Teenage mothers ' knowledge of sex education in a general hospital of the Umtata district

There has been growing concern about the increase in teenage pregnancies in relation to the teenagers’ knowledge of human sexuality and the impact sex educa­ tion has on these teenagers in both the urban and rural areas. The aim of the study was to assess the knowledge of sex education and the health beliefs of teenagers with regard to teenage pregnancy. A descriptive study was conducted in the Umtata district of the Eastern Cape. The sample involved 42 teenage mothers drawn from local rural and urban areas at­ tending a Well Baby Clinic at Umtata General Hospital. A questionnaire was used as the method of data collection. Data analysis was done by a software package called SAS. The study revealed that teenagers receive almost no sex education from health personnel and only a little from their parents. The study also revealed that most of these teenagers live with their mothers only instead of both parents. It also became clear that unsafe or unprotected sexual behaviour was practised by these teenag­ ers although teenagers supported the idea of their partners using condoms. The most common problem resulting from teenage pregnancy, as indicated from the study results, was the financial burden on parents and lost educational oppor­ tunities by the girls. In the recommendations the parents’ involvement in sex educa­ tion and the improvement of recreational facilities for both urban and rural areas are highlighted. In conclusion, the study has shown the need for more efforts to solve the problem of inadequate sex education and to change the health beliefs of teen­ agers.


"lack o f information about sex leads to sexual dysfunction; teenage pregnancy, sexual abuse and sexually transmitted diseases." abstract
There has been growing concern about the increase in teenage pregnancies in relation to the teenagers' knowledge of human sexuality and the impact sex educa tion has on these teenagers in both the urban and rural areas.The aim of the study was to assess the knowledge of sex education and the health beliefs of teenagers with regard to teenage pregnancy.A descriptive study was conducted in the Umtata district of the Eastern Cape.The sample involved 42 teenage mothers drawn from local rural and urban areas at tending a Well Baby Clinic at Umtata General Hospital.A questionnaire was used as the method of data collection.Data analysis was done by a software package called SAS.
The study revealed that teenagers receive almost no sex education from health personnel and only a little from their parents.The study also revealed that most of these teenagers live with their mothers only instead of both parents.It also became clear that unsafe or unprotected sexual behaviour was practised by these teenag ers although teenagers supported the idea of their partners using condoms.The most common problem resulting from teenage pregnancy, as indicated from the study results, was the financial burden on parents and lost educational oppor tunities by the girls.In the recommendations the parents' involvement in sex educa tion and the improvement of recreational facilities for both urban and rural areas are highlighted.In conclusion, the study has shown the need for more efforts to solve the problem of inadequate sex education and to change the health beliefs of teen agers.

Research Article
Teenage health issues are a relatively new feature in society, since teenagers are generally regarded as having good health and strong physiques (WHO, 1990:23).This perception about teen agers means that there is more empha sis on maternal and child health care services mainly targeted at groups such as expectant mothers and children un der the age of five years.As a result, teenagers are poorly accommodated in the above health services because some of them are still at school and others fall into the category of mothers (Williams, 1995:1).Sex education and counselling on sexual problems for teenagers are part of a to tal health care strategy for this category of people.Lack of information about sex leads to sexual dysfunction, teenage pregnancy, sexual abuse and sexually transm itted diseases (Searle, Brink & Grobbelaar, 1989:347).It is estimated that more than 80% of the population supports school sex educa tion.Though sex education is consid ered legal in most countries, many sex educators are hesitant to include all top ics of sex related issues.They would rather put more emphasis on anatomy and physiology out of fear and the con trove rsy a ssociated w ith sex issues (Miller, 1992:352).

problem statement
In the past few years, schools in the Umtata district have not been providing sex e ducation because of te chn ical p ro b le m s (W illia m s, 1995:3).The Umtata General Hospital in the Eastern Cape is experiencing shocking numbers of teenage pregnancies as revealed by a study conducted on sexuality among school girls in the Transkei region (Buga, Amoko & Ncayiyana, 1995:6).C o m p la in ts fro m p rin c ip a ls o f th e schools around Umtata have been pour ing into the school health nurses' office.The principals presented documented evidence of problems facing teenagers in the local schools of the Umtata dis trict.The problems range from physical changes to pregnancy and sexual rela tions (Williams, 1995:5).

research question
What knowledge and opinions do teen age mothers have regarding sex issues?

objectives
• To assess the knowledge and opin ions of teenage mothers who attend a Well Baby C linic at Umtata H ospital about sex education • To determine whether teenage moth ers were given sex education prior to pregnancy • To make recommendations appropri ate for the role of the community health nurse in the prevention of teenage preg nancies

definition o f terms
The following definitions could be made in order to have a clear understanding of the study: t e e n a g e r This is a young person in his or her teens.This phase of psychosexual develop ment starts at about 11-13 years and continues up to 19 years.

