Perceptions of sexually transmitted diseases among teenagers

An ex p lo ra to ry d e sc rip tiv e study w as u n d ertak en , focussing on sexually transmitted diseases (STD) among teenagers. The aim of the study was to explore and de­ scribe the possible reasons for the high rate o f sexually transmitted diseases in teenagers. The perceptions of teen­ agers and community nurses regarding sexually transmit­ ted disease among teenagers involved in the teenage clinic in a specific predominantly black area were assessed. Twenty teenagers and five community nurses were par­ ticipants in the study. Two focus group interviews were conducted with teenagers and community nurses. It can be concluded that the attitudes of community nurses may have an influence on the high rate of sexually transmitted diseases among teenagers. The knowledge o f the teenag­ ers about sexually transmitted diseases is often based on myths and misconceptions which could be intensified by the community nurse. The recommendations made are that the education stand­ ards o f all com m unity nurses should be review ed and adapted to meet the needs o f teenagers attending the teen­ age health services. The policy on in-service training must be reviewed and monitored. Community nurses’ inten­ sive training on teenage health service delivery and sexu­ ally transmitted diseases services should be in accordance with the principles of Primary Health Care. Community nurses need to attend intensive courses on interpersonal skills specifically related to teenagers. Selection proce­ dures for recruiting community nurses to attend to teen­ agers specifically should be researched. Teenagers should be involved in planning programs and the teenage clinic should be evaluated frequently to improve the standards. The availability of adequate teenage health services can result in a decrease in sexually transmitted diseases among teenagers. Uittreksel ‘n Verkennende beskrywende studie is ondemeem, met die fokus op seksueel oordraagbare siektes onder tieners. Die doel van die studie is om die moontlike redes vir die hoë syfer van seksueel oordraagbare siektes onder tieners te verken en te beskryf. Die persepsies van tieners en g em een skapsverp leegkund iges aangaande seksueel oordraagbare siek tes onder tieners betrokke by die tienerkliniek in ‘n oorwegend swart gebied is ondersoek. Twintig tieners en vyf verpleegkundiges was by die studie betrokke. Twee fokus-groeponderhoude is met tieners en gem eenskapsverpleegkundiges gehou. Daar is tot die g e v o lg tre k k in g gekom dat d ie h oud ing van gemeenskapsverpleegkundige ‘n invloed op die hoë syfer van seksueel oordraagbare siektes mag hê en dat die kennis van die tieners oor seksueel oordraagbare siektes op mites en w anopvattings berus wat deur die gem eenskaps­ verpleegkundige versterk kan word. D ie a a n b ev e lin g s w at gedoen w ord , is dat die opleidingstandaarde van die gemeenskapsverpleegkundige hersien en aangepas moet word om in die behoeftes van tieners wat van hierdie gesondheidsdiens gebruik maak, te voorsien. Die beleid oor indiensopleiding moet hersien en gemonitor word. Gemeenskapsverpleegkundiges se intensiewe opleiding in dienslewering aan tieners en in seksueel oordraagbare siektes moet met die beginsels van Prim êre G esondheidsorg ooreenstem . Gem eenskaps­ v e rp le e g k u n d ig e s m oet in ten s iew e k u rsusse in interpersoonlike vaardighede wat spesifiek met tieners verband hou, byw oon. D ie keuringsprosedures om gemeenskaps-verpleegkundiges te w erf om spesifiek met tieners te werk, moet ondersoek word. Tieners moet betrokke wees by die beplanning van die programme en die kliniek vir tieners moet dikwels geëvalueer word om sodoende die standaard te verhoog. Die beskikbaarheid van toereikende gesondheidsdienste aan tieners behoort tot ‘n afname in seksueel oordraagbare siektes onder tieners te lei.


