Chapter 1

MATERIAL AND METHODS

1.1.   General Goal and Main Objectives

Goal:

The general goal of this investigation is the following:

Obtaining baseline information on Sexual and Reproductive Health (SRH) related knowledge, attitude, and practice among young people and adults over 24 years of age in the project target areas and development of rational approach towards adolescent's health protection.

To achieve this goal we established the following implementation objectives:

Implementation Objectives:

1.      To assess needs and demands for provision of sex education for young people and improved access to sexual health care services through conduction of questionnaire based survey-interviews among representative number of 900 young people between the ages of 13-24 years old (including students, institutionalized children and those dropped out from educational institutions), and 900 adults above the age of 24 (including parents/guardians, health providers, as well as teachers/educators and administrators of the public and boarding schools, orphanages, colleges, universities).

2.      To reveal the impact of sex education on sexual behavior and sexual health of young people through conduction of case studies among 150 respondents between the ages of 13-24 years old, including young people, which: a) participated in the training courses on sexuality and sexual and reproductive health, b) received relevant information from previously trained peer educators and c) never had an access to accurate information about these issues.

3.      To develop feasible and culture-appropriate recommendations towards improved access for young people to the SRH related information and health care services, which can be put into practice by the MOH and MOES.

Specific Objectives:

To assess:

·        Demographic and socio-economic profile of the respondents;

·        The level of awareness about sexuality, puberty, conception, fertility regulation and STI/HIV/AIDS;

·        The common pattern of sexual, marital, and reproductive behavior;

·        The common pattern of family planning and abortion use;

·        The attitude towards provision of sex education to adolescents;

·        Own experience in obtaining and providing information on sexuality, and sexual and reproductive health issues.

To develop:

·        feasible and culture-appropriate recommendations for MOH and MOES on a plan of actions towards introduction of sex education as a separate subject in the curriculum of the public schools and creation of public network of “youth-friendly” SRH services.

The outcome objectives:

As an outcome of this study the governmental authorities, non-governmental organizations and international agencies will be provided with the baseline information on sexual and reproductive health knowledge, attitude, and practice of adolescents and adults living in City of Yerevan, and urban and rural areas of the Ararat Region, together with the feasible and culture-appropriate recommendations on plan of action towards protection of the adolescent’s health.

1.2.   Definitions Used

In this report we referred to definitions approved by the WHO Regional Office for Europe[1].

Abortion:

Termination of pregnancy (expulsion or extraction of embryo/fetus) before 22 weeks of gestation or below 500 gr. of weight.

Adolescence, youth, and young people:

The term “adolescence” has been defined as including those aged between 10 and 19, and “youth” as those between 15 and 24; “young people” is a term that covers both age groups, i.e. those between the ages of 10 and 24. True adolescence, however, being the period of physical, psychological, and social maturing from childhood to adulthood, may fall within either age range.  

Adolescent reproductive health:

The goal of overall improved adolescent reproductive health involves: more responsible and equitable relationships between young men and young women before and during marriage; decreased incidence of pregnancy before maturity; lower rates of exposure to and contraction of sexually transmitted infections; and improvement of women’s status.

The means by which adolescent reproductive health is achieved include: improvement of the knowledge and understanding among all key groups of society – including young people themselves – of the physical, psychological and social aspects of adolescent reproductive health; increased training of key people with influence on adolescents, and of adolescents themselves, in counseling and communication skills; promotion of policies and programmes that reflect the best ways of meeting the reproductive health needs of adolescents, with emphasis on young people as a resource for health and provision of alternatives to early childbearing for young women, including better education to improve their status.

Family:

The family has been variously described as the nucleus and pillar of society and the natural bridge between the individual and society.

Family planning:

Implies the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their birth. Family planning is achieved through contraception defined as any means capable of preventing pregnancy – and through treatment of involuntary infertility. The contraceptive effect can be obtained through temporary or permanent means. Temporary methods include: periodic abstinence during the fertile period, coitus interruptus (withdrawal), using the naturally occurring periods of infertility (e.g. during breast-feeding and postpartum amenorrhoea), through the use of reproductive hormones (e.g. oral pills and long-term injections and implants), placement of a device in the uterus (e.g. copper-bearing and hormone-releasing intrauterine devices), interposing a barrier that prevents the ascension of the sperm into the upper female genital trace (e.g. condoms, diaphragms, and spermicidal substances). Permanent methods of contraception include male and female sterilization.

Fertility regulation:

Is the process by which individuals and couples regulate their fertility. Methods that can be used for this purpose include, among others, delaying child bearing, using contraception, and seeking treatment for infertility, interrupting unwanted pregnancies, and, in the case of mothers with an infant or a small child, breast-feeding.

