that pre-post testing has to be integrated in a way that motivates players to improve their scores in the post-test. The pre-test results did provide useful information about players' knowledge of human anatomy and mechanisms of human reproduction prior to gameplay and validated the tool as a means of data collection. Conclusion: Adding outcomes assessment required asking players questions about sexual anatomy and function with little or no introduction. This process undermined elements of the initial game design and made the process less enjoyable for participants. Understanding these failures has been a vital step in the process of iterative game design. Modifications were made to the pre-post test process for future deployments so that the process of assessment does not diminish enthusiasm for game play or enjoyment and motivates completion of the post-test as part of gameplay.

Use of Sexually Explicit Materials as Sex Education Tools to Reduce the Number of Recurrences of Urinary Tract Infection in Sexually Active Women

Context: As sexual intercourse is a known risk factor for recurrent urinary tract infection (UTI) in women, we decided to evaluate a novel method of sex education using sexually explicit materials (SEM) to reduce the number of recurrences of UTI in sexually active women, when the other preventive measures fail to reduce the number of recurrences of UTI in these women.

Methods: After obtaining written informed consent and ethical committee approval, sexually active women with a single sexual partner, who presented for recurrent symptomatic UTI following sexual intercourse, were included in this study. The absence of recurrence for 6 months, successful postcoital drug prophylaxis, the presence of comorbidities, anatomical abnormalities of the genitourinary tract (GUT), history of instrumentation of GUT, and use of contraception were exclusion criteria. Their demographic profile, socioeconomic status, imaging studies, pre- and post-intervention urine culture profile and pre- and post-intervention sexual practices were recorded. During every visit, all these women along with their male partners were given sex education sessions about healthy sexual practices using SEM. Data is analyzed.

Results: Study period was January 2012 to June 2018. A total of 107 women with the mean age of 30.11 years were included in the study. A total of 82% of UTI were due to Escherichia coli, whereas the other cases were attributable to Klebsiella, Proteus, and Staphylococcus saprophyticus. Their preintervention yearly incidence of documented UTI was 4.04 episodes which reduced to 1.91 episodes post intervention.

Conclusions: Sex education with SEM can be an option to treat recurrent UTI in sexually active women.

A Qualitative Exploration to Understand the Sexual Behavior and Needs of Young Adults: A Study Among College Students of Pune, India

OBJECTIVE

Youth and adolescents are the priority population to target the interventions as risky behaviors persist and they contribute to almost half of the new Human immunodeficiency virus (HIV) infections. The youth in India have a unique and diverse need of sex health education. The present study was conducted with the objective to understand their sexual behavior and requirements of sexual health.

METHODS

Focus group discussions were conducted among 74 college students, separately for boys and girls. The participant students were from different streams of education. The domains of enquiry were related to the relationships, risk behaviors, sources of information and use of technology for sex health education. The qualitative data was analyzed based on the themes and subthemes derived from these discussions.

RESULTS

A majority of the youth favoured active involvement of parents, school teachers in sex health education. They suggested that better-informed parents lead to better-informed adolescents. Open discussion with experts was also desired by the students. The use of mobile/web based application for sex health education and awareness about HIV and sexually transmitted infections (STIs) was preferred, however, they suggested that based on personal requirements, individual need based counseling and guidance is important.

CONCLUSIONS

Active parental involvement and open discussions on sexuality were the preferred options by the student to seek the knowledge and guidance. Innovative mobile application for sex health education will be useful for the young adults for information and communication. The study highlighted a need to develop a holistic approach to generate a culturally-sensitive sex health education and life skills model.

Strategies to facilitate safe sexual practices in adolescents through integrated health systems in selected districts of Zimbabwe: a mixed method study protocol

Background

Zimbabwe has the highest teenage pregnancy rate in Sub Saharan Africa. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) prevalence in adolescents that are from tribes that perform cultural initiations and subscribe to certain norms are higher than the national prevalence which is estimated at 12% (18 and 13.6% respectively) in Zimbabwe. Indigenous Health Systems (IHSs) and Modern Health Systems (MHSs) in Zimbabwe run parallel thereby introducing challenges in the management of adolescent sexual health due to conflicts. This study seeks to develop strategies that will facilitate the integration of IHSs and MHS in Mberengwa and Umguza districts.

