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 Epidemiology and Society Health Review| ESHR 
Vol. 4, No. 1, 2022, pp. 21-28 ISSN 2656-6052 (online) | 2656-1107 (print) 
 
 

      10.26555/eshr.v4i1.5062  

21  
 

  

Research Article 
 
Assessment of Reproductive Health Awareness among 
Adolescent Girls in a City of South India: An Interventional 
Study 
 
Josephine Priya K1*, Ranganath T. Sobagaiah2, Ipsita Debata3  

1 Senior Assistant Professor, Department of Community Medicine, K.A.P. Viswanatham 
Government Medical college, Tiruchirapalli, Tamilnadu, India 

2 Professor and HoD, Department of Community Medicine, Bangalore Medical College and 
Research Institute, Bangalore, Karnataka, India 

3 Associate Professor, Department of   Community Medicine, Akash Institute of Medical 
Sciences and Research Center, Bangalore, Karnataka, India 

 
* Correspondence: drjosephinek@gmail.com. 
 
Received 25 October 2021; Accepted 21 January 2022; Published 31 January 2022 
 

ABSTRACT 

Background: An adolescent in the age group of 10 – 19 years is subjected to the vicious cycle 
of early marriage; early, repeated pregnancies; poor nutrition and ill health. In developing 
countries, close to 12.7 million girls under the age of 19 give birth each year. Adolescents lacking 
in knowledge of reproductive health will not be able to make informed decisions. A study to 
evaluate and improve the existing awareness levels of reproductive health among adolescent 
girls in the South of India is the need of the hour. 
Objectives: This study aimed to assess the existing reproductive health awareness among 
adolescent girls and evaluate the change in awareness levels of reproductive health after 
educational intervention.  
Methods: A descriptive study with an educational interventional was carried out in high schools 
and pre university colleges in a city of south India. 800 students from Class VIII to XII from 6 
educational institutions were studied using a standardized, pre validated questionnaire. Baseline 
evaluation of reproductive health awareness among these students was done followed by an 
educational health intervention. Post intervention awareness levels were assessed using the 
same questionnaire after an interval of three months to evaluate for change. 
Results: The mean age of the study population was found to be 14.91 (+1.45) years. Teaching 
intervention improves knowledge on reproductive and sexual health (p < 0.001). Predictors of 
poor pre intervention knowledge levels: those with uneducated fathers (OR= 0.31, p=0.005); not 
on social networking sites (OR= 0.23, p<0.001); lower age (early adolescence) (OR= 2.46, 
p<0.001); school going adolescents (OR= 3.47, p<0.001)  
Conclusion: This study highlights the gross deficiencies present among adolescent girls with 
respect to reproductive and sexual health awareness. Various measures must be put into place 
to ensure better reproductive health of the adolescent. 

Keywords: Adolescent; Reproductive health; Intervention 



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INTRODUCTION 

The World Health Organization (WHO) identifies adolescence as the period in human growth 
and development that occurs after childhood and before adulthood, from ages 10 to 19 (1). In 
this critical phase of transition they are burdened by physical and mental changes and also 
have to deal with various other stressors. Due to the psychological, emotional, hormonal and 
physical changes it is necessary to empower the adolescent with education regarding 
reproductive and sexual health. 

Today's adolescents are 1.2 billion strong and constitute 16% of the world's population (2). 
More than half of the world’s adolescents live in Asia. India has the highest adolescent 
population in the world, with an estimated 253 million adolescents, constituting 21.4% of the 
country's population (3,4). India also has the highest proportion of adolescents closely 
followed by China with 201 million adolescents (4). 

This age group is one of simple but crucial reproductive health needs- like menstrual hygiene, 
contraception and safety from Sexually Transmitted Infections (STIs). These when unattended 
lead to problems of public health importance such as adolescent pregnancy, unsafe abortion, 
Reproductive Tract Infections (RTIs), STIs and Acquired Immuno-Deficiency Syndrome 
(AIDS) and social problems. These in turn lead to adverse pregnancy outcomes like Low Birth 
Weight (LBW) and high Infant Mortality Rate (IMR). 