Fertilization and Conception:

Fertilization refers to the union of an ovum and sperm. Conception has been defined as occurring at the time of implantation of the fertilized ovum into the wall of the uterus – i.e. that point in the biological development corresponding to the beginning stages of a unique biological organism.

Reproductive Health:

Within the framework of WHO’s definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and systems at all stages of life.

Reproductive health implies that people are able to have responsible, satisfying and safe sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

Sexual Health:

Sexual Health is integration of the somatic, emotional, intellectual, and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication, and love. Thus the notion of sexual health implies a positive approach to human sexuality, and the purposes of sexual health care, should be the enhancement of life and personal relationships and not merely the counseling and care related to procreation or sexually transmitted diseases.

Sexuality:

Human sexuality is a natural part of human development through every phase of life and includes physical, psychological, and social components.

1.3.    The methodology of the survey and case studies

The questionnaire-based survey was designed to collect relevant information from a representative sample of 900 young people 13-24 years old (including students, institutionalized children and those who dropped out from educational institution), and 900 adults above the age of 24 (including parents/guardians, health providers and teachers/educators/administrators of the public and boarding schools, orphanages, colleges, universities), in 15 urban and 15 rural communities of the project target area, including the capital of Armenia - the city of Yerevan, and the region Ararat.

The case studies were designed to investigate the impact of provided sex education on sexual and reproductive behavior and sexual health of young people through in-depth interview of 150 respondents 13-24 years of age (including students, institutionalized children and those who dropped out from educational institution) in the selected urban and rural communities of the project target area. Three main focus groups of young people were investigated:

A.     Young people, which received information on sexuality, and sexual and reproductive health after participation in the relevant training courses, provided by the AFHA at least 6 months before this study (n=50).

B.     Young people, who received information on sexuality, and sexual and reproductive health from previously trained peer educators (n=50).

C.      Young people, who never had an access to accurate information on sexuality, and sexual and reproductive health (n=50).

Sample selection for the survey:

Determination of the sample size for the survey was based on official data concerning the size of the target population, as well as the confidence, precision desire, and variables of the study. The sample of eligible respondents was selected from the total population of males and females above 12 years of age using the method of Random Cluster Sampling with a multistage sampling design. Each eligible respondent had exactly the same chance to be selected for the survey-interview.

The sampling procedure was done in different stages. At the first stage, we selected 11 urban communities in the city of Yerevan (according to 11 administrative divisions), as well as 4 urban communities (the city of Artashat, towns Ararat, Vedi, and Masis) and 15 rural communities (villages) in the Ararat region. Then, the sample universe of the total population of males and females above 12 years of age living in Yerevan and Ararat region was divided into 60 clusters of approximately equal numbers of people following administrative or geographic subdivisions, as far as possible.

The interval between the clusters was equal to the number “K”, which was calculated through division of the total cumulative number of males and females above 12 years of age, which are living in the project target areas, by figure 60 (number of clusters).

In total, 22 clusters were specified in the city of Yerevan, 8 clusters – in 4 urban communities of the Ararat region, and 30 – in 15 villages of the Ararat region. In the targeted locations 39 public schools, 2 boarding schools, 3 orphanages, 16 colleges, 12 universities/institutions, and 39 health facilities were identified as targets. The final selection of these institutions was done after the meeting with administration of the targeted facilities and introducing the purpose of the survey.

At the last stage, eligible respondents were selected from the staffing list and institutional records. Each eligible respondent, regardless of gender, occupation, or other status had exactly the same chance to be selected for the survey-interview. All potential participants of the survey were informed about its purpose and confidentiality of the provided personal information. Participation of each selected respondent was absolutely on a voluntary basis and was carried out as far as possible with respect to privacy. Finally, 30 eligible respondents (approximately 50% of young people and 50% of adults) were identified and interviewed in each selected cluster after obtaining their informed consent (1800 respondents in total).

Sample selection for the case studies:

The participants of the first focus group (Group A) was randomly selected from the list of 292 peer educators 13-24 years of age, which have been trained on sexuality, and sexual and reproductive health, after participation at the relevant training courses, provided by the AFHA at least 6 months before this study. Among them were students of urban and rural public schools, colleges and universities/institutes of Yerevan and Ararat Region, as well as 1 young man, who had completed his education.

The participants of the second focus group (Group B) were young people of the same age, which had received information on sexuality, and sexual and reproductive health from the previously trained peer educators. These respondents were selected randomly from the list of “trainees” provided by these peer-educators.

The participants of the third focus group  (Group C) never had an access to accurate information on sexuality, and sexual and reproductive health. They were selected from those public schools, colleges and universities, where sex education subject was never introduced.

