Üniversite gençlerine yönelik olarak geliştirilen cinsel sağlık ve üreme sağlığı eğitim programının etkinliği

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Introduction
Adolescents account for 20% of the population of
world (1). According to the results of the 2000 census
carried out by the Turkish Institute of Statistics, 10-
21 age group forms the 21.1% of the population (2).
Although they account for such a large proportion
of the population, health needs of adolescent youth
have largely been neglected in many countries of the
world including our country, Turkey (3,4).
It is known that one of the most important problems threatening the health and the future of youth
is risky behavior related to sexual health and reproductive health (SHRH) (5,6). Rapid increase of the
youth population, starting sexual activity at earlier
ages, and sociocultural changes in many cultures increased the need for reproductive health education in
this age group (7-10). As young people do not have
adequate information on subjects related to SHRH in
situations when they engage into early sexual activity, they are faced with important physical, economic
and psychosocial problems such as unwanted pregnancy and sexually transmitted diseases (11,12).
Recently, health problems regarding reproduction
were considered within the framework of Maternal
and Children’s Health. This present approach does
not suffice to address all reproductive health problems due to important sociodemographic changes
occurring in our country and the rest of the world
in the last two decades (13). Therefore, the concept
of reproductive health was first formulated in the
International Population and Development Congress,
which was held in Cairo in 1994. In this conference,
reproductive health was considered as a whole involving sexuality and was considered as a basic right
of all individuals at each stage of life (young or old)
(14-17).
Although service has been offered for more than 3
decades in the context of Basic Health Services, there is
no routine health service taking the information and
* Department of Nursing, Başkent University Faculty of Health Sciences
**Department of Nursing, Hacettepe University Faculty of Health Sciences
Reprint request: Gül Pınar, Department of Nursing, Başkent University
Faculty of Health Sciences, Eskisehir Yolu 20.km, 06530, Ankara, Turkey
E-mail: gpinar@baskent.edu.tr
Date submitted: June 08, 2010 • Date accepted: October 04, 20102 • March 2011 • Gulhane Med J Pınar and Taşkın
consultation need of youth on SHRH into account
(18). Lately, in order to compensate for this lack, The
Ministry of Health has initiated SHRH services for
youth as a more comprehensive program conducted at
the university. Although these can be considered positive developments, they are not sufficient by themselves (19). A national basic strategy for the solution
of the SHRH problems of the young people is needed
to enhance training programs in the framework of preventive health services (20,21). As stated earlier, important steps have been taken in our country on this
issue. However, these activities are short lasting conferences targeting certain age groups (12-14 y). In this
context, there is no theoretical and practical interactive training program which is prepared for university
youth and whose efficiency was evaluated.
Therefore, in order to meet the needs of university
youth for training on sexual matters to a certain degree, the researcher planned to develop a SHRH training program envisaged as an elective. This research is
important in that it contributes to the accumulation
of knowledge on the subject and sheds light on the
development of such training programs.
The short-term aim of this study was a) to determine the information, opinion and experiences of
youth regarding SHRH and b) to investigate the effect
of SHRH training programs on the information and
skills of the youth. The long-term aim of this study
was to a) try a SHRH training model that can be used
by all university students and b) to develop recommendations for adding SHRH training programs to
counseling services offered to students in Başkent
University (BU) Student Health Center and to improve the students level of information on SHRH.
The hypotheses of the study: H1
: Mean posttest scores
of the study group are significantly higher in the posttest compared to pretest scores. H2
: Posttest scores of
study group are significantly higher than those of
control group. H3
: The difference between the pretest and posttest scores of the study group is significantly higher than the difference between the pretest
and posttest scores of the control group. H4
: Posttest
mean skill scores of the study group are significantly
higher than pretest mean skill scores.
Material and Methods
This study, carried out with the aim of evaluating the efficiency of the SHRH Training Program
(SHRHTP) developed for university youth, is an intervention study which has a pretest, posttest and control group. It was carried out at BU Center Campus.
The population of the study comprises 200 students attending third year classes in the Education
Faculty of BU in the academic year of 2006-2007. In
the faculty, the departments of Class teacher (n=41),
preschool teaching (n=43), mathematics teaching (n=43), Turkish (n=41) and computer teaching
(n=35) are present. All populations were included
in the study. Only the students of preschool teaching department were excluded from the study as
they received SHRH lessons in their second year.
