Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13562 Reproductive health education to improve knowledge and attitudes among blind adolescents Wiwin Widayani,1,2 Kurniaty Ulfah,2 Achmad Hufad,1 Viena Rusmiati Hasanah1 1Faculty of Education, Universitas Pendidikan Indonesia, Bandung; 2Department of Midwifery, Politeknik Kesehatan Kemenkes Bandung, Bandung, Indonesia Abstract Blind adolescents face significant barriers to accessing repro- ductive health education, increasing their risk of misinformation and vulnerability to reproductive health issues such as Sexually Transmitted Infections (STIs) and sexual abuse. This study evalu- ates the effectiveness of Braille modules in improving the knowl- edge and attitudes of blind adolescents toward reproductive health. This quasi-experimental study used a one-group pretest- posttest design with a Research and Development (R&D) approach. It was conducted in two phases: developing and validat- ing a Braille module, followed by its implementation among 25 blind adolescents. The knowledge and attitude assessments were conducted using structured questionnaires. The Shapiro-Wilk test confirmed non-normal data distribution, and the Wilcoxon signed- rank test compared pre-test and post-test scores. The study found an increase in knowledge scores, with the minimum score rising from 0 (pre-test) to 25 (post-test) and the maximum score increas- ing from 75 to 85. The median knowledge score improved from 50.00 to 60.00, though not statistically significant (p = 0.09). For attitudes, the minimum score decreased from 30 to 28, whereas the maximum declined from 96 to 91, resulting in a small increase in the median attitude score from 81.50 to 82.00. This change was not statistically significant (p = 0.10). Adolescents with blindness may have better knowledge and attitudes regarding reproductive health if they use braille modules. However, combining them with other teaching strategies or media could increase their efficacy. Introduction Health education is crucial for individual and community wellbeing. However, access remains limited for vulnerable popu- lations, especially those with visual impairments.1 Visual impair- ment due to illness, injury, or genetics significantly affects quality of life and social integration, limiting access to essential health information and services, including reproductive health education. Adolescence, a critical developmental stage characterized by rapid changes, requires an understanding of reproductive health for well-being. Unfortunately, the lack of access to visual learning materials exacerbates knowledge gaps, increasing the risk of unin- tended pregnancy, STIs, and sexual violence.2–4 The scale of the issue is substantial, particularly in Indonesia, where approximately 4 million individuals are estimated to have visual impairments, including adolescents.5–7 Limited access to visual information makes it challenging for blind adolescents to understand reproductive health topics, often leading to misinfor- mation and unsafe practices. Barriers such as mobility restrictions, a lack of disability-friendly healthcare services, stigma, and inad- equate family support further exacerbate this issue. These obsta- cles hinder access to essential reproductive health services, increasing the likelihood of reproductive health complications and social exclusion.8,9 Several efforts have improved reproductive health education for adolescents, including the Adolescent Care Health Service (ACHS) and Youth Care Services (YCHS);10–12 however, signifi- cant gaps remain. For visually impaired adolescents, alternative resources such as audio recordings, braille materials, and guided instruction have been introduced but remain insufficient and inconsistently implemented.9,13 Many visually impaired adoles- Correspondence: Wiwin Widayani, Faculty of Education, Universitas Pendidikan Indonesia, Bandung, Indonesia; Department of Midwifery, Politeknik Kesehatan Kemenkes Bandung, Bandung, Indonesia E-mail: Wiwinwidayani22@upi.edu Key words: blind adolescents; attitudes; Braille module; knowledge; reproductive health. Contributions: WW conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; KU conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; AH conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; VRH methodology, visualization, writing – review & editing; SS resources, investigation, and writing –review & editing. Conflict of interest: the authors declare no competing of interest. Ethics approval and consent to participate: the Health Research Ethics Commission of Poltekkes Kemenkes Bandung has approved this study (number 49/KEPK//EC/X/2024). Respondents' signed consent was sought for primary data collection, with the assurance of anonymity and the option to withdraw at any moment. