Objectives: To assess attitudes and awareness regarding sexual health education and services among young individuals in Pakistan.
Methods: A cross-sectional survey was conducted in urban and semi-urban districts of Sindh, Pakistan, in
2010. A self-administered questionnaire was distributed in-hand among 200 young people aged 16-25 years; who were selected on the basis of convenience sampling. Of the questionnaires distributed, 165 (82%) were returned. After checking for quality and consistency, 150 (75%) forms were found good enough to be used for categorical analysis, using PASW Statistics 18 for Mac 2008 version.
Results: Of the 150 participants, 94 (63%) were males and 56 (37%) were females. A quarter of them (n=38; 25.3%) said sexual health services were available too far away from their area. Besides, they also found the staff to be \'not competent.\' Almost one-third (n=49; 32.7%) reported of not having matching gender choice (male or female) of professionals with whom they could feel comfortable sharing their sexual health concerns. Majority of the participants (n=101; 67.3%) considered trained health professionals as the primary source of sexual health education, whereas, 90 (60%), 75 (50%), and 59 (39.3%) also reported to have secondary sources, including internet, parents and telephone helpline respectively.
Conclusion: Sexual health education and services for the young are barely enough or satisfactory in terms of quantity and quality in Pakistan, suggesting a case for having curriculum-based sex education implemented in academic institutions.
Keywords: Sex health education; Sexual health services; Perceptions towards Sexual Health Education. (JPMA 62:708; 2012).
Limited access to information and services for young people decreases their self-confidence and the ability to make informed choices.6 For example, a study in Sri Lanka revealed lack of knowledge among youngsters aged 17-19 years to result in low self-confidence and psychological distress, especially with regard to masturbation practices and menstruation periods.7
Demographically high proportion of youth, low literacy rate, low knowledge about Sexually Transmitted Infections (STIs), delayed marriages, and poor health indicators are few major risk factors in raising the susceptibility of young people contacting sexually transmitted infections in Pakistan.8
Literature about sexual and reproductive health for young people is scarce in Pakistan.9 Young people in Pakistan have very limited knowledge about sexual and reproductive health, and majority of them have different misconceptions.10 For example, a study conducted on young boys and girls aged 10-19 years in Karachi found that 54% participants had no information on any STI.11 A qualitative study on adolescents reported that girls perceived menstruation as the ability to give birth; and that having a shower during menstruation periods is harmful for their health.12 Another study representing young men aged 18-21 years reported having fears of detrimental effects as a result of masturbation, varying from erectile dysfunction (30.4%) to physical (76.4%) and sexual weakness (10.9%). Feelings of guilt associated with masturbation were also reported by 76% of the participants. Young people experience many negative psychological effects due to their lack of knowledge about sexuality.10 They want to learn about their bodies9,11 as 88% participants, in a study, maintained that sexual health should be included in school curriculum.13
Young persons\' perceptions about need of sex education, satisfaction with sexual health services, and knowledge about STIs has attracted very little space from research point of view in Pakistan.11 Therefore, this study was aimed to assess youngsters\' awareness and attitude towards the availability of sexual health education and sexual health services in the country.
The study participants were recruited from both public and private academic institutions, using the convenient sampling method. The eligibility criterion was restricted to age between 16-25 years, regardless of gender and particular subject of study at the institution. In total, 200 questionnaires were distributed in-hand along with an information sheet explaining their participation in the research. Study participants were facilitated by a trained research assistant at each study site. They were given options to either complete-and-return the questionnaire on-spot; or take it home and return it later by a set date in a sealed envelope which was provided with the questionnaire. Majority of the participants (n=158; 79%) opted to return the questionnaire later, and the envelopes were subsequently collected by the research assistant. Altogether, 165 filled questionnaires were received. The quality and consistency of the forms were checked and the responses from 150 questionnaires were found suitable for entry and further analysis.
The data-collection tool was a quantitative-structured questionnaire, which was translated into three languages: English, Urdu and Sindhi. The translated questionnaire was piloted on 05% of the total sample size, randomly selected in similar settings before the study. Statistical analysis of the data was undertaken using PASW Statistics 18 for Mac 2008 version. The data was analysed to produce descriptive statistics.