Accordingly, 84 students in mathematics and Class
teacher departments were included in the study
group and 73 students in Computer and Turkish
teaching departments, which were in different buildings (with the idea that interaction between students
was possible during the education SHRHTP process)
were included in the control group, thus, overall 157
students constituted the study group.
In order to conduct the research, necessary approval was obtained from the B.U. Research and Ethics
committee. The participating students were informed
about the subject and the aim of the study and they
were assured about the confidentiality of the information in personnel information forms before verbal
and written informed consent was obtained.
Independent variables were sociodemographic characteristics of the students, sociodemographic characteristics of their parents, personal interests and habits
of students, the ideas of students regarding SHRH training, experiences of students with SHRH and opinions
on sexual relations. Dependent variables were mean
information and skill scores of students after SHRHTP.
Data collection tools were developed by the researcher utilizing the literature on the subject
(5,18,22). The data of the research were collected by
means of three different forms. A. FORM 1-personal information form: This form includes overall 43
questions on the students themselves (n=11), sociodemographic characteristics related to their families
(n=5), personal interests and habits (n=5), opinions
regarding SHRH training (n=6), experiences with
SHRH and opinions on sexual relations (n=16). B.
FORM II. SHRH Information Scale (SHRHIS): In the
first stage of the preparation of SHRH information
scaled, the aims of the subjects in the program and
the class hours they cover were taken into consideration and questions were prepared according to the
flow system of modules (Figure 1).
In SHRHIS, multiple-choice questions (five choices)
are usually present. In the development of the tool,
behavioral aims of the subjects in SHRHTP were considered and 100 critical behaviors were determined.
Questions proper to targeted behavior were prepared.
Stage by stage classification of the targets in SHRHTP
was restricted with the remembering, understanding Volume 53 • Issue 1 Sexual health training program • 3
and applying levels found in the cognitive training
targets taxonomy of Bloom (23). In the preparation
of SHRHTP, subjects especially needed by university
youth in terms of SHRH were given precedence.
Studies on the validity of SHRHIS
1. Language, psychometric and scientific control of
SHRHIS: SHRHIS was to be used as premiddle and
posttests and for scientific review related to the validity of content five specialists in obstetrics and public
health nursing were consulted. The technical characteristics of SHRHIS (language and psychometric rules)
were evaluated independently by two experts from
the measurement-evaluation department of the BU
Faculty of Education and Ankara University Faculty
of Education. As seen in Table I, in line with the recommendations, 20 questions for each module, which
has six class hours, were determined and for the pilot
trial overall 80 questions were taken and an SHRHIS
sketch was made ready for pilot trial administration
(Table I).
Pilot trial administration of SHRHIS: The pilot was
made with 150 third year students at BU Science and
Literature Faculty and 50 third year students from the
nursing department who consented to participate.
Care was taken to choose students with a similar socio-cultural profile to the students of the Faculty of
Education where the actual trial was to be performed.
All students except for those of nursing department
had not received any training on subjects associated
with SHRH previously and had not participated in
such a study previously. The administration of the
scale lasted approximately 25-30 minutes.
2. Question analysis: a) Problems with questions:
Evaluation was made using students who received
training on SHRH previously and those who did not
do so. The students in the nursing department were
regarded as the criteria of comparison. Through
evaluations, both the index of the difficulty of questions (Pj), which showed the number of students
answering correctly and the differentiating capacity of the questions (rjx- differentiating between the
students who knew and those who did not know)
were found. Pj was transformed into percentage values and the interpretations of the study were made
based upon these percentages. In the framework of
SHRHIS, questions whose correct answers were below 0.20 and over 0.80 and those which do not have
any difference were excluded from test as they were
determined not to contribute to the test. Questions
whose correct answer percentage was between 0.40-
080 were included in the test without making any
changes. For the questions whose percentage of
correct answers was between 0.20-0.39, were analyzed again and either the question itself or answer
choices were revised. Through the analysis made on
the scores of the group which received SHRH training, the difficulty index (pj) was found to change
between 0.60-0.79. (Whether the difference significant tested using t test for dependent groups). For
differences, p value of 0.05 was considered significant. Of 80 test questions, significant values were
seen in 68 (p<0.05). In the pilot trial of SHRHIS, average 75.9% of the third year students of nursing
department and 42.6% of the students in Science
Literature faculty answered the questions correctly.
