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Opinions of midwifery students on adolescent sexuality and reproductive health in Turkey.

In the last 20 years, worldwide, unprotected sex, unwanted pregnancies, abortions, and sexually transmitted diseases among adolescents have become significant health problems (Blum & Nelson-Mmari, 2004; Olukoya, Kaya, Ferguson, & Abouzahr, 2001; Zwane, Mngadi, & Nxumalo, 2004). The first time adolescent reproductive health and rights were evaluated in an international context was at the United Nations International Conference on Population and Development (UNICPD) in 1994. Although a consensus has been reached about the importance of dealing with the needs of adolescents in terms of sexuality and reproductive health, services provided in this respect have been inadequate (Rivers, Aggleton, & Coram, 2002; UNFPA, 2003).

Adolescent sexuality is a significant moral issue that has been shaped by cultural norms and values in different societies (Sandfort & Ehrhardt, 2004). Many societies prohibit, deny and/or ignore the existence of premarital sexual activity (Ahlberg, Jylkas, & Krantz, 2001; Olukoya et al., 2001). For example, young people face sex-stratified norms that espouse gender double standards in India (Alexander, Garda, Kanade, Jejeebhoy, & Ganatra, 2006). In Turkey premarital sex for a woman is regarded as wrong. The pride and honor of a woman is based on her sexual behavior (Sahinoglu-Pelin, 1999). However, it is a fact that despite the adverse results of premarital sexual activity and the moral prohibitions surrounding it, many young people indulge in unprotected premarital sex (Warenius et al., 2006). Midwives and nurses together form one of the most important professional groups to whom adolescents apply at health centers for their reproductive health needs (WHO, 2004).

Health professionals who work at reproductive health centers have the responsibility of acting as a bridge between the reality of premarital sexual activity among adolescents and the values and conventions of the society in which they live (Warenius et al., 2006). Midwifery students, as members of society, may have values and perspectives on sexuality and reproductive health that conflict with the needs of adolescents. If this is so, these health professionals of the future stand to face serious ethical dilemmas in their careers (Leppa & Terry, 2004). The purpose of the present study was to evaluate the views of midwifery students concerning adolescent sexuality, the use of contraceptive methods, and abortion and to explore the effects of a family-planning course on the way they thought.

MATERIALS AND METHOD

The research was planned as a descriptive-comparative study. A total of 55 second-year midwifery students constituted the population of the study and all were included in the sampling. Research data were collected in two stages during the course of a family-planning class in the Spring term of the academic year 2006-2007. In the first stage, before the start of the family-planning class, students were asked to fill out a questionnaire in one session on March 1, 2007. The students were asked to fill out the same questionnaire four months later at the end of the academic year. The first part of the questionnaire contained 12 questions identifying the students' demographic characteristics. The second part was made up of 13 questions designed to evaluate the students' thoughts about adolescent sexuality, the use of contraceptive methods, and abortion. Variables of students' attitudes were determined using closed-ended (agree/do not agree) questions, and the questionnaire form was not scored.

Family planning is a course composed of 42 hours of theoretical and 56 hours of practical work that midwifery second-year students take in the Spring semester. Clinical practice in this course is provided to students by the family-planning units of the public health centers and is focused on developing the students' family-planning counseling skills. The School of Health Administration at Selcuk University, Konya, gave permission to conduct the research. Students were informed about the research and all of them voluntarily agreed to take part.

Data were evaluated with the SPSS program using percentage distribution, chi square test, and McNamara's Test. An alpha level of p < 0.05 was considered statistically significant for all analyses.

RESULTS

It was established that the students participating in the study were of an average age of 20.4[+ or -]1.10 and that 67.3% were living in Central Anatolia. All of the students in the study were Muslims. It was found that 58.2% of the students were of the ages 18-20, that 81.8% of the students' mothers had an elementary school education or less, and that 49.1% of their fathers were elementary school graduates. A proportion of 85.5% were of an average economic status and 65.5% lived in metropolitan areas. It was found that 47.3% of the students in the study group felt that they had adequate knowledge about sexual/reproductive health and that 40% discussed sexual/reproductive health with their families. Of the students, 23.6% stated that they received information about sexual/reproductive health from the media and only 7.3% said that the source of their knowledge was health professionals.