Methods

This research will be conducted in two phases. The first phase would utilise a concurrent triangulation mixed methods design with both qualitative and quantitative approaches. The findings from the qualitative and quantitative approaches would be merged through a comparison of findings side by side. The second phase would focus on the development and validation of strategies that would facilitate the integration of IHSs and MHSs. The Strength, Weakness, Opportunity and Threat (SWOT) analysis would be applied on interfaced findings from phase one. The Basic Logic and the Build, Overcome, Explore and Minimise (BOEM) models would then be used to develop strategies based on the SWOT findings. The developed strategies would be validated through the application of Delphi technique and administration of checklist to selected key stakeholders through organised workshops.

Discussion

There have been no known studies found in the literature that explores the possibility and developed strategies of integrating IHSs and MHSs so as to promote safe sexual practices in adolescents. Most programs on sexual health have ignored the role of IHSs and MHSs in influencing safe sexual practices leading to them failing to attain desired goals. A lot of emphases has been targeted at minimising the spread of Sexually Transmitted Infections (STIs) through advocating for utilisation MHSs rather than focussing on an integrating systems that are meant to manage Adolescent Sexual Health (ASH) related issues. The study protocol was approved by the University of Venda Ethics Committee Registration (SHS/19/PH/17/2608) on the 26th of August 2019.

A family physician's journey in exploring sexual health perceptions and needs in a boarding school community

Introduction and Context:

Sexual health in schools is neglected in most developing countries,^[1] however, it is emerging as a major need of the hour. This article captures the author's experience as a family physician in a boarding school setting in India highlighting the need and possible solutions pertaining to sexual health in the school community.

Setting:

An international boarding school in India with approximately 600 students, 500 teachers, and administrators who lived on the school campus and 500 support staff who lived off-campus.

Materials and Methods:

Three events prodded the author to explore perceptions and needs pertaining to sexual health in the school community. Being a difficult area of inquiry, this was done as informal qualitative research by dialoguing with six groups of people in the school community: School counselors, parents, student supervisors such as teachers, advisors and dorm parents, school administrators, support staff, and the students and the responses were collated.

Observations:

A mere 17.9% of grade 5 to 12 students, of age-groups 10 to 19 never had a conversation with their parents about sexuality. Students were largely ignorant or misinformed on most sexuality-related issues but engaged well when offered anonymity or safe space. Though all stakeholders in the school agreed that students needed an age-appropriate, gender and culture-sensitive, scientific and comprehensive sex education, parental responses were mixed.

Conclusion:

The author's journey as a family physician in a school setting has prompted exploration of a wholistic model for the provision of comprehensive sexual health in schools and the emerging role of a family physician in schools.

Frequency and determinants of health care utilization for symptomatic reproductive tract infections in rural Indian women: A cross-sectional study

Introduction

The public health burden of reproductive tract infections (RTIs) among women in rural areas of low-income countries is poorly addressed because health care seeking for treatment of RTIs is inadequate. There are gaps in knowledge about whether low care seeking behavior stems from challenges in accessing health care versus women's recognition of and response to RTI-specific disease symptoms. We aim to identify determinants of care seeking behavior and analyze the difference in utilization of health care resources in response to symptoms of an RTI versus non-RTI disease symptoms in rural India. This will aid in the design of interventions that promote RTI care seeking behavior.

Methods

Our analysis uses data from a cross-sectional, population-based surveillance survey among rural, non-pregnant women in Odisha, India, from 2013–2014 (n = 3,600). We utilized bivariate logistic regression to determine the degree that certain determinants are associated with a woman’s likelihood to seek RTI treatment, and chi-Squared tests to assess for differences in health care resources used for non-RTI versus RTI symptoms.

Results

Married women were significantly more likely to seek health care for RTI symptoms (Odds Ratio (OR) = 1.9, 95% Confidence Interval (CI): 1.2–3.0) while unmarried adolescents were less likely to seek treatment (OR = 0.4, CI: 0.2–0.6). There was no association between RTI health care seeking with education level, belief about whether symptoms can be treated, or poverty. The majority (73.8%) of women who did not seek treatment for RTI symptoms reported not seeking treatment because they did not know treatment was needed. Women utilized formal health care providers at a higher rate in response to RTI symptoms than in response to their most recent symptoms of any kind (p = 0.003).

Conclusions

Community-based reproductive health education interventions are needed to increase health care seeking behavior for RTIs in rural Indian women. Interventions should target unmarried women and focus on both sexual health education and access to care.