Uittreksel
'n Verkennende beskrywende studie is ondemeem, met die fokus op seksueel oordraagbare siektes onder tieners.Die doel van die studie is om die moontlike redes vir die hoë syfer van seksueel oordraagbare siektes onder tieners te verken en te beskryf.Die persepsies van tieners en g e m e e n sk a p sv e rp le e g k u n d ig e s aan g a an d e sek su eel o o rd raag b are siek te s o n d er tie n e rs b etrokke by die tienerkliniek in 'n oorwegend swart gebied is ondersoek.Twintig tieners en vyf verpleegkundiges was by die studie betrokke.Twee fokus-groeponderhoude is met tieners en gem eenskapsverpleegkundiges gehou.D aar is tot die g e v o lg tre k k in g g e k o m d a t d ie h o u d in g van gem eenskapsverpleegkundige 'n invloed op die hoë syfer van seksueel oordraagbare siektes mag hê en dat die kennis van die tieners oor seksueel oordraagbare siektes op mites en w an o p v attin g s berus w at d eu r die g em eenskaps verpleegkundige versterk kan word.D ie a a n b e v e lin g s w at g e d o e n w o rd , is d at die opleidingstandaarde van die gemeenskapsverpleegkundige hersien en aangepas moet word om in die behoeftes van tieners wat van hierdie gesondheidsdiens gebruik maak, te voorsien.Die beleid oor indiensopleiding moet hersien en gem onitor word.Gem eenskapsverpleegkundiges se intensiewe opleiding in dienslewering aan tieners en in seksueel oordraagbare siektes moet met die beginsels van Prim êre G esondheidsorg ooreenstem .G em eenskaps v e rp le e g k u n d ig e s m o et in te n s ie w e k u rsu sse in interpersoonlike vaardighede wat spesifiek met tieners verband hou, byw oon.D ie k eu rin g sp ro sed u res om gem eenskaps-verpleegkundiges te w erf om spesifiek met tieners te w erk, m oet ondersoek word.Tieners moet betrokke wees by die beplanning van die programme en die kliniek vir tieners moet dikwels geëvalueer word om sodoende die standaard te verhoog.Die beskikbaarheid van toereikende gesondheidsdienste aan tieners behoort tot 'n afname in seksueel oordraagbare siektes onder tieners te lei.

Introduction
In a specific predom inantly black area, sexually transm itted disease clinic statistics have indicated that there is an increased rate o f sexually transm itted diseases in teenagers.Figures for 1994 obtained from the A nnual health report o f this local authority show a rise o f more than 10%, if com pared to 1995 figures.Every Tuesday teenagers com e to the local authority health clinic for counselling, health education, fam ily plan ning and the m anagem ent o f m inor ailments.Sexually trans mitted diseases have been reported as the major problem for most teenagers visiting these health clinics.
Clark (1992:767) stated that the incidence o f most sexually transmitted diseases is rising and because o f the sometimes devastating consequences o f the disease (for example blind ness in infants exposed to syphilis, gonorrhoea or herpes), it's increasing incidence is o f concern to community health practitioners and the general public.Evidence o f this con cern can be seen in the fact that fifteen o f the South African national health objectives for the year 2 0 0 0 are related spe cifically to sexually transm itted diseases.According to the National Health Policy (1991:1) in South Africa, it has been estim ated that one million patients seek treatment for sexually transmitted diseases every year at local authority health clinics and private practices, and that many more are seen at hospital outpatient departm ents and primary health care clinics.The World Bank has estim ated the annual incidence of sexu ally transmitted diseases in South A frica to affect 11 % of the population.O f the three thousand w om en who com e to Baragwanath Hospital every year with incomplete abortion, three hundred are between the ages of sixteen and twenty.In this age group, the main cause of incomplete abortion is proved to be infections o f sexually transmitted diseases as stipulated in the Planned P arenthood A sso ciatio n o f South A frica (PPASA).The consequences o f this will have a devastating impact on the South African econom y and threaten national efforts for reconstruction and developm ent as indicated in the Planned Parenthood Association o f South Africa.
The num ber o f teenagers diagnosed at the local authority health clinic in a specific predom inantly black M etropolitan area is increasing at an alarming rate, as shown by the fol lowing statistics.Ages range betw een sixteen and eighteen.Total number o f teenagers diagnosed: January to December 1994:350 Total number o f teenagers diagnosed: January to December 1995:655 Total number of teenagers diagnosed: January to December 1996:890 The main reason for this investigation was the increase in the statistics, ill health and instability.
Sexually transm itted diseases are not only causing health problems, but have social and econom ic implications for eve ryone.
The nurse, through the health delivery system, facilitates the promotion, m aintenance and restoration o f individual health, the family and the community.Com m unity nurses are being engaged in nursing activities directed toward continuing and preserving the health status o f individuals, families and the community.Despite all the efforts made by community nurses, 65% of the teenagers are victims o f health problems.The question arises what the perceptions o f the teenager and com munity nurse are with regard to sexually transmitted diseases among teenagers.
The objectives o f the study are to explore and describe (a) the perceptions o f teenagers living in a specific predominantly black M etropolitan area regarding sexually transmitted dis eases, (b) com munity nurses' perceptions o f sexually trans mitted diseases among teenagers in a specific predominantly black M etropolitan area and (c) to write guidelines on the prevention o f sexually transmitted diseases among teenagers for the community nurses.