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Received: 31 December 2024. Accepted: 11 March 2025. Early access: 11 April 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13562 doi:10.4081/hls.2025.13562 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 108] [Healthcare in Low-resource Settings 2025;13(s1):13562] cents lack access to comprehensive educational materials, whereas healthcare providers often have limited training in disability- friendly reproductive health education. Additionally, stigma and discrimination prevent blind adolescents from seeking appropriate health information and services.14–16 To address these challenges, a thorough and innovative repro- ductive health education program tailored to visually impaired adolescents is needed. The lack of reliable information sources and the shame associated with accessing them exacerbates disparities in reproductive health education. Despite equal rights to informa- tion and healthcare, barriers to access, social engagement, and mobility constraints create significant inequities.14,17,18 These limi- tations hinder their comprehensive understanding of reproductive health, increasing their vulnerability to unintended pregnancies, STIs, and sexual violence. Deficiency in knowledge and positive attitudes toward reproductive health adversely affect physical and mental well-being, reinforcing marginalization in education and healthcare.14,19 Therefore, accessible learning materials and methodologies must be developed for blind adolescents, utilizing diverse media, such as braille, audio formats, and direct instruction. Collaboration among healthcare providers, educators, and disability organiza- tions is crucial for program success. Addressing stigma and improving awareness among healthcare professionals and families are imperative.16,19 This study evaluated the efficacy of Braille modules in enhancing the knowledge and attitudes of blind adoles- cents regarding reproductive and sexual health. The findings are expected to provide insights for more inclusive educational pro- grams and inform improved policies for the reproductive health of visually impaired teenagers. Materials and Methods Design study This study developed and evaluated the efficacy of a Braille module to enhance the knowledge and attitudes of blind adoles- cents regarding reproductive and sexual health. A pre-experimen- tal, one-group, pretest-posttest design was employed, incorporat- ing a Research and Development (R&D) methodology. The mod- ule development process consisted of a needs analysis, design, expert validation, and preliminary testing. The module was tested in 25 special schools for visually impairments. Students who had completed the pre-test received the module as an intervention, and their performance was subsequently assessed through a post-test. Population and Sample The study population comprised all SLBN (Sekolah Luar Biasa Negeri) teenagers in Bandung City and Cimahi City. Participants were teenagers from SLBN A schools in these cities. Based on the results of paired numerical tests, the minimum required sample size was determined to be 25 students.20 The sam- ple size was calculated using Cohen’s Sample Size Formula for Mean Differences. n = ( Zα + Zβ ) S 2 X 1 - X 2 Information: n : sample size Zα : standard deviation alpha (degree of significance 95% then Zα = 1.96) Zβ : beta standard deviation ( test power of the study 1- β = 80% then Zβ = 0.84) X 1 -X 2 : minimum mean difference considered significant = 42 S : combined standard deviation determined from the literature (Kusuma and Budiono, 2017) = 18.1 Purposive sampling was employed in this study based on pre- defined inclusion and exclusion criteria. The inclusion criteria for the second phase of the study were as follows: adolescents aged 10 to 19 years who were enrolled in special needs schools, willing to participate in the entire research process, proficient in braille read- ing, able to read Braille letters accurately, owned a cell phone, and had the ability to use the TalkBack program. The exclusion criteria included adolescents with hearing impairments or those with addi- tional challenges such as intellectual disabilities or autism Data collection Through the completion of a knowledge and attitude question- naire, the respondents’ knowledge and attitudes were gathered directly. To evaluate the validity and reliability of the measuring tool, a trial was conducted before the implementation of the ques- tionnaire. The knowledge and attitude questionnaire was subjected to a validity test using the Pearson’s product-moment correlation. The Cronbach’s alpha reliability coefficient was employed in the instrument’s reliability test. This research was carried out in two phases: the initial phase of creating a Braille module involved analyzing the needs and characteristics of the students, with material elements referencing earlier qualitative research.21 The outline, layout, comprehension assessment, and delivery format were considered when designing the program. Following the preparation of the draft, material experts and media experts validated the module and made revi- sions based on their feedback. Before the final revision, the visual- ly challenged students completed a readability test, which pro- duced a final module for public trials. Students at a special school for the blind were put on public trial during the second round. Before the experiment, an informed consent script was used to explain the research process, and con- sent was obtained