As the study did not involve any physical or emotional harm to the participants, participation was made purely on voluntary basis for which verbal consent was obtained from all the participants. Confidentiality of the participant was ensured by coding individual responses on unique participant identification codes. The study received ethical approval from the Ethical Review Committee of the School of Health and Related Research (ScHARR), University of Sheffield, England.
Regarding sexual health service, 47 (31.1%) of the young people admitted to having a fear that a friend might find out that they had asked for an advice about sexual health, and this stopped them from seeking any medical help (Table-2).
There were 38 (25.3%) who said sexual health services were far away for them to make use.
Of the participants 37 (24.7%) commented about the attitude of staff at such health facilities as "unwelcoming" about sexual health concerns. It was observed that 41 (27.3%) of the participants perceived health facility staff as "not competent", whereas, 49 (32.7%) reported of not having gender choice (male and female) in terms of professionals with whom they could feel comfortable sharing their sexual health concerns. Besides, 51 (34%) young people acknowledged that very often they feared discussing sexual matters with anyone, while 41 (27.3%) would rather not know if they had an STI, including HIV/AIDS.
In terms of sexual health education, a majority of respondents favoured the concept of initiating the subject at some level of the academic process: primary (n-30; 20%); secondary (n=51; 39.3%); or college/university (n=95; 63.3%). However, 80 (53.3%) disagreed with the basic concept. With regard to the primary source of sexual health education, 101 (67.3%) participants favoured trained health professionals, while 90 (60%), 75 (50%), and 59 (39.3%) thought of secondary sources like the internet, parents, and telephone helplines, respectively. These observations were compared with global trends (Figure).
The study also showed that existing sexual health services are inaccessible, that many staff are incompetent and unwelcoming, and that the services are not young-people-friendly. It is well known that stigmas associated with STIs deter many people from seeking sexual health services, the attitude and knowledge of staff play a vital role in building confidence and trust among healthcare seekers.14,15 The review of the literature showed that unfavourable attitude results into under-reporting of unwanted pregnancies, and abortions in Pakistan.16 This study showed that one-third of the young people feared discussing their sexual health problems with anyone. This indicates that they have less trust and more fear of breaking confidentiality about their sexual health. It is well discussed that if the confidentiality is compromised, young people will be less likely to use the services or will be less than honest about their sexual health conditions.15
The findings of this study implied that the government should re-evaluate the existing sexual health services and should make them more young-people-friendly.
The findings of the study are consistent with many other studies, in suggesting that young people want to learn about their sexual health.9,11,13 Throughout the world, schools have been recognised as an important place for sex and STI/HIV education.17 Strategies based on a written curriculum in school on HIV/STI education are promising interventions in terms of a reduction of unsafe sexual risk behaviours among the young.18 Several studies and reviews have concluded that school-based sexual health education for young people improves their understanding on sexually transmitted infections, including HIV/AIDS, reduces risky behaviour like unsafe and unprotected sexual intercourse, and develops skills to communicate effectively and make healthy relationships.18,19
This study adds to the literature that suggests that young people want sexual health education to be taught in academic institutions of Pakistan. Young people said that the content of sex education should include family values such as responsibility of parenting; physical and emotional changes at puberty; biology of sex; human reproduction; contraception; and information about STIs including HIV/AIDS.
The study had many methodological limitations that may have influenced its results. Since the participants were recruited from academic institutions and the majority had higher secondary education level, therefore, it is difficult to generalise the findings on common young people in the local context. The quantitative nature of the questionnaire might have prevented participants from sharing their views that might have been different from the statements and options available in the questionnaire. Besides, because of the standardised nature of the questionnaire, participants who misunderstood any point might not have had an explanation of the questions concerned. Moreover, there is always doubt about the honesty of the participants\' responses when self-administered questionnaires are used. Inclination of socially acceptable responses might be possible due to the sensitive nature of the topic.