Terminology
The following term inology are defined: •Sexually Transm itted Diseases (STD) A ccording to Devenish, Funnel and G reathead (1992:193), sexually transm itted diseases are diseases that are passed on by sexual contact.

•Resources
Resources in the patients' environment include assets or means o f assisting the patient in facilitating his/her quest for w hole ness.Resources in the patients' internal environm ent include physical, mental and spiritual resources.Resources in the patients' external environm ent include personal resources (like significant others) and professional resources (like people and organisations_ Poggenpoel (1992:8).

•Teenager
A teenager in this study is defined as a boy or a girl whose age ranges from sixteen to eighteen years.

•Com m unity nurse
The community nurse in this study refers to any registered nurse working in the clinic, irrespective o f w hether he/she has received specialised training in community nursing.

•Perception
Perception is defined as the individual's knowledge o f sexu ally transmitted diseases as well as his or her opinions and attitudes about sexually transmitted diseases.

Research design and method
The design of this study is both explorative and descriptive.Focus group interviews were conducted with tw enty teenag ers attending the teenage clinic in a specific predom inantly black M etropolitan area as well as with five com m unity nurses working in the clinic.These interviews took place while the teenage clinic was in operation.
The study was divided into three phases: The purpose of phase 1 was to explore and describe the perceptions o f teen agers about sexually transmitted diseases am ong teenagers.The purpose o f phase 2 was to explore and describe the per ceptions o f com m unity nurses about sexually transm itted dis eases among teenagers and the purpose o f phase 3 was to write guidelines for the community nurses on the prevention of sexually transmitted diseases among teenagers.
The sample o f teenage interviewees o f the study were twenty black teenagers, that is the ( 1 0 ) boys and ten ( 1 0 ) girls who had been attending the teenage clinic and five com m unity nurses, working at the same clinic.Participation was volun tary.The sample was purposive to enhance contextuality.
Ethical consideration was maintained throughout.The re search interviewer-interviewee relationship was non-threat ening and emotionally safe and the human rights o f the inter viewees were respected.Informed consent was obtained from the interviewees in an inform ational letter com m unicating the essential inform ation pertaining to the research.Focus group interviews were used.The research interviewer asked one central question, namely: "W hat is your percep tion about sexually transmitted diseases among teenagers."In Zulu and Setswane the question were: "U ngathini wena ngokugula kw e canci ku basha?Ke eng pono ya gago ka bolw etse ba thobelano go basha?Field notes w ere taken throughout the interview s regarding, non-verbal cues and practical problem s (G uba and Lincoln, 1985:327).K erlinger 's (1986:477-483) m ethod o f data analy sis was utilized.The researcher looked for natural varia tions in the data, such as variations in the focus group proc ess, how participants responded, and how these affected the group process.The researcher, together with an independent coder met to obtain consensus on the categories identified.A protocol for data-analysis was provided for the independent coder.Guba and L incoln's (1985) strategy for ensuring the validity and reliability o f the study was used to guide the researcher in the study.They advocated the desirability o f prolonged engagement, persistent observation, triangulation and m em ber checks which was adhered to.

Results
The main them es derived from data obtained from the teen age and com m unity nursing respondents are grouped as fol lows: Sense o f belonging in teenagers, attitudes o f com m unity nurses towards teenagers, spiritual b elief and morality, sources of pressure and influence, im pact o f the m edia on teenagers, responsibility for ow n action am ongst teenagers, accessibil ity and acceptability o f the health service.