SEX EDUCATION
This refers to education or guidance which makes teenagers aware of their bodies, particularly in respect of repro ductive anatomy and physiology.It is a part of comprehensive life skills training which prepares individuals for emotional and physical changes they will be going through.

theoretical framework
The study was based on a health belief model as proposed by Redman (1984).In view of the assumptions of the health belief model, teenagers are expected to take responsible, inform ed decisions when they believe that they are suscep tible to pregnancy and sexually transmit ted diseases.When they perceive these problems to have serious effects on their lives, they will use safer sex methods to reduce the likelihood of the occurrence of these problems.

literature review
The problems encountered by the youth are coupled with the critical situation of health services in the rural Eastern Cape.These problems include scarce facilities, medical supplies and resources.Several studies have identified a series of circumstances in general that place teenagers in a high risk category.These include not only the individual factors but those of the family, institutions and the e n tire so c ie ty (Buga, A m o ko & Ncayiyana, 1995:6).
The worst problem facing teenagers is peer group p re ss u re (O skow itz, 1993:62;Koyana, 1995:2).Girls are not strong enough to resist the pressure put on them by their peers.Though they may not be ready to sleep with boys, they find themselves yielding because they are ridiculed and sometimes ostra cised by o th e r g irls w ho call them " nuns" .Some are intimidated and told that if they do not engage in sexual in tercourse they will become sick or crazy.At the same time nothing is mentioned to teenagers about safe sex.
Socio-econom ic factors also play a major role in dictating the behaviour of teenagers.These factors may be a lack of housing and recreational facilities in the villages.Time and energy are thus channelled to sexual activities.On the othe r hand, te en ag e rs live fa r from schools with little or no pocket money most of the time.As a means of earning some income, they engage in sexual activitie s w ith o ld er men fo r m oney (Koyana, 1995:3).
Sex education has been a source of great controversy in some communities where people fear that providing sex education will encourage and promote sexual activity and promiscuity among teenagers who are not yet involved in these activities (Oskowitz, 1993:64).As a result, teenagers are often confused and do not know where to go for advice and counselling because they are re garded as too young to be treated by the practitioners and too old to seek ad vice from paediatricians (WHO, 1990:22).
Teenagers have expressed a fear of ap proaching their parents about contra ceptive methods.The same girls are afraid to lose .theirboyfriends.If they do not com ply with the dem and for sex, th e re is g re a te r risk o f th e ir being dumped by their boyfriends (Koyana, 1995:3).
Parents themselves are in a dilemma be tween upholding the traditional and cul tural values with religious beliefs at the expense of their daughters.Some par ents are unhappy that their daughters may be taught sensitive sexual matters by people who do not have the same home values.
One sh o u ld n ot fo rg e t the c o n s e quences of teenage pregnancies.One consequence is that teenage girls turn to illegal abortions which often result in co m plications and even death.The majority of these girls are still biologically immature for effective childbirth.Prena tal care is usually inadequate as com pared to that given to adult wom en (WHO, 1990:22).
Secondly, teenage fathers at times ex perience the same emotional and psy chological problems as teenage moth ers.Problems such as unemployment, poor accommodation and poor health are common (WHO, 1990:23).
Thirdly, teenage mothers may end up being single parents because there is less chance of marriage.Single moth ers in particular need support through out their lives in bringing up their babies (Miller, 1992:353).

research design and methodology
A descriptive design was chosen by the researchers, since the researchers were interested in identifying sex education received or given to teenagers and the health beliefs of teenagers regarding teenage pregnancy and sexually trans mitted diseases.The population consisted of teenage mothers from the Umtata district who had visited the Well Baby Clinic.One re quirement was that the babies they were carrying had to be their first babies.A sample of 42 respondents was drawn from the population of teenage mothers.A system atic random sam pling te ch nique was chosen where every third teenage mother was selected and re quested to participate in the study.

instrumentation
The two constructs of the study were sex education and the health beliefs of teen agers.Since there were no existing tools to m easure the tw o c o n s tru c ts a d equately, a new tool was constructed by the researchers.

Sex education:
The to o l co nta ine d questions that assessed whether sex education was given to teenagers prior to pregnancy.It also contained state ments/questions that examined the sta tus of the person who gave sex educa tion and their relationship to the teenag ers.