individually using Google Forms, Zoom, Talkback, or Screen Reader software. Respondents were assem- bled in a school classroom for the pre-test, and the enumerator pro- vided a clear explanation of how to complete the knowledge and attitude questionnaire. The enumerator had previously undergone training on post-tests, research observations, and data collection methods. The respondents used a smartphone and talkback appli- cation to access the digital version of the questionnaire. After the pre-test, participants were given a Braille instruction- al module with a reading guide for each segment. Through the WhatsApp group, participants were asked to report what they understood. The duration of instruction with the Braille module was one week. A post-test was then administered once using a Google form to evaluate how much knowledge and attitudes had changed following the intervention. Ethical clearance This study was approved by the Health Research Ethics Commission of Poltekkes Kemenkes Bandung (number 49/KEPK//EC/X/2024). The respondents’ signed consent was sought for primary data collection, with the assurance of anonymi- ty and the option to withdraw at any moment. Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13562] [page 109] Data analysis Data analysis in this study included univariate and bivariate analyses. Based on the normality test, the data obtained from the Shapiro-Wilk results in the pretest and post-test are not normally distributed; therefore, a nonparametric test was carried out using the median value. Bivariable analysis was carried out to determine the differences in knowledge and attitudes before and after the edu- cation/information program using the Wilcoxon test because the data were not normally distributed. Results In this study, 25 respondents were obtained from SLBN A Pajajaran, Bandung City, SLBN Citeureup, and Cimahi City. Respondent characteristics include age, gender and education level. Univariate analysis Table 1 shows that the majority of respondents were aged 17– 19 years (42%), female (67%), and with a high school education level (50%). Knowledge and Attitude Scores of Blind Adolescents Table 2 presents the distribution of knowledge and attitude scores before and after the intervention. The minimum knowledge score increased from 0 (pre-test) to 25 (post-test), indicating improvement after receiving education. The maximum knowledge score increased from 75 to 85. Similarly, for attitude scores, the minimum score decreased slightly from 30 to 28, while the maxi- mum score decreased from 96 to 91. Bivariate analysis A bivariate analysis was conducted to examine the effect of education on knowledge and attitudes before and after the inter- vention. Based on Table 3, the respondent knowledge scores between the pretest and the post-test had an increase in the median value of 10.00, and the attitude score had an increase of 0.5 medi- ans before and after the intervention, although statistically, there was no difference in knowledge and attitudes before and after the intervention with p> 0.05. Table 3 presents the differences in the knowledge and attitude scores before and after the intervention. The median knowledge score increased from 50.00 ± 5.0 (pre-test) to 60.00±3.8 (post-test), while the median attitude score increased from 81.50±4.0 to 82.00±2.7. However, statistical analysis using the Wilcoxon test indicated that these differences were not statistically significant, with p-values of 0.09 for knowledge and 0.10 for attitude, both exceeding the significance threshold of 0.05. Discussion The findings indicate that reproductive health education posi- tively impacts knowledge among blind adolescents, although atti- tude score changes were not statistically significant. Most respon- dents were female (67%) and aged 17-19 years (42%), with half at high school level. These demographics provide a context for inter- preting the results, as older adolescents and those with higher edu- cation may better understand and retain their health-related infor- mation. Univariate analysis showed increased minimum and maximum knowledge scores after the intervention, suggesting that the pro- gram effectively enhanced the participants’ understanding of reproductive health. These findings align with research demon- strating a substantial knowledge increase from special education interventions for individuals with disabilities, including the blind. The comprehension of blind adolescents improves because of the techniques that facilitate information absorption.22,23 The trend of increasing knowledge scores among visually impaired teenagers suggests that providing reproductive health information through suitable media can enhance comprehension. However, the attitude scores showed a slight decrease in both the minimum and maxi- mum values post-intervention. One explanation is that newly acquired knowledge may have led to cognitive dissonance, where- by participants reassessed their beliefs and attitudes toward repro- ductive health.24,25 This phenomenon has been observed in studies in which increased knowledge does not immediately translate into positive attitudinal changes. The