Know ledge of te en ag ers regardin g sexually tran sm itted diseases
Teenagers have some inform ation about some aspects in sexu ally transm itted diseases, but the inform ation is surrounded by myths and m isconceptions, such as the one teenager that says urination im m ediately after sex can clear diseases.A n other myth as stated by a teenage respondent is: "Sexually transmitted diseases is a disease o f only dirty and prom iscu ous people.If you are not sleeping around you are not in danger." The com m unity nurses' perceptions regarding the know ledge of teenagers were inter alia: "The teenagers have a problem.They think they know; m eantim e they do not know anything.They have a pride w ithin them selves.W hen they visit the clinic, they only expect you to provide the service and let them go."Lack of accurate inform ation concerning both sexu ally transm itted diseases and the prevention m akes it difficult to dismiss negative attitudes based on rum ours.As indicated in Friedm an (1993:96), young people them selves generally do not have adequate know ledge about sexually transm itted diseases.

Sense of belonging in te e n a g e rs
Teenagers believe in relationships.Relationships are the es sential core o f teenage developm ent.Teenagers feel lonely and withdrawn if they are isolated by their peers.Teenagers collectively believe in com ing together in various subgroups and evolving teenage values, attitudes and expectations.It may involve numerous patterns o f acceptable or unacceptable behaviour.The community nurses inter alia expressed the following perception in this regard: "Teenagers have a prob lem with themselves; they do not believe in their own self.That is why all the time they are behaving in such a way to please a friend, partner or a group."Erikson (1968:45) considers relationships to be essential to teenage development and strongly emphasize that relation ships during teenage years are not primarily a sexual matter: it is the process o f interpersonal developm ent that is most im portant.

A ttitu d e s of com m unity nurses tow ards teenagers
The teenagers have experienced the community nurses' atti tude as negative, unapproachable and with no commitment to teenagers.Com m unity nurses have poor listening skills and behave in an inhuman way.Com m unity nurses have poor interrelationship skills, minimal support and low esteem for the teenagers.They use jargon that teenagers do not un derstand.Teenagers are not treated with respect; teenagers do not perceive their interaction with community nurses as good and are not acknowledged in teenage usage o f service.Poor interaction causes com m unication barriers and drives the teenagers to seek inaccurate knowledge from their peergroup.The ideas were expressed in sentences like: "I no longer like the teenage clinic, I hate the nurses; they think we are kids.""Sisters are monsters they have a bad attitude, they do not treat us as hum an beings." Community nurses had the following perceptions regarding the attitudes o f teenagers: "They come to the clinic with a negative attitude.They always want things done their way.Teenagers are also rude.That is why we give them that kind of service.They com e to the clinic to show you that they are sexually active." De Wet (1988:78-79), is of the opinion that nurses' non-verbal behaviour can, of course, also be a major aid or obstacle to his or her patients' management.The face is an exquisite instrument to communication and persuasion.The most fundam entals kinds o f emotion that have clearly been associated with certain facial expressions include friend liness, anger, interest, disgust, sadness, happiness, contempt and determ ination.

Spiritual belief and m orality
Community nurses were o f the opinion that "Teenagers are affiliated to different religious beliefs though they behave to tally different to what they are suppose to".Everyone has the right to freedom o f conscience, religion, thought, belief and opinion as indicated in the Constitution of South Africa (Act 108 o f 1996).Religious observances may be conducted at state or state aided institutions, provided that those observ ances follow rules made by the appropriate public authori ties.Religion and morality have been indicated as dictating moral values around which teenage sexual behaviour is or ganised.Rensburg (1995:369) stated that South Africa is in the posi tion of having its people belonging to all the major religious followings o f the world.

Sources of pressure and influence
According to the teenage respondents parents, teachers and other community leaders have had a negative impact on teen agers, especially their dem ands and high expectations.Teen agers have to be ideal and behave according to their parents', leaders' and society' expectations.They do not look at the teenagers as unique and different, also as human beings who have to decide the way they want to think.Community nurse respondents are o f the opinion that "The significant others can have a positive and negative impact on teenagers.The high dem ands we have on our teenagers are the ones that make them stubborn and decide to stay all day in the streets with friends".Craig (1976:383) indicated that sociologically, teenagers are in a contradictory situation.On the one hand, society re gards them with adulation, glorifying youth, care-freeness and leisure.On the other hand, most high schools are incredibly boring and alienating institutions, wasting their students' time in meaningless, depersonalised routines.