From the results shown in the table it can be seen that, before the course, 87.3% of the students believed that a girl should remain a virgin until she married, but that this percentage changed to 81.8% after the course. Both before and after the course, 81.8% of the students believed that it was wrong for boys and girls to have sexual intercourse before marriage, and 18.2% believed that men/boys could have sexual intercourse before marriage whereas 95.4% said that a girl had to think of the consequences of sexual intercourse before marriage. In the context of abortion, 50.9% of the students believed that abortion was morally wrong, 38.2% said abortion, to terminate an unwanted pregnancy, was unacceptable, and 56.4% would be uncomfortable to learn that a girl wanted to have an abortion. When the students were asked about contraceptive methods, 23.6% said that only married couples should be allowed to receive information on birth control methods. A percentage of 92.7% believed that men should receive education in the use of condoms, and 20.0% said that girls and boys should not be allowed to use birth control methods even when they were sexually active. A proportion of 5.5% of the students said that they would think a girl was of immoral character if she wanted to learn about birth control methods. It was established that there were no significant differences between beliefs before or after the course. It was only in the group of students (29.1%) who said before the course that it was inappropriate for unmarried couples to ask for information on contraceptive methods that a significant change in belief was seen among 10.9% of the students after the course (p < 0.05).

DISCUSSION

The study focused on the evaluation of the opinions held by midwifery students on adolescent sexual/reproductive health. It was found that the majority of the students who participated in the study lived in the region of Central Anatolia. Lifestyles in this region are predominantly traditional, and social-value judgments have a considerable influence on daily life. While 47.3% of the students in the study said they were informed about sexual/reproductive health, only 40% said that they could talk to their families about these issues. It was established that sources of knowledge for these students were, to a great extent, the publishing and broadcasting media, and that only 7.3% obtained advice from health professionals. Many studies have asserted that knowledge and attitude are important determinants in practices related to reproductive health (Balaiah et al., 1999; Popov, Visser, & Keeting, 1993; Vural, Vural, Diker, & Yucesoy, 1999). It has been stated in studies conducted in Turkey that adolescent knowledge about sexual/reproductive health is very inadequate (Karababa et al., 1993; Musal & Ucku, 1993; Topbas, Can, & Kapucu, 2003). A study by Inandi, Tosun, and Guraksin (2003) points out that university students are lacking in knowledge in these matters.

In a study by Kara, Hatun, Aydogan, Bahaoglu, and Gokalp, in 2003, 22.1% of adolescents stated that they had had at least one sexual experience. The problems of adolescent sexuality and reproductive health continue to be sensitive issues in Turkey. Premarital sex is frowned upon and society's attitude to casual and extramarital sexual relations is quite rigid (Ince, Ugurlu, & Ozyildirim, 2006). Sexual activity is viewed as inappropriate by Moslems before marriage, but on the other hand, more tolerance in this respect is shown to men (Rademakers, Mouthaan, & de Neff, 2005). This discrepancy between the genders results in more damaging outcomes for women (Blanc, 2001; Tangmunkongvorakul, Kane, & Wellings, 2005). In the present study it was found that, in keeping with social-value judgments, a large majority of the student subjects considered virginity to be important and premarital sex to be wrong, holding the view as well that girls should be aware of the possible results of premarital sexual activity. There was no difference in student beliefs in this respect before or after the course. In their study of midwifery students, Klingberg-Allvin, Van Tam, Nga, Ransjo-Arvidson, and Johannsson (2007) similarly found that students did not believe that premarital sex was morally right. In addition, Klingberg-Allvin, Nga, Ransjo-Arvidson, and Johansson (2006) found in their study of midwives, nurses, and doctors that health professionals did not approve of premarital sexual relations. Tangmunkongvorakul et al. (2005) found that health staff working in sexual/reproductive health services generally displayed a judgmental attitude toward young people. On the other hand, in the study, results showed that these professionals were more tolerant toward young men and more judgmental about young women. In their research, Rademakers et al. (2005) found that health personnel felt ethically compromised in the face of demands for virginity certification or hymen repair, particularly in the case of young Islamic women. Similarly, Warenius et al. (2006) established that adolescent sexuality was seen as a serious moral issue and that midwives and nurses found it inappropriate for young people to engage in premarital sex, use contraceptive methods or have abortions. Health professionals need to consider the sexual inequalities facing girls and, apart from their own value judgments, accept responsibility in ensuring the prevention of unwanted pregnancies and promoting safe sex (Brabin, Chandra-Mouli, Ferguson, & Ndowa, 2001).