Mean number of correct answers was higher in the
group that received training.
Table I. Distribution of the pretest and posttest mean information scores
Group
Test
Pre-test t* p
X±SS
Pos-test
X±SS
Study 28.76±8.04 47.85±2.97 -19.24 0.000
Control 25.30±6.85 30.20±7.87 -4.52 1.300
Test
Group
Study t** p
X±SS
Control
X±SS
Pretest 28.76±8.04 25.30±6.85 0.653 0.150
Posttest 47.85±2.97 30.20±7.87 17.79 <0.001
*: Paired sample t test was used. **: Student’s (independent sample) t test was used
Modules of SHRHTP Number % weight
of subjects
The number
of questions
The number
of questions
in pilot trial
Introduction 1 week/3hours - -
1
st
module: SHRH of youth 2 week/6hours 25 20
2
nd
module: repr. system/
pregnancy
2 week/6hours 25 20
3
rd
module: family planning 2 week/6hours 25 20
4
th
module: SHRH 2 week/6hours 25 20
Closing-evaluation 1 week/3hours - -
Total 10 week/30 hours 100 80
Figure 1. Percentage weight and number of questions in SHRHIS
sketch4 • March 2011 • Gulhane Med J Pınar and Taşkın
b) Differentiation capacity of questions: In order
to determine the capacity of questions to differentiate the students who knew from those who did not
know, correct answers of the students who did not
receive training were evaluated and overall score was
obtained for each student. Questions whose rjx value, which demonstrates the contribution to overall
score in multidimensional scale systems, was 0.10 or
lower were included in the scale according to evaluation model of SHRHTP. In view of these data, each
question was reviewed and questions that did not
contribute to test were excluded. After pilot trial, test
and questions statistics were calculated and the coefficient of reliability was obtained. Based on the data
obtained with question analysis, questions with low
efficiency were revised, those without contribution
to scale were excluded and 55 questions were chosen.
Values may vary between 0-55.
Studies on the reliability of SHRHIS-Inner consistency:
In the determination of the reliability of measurement tool, K20 equation and inner consistency coefficient of reliability were calculated. Accordingly, K20
reliability for all group was calculated to be 0.7874. In
the literature, it has been stated that for scales used
in researchs a reliability coefficient varying between
0.70-0.80 is adequate (23). This value was considered
adequate for a pilot trial. After the exclusion of questions with undesired characteristics, reliability was
found to increase to 0.8181. According to these values, it can be suggested that the questions are capable of measuring the characteristics in the program;
SHRHIS has inner consistency and is free from random mistakes.
C. FORM III. SHRHTP Skill Evaluation Guides: In
the present study, with the aim of facilitating the
learning the steps the application skill by the students and deciding on the competence of the students, “Skill Evaluation Guides” which are in accordance with the standards have been developed. In
view of the information in the literature, four different “Skill Evaluation Guides” developed in order to
demonstrate whether the youth is able to make the
‘breast examination’, ‘testis examination’ and can
use ‘female and male condom’ (which have priority
among the things they should know) and to evaluate
their performance. Before training, study group was
asked to carry out the above mentioned procedures
on an anatomic model with the aim of preevaluation.
Then, their performance was analyzed. Guides were
applied to each student before and after training.
D. FORM IV. Evaluation Form After Training: The
opinion of the students as regards SHRHTP was obtained by the investigator using ‘evaluation form after training’. This form has scales from 0 to 5 (1: I
absolutely do not agree, 2: I do not agree, 3: I am not
sure, 4: I agree, 5: I absolutely agree). Through this
form, students were asked to evaluate the subjects
of SHRHTP and various components of the program
such as the duration of program, information offered,
education methods employed, tolls used, the status
of obtaining new information and trainer. This form
was filled by the students in 10 minutes.