2. UNAIDS. Impact of HIV and sexual health education on the sexual behaviour of young people. A review update by UNAIDS 2007. (Online) (Cited 2010 April). Available from URL: http://data.unaids.org/publications/IRC-pub01/jc010-impactyoungpeople_en.pdf.
3. Braverman PK, Strasburger VC. Sexually transmitted diseases. Clin Paediat (Phila) 1994; 33: 26-37.
4. World Health Organization. Toward universal access: Scaling up priority HIV/AIDS interventions in the health sector. Geneva: WHO 2007.
5. FPA for Northern Ireland. Sex education in schools. Family planning association for northern Ireland. (Online) (Cited 2011 April) Available from URL: http://www.hpani.org/Resources/sexual/pdfs/sexedinschools.pdf.
6. UNAIDS. Young people and HIV/AIDS, Opportunity in crisis. UNAIDS 2002. (Online) (Cited 2010 April) Available from URL: http://data.unaids.org/topics/young-people/youngpeoplehivaids_en.pdf.
7. Agampodi SB, Agampodi TC, Ukd P. Adolescents perception of reproductive health services in Sri Lanka. BMC Health Serv Res 2008; 8: 98.
8. Siddiqui MH, Siddiqui JA, Ahmed I. Demographic profile and clinical features of admitting HIV patients in a tertiary care teaching hospital of Karachi Pakistan. Pak J Med Sci 2009; 25: 861-4.
9. Qazi Y. Adolescent reproductive health in Pakistan. In:Bott S, Jejeebhoy S, Shah I, Puri C. (eds). Towards adulthood: exploring the sexual and reproductive health of adolescents in South Asia. Geneva: World Health Organization, 2003; 78-80.
10. Khan A, Pine P. Adolescents and reproductive health in Pakistan: a literature review. Population council final report 2000.
11. Ali TS, Ali PA, Waheed H, Memon AA. Understanding of puberty and related health problems among female adolescents in Karachi, Pakistan. J Pak Med Assoc 2006; 56: 68-72.
12. Mohamed S. Addressing gender inequality in adolescent life skills education: Aahung\'s experience in Pakistan. International women health 2004.
13. Majid S. Reproductive health awareness in adolescent girls: report of a survey. J Coll Physcians Surg Pak 1995; 5: 214.
14. Leili S, Elham S, Farkhondeh S. A population based survey of HIV/AIDS knowledge and attitude in general public, Bandar-Abbas, Iran. Pak J Med Sci 2008; 6: 838-44.
15. Thomas N, Murray E, Rogstad K. Confidentiality is essential if young people are to access sexual health services. Int J STD & AIDS 2006; 17: 525-9.
16. Rehan N. Attitude of health care providers to induced abortion in Pakistan. J Pak Med Assoc 2003; 53: 7.
17. Mukoma W, Kagee A, Flisher AJ, Mathews C. School-based interventions to postpone sexual intercourse and promote condom use among adolescents. The Cochrane Collaboration. Published online first; 21 Jan 2009. doi: 10.1002/14651858. CD0064-17.
18. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviours of young people throughout the world. J Adolesc Health 2007; 40: 206-17.
19. Wellings K, Wadsworth J, Johnson AM, Field J, Whitaker L, Field B. Provision of sex education and early sexual experience: the relation examined. BMJ 1995; 311: 417-20.
Methods: A cross-sectional survey was conducted in urban and semi-urban districts of Sindh, Pakistan, in
2010. A self-administered questionnaire was distributed in-hand among 200 young people aged 16-25 years; who were selected on the basis of convenience sampling. Of the questionnaires distributed, 165 (82%) were returned. After checking for quality and consistency, 150 (75%) forms were found good enough to be used for categorical analysis, using PASW Statistics 18 for Mac 2008 version.
Results: Of the 150 participants, 94 (63%) were males and 56 (37%) were females. A quarter of them (n=38; 25.3%) said sexual health services were available too far away from their area. Besides, they also found the staff to be \'not competent.\' Almost one-third (n=49; 32.7%) reported of not having matching gender choice (male or female) of professionals with whom they could feel comfortable sharing their sexual health concerns. Majority of the participants (n=101; 67.3%) considered trained health professionals as the primary source of sexual health education, whereas, 90 (60%), 75 (50%), and 59 (39.3%) also reported to have secondary sources, including internet, parents and telephone helpline respectively.
