Introduction

One fifth of India’s population comprises of adolescents (Dambhare et al. 2010). They are prone to suffer from problems related to reproductive and sexual health, nutrition, and mental and behavioral issues. Specifically, the stage of adolescence is termed as a period of opportunity and vulnerability (Malina 1974). The adolescents get new ideas and like to explore new options. Adolescents undergo various changes due to the hormonal changes. When these changes remain unattended to, or their queries remain unanswered, they tend to get stressed. It is evident that almost all adolescents have doubts related to their growth, development, and matters related to reproductive and sexual health (RH and SH). Majority of parents are not comfortable in providing RH or SH education or discussing issues related to this with their adolescents (Parwej et al. 2005). RH matters of adolescents tend to be the last topic of discussion for parents and their adolescents in India (Jejeebhoy 1998; Agrawal et al. 2007; Joshi et al. 2006). In this rapid world of urbanization, do parents give ample time to discuss the reproductive health aspect of adolescents? Or are gadgets and media the sole guide for adolescents to know about their reproductive health aspects? What role do teachers play in schools? Is sex education really needed in our academic syllabus? Most of the time, adolescents receive wrong information on their rapidly changing body proportions (Field et al. 2001). Chances of myths and misconceptions prevail among adolescents. So, it is mandatory to provide proper information about RH to adolescents, so they are better prepared to deal with these issues. Though there is a need to educate the adolescents on reproductive sexual matters, parents, teachers often oppose such educational programs. This may be due to the fear that imparting sex education would lead to experimentation with sex, which is contradictory to scientific evidence (Mahajan and Sharma 2005). Ample studies have been done abroad that have focused on concerns of parents and caregivers about RH matters of their adolescents (Torres et al. 1980; Reddy et al. 2002; Furstenberg et al. 1984; Ngom et al. 2003). Our aim was to study the perception of parents and teachers about adolescent upbringing with a special focus on RH, services and schemes provided for adolescents RH.

Methods

Institutional ethical committee clearance was obtained prior to the initiation of the study. Each participant was first provided with explanation of the purpose, general consent, and time commitment involved in participating in the discussion, and assurance of confidentiality. Written informed consent was also obtained prior to the study.

The present study was conducted from November 2013 to April 2015 in two coastal districts of Karnataka (Dakshina Kannada and Udupi) in India. These districts have a mix of both rural and urban populations. A literacy rate of 86.2% in Udupi, ranks it as one of the most literate districts in the state.

Obtaining quantitative information about adolescent RH changes from parents and teachers is not an easy task. Discussions and interviews are the best way to extract information from participants about adolescent RH matters. So focus group discussions (FGD) are quite quick and relatively easy to set up. The group dynamics can provide useful information that individual data collection may fail to collect. A qualitative study design—FGD was developed to obtain our study objective (Meadows 2003; Kitzinger, 1994) of assessing the perception of parents and teachers on adolescent RH, services and schemes provided by the government for adolescent RH.

Participants were selected through stratified purposeful sampling. From each district, two blocks (taluks) were selected at random. Among the selected blocks, a rural and an urban area were further selected at random. An Anganwadi (community center) was selected and the in-charge was contacted to obtain the list of parents who sent their adolescents to these Anganwadis. The parents (mothers only) of adolescents were contacted individually, and the study objectives were discussed. If they agreed to participate in the study, they were given subject information sheet explaining all details of the study.

Similarly, from the selected rural and urban areas, a high school was selected randomly. The teachers who dealt with adolescents were contacted individually, and they were explained the purpose of the study. Informed consent was obtained from the teachers who agreed to participate in the study. Separate FGD were conducted for teachers and parents and each FGD had 10 to 15 participants. Each session lasted for about 90 to 120 minutes. No prior professional-client relationship existed between participants and the FGD team (a moderator, a note keeper cum recorder and a person to design sociogram).

The FGD were audio recorded with the participants consent. The audio records were transcribed in the local language, made in to English transcripts and back translated to the local language. To validate the translation, an independent language expert in local language and English went through both the transcripts to validate it. Necessary corrections were made and the same were incorporated. Thematic analysis was done and codes were generated to summarize the views expressed by the participants. The study panel discussed all the transcripts to reach a common consensus on the coding. Data was sorted and synthesized according to each theme for interpretation.