The questionnaires’ content:

The two types of the anonymous questionnaires (for adults and for young people) were developed by the AFHA researchers for the survey and three types for the case studies. All questionnaires, however, included the following sections: a) identification, b) demographic and socio-economic profile, c) the level of awareness about sexuality, puberty, conception, fertility regulation and STI/HIV/AIDS, d) sexual, marital, and reproductive behavior, including also family planning and abortion use, e) own experience in obtaining and providing information on sexuality, and SRH issues, and f) the attitude towards provision of sex education to adolescents. The range of issues in the questionnaires is summarized in Table 1.1.

Table 1.1. Summary of the issues in the questionnaires

In addition, the questionnaires for the case studies included sections on the history of participation in the training courses on Sexual and Reproductive Health issues and on willingness to be involved in the adolescent’s health related projects. All questionnaires have been tested previously in the pilot investigation. 

Fieldwork and interviewing methods:

The AFHA Project Manager and team of researchers were responsible for the recruitment and training of interviewers, data collection, processing, and evaluation. There were three male and three female interviewers, which were provided with one weeklong training course and practical training during the pilot study. The experienced trainers with an appropriate background conducted the training of interviewers. Each interviewer received written instruction on sample selection methods, interviewing techniques and questionnaire completion for the survey and the case studies. The special reference was made on importance of obtaining informed consent of respondents, asking the questions exactly as they were phrased in the questionnaire, and on recording the responses as they were given. It was reinforced that all interviewers should ask each question in an identical manner to minimize interviewer's bias.       

Data collection for the survey and case studies was started in October 2001 and finalized by the end of December 2001. There were 6 interviewers, which were divided in pairs and provided with transportation. Each team involved in the survey, received a working plan and the list of selected clusters to be surveyed. Interviews for the survey were administered in schools, colleges, universities, orphanages, boarding schools, and health facilities or in the homes of eligible respondents, in the supermarket or roadway. The team leaders supervised selection of the starting and subsequent points for the survey, and monitored data collection. Before leaving selected locations, they checked questionnaires in order to obtain missing information if necessary.

Interviewers involved in the case studies, received lists of names, addresses and telephone numbers of the eligible respondents, as well as portable tape-recorder and photo-camera for project documentation. The interviews were administered in schools, colleges, universities, or at the AFHA “Youth Center” in Yerevan.

On making verbal contact with the first respondents in the institution or household, the interviewers introduced themselves and explained the purpose of their visit. They mentioned that all information collected would be used only for research purposes and would be treated in a confidential manner. After obtaining informed consent, the eligible respondents were identified. Interviewer explained the purpose and benefits of the survey and case studies, and tried to obtain his/her informed consent to participate. However, participation by each selected respondent was absolutely on a voluntary basis. The interview was conducted in confidential manner as much as possible (without the presence of any other person, including teachers, family members, etc.), and in a place convenient for the interview.

Refusal rate:

The survey sample of 1800 eligible respondents was identified after 1987 attempts to obtain informed consent to participate. In total, 187 respondents out of those approached  (9.4%), refused to participate in the survey. Most of those, who refused to be involved in the survey, were of male gender (72%). Besides, interviewers had difficulties in finding adult males at the targeted educational institutions and health facilities, since most of the teachers, educators, and health providers were of female gender. It was difficult also to find adult males at home during the daytime. In fact, only 7 young girls out of 162 of those approached  (4.3%), refused to participate in the case studies.  

The interview status for the survey:

More than one half of the survey respondents (52%) were from urban areas, 36% - from the city of Yerevan. The majority (63%) of respondents were from  Ararat Region, and 863 (48%) respondents were from rural areas (Table 1.2.).

Table 1.2. Interview status for the survey, by selected communities 

Most of interviews for the survey (about 55%) took place at the educational institutions, about 19% - at home of eligible respondents, about 16% - at the health facilities, and more than 10% - at supermarkets or roadways (Table 1.3). Young people have been reached mainly (76%) at the targeted educational institutions.

Table 1.3. Interview status for the survey, by place of interview 

The interview status for the case studies:

The interview status for the case studies is presented in Table 1.4. One half (50%) of the respondents are from Yerevan and another half (50%) from the Ararat Region.  There are 25 (16.7%) rural respondents, which live in the village Mkhchyan.

Table 1.4.  Interview status for the case studies, by selected communities 

Table 1.5 shows that public schools have been used as a place for interview for the case studies in 50% of the cases, and the AFHA Youth Center in Yerevan - in one third of the cases (33%).

Table 1.5. Interview status for the case studies, by place of interview