The Factors that Determine Reproductive Health Characteristics of Adolescents in Serbia

The aim of the work is to assess vulnerability degree of reproductive health in adolescent population in Serbia by analyzing their sexual behavior. The paper is based on data from a National health survey of the population in Serbia in 2013 (without Kosovo and Metohija region), conducted by the Ministry of Health of the Republic of Serbia. For the purposes of this study, the data used are referred to households and population of age 15 and over, so that the final number for analysis is a sample of 1722 respondents aged 15-24. The study included demographic characteristics of respondents (age, gender, settlement type, region) and the characteristics of reproductive health: sexual behavior, use of contraceptive protection, knowledge and attitudes towards HIV, protection of reproductive health. χ2 test was applied for testing differences in frequency of categorical variables. All results with a probability that equals to or is less than 5% (p≤0.05) are considered statistically significant. Among the respondents, there were more than half (53.5%) of sexually active adolescents. The highest percentage of them- 16.6% responded that they had first sexual intercourse at the age of 17. 53.4% of adolescents had sexual intercourse with one partner, 26.4% of respondents had sexual intercourse with two or more partners. The most commonly used contraceptive method was interrupted intercourse (coitus interruptus) with 34.7% of respondents.

Primary Prevention of Intimate Partner Violence Among Recently Married Dyads Residing in the Slums of Pune, India: Development and Rationale for a Dyadic Intervention

BACKGROUND

Intimate partner violence (IPV) is frequently experienced by women of low socioeconomic status in India. It is a human rights violation and associated with negative effects on physical and mental well-being, underscoring the need for effective prevention strategies.

OBJECTIVE

This study aimed to develop a dyadic intervention for the primary prevention of IPV among newly married couples residing in slum communities in India.

METHODS

The intervention was developed using a community-based, mixed-methods design rooted in couple-interdependence theory and guided by the intervention mapping (IM) framework. It used the six critical IM steps to inform the content and delivery of the intervention: (1) needs assessment, (2) preparation of matrices of change objectives, (3) selection of theory-based methods and practical applications, (4) production of intervention components and materials, (5) intervention adoption and implementation, and (6) evaluation planning.

RESULTS

The resulting Ghya Bharari Ekatra (Take a Flight Together) intervention is intended to be delivered in 6 weekly sessions by a trained pair of male and female lay community educators to groups of 3 to 5 newly married couples in the community in which they reside. It uses games, discussions, self-reflections, and skill-building exercises to cover the following topics: enhancing relationship quality time, self-esteem and resilience, communication and conflict management, goal setting and implementation, sexual communication and sexual health and reproductive health knowledge, and redefining and challenging norms surrounding IPV occurrence. The formative work guided the protocol, including module duration and timing (2-hour sessions of convenience to participants), ordering of modules (based on potential level of interest and sensitivity of the topics), content (ie, informed scripts of role plays and films), intervention delivery methods (ie, interactive activities), and selection of the interventionists (based on capacity to connect with participants) and venue (community-based, convenient, and safe spaces). Ghya Bharari Ekatra was piloted between January and May 2018, and evaluation is presently underway.

CONCLUSIONS

Ghya Bharari Ekatra is evidence-based, grounded in intervention-mapping, and developed and iteratively refined using a community-based participatory research approach, suggesting it has great potential to be an acceptable and effective solution to preventing IPV among newly married couples.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03332134; https://clinicaltrials.gov/ct2/show/NCT03332134.

Intersections of girl child marriage and family planning beliefs and use: qualitative findings from Ethiopia and India

Child marriage and subsequent early first birth is a considerable social, economic and health concern, and a pervasive practice in sub-Saharan Africa and South Asia. This study explores barriers and facilitators to family planning among women and girls, and their marital decision-makers subsequent to receipt of child marriage prevention programmes in Ethiopia and India. In-depth interviews with 128 women and girls who were married as minors or who cancelled or postponed marriage as minors and their marital decision-makers were analysed using content analysis. Respondents identified social norms, including child marriage and pressure to have children, and lack of information as barriers to family planning. Benefits included delayed first birth and increased birth spacing, improved maternal and child health and girls' educational attainment. Respondents associated family planning use with delayed pregnancy and increased educational attainment, particularly in Ethiopia. Child marriage prevention programmes were identified as important sources of family planning information. Ethiopia's school-based programme strengthened access to health workers and contraception more so than India's community-based programme. Findings highlight young wives' vulnerability with regard to reproductive control, and support the need for multi-sector approaches across communities, schools and community health workers to improve family planning among young wives.