Health beliefs:
The health beliefs in this tool were measured as influenced by the sex education given.This construct was measured by the following concepts in the tool: • Attitudes • Opinions

• Knowledge
Curationis March 1999 59 • Sex p ra c tices with regard to the prevention of te e n a g e p re g nan cy and the spread of sexually tra n s m itte d d is eases S tru ctu re d q u e s tio n n a ire s were used by the re searchers to c o l lect data from the teenage m others.The que stion s in cluded both open-ended and closed questions.The questions were form u lated to find out about the knowledge, opinions and attitudes on sex education in relation to the increasing rate of teen age pregnancies.They also assessed the effectiveness of the sex education programme for school girls in the areas around Umtata.

Reliability and validity
The reliability test method used was di vided in half at the time of scoring the results of the pretest.The two halves of the test produced approximately equal scores.The suitable measuring aspect of valid ity in this study was content validity.It was imperative to consult experts on teenage sexuality.The researchers referred the instrument to obstetricians, community health nurses, school health nurses, health educators and researchers, who judged the content of the questionnaire in relation to variables that it was sup posed to measure.The theoretical con structs were found to be adequately measured.They were further found to measure the construct of sex education.

ethical consideration
It was important for the researchers to obtain informed consent from the par ticipants before conducting the study.A letter was distributed to each respond ent explaining the purpose of the study and the conditions under which the re spondent had to participate in the study.Permission to conduct the study was also obtained from the matron of the Um tata G eneral H ospital w here the study was conducted.Privacy during the gathering of information was ensured.The anonymity of respondents was also guaranteed by the researchers in that names of the respondents were not re quired.Confidentiality of the information given was also guaranteed by the re searchers.

research setting
The research was co nd ucte d at the Umtata Hospital's Well Baby Clinic.The

data analysis and findings sample description
Of the 66 questionnaires that were dis tributed to the respondents, 42 were com pleted and returned.The sample consisted of teenage girls who had be come pregnant for the first time.The teenage mothers were selected when visiting the Well Baby Clinic for immuni sation of their babies.Grade: A sm all p e rce n ta g e , i.e. 9,5% (N=4), were in th e low e r g ra de s, i.e. less than grade 7. The majority of girls, i.e. 50% (N=21), were in grades 8-10.There were no differ ences identified in terms of the grades between urban and rural girls.

Teenagers who received sex educa tion:
The majority of teenagers received sex education (59,5%), 31% did not re ceive sex education and 9,5% did not respond to this question.
Education on contraception: Some

Use of contracep tion:
The majority of te e n a g e rs did not use any co n traceptive method (71,4% (N = 30)).See table 5.
The type of method used: Among those who used contraceptives, the most com monly used method was the pill (19% (N = 8)) and a b s tin e n ce .O nly 2,4% (N=1) used condoms.

O pinions on the use of condoms by their partners:
A lth o u g h 26,2% (N = 11) were not sure, the sam e n u m b e r ( 26 Opinions on teenage pregnancy as a social problem: All the respondents agreed that teenage pregnancy is a so cial problem.Some did not give reasons why they said so.Among the many rea sons given as to why teenage preg nancy is a social problem were the following: 1. Financial in c o n v e n ie n c e to parents 2.
Teenage fa th e rs not paying lobola or support ing the child and or denying the child 3.
Teenage mothers too young to bring up babies 4.
S c h o o lin g is delayed
The baby may be abandoned by the mother and left with grannies who are less capable of looking after the baby 7.
Unacceptance of the pregnant girl by the parents 8.
Inability to clothe and feed the baby, with the concomitant results 9.
Less opportunities for good pay ing jobs 10.
Teenage p re g n a n c y leads to overpopulation and a cycle of poverty for the less privileged girls The first two opinions were given by more respondents.Because some of these responses appeared more than twice by other respondents, it became very difficult to make frequency counts and percentages of respondents on the above matters.
The possibility of becoming pregnant when the teenagers had knowledge of sexual matters: The majority of the teen agers were uncertain if they would have become pregnant if they had had knowl edge of sexual matters (64,3% (N=27)).However, 21,4% (N=9) were positive that they would not have become pregnant.See table 6.

Support for inclusion of sex education in school syllabi
The feeling of many respondents was that sex education should be included in the school curriculum (66,7% (N=28)).About 23,8% (N=10) did not support this view and 9,5% (N=4) did not respond to this question.