Im pact of the m edia on teenagers
The media can have a positive and a negative impact on teen agers.The media can have an impact on the development of the teenagers.It is a good tool to send the m essage across; it can reach many people within the blink of an eye.The media has been used and is still being used positively to educate the patients, and the inform ation revealed is m ostly com pre hended.The media has been regarded as a negative source that provides teenagers with rom antic series that in later life tempt the teenager to imitate what he/she once observed in the media.Com m unity nurses are aware o f the positive in fluence that the m edia can have on the teenagers.Clark (1992:771) stated that media presentations of sexual activity as desirable behaviour may have an influence on the high rate o f sexually transm itted diseases.Portrayals of popu lar heroes and heroines as "sexy" and sexually active have fostered imitative behaviour, particularly among teenagers.

Responsibility fo r own a ction am ong teenagers
Teenagers are responsible and accountable for their own ac tions.Teenagers are aware that they have to protect them selves from being infected.Com m unity nurses are taking the responsibility o f blaming them selves as unproductive, ineffi cient and ineffective in the rendering o f an optimal high stand ard of care.Community nurses' attitudes and lack o f com mitment may mainly have an influence on the high rate of sexually transm itted diseases am ong teenagers.Rogers (1973:15) way back in 1973 m entioned that com m u nication, as the only link between the nursing staff and black teenagers is regarded as an indispensably supportive baseline o f human learning.It is the interwoven thread that holds the whole process of sex education together or could alternatively, weaken it.It is therefore essential to grasp and implement the basics o f two-way comm unication in sex education.

Accessibility and ac ce p tab ility of the health service
Teenagers respondents stated that there is geographic acces sibility because the teenage clinic is situated in an area where there is lot o f transport, and it is centrally situated; it is easy to reach.The service is not functionally accessible, as teen agers cannot receive appropriate care as the need arises.Clinic service is not acceptable to teenagers as it does not involve the teenagers in the planning o f teenage programmes.The service does not offer confidentiality, as teenage services are not separated from the adult service.Ideas were expressed like "we are not included in the plan ning o f teenage program m es, we do not understand where the community nurses collect their educational topics, their topics are boring" ."Teenage clinic is only once a week, it is difficult to attend on Tuesdays and there is no privacy as is not separated from adult clinic" .Com m unity nurses were in agreement with the teenagers re garding the accessibility and acceptability o f the health serv ice to the teenagers.For exam ple they stated that "teenagers are not actively involved during the health education sessions" .Proctor (1986:16), as indicated in Curationis (Vol.13 o f De cember, 1990:16), says services should be conveniently avail able, confidential, located in a safe, fam iliar place and sepa rated from adult services.

Conclusions
The study lead the author to inter alia the following conclu sions: The study has shown that even though some o f the respond ents were aware o f sexually transmitted diseases as a prob lem, the inform ation is still surrounded by myths and mis conceptions.Com m unity nurses need to conduct educational campaigns in all com m unities in languages that can be un derstood if further spread is to be prevented.Attitudes o f community nurses have been regarded as the cause o f increase rate o f sexually transmitted diseases and have made it difficult for the teenagers to communicate openly.Com munity nurses' technical language makes it difficult for the teenagers to understand.The credibility o f the community nurses is im portant.They need to prove that they are accountable, concerned, caring, approachable and em pathetic in their profession.They need to have a listening skill at all times.Teenagers should be considered at all times and be involved in planning program m es of their teenage clinic.Selection procedures for recruiting community nurses to attend specifi cally to teenagers should be considered.