Research Instrument

Existing literature review on parents and teachers perception about adolescent reproductive health revealed dearth of studies on reproductive health services for adolescents in India. A broad conceptual framework was developed that could guide empirical research focusing on adolescent reproductive health perceptions on unmet reproductive health needs, awareness regarding the existing reproductive health services for adolescents and gathering inputs regarding better modalities of service delivery. An interviewer guide was developed in the local language (Kannada) and was pre-tested on a pilot sample. The guide consisted of open-ended questions related to broader themes—adolescent nutrition, adolescent mental health, upbringing of adolescents, perceived RH problems, health seeking behavior, awareness on RH changes, knowledge on RH services, and expectations to access RH services for adolescents.

Results

A total of 90 participants took part in FGD. Among them, 50 were parents (only mothers) and 40 were teachers (Table 1)

Table 1 Distribution of participants in FGD
Full size table

The themes that were discussed are as follows:

Adolescent Nutrition

The purpose of introducing this theme was to put the participants at ease and more cooperative for the discussion. Adolescent nutrition is one of the most widely researched topics, but from qualitative research view many aspects remain untouched in the Indian context.

Media has popularized junk food so much that our adolescents prefer to have these unhealthy foods over the healthy food that we prepare at home. They even demand pocket money for having junk food. - An Urban Mother

Students prefer to stay hungry rather than eating healthy food. They fail to realize that junk foods will not provide any nutrition to them - An Urban Teacher

The Government has provided nutritional schemes like mid day meals, daily milk to schools, but I do not think that private schools can avail those facilities. The quality of food is mediocre and can be improved - A Rural Teacher

Adolescents also do not drink enough water and fail to understand its importance. - A Rural Mother

We do lay an emphasis about the importance of consuming green leafy vegetables among our students. For adolescent girls it is very important - Rural teachers

Girls undergo menstrual changes so it is advisory for them to eat lot of iron rich foods; there is no mandatory diet regime for boys - An Urban Mother

Our daughters do not eat because they want to be slim. Some advertisements have shown that girls should eat less so they remain slim - Rural mothers

School boys instead of doing exercises order muscle building products to get six pack abs. They eat only twice a day. No fruits and all. Celebrities promote these products. - Urban mothers

According to the participants, media has portrayed junk foods to be nutritious for adolescents. Media has become a determinant of adolescent health. It could be inferred that only government schools benefit from the nutritional schemes provided by the government. Mothers and teachers projected the concept of providing more nutritious food to girls because they undergo menstrual changes.

Adolescent Mental Health

The theme of adolescent mental health generated a lot of views. Mothers and teachers believed that it was mental health of adolescents that required immediate attention by health care experts. If this entity was well maintained, then many adolescent health issues could be averted. Parents and teachers felt that it was academic issues and peer relationships of adolescents that needed to be addressed first rather than RH matters. There were mixed opinions among the participants on maintaining a friendly relation with their adolescents. Cordial environment at home and school were the prime requisites of adolescents for a sound mental health. Mothers expressed their views that due to socio-cultural pressure they focus on girls more than the boys. They stated that girls though being under lots of restriction still get all the necessary care and attention that they need unlike boys. Peers and media were the main enemy of the young generation.

At present, adolescents stress more on exams; the normal fear of exam has become phobia - A Rural Teacher

Adolescent changes when left unattended could affect them psychologically; gradually, they try to hide their concerns and possibly could lead to depression or other mental health problems - Rural teachers

Most of adolescent problems arise at home. Quarrels, consumption of alcohol, smoking at home, financial problems were the main issues. They become more aggressive, rebellious in nature owing to these - A Rural Teacher

We have counseling facilities for our students, so it could help solve their problems. Almost all adolescents discuss their issues with friends only and believe them more than parents, teachers. Most of the times friends mislead with wrong or incomplete information - An Urban Teacher

Boys tend to get addicted easily to bad habits because of friends and media, especially Whatsapp, social networking, and movies - Urban parents

We always monitor about the whereabouts of our girls but in case of boys we do not monitor them. We always keep a check on the friends our daughters make but for boys; it is their choice to make friends. Girls are obedient and sincere in studies unlike boys - Urban parents

They watch everything on mobiles, internet. Media affects them mentally. It is not only boys; even girls watch pornographic content through internet. It is very hard for us to know what our children do on mobiles but we always see them with mobiles - Rural parents

When a boy does a mistake, society never raises any concern for the incident but when a girl makes a mistake, it is discussed by all. This makes the girl and her parents always stressed. So parents focus more on girls and provide them all attention rather than the boy in the family. So it becomes easy for the boy to get spoilt mostly due to friends - A Rural parent

Whatsapp and messages provoke adolescents to be spoilt. They make groups and pass information about places to meet after college and then they indulge in all wrong things - Urban parents

Reproductive Health Problems

The previous themes had made the participants comfortable enough to introduce the topic of RH of adolescents and its various aspects. Sex education was the most important aspect that needed to be dealt with adolescents for understanding their RH matters. It was mentioned that as girls have menstrual issues, they receive all attention and guidance whereas boys do not receive any such special care or guidance.