Adolescent girls in India are a largely invisible population, amounting to 113 million, or 20% of 
the world’s adolescent girls. They are trapped in a society with varied socio-cultural practices 
that leaves them powerless to make essential life-choices (5). Issues such as lack of autonomy 
to take decisions regarding marriage, sexual relations, education, career, etc still plague this 
age group (6). Adolescent females are often subjected to the vicious cycle of early marriage, 
early and repeated pregnancies, poor nutrition and ill health. In developing countries, close to 
12.7 million girls under the age of 19 give birth each year (7,8). Data from National Family 
Health Survey- 4 (NFHS 4) reported 33,928 live births by women under 20 years of age in 
India (9). 

Even with programmes such as the Rashtriya Kishor Swasthya Karyakram (RKSK), 
Reproductive, Maternal, Newborn, Child and Adolescent Health, the health of the girl child has 
always been an area of neglect in our country. Menstrual practices are also shadowed by 
unnecessary and sometimes even harmful cultural or superstitious practices in many countries 
(10,11) and this leads to a greater need for health awareness in the adolescent period. 
Improving the reproductive health among adolescent girls can only occur by educating them 
and promoting health awareness and healthy behaviour among them. Better reproductive 
health awareness will promote a decrease in morbidity and mortality, fair delivery of 
adolescent healthcare rights, and subsequently safeguard future generations (12). It has also 
been seen that menstruation also significantly impacts the education of the girl child (13). 

Until recently still lack of data pertaining to reproductive health awareness among adolescent 
girls from South India. A study to evaluate and improve the existing awareness levels of 
reproductive health among adolescent girls in the South of India is the need of the hour. 

 



Josephine Priya (Assessment of Reproductive Health Awareness among Adolescent Girls in a City of South India) 
 

 

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METHOD 

A cross sectional study with an educational intervention was carried out among adolescent 
girls from randomly selected High Schools and Pre-University (PU) colleges in urban 
Bangalore during the period from January to May 2017. Based on a previous study by Pratinidi 
et al. (14) the change in awareness levels post intervention was found to be 19.05% at 5% 
significance with 15% allowable error, sample size was calculated to be 754 (rounded off to 
800). Among the schools that consented to participate in the study, a total of 6 educational 
institutions, 4 schools and 2 PU colleges were randomly selected from the master list of eligible 
schools and PU colleges in the city. Based on the strength of these institutions it was decided 
that all girl students in these schools and colleges will be included in the study in order to 
achieve the desired sample size. For the purpose of equal representation across the age 
group 400 students from high schools and 400 from PU colleges were included in the study. 
Students absent on the day of the study-either for pretest or posttest were excluded from the 
study. 

Data collection was started after obtaining clearance from the Institutional Ethical Committee. 
Permission was obtained from the education officer of Bhruath Bangalore Mahanagara Palike 
(for corporation schools), Deputy Director of Public Instruction, Bangalore city (for private 
schools) and Deputy Director of PU board. As the students are minors, informed consent for 
study was obtained from the parents of the students through teachers, assent was obtained 
from students. Pre and post test assessments were conducted six months apart. Data 
regarding socio demographic profile and various aspects of reproductive health were collected 
by pre tested, semi-structured questionnaire administered to the students (self-administered 
questionnaire method). A modified WHO questionnaire on Adolescent Reproductive and 
Sexual Health was used.  

For the educational intervention, teachers selected by the institution were trained on relevant 
aspects of adolescent reproductive health. The educational intervention was delivered three 
months after the pretest with the aid of power point presentations, by the trained teacher in 
the presence of the doctor. Education was carried out on topics such as physiology of 
pregnancy, sexually transmitted infections-modes and prevention, contraception, etc. for 
duration of 2 hours in each institution. For scoring, each right answered was scored as 1 and 
wrong answer as 0. The aggregate score of all domains was summed to arrive at the total 
score. The academic performance of the students was assessed based on the average score 
in the previous exam. This was recorded from the students’ marks card with the help of the 
class teacher. Posttest evaluation was carried out three months after the educational 
intervention was delivered. 

Data was entered onto a computerized Excel (Microsoft Excel 2007) spread sheet and analyzed 
using SPSS version 20. Descriptive analysis was done (means, proportions, and percentages) 
for demographic variables. Categorical variables were compared using Chi square test. Intra 
group comparisons were done using the Paired t- test (for continuous data) and Wilcoxon 
Matched Pairs Signed-Ranks Test (for categorical data). Variables found to be significantly 
associated with knowledge levels by the Chi square test were analyzed for their simultaneous 
influence on the same by logistic regression. P value of < 0.05 was considered significant. 