Guidelines for community nurses
The guidelines focus on the following: Community nurses should explain to the parents that the teen ager seeks m eaning in a society increasing devoid o f m ean ing.Teenagers w ant com m itm ent and involvem ent in a world that often seems to them like a m achine rolling on, irrespec tive o f their endeavours.
Community nurses should strive to develop m ore trusting re lationships betw een teenagers and their parents, and these will improve decision-m aking skills on teenagers and allow a more informed choice regarding sexual activity.
Utilisation o f the m edia [Sapire,1990:799; D evenish, Fun nel and G reathead, 1992:162] Community nurses should: ♦preview m aterial before show ing it to teenagers to assess relevance and appropriateness to that group; ♦use the m ass m edia, such as television, videos, posters, ra dio and other in order to popularise key prevention concepts and develop life skills education for teenagers in and out of school; ♦discourage teenagers from adopting values and sexual be haviour as portrayed on television series by indicating that television is not reality based at all times, and that life is more complicated than soap operas.
Accepting responsibility [Sappire, 1990:145] Community nurses should: ♦through group work, empower teenagers with self-responsi bility, confidence and self-worth when attending teenage clinic on Tuesdays; ♦educate the teenagers to be accountable for their own deeds and accept the consequences thereof; ♦always educate teenagers to keep an open-mind and do away with prejudice.
Service accessibility and acceptability [Friedman, 1993:72] Community nurses should: ♦evaluate the teenage service frequently, and include manag ers in the evaluation; ♦encourage interactive approaches to enable both teenagers and com m unity nurses to participate.Com m unity nurses should ensure that teenagers participate actively in teenage program m es; ♦consider the accessibility o f the service, whether geographi cally or functionally.
The teenage clinic should be separated from the adult serv ices.Teenage services should be held for teenagers at suitable times and with community nurses trained to work with them.T een ag e h e a lth se rv ic e s sh o u ld u n d e rta k e o r su p p o rt reorientation and training for all levels of existing personnel and revised programmes for the training o f community health personnel.

Recommendations
It is recom m ended that research be done on the communica tion skills com m unity nurses' needs to be able to motivate and counsel teenagers for the teenage clinic and that criteria for selection o f community nurses for the teenage clinic be developed.
It is also recom m ended that the training o f community nurses for their role as teenage educators and counsellors be re-em phasised to ensure that all community nurses can optimally fulfil their role as laid down in the community nurse's scope o f practice, and continuous evaluation of the com m unity nurses' attitudes in the provision o f the service should be en hanced.
Further research should be undertaken regarding the knowl edge, attitudes and educational needs o f teenagers, parents and the com m unity in the area of sexually related problems.
A comparative study including different racial groups of teen agers may also be helpful to ensure that global guidelines and recom m endations can be deduced.There should be continu ous ongoing education conducted by community nurses, par ents and teachers to equip the teenagers with knowledge and do away with m yths and misconceptions.

Concluding remark
Com m unity nurses' and teenagers' attitudes should be the core o f the service deliverance.Community nurses should provem ent o f teenagers' knowledge [Clark, 1984:392] It is im portant that the com m unity nurse should encourage the teenagers to share their knowledge at either a formally structured or a conversational level.An assessm ent o f the knowledge, attitudes, concerns and be havioural needs o f teenagers at whom the program m e is tar geted as well as o f those who work with them should be in corporated in the planning phase o f any lifestyle educational program m e.The selection and training o f com m unity nurses w ho will present a program m e are o f paramount importance in the suc cessful im plementation o f teenagers' lifestyle educational pro gramme.The environm ent within which lifestyle education takes place is an important contribution factor to the success o f a pro-gramme.The creation o f an environm ent based on respect, trust and acknow ledgm ent o f differences will facilitate the growth o f know ledge and the developm ent o f skills.Strengthening the sense o f belonging [D evenish, Funnel and G reathead, 1992:75; C orbett and M eyer, 1987:123] "Partnership" is the key.R elationships are the determ inants o f much o f w hat hum an beings do.The com m unity nurses should help teenagers by highlight ing the positive aspects o f peer pressure, rather than by con tinually harping on the negative.Changing o f attitudes [de Wet, 1988:78-79] The attitude and ability o f the com m unity nurses are o f cru cial importance in the service deliverance.Community nurses working with teenagers should be equipped with interpersonal skills to accom m odate teenagers specifi cally and to attend frequent in-service training, to keep them informed o f the latest updates o f teenage problem s.Health structures should give priority to the full utilisation of human resources by defining the technical role, supportive skills, know ledge and attitudes required for each com m unity nurse to ensure effective prim ary health care.Spiritual b elief and m orality [Sapire, 1986:291] M oralising is the direct, although som etim es subtle, inculca tion o f the adults' values in the teenagers.Com m unity nurses should know the norm s and values o f the society and the expectations so as to transfer the know ledge to teenagers in the form o f health education, and avoid the risk o f choosing the less desirable values.Sources o f p ressu re and th eir in flu en ce [C orb ett and Meyer, 1987:125] Community nurses should educate parents, relatives and com munity leaders not to have exaggerated expectations o f their teenagers.