Conclusion: Sexual health education and services for the young are barely enough or satisfactory in terms of quantity and quality in Pakistan, suggesting a case for having curriculum-based sex education implemented in academic institutions.
Keywords: Sex health education; Sexual health services; Perceptions towards Sexual Health Education. (JPMA 62:708; 2012).
Introduction
The proportion of young persons is growing faster in the world.1 Risky sexual behaviours, such as early sexual debut, premarital sex, multiple partners and bisexual orientation, are also increasingly becoming common among young people.2,3 Sex education for the young has remained a limited and controversial issue in many countries across the world.1 According to the World Health Organisation bulletin 2007, many nations worldwide pledged that by 2007, more than 90% of young people in their countries would be able to correctly recognise the modes of HIV transmission and its prevention. However, available evidence shows that only 40% of young males and 36% of females have appropriate knowledge of HIV/AIDS.4 Health education is a basic right of young people. It improves their knowledge about their bodies, gives them the opportunity to understand their responsibility in society, and helps them develop negotiating skills.5 However, sexual and reproductive health is entangled in complex societal stigmas, fears, misconceptions and misinformation.1Limited access to information and services for young people decreases their self-confidence and the ability to make informed choices.6 For example, a study in Sri Lanka revealed lack of knowledge among youngsters aged 17-19 years to result in low self-confidence and psychological distress, especially with regard to masturbation practices and menstruation periods.7
Demographically high proportion of youth, low literacy rate, low knowledge about Sexually Transmitted Infections (STIs), delayed marriages, and poor health indicators are few major risk factors in raising the susceptibility of young people contacting sexually transmitted infections in Pakistan.8
Literature about sexual and reproductive health for young people is scarce in Pakistan.9 Young people in Pakistan have very limited knowledge about sexual and reproductive health, and majority of them have different misconceptions.10 For example, a study conducted on young boys and girls aged 10-19 years in Karachi found that 54% participants had no information on any STI.11 A qualitative study on adolescents reported that girls perceived menstruation as the ability to give birth; and that having a shower during menstruation periods is harmful for their health.12 Another study representing young men aged 18-21 years reported having fears of detrimental effects as a result of masturbation, varying from erectile dysfunction (30.4%) to physical (76.4%) and sexual weakness (10.9%). Feelings of guilt associated with masturbation were also reported by 76% of the participants. Young people experience many negative psychological effects due to their lack of knowledge about sexuality.10 They want to learn about their bodies9,11 as 88% participants, in a study, maintained that sexual health should be included in school curriculum.13
Young persons\' perceptions about need of sex education, satisfaction with sexual health services, and knowledge about STIs has attracted very little space from research point of view in Pakistan.11 Therefore, this study was aimed to assess youngsters\' awareness and attitude towards the availability of sexual health education and sexual health services in the country.
Subjects and Methods
A cross-sectional survey was conducted, using a self-administered questionnaire. In order to have representation from both urban and rural populations, two distinct study sites (district Hyderabad, which is predominantly urban, and village Sakrand in district Nawabshah) in the Sindh province of Pakistan were selected.The study participants were recruited from both public and private academic institutions, using the convenient sampling method. The eligibility criterion was restricted to age between 16-25 years, regardless of gender and particular subject of study at the institution. In total, 200 questionnaires were distributed in-hand along with an information sheet explaining their participation in the research. Study participants were facilitated by a trained research assistant at each study site. They were given options to either complete-and-return the questionnaire on-spot; or take it home and return it later by a set date in a sealed envelope which was provided with the questionnaire. Majority of the participants (n=158; 79%) opted to return the questionnaire later, and the envelopes were subsequently collected by the research assistant. Altogether, 165 filled questionnaires were received. The quality and consistency of the forms were checked and the responses from 150 questionnaires were found suitable for entry and further analysis.