 

 



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The following definitions were used for analysis:  

1. Educational status of parents: those with a minimum education of 10th standard were 
considered as Educated while those with no formal education received/ less than 10th 
standard were considered as Not educated 

2. Knowledge levels (pre and posttest): those with a score of 25 – 36 were categorized 
as Good; 10 – 24 were considered Average and 0 – 9 were classified as having Poor 
knowledge levels 

3. Academic performance (based on the average score in the previous exam recorded 
from the students marks card) was classified as good if they had an annual average 
score of 80% or above; Average if the annual average score was 65% - 79% and Poor 
when the annual average score was 64% or below 

RESULTS 

Data analysis revealed a total of 800 students participated in the study. 474 (59.3%) study 
participants were from high schools and 326 (40.7%) from pre university colleges. The mean 
(SD) age of this group was found to be 14.91 (1.45) years. Of the 800 students, 158 (20%) 
belonged to class 8, 174 (22%) to class 9, 142 (17%) were from class 10, 182 (23%) from 
class 11 and 144(18%) were from class 12.647 (80.9%) students were Hindus, 86 (10.6%) 
were Muslims, 60 (7.5%) were Christians. 

There was significant improvement in knowledge levels post the educational intervention, in 
all domains-namely pertaining to puberty, menstruation, pregnancy, contraception, STDs and 
HIV and abortion (p <0.001) [Table 1]. 

Table 1. Knowledge across different domains 

KNOWLEDGE 
DOMAINS 

Mean (SD) p* 
PRE-TEST POST TEST 

PUBERTY 1.72 5.36 <0.001 
MENSTRUATION 4.54 6.11 <0.001 
PREGNANCY 2.52 6.58 <0.001 
CONTRACEPTION 1.05 4.14 <0.001 
STDs and HIV 2.97 6.97 <0.001 
(*Paired t test, at 95% CI) 
ABORTION (abortion is the best method 
of preventing pregnancy) 

37.3% (n=298) 22.6% (n= 181) <0.001 

(*Mc Nemar’s test) 
 

All students showed significant improvement in knowledge levels post educational 
intervention. During the pretest it was seen that 414 students and 71 students respectively 
were average and good in their knowledge levels, it improved to 75 only (average) and 723 
(good) in the post-test. Only 2 students who initially showed poor knowledge levels remained 
in the same group post the educational intervention (0.6%) [Table 2]. 

 

 



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Table 2: Change in performance of students in terms of knowledge categories 

 Post test TOTAL p* 
 
 

Pre test 

 Poor Average Good  
 

<0.001 
Poor 2 51 262 315 

Average 0 22 392 414 
Good 0 2 69 71 

TOTAL 2 75 723 800 
(*Wilcoxon Matched Pairs Signed-Ranks Test, at 95% CI) 

The effect of the educational intervention was calculated using effect size and it was found 
that the maximum effect was seen in the puberty domain with an effect size of 1.8 [Figure 1] 

 

Figure 1. Effect size of the various domains 

Academic performance was seen to have a significant impact on the baseline knowledge 
possessed by the adolescent girls. Among the good academic performers, 59.7% (n=228) 
were found to have good reproductive and sexual health awareness in the pre intervention 
stage [Table 3]. 

Table 3. Association between academic performance and overall knowledge score prior to 
intervention (outcome variable) 

Academic 
performance 

Pre intervention knowledge levels Total χ2 p 
Poor Good  

 
0.002 

Good 154 (40.3%) 228 (59.7%) 382 

Average 91 (31.2%) 201 (68.8%) 292 

Poor 52 (49.1%) 54 (50.9%) 106 
Total 297 483 780 

 

The knowledge levels of students with fathers who have an education of at least 10th standard 
were 0.31 times better than those whose fathers had lesser education. Knowledge levels of 
adolescents who were a part of one or more social networking sites was 0.23 times better than 

1,8 1,78 1,74

1,34

0,94

0
0,2
0,4
0,6
0,8

1
1,2
1,4
1,6
1,8

2

Puberty Pregnancy Contraception STDs and HIV Menstruation

Effect size



Josephine Priya (Assessment of Reproductive Health Awareness among Adolescent Girls in a City of South India) 
 

 

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those who were not a part of social networking sites. Older adolescents had significantly better 
knowledge than the younger adolescents (OR = 2.46). Adolescents with higher education 
(college) had significantly better knowledge than the school going adolescents (OR = 3.47) 
[Table 4]. 