Reproductive health services in Turkey are conducted under a law enacted in 1961 which socialized health services. In addition, the termination of pregnancy up until the 10th week was legalized in 1983 (Akin & Oktay-Kocoglu, 2002). Although abortion has been made legal, the procedure is still one of the country's controversial issues in terms of social-value judgments. More than 50% of the students in the study found abortion morally wrong both before and after taking part in a family-planning course, stating they were uncomfortable with the issue. On the other hand, the students did indicate that receiving education on contraception from advisors was appropriate, whether or not young men and women were married. Klingberg-Allvin et al. (2007) also stated in their study that students did not find abortion morally correct in itself but thought that it was acceptable to terminate an unwanted pregnancy with abortion. The study definitively showed that these young people were in need of effective family-planning advisory services. It was seen that value judgments of students were not different before or after a family-planning course. Altun (2003) states that midwifery and nursing students are unable to evaluate their own value judgments adequately and that they have difficulty in the transition into their future professional roles. Jones, O'Toole, Hoa, Chau, and Muc (2000) say that educational methods should provide an opportunity for questioning social-value judgments, allowing students to review these values, and giving them time to evaluate their own beliefs. Warenius et al. (2006) also assert that there is a need for educational programs that encourage midwifery and nursing students to become aware of the facts of adolescent sexuality and focus on developing critical thinking skills within the framework of cultural and moral issues. It has been shown that educational programs must be carefully designed to address the moral conflicts involved in this context and that more time should be allotted to the issues of adolescent sexual and reproductive health.

In the present study, a significant statistical difference was seen between beliefs before and after the students did the family-planning course only on the subject of providing counseling services to unmarried couples (p < 0.05). The reason for this may be that more time was spent in the course in exploring the characteristics of the target groups to whom counseling services and education about methods were provided as a part of the main goal of providing family-planning services.

The reason for finding no change in the attitudes of the students may be because of the obligatory content of the lessons and because there is no course about adolescent sexual/reproductive health in the curriculum. Creating an attitude free from the common social-value judgments requires more discussion about the subject as part of young people's education, and subjects such as gender discrimination, and the rights of the adolescent, should be incorporated in the content of lessons.

In this study it was found that the views held by students about adolescent sexual and reproductive health are affected by social value judgments. The recommendation of the authors is that students be encouraged, through the implementation of appropriate educational programs, to adopt a professional viewpoint on the subject of adolescent sexual/reproductive health independent of the value judgments prevalent in the population. In the view of the authors of this study, it would also be highly desirable to conduct more research that will shed light on social-value judgments and moral attitudes of health personnel toward the issues of adolescent sexual and reproductive health.

REFERENCES

Ahlberg, B. M., Jylkas, E., & Krantz, I. (2001). Gendered construction of sexual risks: Implications for safer sex among young people in Kenya and Sweden. Reproductive Health Matters, 9(17), 26-36.

Akin, A., & Oktay-Kocoglu, G. (2002). Reproductive health international decisions and practices of Turkey. Hacettepe Society Doctor's Bulletin, 23(3).

Alexander, M., Garda, L., Kanade, S., Jejeebhoy, S., & Ganatra, B. (2006). Romance and sex: Premarital partnership formation among young women and men, Pune district, India. Reproductive Health Matters, 14(28), 144-155.

Altun, I. (2003). The perceived problem-solving ability and values of student nurses and midwives. Nurse Education Today, 23, 575-584.

Balaiah, D., Naik, D. D., Parida, R. C., Ghule, M., Hazari, K. T., & Juneja, H. S. (1999). Contraceptive knowledge, attitudes and practices of men in rural Maharashtra. Advances in Contraception, 15, 217-34.

Blanc, A. K. (2001). The effect of power in sexual relationships on sexual and reproductive health: An examination of the evidence. Studies in Family Planning, 32(3), 189-213.

Blum, R. W., & Nelson-Mmari, K. (2004). The health of young people in a global context. Journal of Adolescent Health, 35, 402-418.

Brabin, L., Chandra-Mouli, V., Ferguson, J., & Ndowa, F. (2001). Tailoring clinical management-practices to meet the special needs of adolescents: Sexually transmitted infections. International Journal of Gynecology and Obstetrics, 75, 123-136.