The data-collection tool was a quantitative-structured questionnaire, which was translated into three languages: English, Urdu and Sindhi. The translated questionnaire was piloted on 05% of the total sample size, randomly selected in similar settings before the study. Statistical analysis of the data was undertaken using PASW Statistics 18 for Mac 2008 version. The data was analysed to produce descriptive statistics.
As the study did not involve any physical or emotional harm to the participants, participation was made purely on voluntary basis for which verbal consent was obtained from all the participants. Confidentiality of the participant was ensured by coding individual responses on unique participant identification codes. The study received ethical approval from the Ethical Review Committee of the School of Health and Related Research (ScHARR), University of Sheffield, England.
Results
Of the 150 participants, 94 (63%) were male and 56 (37%) were female. Only 42 (28%) were married (Table-1).Regarding sexual health service, 47 (31.1%) of the young people admitted to having a fear that a friend might find out that they had asked for an advice about sexual health, and this stopped them from seeking any medical help (Table-2).
There were 38 (25.3%) who said sexual health services were far away for them to make use.
Of the participants 37 (24.7%) commented about the attitude of staff at such health facilities as "unwelcoming" about sexual health concerns. It was observed that 41 (27.3%) of the participants perceived health facility staff as "not competent", whereas, 49 (32.7%) reported of not having gender choice (male and female) in terms of professionals with whom they could feel comfortable sharing their sexual health concerns. Besides, 51 (34%) young people acknowledged that very often they feared discussing sexual matters with anyone, while 41 (27.3%) would rather not know if they had an STI, including HIV/AIDS.
In terms of sexual health education, a majority of respondents favoured the concept of initiating the subject at some level of the academic process: primary (n-30; 20%); secondary (n=51; 39.3%); or college/university (n=95; 63.3%). However, 80 (53.3%) disagreed with the basic concept. With regard to the primary source of sexual health education, 101 (67.3%) participants favoured trained health professionals, while 90 (60%), 75 (50%), and 59 (39.3%) thought of secondary sources like the internet, parents, and telephone helplines, respectively. These observations were compared with global trends (Figure).
Discussion
The study underscored increased level of dissatisfaction among the young with the available sexual health services in Pakistan and highlighted the need to have curriculum-based sexual education in academic institutions.The study also showed that existing sexual health services are inaccessible, that many staff are incompetent and unwelcoming, and that the services are not young-people-friendly. It is well known that stigmas associated with STIs deter many people from seeking sexual health services, the attitude and knowledge of staff play a vital role in building confidence and trust among healthcare seekers.14,15 The review of the literature showed that unfavourable attitude results into under-reporting of unwanted pregnancies, and abortions in Pakistan.16 This study showed that one-third of the young people feared discussing their sexual health problems with anyone. This indicates that they have less trust and more fear of breaking confidentiality about their sexual health. It is well discussed that if the confidentiality is compromised, young people will be less likely to use the services or will be less than honest about their sexual health conditions.15
The findings of this study implied that the government should re-evaluate the existing sexual health services and should make them more young-people-friendly.
The findings of the study are consistent with many other studies, in suggesting that young people want to learn about their sexual health.9,11,13 Throughout the world, schools have been recognised as an important place for sex and STI/HIV education.17 Strategies based on a written curriculum in school on HIV/STI education are promising interventions in terms of a reduction of unsafe sexual risk behaviours among the young.18 Several studies and reviews have concluded that school-based sexual health education for young people improves their understanding on sexually transmitted infections, including HIV/AIDS, reduces risky behaviour like unsafe and unprotected sexual intercourse, and develops skills to communicate effectively and make healthy relationships.18,19
This study adds to the literature that suggests that young people want sexual health education to be taught in academic institutions of Pakistan. Young people said that the content of sex education should include family values such as responsibility of parenting; physical and emotional changes at puberty; biology of sex; human reproduction; contraception; and information about STIs including HIV/AIDS.