SHRH Training Program: SHRHTP was prepared in
four modules in accordance with the age and developmental characteristics of the students and experts
were consulted in their preparation. Experts evaluated the content, target and education targets of the
program, education methods, length of the time
reserved for subjects and whether the program was
appropriate for university students. SHRHTP was given to study group for overall 30 hours (three hours
weekly for ten weeks). SHRHIS was administered to
study group three times (pretest before training, middletest just after the individual modules and posttest
after the end of program) and to control group twice
(simultaneously with the control group as pretest and
posttest).
The question difficulty index of the questions in
the sketch of SHRHIS was transformed into percentage and in the examination of the difference between
groups, Pearson chi square test was used. In the pilot trial of SHRHIS, in order to test the relevance of
the questions, double point correlation test was used.
In order to test whether there is any difference between the measurement of the same individual at
different times or conditions, paired sample t test
was used before and after training. In the comparison of the pretest and posttest scores of study and
control groups, for independent samples t test was
used and the significance of the difference between
independent variables with more than one subgroup
and whose effect on an dependent variable was investigated, Mann Whitney U test was used instead of t
test. In the evaluation of groups with regard to some
sociodemographic variables and the comparison of
the correct answers to SHRSIS, Fisher and Pearson chi
square tests were used.
Results
The sociodemographic characteristics of the students were as below: majority were between the ages
of 19-22 (63.1%), 84.1% were female, and 15.9% male,
63.7% were single, 92.3% had social security, 84.7%
had monthly expenditures covered by family/relatives,
74.5% lived in city center until 1 year old and 82.2%
lived with their family/relatives. As to parents, the Volume 53 • Issue 1 Sexual health training program • 5
Table II. The distribution of the differences between pretest and posttest scores according to module
SHRHTP Practice Minimum
score
Maximum
score
Pretest X±SS Posttest X±SS Score difference
X±SS
t* p
Male condom 11 33 11.69±1.44 29.74±2.21 18.05±26.9 61.43 <0.001
Female condom 11 33 11.82±0.71 28.66±3.24 16.84±3.63 43.04 <0.001
Testis examination 14 52 14.23±0.48 37.23±4.64 23.00±4.62 45.90 <0.001
Breast examination 16 48 21.38±1.88 41.58±3.25 20.20±4.30 45.57 <0.001
*: Paired sample test was used
mothers of the majority of students were high school or
university graduates, fathers were university graduates,
90.4% parents were still married, 59.8% of the mothers and 64.3% parents were still employed. Of male
students, 82.6% and of female students 58.3% smoked
regularly, 29.3% never used alcoholic beverages, 22.3%
tried alcohol before and 46.5% drank alcoholic beverages occasionally. Although 44.6% stated that they had
experienced a problem regarding SHRH previously, (irregular menstruation, menstruation pain, ejaculation
precox and erection problems), 58.6% did not refer to
any health institution for the solution to their problems. 55.3% spoke of matters related to SHRH mostly
with their mothers, and 19.7% had previous sexual experiences. They had their first sexual experiences with
their lovers (72.4%) and at adolescent age (51.6%). Of
the students who were sexually active, 48.3% stated
that they used a condom in their first sexual experience. While 56.7% of the males considered premarital
sex normal, this rate falls to 33.7% in females. The students had not received any training as regards SHRH
previously. 34.2% stated that they wanted to get information on SHRH and 32% on Family Planning (FP). In
the evaluation, sociodemographic characteristics of the
students in the study group were found to be similar to
those of students in the control group, with no statistically significant difference (p>0.05).
As shown in Table I, the pretest mean score of
study group was 28.76±8.04, while it increased to
47.85±2.97 in the posttest, with a statistically significant difference (p<0.05). In the control groups,
the corresponding values were 25.30±6.85 and
30.20±7.87, respectively, the difference being insignificant (p>0.05).
It was demonstrated that the study group increased
their scores in all modules after training compared to
the control group, with a statistically significant difference (p<0.05). (Table I)
In Figure II, it was determined that correct answers
were mostly in third (FP module) and fourth (SHRH
module) modules, indicating that the students answered a higher number of questions in these modules correctly. When scores were evaluated according
to SHRHTP, in all modules a significant difference
were found between pretest and posttest mean information scores (p<0.05). Accordingly, in the study
group an important increase was observed in the
study group in all modules while no such increase
were observed in the control group (p>0.05). The students in the study group increased their scores from
pretest to posttest. In the middletest and posttest, the
score range of almost all students was between 40-
49, hence they increased their information level over
70% and answered more questions.