Table 4. Predictors of pre intervention knowledge by regression analysis 

Predictor variables Odds ratio 95% Confidence Intervals p 
Lower limit Upper limit 

Father’s education 0.31 0.138 0.699 0.005 
Socio-Economic Status 0.87 0.696 1.078 0.19 
Academic performance 0.81 0.633 1.032 0.087 

Social networking 0.23 0.117 0.440 <0.001 
Age groups 2.46 1.674 3.617 <0.001 

Educational status (in 
college vs School) 

3.47 2.197 5.465 <0.001 

 

DISCUSSION 

Adolescence is an impressionable and vulnerable stage in a child’s life. Foundations of a 
healthy and responsible lifestyle must be laid in the formative years. Education plays a great 
role in shaping the behaviour and choices made by adolescents.This study highlights the gross 
lacunae that are present in adolescents with respect to reproductive and sexual health. The 
factors that are surprising and warrant consideration are that most of these adolescents have 
already attained menarche and are going through their reproductive cycles every month but 
are grossly ignorant regarding the physiology of the same. In an age and time where 
connectivity is highly valued and the internet is just a tap away, it is surprising to note that 
simple messages of menstrual hygiene, prevention of STDs, importance of good health care 
in the adolescent age group, etc. have been ineffective in reaching the target group. 

A study conducted in government schools of Delhi found that only 40% girls had prior 
knowledge of menstruation (15). A scoping review found puberty and menstruation knowledge 
among young adolescents in low-and middle-income countries to be inadequate (16). Our 
study showed around 9% of the students possessed poor knowledge of menstruation prior to 
the intervention. 

This study shows a significant improvement in knowledge among the adolescents post 
educational intervention. This is similar to the studies by Manjula R. et al. (17) and various 
other studies from India and abroad (18), who found that there was overall significant change 
in knowledge (p<0.001) after educational intervention. This is also similar to a study done by 
Pratinidi A K et al. (14) where it was observed that the change in knowledge was 8 marks and 
19.05% increase in percentage between pre and post-test (p < 0.00). A study conducted by 
Rao R. et al. (19). showed that the knowledge regarding menstruation and menstrual hygiene 
among adolescent girls improved significantly from 77.2% to 95.6% and 91.8% to 100% 
respectively after intervention (p < 0.0001). 

There are not many studies that have looked at the impact of educational intervention in the 
different domains. Our study has shown that the highest impact was in the puberty domain. 
This is probably because the adolescent students can better relate to this current phase of 
their life. However other domains followed closely in effect size. 



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CONCLUSION 

Better reproductive health awareness is the need of the hour. With a fast growing adolescent 
population such as in our country, emphasis on educating girls on reproductive health will 
improve the general health of our population and reflect in the improvement of our health 
indicators. Educational intervention, as seen from this study, is a highly effective means of 
achieving the same. In agreement with a study done among 12- to 19-year-old females in 
Karaj, Iran (20), we also feel that it is important to maintain continuous training at the school 
level to improve the knowledge of these adolescent girls. Thus, as seen in this study and 
taking into account the factors identified by a qualitative study done by Zainab Alimoradi, it is 
necessary to strengthen education pertaining to reproductive health while simultaneously 
improving healthcare access and delivery to adolescents (21). 

Various measures must be put into place to ensure better reproductive health of the 
adolescent. At the individual level it is important to teach adolescent girls to pay attention to 
good nutrition, cleanliness, hygiene and responsible reproductive behavior. Efforts must be 
made to teach and educate the girl child on the anatomy and physiology of the reproductive 
system. At the family level parents must take initiatives to assume their primary role in the 
sexual education of their children, rather than relying on the schools to provide the appropriate 
orientation. They must be encouraged to provide emotional and psychological support to the 
adolescent. 

At the community level it is vital to have culturally appropriate Information, Education and 
Communication strategies for improving adolescent reproductive health. More teachers must 
receive training in sexual and reproductive health topics, taking into account the special 
characteristics of the adolescent population. Appropriate curriculum, methodologies and 
materials should be developed taking into account cultural differences. This is further 
supported by findings of the study by Sarah Blake et al. (22) where in it was seen that 
adolescents showed interest in learning about reproductive health when provided with the 
appropriate resources. 

Authors' contribution 

Dr. JPK- research design, data collection, analysis and manuscript writing. Dr. RTS- research 
design, analysis. Dr. ID- data collection, analysis  

Funding 

This research has not received external funding” for research without a donor 

Conflict of interest 

There is no conflict of interest in this research.  

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