Inandi, T., Tosun, A., & Guraksin, A. (2003). Reproductive health: Knowledge and opinions of university students in Erzurum, Turkey. The European Journal of Contraception and Reproductive Health Care, 8, 177-184.

Ince, N., Ugurlu, F., & Ozyildirim, B. (2006). Effectiveness of various educational methods on AIDS and stigma in adolescent in the Silivri district of Istanbul. Istanbul Medical Faculty Journal, 69(3), 63-69.

Jones, P. S., O'Toole, M. T., Hoa, N., Chau, T. T., & Muc, P. D. (2000). Empowerment of nursing as a socially significant profession in Vietnam. Journal of Nursing Scholarship, 32(3), 317-321.

Kara, B., Hatun, S., Aydogan, M., Babaoglu, K., & Gokalp, A. S. (2003). Evaluation of health risk behaviors among high school students in Kocaeli [in Turkish]. Pediatric Health and Diseases Journal, 46, 30-37.

Karababa, A. O., Ari, G., & Berktas, S. (1993). Knowledge level of high school students about adolescence. III. Public Health Days, Kayseri, 167-71.

Klingberg-Allvin, M., Nga, N. T., Ransjo-Arvidson, A. B., & Johansson, A. (2006). Perspectives of midwives and doctors on adolescent sexuality and abortion care in Vietnam. Scandinavian Journal of Public Health, 34, 414-421.

Klingberg-Allvin, M., Van Tam, V., Nga, N. T., Ransjo-Arvidson, A. B., & Johansson, A. (2007). Ethics of justice and ethics of care. Values and attitudes among midwifery students on adolescent sexuality and abortion in Vietnam and their implications for midwifery education: A survey by questionnaire and interview. International Journal of Nursing Studies, 44, 37-46.

Leppa, C. J., & Terry, L. M. (2004). Reflective practice in nursing ethics education: International collaboration. Journal of Advanced Nursing, 48(2), 195-202.

Musal, B., & Ucku, R. (1993). Menarche and menstruation characteristics of the female adolescent. III. Public Health Days, Kayseri, 172-176.

Olukoya, A. A., Kaya, A., Ferguson, B. J., & Abouzahr, C. (2001). Unsafe abortion in adolescents. International Journal of Gynecology & Obstetrics, 75, 137-147.

Popov, A. A., Visser, A. P., & Ketting, E. (1993). Contraceptive knowledge, attitudes, and practice in Russia during the 1980s. Studies in Family Planning, 24, 227-235.

Rademakers, J., Mouthaan, I., & Neff, M. (2005). Diversity in sexual health: Problems and dilemmas. The European Journal of Contraception and Reproductive Health Care, 10(4), 207-211.

Rivers, K., Aggleton, P., & Coram, T. (2002). Adolescents' sexuality, gender and the HIV epidemic. HIV and Development Programme, UNDP Publications. Retrieved from www.undp.org/hiv/ publications/gender/adolesce.htm

Sandfort, T., & Ehrhardt, A. (2004). Sexual health: A useful public health paradigm or a moral imperative? Archives of Sexual Behavior, 33(3), 181-187.

Sahinoolu-Pelin, S. (1999). The question of virginity testing in Turkey. Bioethics, 13(3/4), 256-261.

Tangmunkongvorakul, A., Kane, R., & Wellings, K. (2005). Gender double standards in young people attending sexual health services in northern Thailand. Culture, Health & Sexuality, 7(4), 361-373.

Topbas, M., Can, G., & Kapucu, M. (2003). Knowledge level of adolescents in some high schools in Trabzon on family planning and sexually transmitted diseases. Gulhane Medical Journal, 45(4), 331-337.

UNICPD. (1994). (United Nations International Conference on Population and Development. 5-13 September, 1994. Cairo, Egypt. See www.iisd.ca/cairo.html

UNFPA. (2003). State of the world population. Investing in adolescents' health and rights. Retrieved from www.unfpa.org/about/report/2003/3chapter.html

Vural, B., Vural, F., Diker, J., & Yucesoy, I. (1999). Factors affecting contraceptive use and behavior in Kocaeli, Turkey. Advances in Contraception, 15(4), 25-36.

Warenius, L. U., Faxelid, E. A., Chishimba, P. N., Musandu, J. O., Ong'any, A., & Nissen, E. B. M. (2006). Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Reproductive Health Matters, 14(27), 119-128.