findings showed no significant correlation between repro- ductive health education and blind adolescents’ knowledge, high- lighting the complexity of influencing factors. This necessitates reassessing frameworks and methodologies that consider material accessibility, familial support, and social stigma. The ineffective- ness of formal education programs may stem from blind adoles- cents’ preference for alternative sources such as e-modules, Internet resources, and TalkBack applications.26,27 Addressing pub- lication bias is crucial, as scientific progress depends on reporting both nonsignificant and significant findings. Future research Special issue Pathways of Change Table 1. Respondent characteristics. Variables Respondents Percentage ( n = 24 ) (%) Age (years) 10-14 7 29 15-16 7 29 17-19 11 42 Gender Man 10 33 Woman 15 67 Education Elementary School 4 12 Junior High School 9 38 High School 12 50 Table 2. Distribution of knowledge and attitude scores of blind adolescents. Indicator Knowledge Attitude Pre-test Post-test Pre-test Post-test Minimum 0 25 30 28 Maximum 75 85 96 91 Table 3. Analysis of differences in knowledge of attitudes of blind adolescents before and after being given education. Education Median ± SE p Pre-test Post test Knowledge 50.00±5.0 60.00±3.8 0.09* Attitude 81.50±4.0 82.00±2.7 0.10* Wilcoxon Test*. [page 110] [Healthcare in Low-resource Settings 2025;13(s1):13562] should explore these results and refine the study design.28,29 Despite the lack of correlation, education can positively impact blind adolescents’ reproductive health knowledge, as demonstrated by effective Braille modules covering human anatomy, reproduc- tive functions, rights, and STI prevention. Accessibility-focused education enhances knowledge, reduces stigma, and fosters open discussions.30,31 Studies confirm that tactile perception in Braille aids knowledge acquisition, and specialized programs using Braille and accessible formats effectively educate blind adoles- cents on puberty, menstruation, bodily changes, and hygiene.18,30,31 This study found that the increase in median attitude score of blind adolescents following the educational program was not sta- tistically significant but suggested a favorable trend, indicating the potential of intervention in influencing adolescent attitudes. Attitudes toward reproductive health are shaped by multiple fac- tors, including information, experiences, culture, social influences, and learning processes, encompassing perceptions, assessments, and willingness to act, with the social environment playing a cru- cial role.32,33 The theory of behavior changes highlights that atti- tudes develop through learning involving experience, comprehen- sion, and social interaction. A positive attitude toward reproductive health may enhance visually impaired adolescents’ awareness of critical issues, such as reproductive organ hygiene, personal boundaries, and preventing risky sexual behaviors. The increase in attitude scores may have been influenced by respondents’ motiva- tion to seek additional knowledge through electronic media after the intervention,13,21,34–36 suggesting personal initiative and external resources shape adolescents’ attitudes. Effective education requires accessible formats, such as audio, braille, and interactive discus- sions, as conventional text-based or visual methods may be inade- quate. Combining multiple media enhances behavioral outcomes.37 Involving parents, educators, healthcare providers, and policymak- ers reinforces knowledge and fosters positive attitudes toward reproductive health.38–41 Education programs should integrate accessible learning formats, leverage technology, and promote stakeholder collaboration to ensure effective reproductive health education for blind adolescents. This study had several limitations. The small sample size lim- ited generalizability to visually impaired adolescents. Only short- term changes were measured, making it difficult to assess long- term impact. Factors like prior knowledge, cultural beliefs, and parental influence, which may have affected effectiveness, were not considered. The study relied on braille module educational methods without incorporating interactive or experiential learning. Future research should include larger samples, longer follow-up periods, and innovative methods to improve reproductive health education for blind adolescents. Conclusions Blind adolescents exhibited enhanced knowledge and attitudes following a reproductive and sexual health education intervention utilizing Braille modules, although the results were not statistically significant. Nonetheless, the rising trend indicates that braille mod- ules may enhance the comprehension of visually impaired adoles- cents. The varied preferences for information access highlight the necessity for a more adaptable and technology-driven teaching methodology. Additional research is advised to incorporate a larger sample size, prolong the intervention time, and employ a broader range of instructional methods and media to enhance the effective- ness and significance of the impact. References 1. 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