Sex education is very crucial for adolescents. However, additional information is also desirable. Most of them are not aware of physical changes; so they have the curiosity to know all the details but do not know whom to approach - Rural teachers

Adolescents tend to get attracted to negative things more than the positive ones. This is due to media, peers or any personal issues - Rural teacher

Once in a class, we had mentioned about oral contraceptives and girls started using them. We did not know whether they were advised clinically or just by listening to us they started using oral contraceptive pills. Such cases are very dangerous and after this incident we decided not to bring in such matters again in classes - An Urban Teacher

Girls have menstrual problems and undergo many complications. It is very irritating and painful for them. But boys do not have any RH problems - Rural mother

Parents must educate adolescents in all the ways possible, boys learn themselves about their RH issues, for girls it is complicated - Urban mother

Knowledge About Available Service

The urban participants were not aware of any RH services for adolescents or any adolescent health service (AHS) provided by the government or any other private health setting. Only few rural teachers were aware of such RH service for adolescents. Government schemes focused more on nutritional aspect of children and it was mentioned by participants that such schemes focused more on adolescent females. In few schools, they focus on sex education. More services from health care providers were expected for the betterment of adolescent RH.

We conduct government sponsored training programs for girls during vacations. It is very useful for but only few girls attend. Also, “Kishori training”—training provided to adolescent girls for sensitizing them about adolescent changes are conducted - A Rural Teacher

Government has introduced health schemes under which iron tablets, folic acid tablets and anti-filarial tablets are distributed to all students-both rural and urban government schools - An Urban Teacher

Government has arranged medical check-ups and counseling in government hospitals on every Thursday especially for adolescents. We promote this concept among our students and want them to visit such clinics if they have any problem - Rural teachers

There is a helpline for children; we have informed them about it. A government scheme- Suvarna Arogya Chaithanya was also started in which a doctor would address a group of students on a monthly basis at schools/clubs. This program should be conducted every year - Rural Teacher

We are not aware of any such AHS or RH services. It is not possible for us to give time to RH concerns during school hours. We do not get time to complete academic syllabus, how can we organize special health programs regularly - Urban teachers

We are ready to help our children but they are not willing to discuss their RH problems with us, especially boys. Girls share their problems with mothers. No special services exist - An Urban Mother

Government schemes are targeted to resolve nutritional issues among adolescents. But there are no such specific schemes for boys. Only government schools can avail these schemes - An Urban Mother

RH facilities should not be restricted to girls only; it should be equally focused on boys. Girls receive many schemes addressing their RH matters directly as well as indirectly. But boys do not receive any such services - Rural Teacher

Suggestion for Improvement:

Participants gave lots of suggestions to improve adolescent RH facilities. Equal distribution of schemes for boys and girls were suggested. Proper advertisements about RH services must be made.

If community volunteers visit schools either once a month or week and make efforts to identify adolescent’s problems then it would be very beneficial - An Urban Teacher

A suggestion box should be kept in every school, children can write their problems so it would be discussed in private with a counselor. Such facility should be made in all schools - An Urban Teacher

More advertisements on RH services for adolescents should be made to promote awareness. Adolescents should be made aware of SNEHA clinic—teen clinic because they misunderstand this special clinic to be a large hospital there would be no confidentiality to share their “secret problem”—These adolescents do not know that such clinics are exclusively meant for adolescents only and each adolescent have special one to one interaction with the doctor. - Rural Teachers

If SNEHA clinic is there and functional on every Thursday afternoon, then how can children go there during school hours? If it has to be made functional, then it must be kept open on holidays when adolescents can go easily - An Urban Mother

Discussion

The results indicate that media determines the food habits of adolescents. Advertisements have determined the food selection for them rather than the nutritive value. Previous studies by Bake 2012; Kotecha et al. 2013; Pramanik et al. 2014 have stated that urban adolescents consume more junk foods; however, our study highlights the fact that in our study settings, no difference was seen among urban and rural students. The effect of media on adolescent nutrition seemed to be harmful. Strict laws and regulations on airing advertisements of nutritional aspects of food materials must be adopted.