Opinions on safe sex
The use of condoms was felt by many teenagers as the safest sex m ethod (42,9% (N = 18)).Some other opinions were also supported, e.g.only one part ner (14,3% (N = 6)).Some teenagers supported the combination of all meas Prem arital sex to be discouraged: Teenagers them selves fe lt that they should be discouraged from having pre marital sex (38,1% (N = 16)).

Active involvement of teenagers in the teenage pregnancy prevention pro gramme:
The feeling of the teenagers is that their peers should be actively in volved in the teenage pregnancy preven tion programmes (73,8% (N=31)).Some of the respondents even gave the rea sons for their support, such as "the fel low teenagers know exactly the pres sures and problem s experienced by teenagers" .
Those who were not in favour of teenag ers being actively involved in the pro grammes did not trust the fellow teen agers to have expert knowledge in deal ing with youth problems, as those teens would also be in the same boat.

discussions
The study revealed that most teenagers live with their mothers only.It also ap peared that teenagers commence their sexual relations and sexual intercourse at the average age of between 15 and 17 while they are in the lower grades, e.g.grades 8-10.Some girls start hav ing sexual intercourse even earlier than that.Though parents are the largest group to give sex education, it seems that this information is too inadequate to equip the teenagers to face the pres sures with regard to sexual matters.This is closely linked to the communication problem between teenagers and par ents.It was also shocking and embar rassing in the study to note how the health personnel have not been of help to these teenagers during this era of pri m ary h ealth care o rie n ta tio n , even though health education should be ad dressing the basic local needs and prob lems.
The study also revealed the rate of un protected sexual behaviour among teen agers.Only 2,4% (N=1) had used con doms as a form of contraceptive.This raises concern not only about the teen age pregnancy rate, but also about sexu ally transmitted diseases, especially the transmission of HIV among all sexually active people.
Teenagers, though, regard the use of condoms as the safest sex method.One wonders whether there are some other reasons why they are not using con doms when they perceive them as the safer m ethod of contraception.Their educators may not be presenting con dom s as an acceptable and realistic m ethod of contraception.Teenagers seem to support the idea of their boy friends using condoms, but girls as a weaker sex seem to yield to pressure, even if they know what is good for them, and they sacrifice their rights in the name of love.Black African women are cultur ally oriented to accept that it is the Crea tor's will for a woman to be inferior to a man and as such they cannot totally re ject and oppose what a man thinks is good.
The teenagers are equally optimistic and approve the inclusion of sex education in the school curriculum.

recommendations
The recommendations are dealt with in three sections:

Nursing practice
A strategy for involving parents in sex education should be developed.This will help them develop a sense of confidence and responsibility within family structures with regard to sex education.Improving and establishing recreational facilities for different sports in both ur ban and rural areas is very important for teenagers so that they have somewhere to spend their leisure time.This may pre vent them from engaging in sexual ac tivities.Budgetary arrangements by the govern ment of the Eastern Cape should be planned to meet the financial costs of buying equipment such as videos and other educational material.Such equip ment may assist school health nurses and teachers in educating the youth about sexuality.All this necessitates gov ernment's commitment and vision at a higher level to support and actively par ticipate in addressing the issue of teen age pregnancies.

Nursing education
It is reco m m en d ed th a t c o m m u n ity health nurses working at clinics and in schools in the area where the study was conducted receive intensive orientation courses on sex education.They should follow a special programme which will be applicable to the entire Eastern Cape.Such a programme should be able to evaluate its impact on the targeted age category.

Further research
After the data in this study were ana lysed, it became clear that there is still a need for further research on various as pects of the problem.These aspects are as follows:

The development of a strategy for in volving parents in sex education
There is a great need for involving par ents in sex edu catio n program m es.Therefore, future research should be conducted with the aim of developing and testing a strategy of this nature.

The development of a sex education programme
A sex education programme for adoles cents staying in both rural and urban areas of the Eastern Cape should be developed and tested.This programme may be part of the school curriculum or it may be an enriching subject offered to the youth.It should contain not only the knowledge needed by the youth about sexual matters, but it should also em power the youth with effective skills to m ake a p p ro p ria te d e c is io n s a b o u t sexual matters.This programme should make them sensitive to the problems associated with teenage pregnancy, and it should equip the youth with life skills that will help them go through their teen age years without becoming casualties of the unfair youth pressures.

conclusion
The study has revealed the extent of the problem of teenage pregnancy in the rural and urban areas of Umtata, and in an already overpopulated and underde veloped area such as Transkei in the Eastern Cape.
totally disa greed with the use o f co n d o m s by their partners.