The study had many methodological limitations that may have influenced its results. Since the participants were recruited from academic institutions and the majority had higher secondary education level, therefore, it is difficult to generalise the findings on common young people in the local context. The quantitative nature of the questionnaire might have prevented participants from sharing their views that might have been different from the statements and options available in the questionnaire. Besides, because of the standardised nature of the questionnaire, participants who misunderstood any point might not have had an explanation of the questions concerned. Moreover, there is always doubt about the honesty of the participants\' responses when self-administered questionnaires are used. Inclination of socially acceptable responses might be possible due to the sensitive nature of the topic.
Conclusion
Low level of knowledge among youngsters and their dissatisfaction with the available sexual health services are the impeding factors undermining the scope of current reproductive health services in Pakistan. Nevertheless, the knowledge sources were largely perceived to exist either in the form of media and internet, and making them formal through academia was largely recommended.References
1. Shaw D. Access to sexual and reproductive health for young people: Bridging the disconnect between rights and reality. Int J Gynecol Obstet 2009; 106: 132-6.2. UNAIDS. Impact of HIV and sexual health education on the sexual behaviour of young people. A review update by UNAIDS 2007. (Online) (Cited 2010 April). Available from URL: http://data.unaids.org/publications/IRC-pub01/jc010-impactyoungpeople_en.pdf.
3. Braverman PK, Strasburger VC. Sexually transmitted diseases. Clin Paediat (Phila) 1994; 33: 26-37.
4. World Health Organization. Toward universal access: Scaling up priority HIV/AIDS interventions in the health sector. Geneva: WHO 2007.
5. FPA for Northern Ireland. Sex education in schools. Family planning association for northern Ireland. (Online) (Cited 2011 April) Available from URL: http://www.hpani.org/Resources/sexual/pdfs/sexedinschools.pdf.
6. UNAIDS. Young people and HIV/AIDS, Opportunity in crisis. UNAIDS 2002. (Online) (Cited 2010 April) Available from URL: http://data.unaids.org/topics/young-people/youngpeoplehivaids_en.pdf.
7. Agampodi SB, Agampodi TC, Ukd P. Adolescents perception of reproductive health services in Sri Lanka. BMC Health Serv Res 2008; 8: 98.
8. Siddiqui MH, Siddiqui JA, Ahmed I. Demographic profile and clinical features of admitting HIV patients in a tertiary care teaching hospital of Karachi Pakistan. Pak J Med Sci 2009; 25: 861-4.
9. Qazi Y. Adolescent reproductive health in Pakistan. In:Bott S, Jejeebhoy S, Shah I, Puri C. (eds). Towards adulthood: exploring the sexual and reproductive health of adolescents in South Asia. Geneva: World Health Organization, 2003; 78-80.
10. Khan A, Pine P. Adolescents and reproductive health in Pakistan: a literature review. Population council final report 2000.
11. Ali TS, Ali PA, Waheed H, Memon AA. Understanding of puberty and related health problems among female adolescents in Karachi, Pakistan. J Pak Med Assoc 2006; 56: 68-72.
12. Mohamed S. Addressing gender inequality in adolescent life skills education: Aahung\'s experience in Pakistan. International women health 2004.
13. Majid S. Reproductive health awareness in adolescent girls: report of a survey. J Coll Physcians Surg Pak 1995; 5: 214.
14. Leili S, Elham S, Farkhondeh S. A population based survey of HIV/AIDS knowledge and attitude in general public, Bandar-Abbas, Iran. Pak J Med Sci 2008; 6: 838-44.
15. Thomas N, Murray E, Rogstad K. Confidentiality is essential if young people are to access sexual health services. Int J STD & AIDS 2006; 17: 525-9.
16. Rehan N. Attitude of health care providers to induced abortion in Pakistan. J Pak Med Assoc 2003; 53: 7.
17. Mukoma W, Kagee A, Flisher AJ, Mathews C. School-based interventions to postpone sexual intercourse and promote condom use among adolescents. The Cochrane Collaboration. Published online first; 21 Jan 2009. doi: 10.1002/14651858. CD0064-17.
18. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviours of young people throughout the world. J Adolesc Health 2007; 40: 206-17.
19. Wellings K, Wadsworth J, Johnson AM, Field J, Whitaker L, Field B. Provision of sex education and early sexual experience: the relation examined. BMJ 1995; 311: 417-20.
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