In Table II, skill scores of the study group for male
condom, female condom use and testis and breast
examination skills were demonstrated after pre, middle and posttest. In all practices posttest scores were
higher than pretest scores with a statistically significant difference (p<0.05). Increases in scores were observed mostly in testis examination (23.00±4.62) and
breast examination scores (20.20±4.30).
Discussion
In statistical analysis, it was observed that the study
group had a high rate of correct answers in the posttest,
which indicated that the H1
hypothesis, which stated
that posttest mean information scores of study groups
were higher than pretest scores, was confirmed. In this
study, results demonstrating that SHRHTP increased
the information of students on SHRH were obtained,
which was consistent with the literature (15,24-27).
In Table I, it was seen that mean score of control
groups increased from 25.30±6.85 in the pretest to
30.20±7.87 in the posttest. Even though there is
Figure 2. The distribution of the correct answers to SHRHIS in study
group to modules
18
16
14
12
10
8
6
4
2
0
pre middle post pre middle post pre middle post pre middle post
Module 1 Module 2 Module 3 Module 46 • March 2011 • Gulhane Med J Pınar and Taşkın
a slight increase in the scores of the control group,
when compared to the answers and scores of the
study group, it can be understood that this increase
was random. In the study groups, the percentage of
correct answers sometimes increased to over 70% on
many questions in the posttest, whereas no such differences were observed in the control group. No student from the control group obtained a correct answer rate of 70% or over in the posttest. However,
as we mentioned before, there was a slight increase
in the scores of the control group although they did
not receive any training. This fact may be attributed
to the search of youth for information on matters related to sex from various sources. In addition, participating in the pretest may have prompted them to
look for answers to certain questions. Based upon the
above distribution patterns, it can be suggested that
unless a training program is given, the expected level
can not be reached in the relevant subjects. This finding is consistent with those in the literature (24,28).
In Table I, it was shown that mean pretest scores
of study and control groups were 28.76±8.04 and
25.30±6.85, respectively (p>0.05). That there was no
significant difference between the groups indicated
that at the baseline information level of the students
in both groups were similar. When posttest scores
were compared, it was seen that they were 47.85±2.97
and 30.20±7.87 in the study and control groups, respectively (p<0.05). This significant difference was
attributed to the training program that the study
group underwent. Therefore, it can be suggested that
SHRHTP increased the information of students on
SHRH. Accordingly, H2
hypothesis, which claimed
that posttest mean information scores in the study
group were higher than those of control group was
corroborated. In the study of Hubbard et al. in 13-14
year old adolescents, a “risk decrease” program was
given to adolescents for 18 months, and it was established that those in the study group had a higher
rate of increase in SHRH information compared to
the control group (p<0.05) (29). Olsen et al. reported that, after the training program they prepared in
the framework of sexual abstinence, the information
level of the youth increased (30). Song et al. investigated the impact of sexual training programs in
schools on the information level of the youth, and
pointed to the significant difference between groups
who received training and those who did not do so
(25). Donati evaluated the efficacy of sexual information training given to 377 students between the ages
of 14-21 studying in schools with a mixed education
program and observed that there were significant differences in the information level of students who received training and those who did not and found in
the follow up evaluations made 4-5 months later that
the information was still permanent (27). In the studies of Cok and Golbası, it was reported that the young
people who received training on sexual matters had
more information on SHRH than others (22,24). Our
results are compatible with those of the mentioned
studies. Accordingly, it can be suggested that the
students participating in SHRHTP were informed on
SHRH and hence the study reached its aim.