In an Indian study (Kotecha et al. 2013), teachers stated “Aishwarya Rai syndrome (named after a famous actress and Miss World: so, all adolescents girls treat her as their idol and eat less to be thin) and Salman Khan Syndrome (named after a famous actor with muscular build-up: so, all boys treat him as their idol). They are not able to differentiate between being muscular or fat.” This concept of body imaging is promoted by media, and it becomes very hard for teachers and parents to make adolescents realize the fact about eating healthy.

A unique finding of our study was that the participants mentioned about the schemes introduced by the government addressing nutritional issues among adolescents and also that only government schools could avail these schemes. It was highlighted that adolescent girls require more attention on their diet as compared to boys.

(Deb et al. 2010; Sun 2012) in their study predicted that the concept of adolescent mental health revolved around academics only. The topic of mental health issues among adolescents receives less attention (Patel et al. 2008; Srinath et al. 2005). A similar trend was reported in our study as well. It was evident that behavioral aspect was considered more important than RH matters. The reproductive health aspects especially in boys tend to receive minimal importance as compared to that of girls. Risky behaviors among adolescent boys in our study area were bike racing and substance use. No risky behavior among girls was reported. They believed that it was due to peers and media that adolescents are getting spoilt. These findings of ours were in congruence to other studies (Flannery et al. 1999; Steinberg et al. 1994; Reed and Rountree 1997). It could be inferred that more studies addressing the concerns of adolescent caregivers must be correlated to views expressed by adolescents. The finding that participants agreeing to provide more care and concern towards adolescent girls than boys was one of its type and had not been reported before in any other study. Societal pressure was suggested as a possible explanation. The societal taboos that girls are more vulnerable to health complications especially RH matters prevailed in our study area. Negative influences of internet, mobiles were the focus of the discussion. Pornography had corrupted young minds. Evidence suggests that pornographic viewing is harmful for adolescents (Mesch 2009; Bercedo et al. 2005; Sharma 1998).

Initially, the participants were reluctant to share their views about adolescent RH. The possible reason could be based on the fact that this was the first time where such FGD was conducted regarding RH. They believed that sex education was very important for the proper upbringing of adolescents. It was also concluded that adolescent boys do not have any sort of RH problems. Girls undergo menstruation; their RH is always given preference at homes, schools. This concept among parents and teachers dealing with adolescents needed to be countered. They possibly could discuss such matters with health experts and receive appropriate measure for providing better health care to adolescents.

The awareness levels about RH services for adolescents were poor among our participants. All agreed that girls receive more facilities from government with in terms of their nutritional and RH status. Equal distribution of such schemes should be made mandatory for boys as well as in private schools. Teen clinics if opened must be seen that they are equally functional. These clinics must be kept open keeping in minding the socio-cultural context of the study settings. The importance of socio-cultural aspects, gender roles on RH services was highlighted in other studies (Marmot et al. 2008; Bond et al. 1999; Varga 2003; Valente and Saba 1998; Stanton et al. 2002). This implies that in Indian context, still more needs to be done for adolescent reproductive healthcare.

Recommendation

More studies dealing with adolescent RH must be carried out in India. Counselors must be appointed by schools to deal with sensitive topics. Health care facilities, health education camps addressing health services provided to adolescents must be carried out regularly. Online services could be beneficial if setup. Target specific interventions and regular follow-ups must be designed.

Conclusion

Our study gives an impression of RH services among adolescents of two districts in South India. The findings should not be taken as a representation of all parents, teachers in the state. Media and peers influenced adolescents in a negative way. Body imaging among adolescents is a new topic which could be researched upon further. Nutritional values of food must be bolstered in schools, community setting. Media must portray the facts about the products that they endorse. Cordial environment at home and schools were the prime requisites for good adolescent upbringing. The views expressed conclude that adolescent boys RH is neglected by the government schemes. Girls receive much better guidance pertaining to the adolescent changes. Helpline facilities should be brought about to solve adolescent RH queries. More advertisements, awareness programs about RHS must be conducted to spread knowledge about RH services. A decision on introducing sex education in the teaching syllabus must be taken at the earliest.

Limitations

The FGD that were conducted was only in two districts.