WHO. (2004). Adolescent health and development in nursing and midwifery education. Available from www.who.int/reproductive-health/docs/nursing-midwifery-education.html

Zwane, I. T., Mngadi, P. T., & Nxumalo, M. P. (2004). Adolescents' views on decision making regarding risky sexual behaviour. International Nursing Review, 51, 15-22.

EMEL EGE, BELGIN AKIN, AND KAMILE ALTUNTUG

Selcuk University, Konya, Turkey

Emel Ege, PhD, Assistant Professor; Belgin Akin, PhD, Assistant Professor; Kamile Altuntug, MSc, doctoral student, all at the School of Health Sciences, Nursing Department, Selcuk University, Konya, Turkey.

This study was presented at the First International Midwifery Congress, on June 20-22, 2007, Istanbul, Turkey. (www.ebko2007.com)

Appreciation is due to anonymous reviewers.

Please address correspondence and reprint requests to: Emel Ege, School of Health Sciences, Nursing Department, Selcuk University, Konya, Turkey. Phone: +90 332 2233542; Fax: +90 332 2416211; Email: emelege@hotmail.com
TABLE 1
Distribution of Beliefs of Students on Matters of Sexual Health/
Reproductive Health

                                      No. in 1st    No. in 2nd
Beliefs on sexual/reproductive        application   application
health *                                number        number
                                          (%)           (%)
1.    It is important for a girl
      to be a virgin before she
      is married.                      48 (87.3)     45 (81.8)

2.    It is wrong for a girl or
      boy to start to have sexual
      intercourse before marriage.     45 (81.8)     45 (81.8)

3.    Men may have sexual
      intercourse before marriage.     10 (18.2)     17 (18.7)

4.    A girl's having sexual
      intercourse marriage is
      unacceptable even though she
      is planning to marry.            42 (76.4)     45 (81.8)

5.    A girl has to think about
      the consequences of
      premarital sexual
      intercourse.                     52 (94.5)     55 (100)

6.    Abortion is morally wrong.       28 (50.9)     34 (61.8)

7.    A girl having an abortion
      is unacceptable even if the
      baby is unwanted.                21 (38.2)     18 (32.7)

8.    I would be very
      uncomfortable to become
      aware that an unmarried girl
      wants to have an abortion.       31 (56.4)     26 (47.3)

9.    Information about birth
      control methods should only
      be given to married couples.     13 (23.6)      5 (9.1)

10.   A man should be informed
      about how to use a condom.       51 (92.7)     44 (80.0)

11.   A girl or boy should not be
      allowed to use birth control
      methods even if they are
      sexually active.                 11 (20.0)      3 (5.5)

12.   If an unmarried girl tried
      to learn about birth control
      methods, I would think that
      girl was not of good moral
      character.                        3 (5.5)       4 (7.3)

13.   It is inappropriate for
      unmarried couples to ask for
      contraceptives.                  16 (29.1)     6 (10.9)

Beliefs on sexual/reproductive         McNamara
health *                                  (p)

1.    It is important for a girl
      to be a virgin before she
      is married.                        0.546

2.    It is wrong for a girl or
      boy to start to have sexual
      intercourse before marriage.       0.789

3.    Men may have sexual
      intercourse before marriage.       0.627

4.    A girl's having sexual
      intercourse marriage is
      unacceptable even though she
      is planning to marry.              0.646

5.    A girl has to think about
      the consequences of
      premarital sexual
      intercourse.                        --

6.    Abortion is morally wrong.         0.307

7.    A girl having an abortion
      is unacceptable even if the
      baby is unwanted.                  0.689

8.    I would be very
      uncomfortable to become
      aware that an unmarried girl
      wants to have an abortion.         0.382

9.    Information about birth
      control methods should only
      be given to married couples.       0.08

10.   A man should be informed
      about how to use a condom.         0.121

11.   A girl or boy should not be
      allowed to use birth control
      methods even if they are
      sexually active.                   0.061

12.   If an unmarried girl tried
      to learn about birth control
      methods, I would think that
      girl was not of good moral
      character.                         1.000

13.   It is inappropriate for
      unmarried couples to ask for
      contraceptives.                    0.024 **

* The percentage of those responding "I agree" to the questions on
sexual/reproductive health are included in the table.

** p < 0.05
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Author:Ege, Emel; Akin, Belgin; Altuntug, Kamile
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:7TURK
Date:Aug 1, 2008
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