It has been established that the study group had
higher score increases in all modules after training
compared to the control group (p<0.05). Accordingly,
the H3
hypothesis, which suggested that the difference between the pretest and posttest scores was
higher in the study group than control group was
confirmed. It has been established that the increases
in scores were similar in all modules but the increases in ‘FP’ and ‘SHRH’ modules were more marked
(Figure 2). As young people consider information on
these issues among the ones they need most, it can
be expected they showed interest in these modules
and exerted effort to get information. Hence, it can
be said that SHRHTP increased the scores of students
in each module. In addition, all students had scores
in the range of 40-49, which they increased to 70%
after posttest, answering more questions. According
to these findings obtained from our study, it was
established that SHRHTP increased the information
level of the students in the study group to a large
extent.
There was no significant difference between different age groups in terms of the difference between
the pretest and posttest scores in the first module
(p>0.05). Although the difference was not significant, with one way variance analysis, it was found
that the increase in the students over 22 was more
marked than that in adolescent age group. This may
be ascribed to the fact that the probability of having
sexual experience increases with age and they need
to obtain information regarding these measures. The
findings of Beydag and Golbasi have been found to
be consistent with those of our study. There was no
significant difference between the sexes in terms of
the difference between pretest and posttest scores in
the first module (t=0.096, p=0.607). Although there
is a higher rate of information increase in male students than female students in all modules, the difference was not statistically significant (p>0.05). While
this result was in keeping with the study of Song et
al. it was contradictory with the studies of Olsen et
al. Beydag and Ozcebe reported a higher rate of increase among female students (p<0.05) (25,30-32). Volume 53 • Issue 1 Sexual health training program • 7
Although reproductive health involves females and
males, its effect is more direct for women. Due to
problems related to reproductive health, human life
is shortened by 15% but, the effect on life is 22% in
women, while it is only 3% in males. As seen, the effect of reproductive health varies between the sexes.
Including the males in the target group in reproductive health programs, and their becoming more conscious of their responsibilities will have a positive
effect on female and family health. As adolescent
males start their sexual lives much earlier than girls
do and are more active, it is very important to inform them about their responsibilities in regards reproductive health.
A different study demonstrated that soldiers born
in the east region had lower knowledge level at both
pre- and post-test compared with those soldiers born
in other regions of Turkey. A comparison of posttest scores between those who were born in and stil
resided in the east region (80.8%) with those of soldiers who were born in but no longer lived in the east
region (83.3%) revealed significant differences. The
study results confirm that living in the eastern region
of Turkey apparently influences lower scores regarding knowledge about reproductive health issues. The
higher prevalence of early marriages determined in
the east region could be considered one of main indicators of this situation. Lack or insufficiency of general education seems to be a major underlying factor
(33).
In Table II, an increase in score over the mean values had been increased in all practices in the posttest. This increase was found to be statistically significant (p<0.05). Accordingly, the H4
hypothesis,
which stated that ‘posttest skill scores in the study
group are significantly higher than those obtained in
the pretest in the study group was confirmed. The
majority of the students in the study group evaluated the training program favorably. Although these
are subjective ideas of the students, this showed that
SHRPTP increased the information level of students.
Training programs based on providing information
and skills are important in that they are steps taken
for a positive development even though they do not
cause changes in behavior directly.
In the present study, SHRHTP has been implemented as a different lesson termed as ‘Sexual
Health Information Training’ in a schedule of three
hours a week and the information and skill levels of
the students were increased. In view of these findings: This SHRHTP model may be integrated in the
education program of all departments as an elective
lesson that can be chosen by all university students.
Follow up studies can be carried out in order to determine whether the skills and information obtained
are permanent and to what extent students can reflect this information to their behavior. In order to
make generalization possible, the study can be repeated with a larger sample in which male and female students are represented equally. Considering
that the information on SHRH is obtained by the
students through their friends, volunteer university
students may be chosen to increase the efficiency of
SHRH training by means of ‘peer training’ programs.
Considering that students obtain information on
matters related to sex through media, reproductive
health awareness of the students may be enhanced
by mass media tools present in the university (radio,
television, web, printed media, online consultancy).
In the study, it has been established that students
want to receive information on SHRH from health
personnel. In this context, the development of
‘Youth Consultation Centers’ in the Student Health
Centers may be suggested. In the present study, no
significant relation has been found between the socio demographic characteristics of the students and
their mean SHRH scores. Possible factors that can influence the SHRH of the youth may be investigated
by in depth studies using the methods of descriptive
studies as well.