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Article Contents

Introduction, purpose of the study, literature search and selection criteria, coding of the studies for exploration of moderators, decisions related to the computation of effect sizes.

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The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis

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Mónica Silva, The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis, Health Education Research , Volume 17, Issue 4, August 2002, Pages 471–481, https://doi.org/10.1093/her/17.4.471

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This review presents the findings from controlled school-based sex education interventions published in the last 15 years in the US. The effects of the interventions in promoting abstinent behavior reported in 12 controlled studies were included in the meta-analysis. The results of the analysis indicated a very small overall effect of the interventions in abstinent behavior. Moderator analysis could only be pursued partially because of limited information in primary research studies. Parental participation in the program, age of the participants, virgin-status of the sample, grade level, percentage of females, scope of the implementation and year of publication of the study were associated with variations in effect sizes for abstinent behavior in univariate tests. However, only parental participation and percentage of females were significant in the weighted least-squares regression analysis. The richness of a meta-analytic approach appears limited by the quality of the primary research. Unfortunately, most of the research does not employ designs to provide conclusive evidence of program effects. Suggestions to address this limitation are provided.

Sexually active teenagers are a matter of serious concern. In the past decades many school-based programs have been designed for the sole purpose of delaying the initiation of sexual activity. There seems to be a growing consensus that schools can play an important role in providing youth with a knowledge base which may allow them to make informed decisions and help them shape a healthy lifestyle ( St Leger, 1999 ). The school is the only institution in regular contact with a sizable proportion of the teenage population ( Zabin and Hirsch, 1988 ), with virtually all youth attending it before they initiate sexual risk-taking behavior ( Kirby and Coyle, 1997 ).

Programs that promote abstinence have become particularly popular with school systems in the US ( Gilbert and Sawyer, 1994 ) and even with the federal government ( Sexual abstinence program has a $250 million price tag, 1997 ). These are referred to in the literature as abstinence-only or value-based programs ( Repucci and Herman, 1991 ). Other programs—designated in the literature as safer-sex, comprehensive, secular or abstinence-plus programs—additionally espouse the goal of increasing usage of effective contraception. Although abstinence-only and safer-sex programs differ in their underlying values and assumptions regarding the aims of sex education, both types of programs strive to foster decision-making and problem-solving skills in the belief that through adequate instruction adolescents will be better equipped to act responsibly in the heat of the moment ( Repucci and Herman, 1991 ). Nowadays most safer-sex programs encourage abstinence as a healthy lifestyle and many abstinence only programs have evolved into `abstinence-oriented' curricula that also include some information on contraception. For most programs currently implemented in the US, a delay in the initiation of sexual activity constitutes a positive and desirable outcome, since the likelihood of responsible sexual behavior increases with age ( Howard and Mitchell, 1993 ).

Even though abstinence is a valued outcome of school-based sex education programs, the effectiveness of such interventions in promoting abstinent behavior is still far from settled. Most of the articles published on the effectiveness of sex education programs follow the literary format of traditional narrative reviews ( Quinn, 1986 ; Kirby, 1989 , 1992 ; Visser and van Bilsen, 1994 ; Jacobs and Wolf, 1995 ; Kirby and Coyle, 1997 ). Two exceptions are the quantitative overviews by Frost and Forrest ( Frost and Forrest, 1995 ) and Franklin et al . ( Franklin et al ., 1997 ).

In the first review ( Frost and Forrest, 1995 ), the authors selected only five rigorously evaluated sex education programs and estimated their impact on delaying sexual initiation. They used non-standardized measures of effect sizes, calculated descriptive statistics to represent the overall effect of these programs and concluded that those selected programs delayed the initiation of sexual activity. In the second review, Franklin et al . conducted a meta-analysis of the published research of community-based and school-based adolescent pregnancy prevention programs and contrary to the conclusions forwarded by Frost and Forrest, these authors reported a non-significant effect of the programs on sexual activity ( Franklin et al ., 1997 ).

The discrepancy between these two quantitative reviews may result from the decision by Franklin et al . to include weak designs, which do not allow for reasonable causal inferences. However, given that recent evidence indicates that weaker designs yield higher estimates of intervention effects ( Guyatt et al ., 2000 ), the inclusion of weak designs should have translated into higher effects for the Franklin et al . review and not smaller. Given the discrepant results forwarded in these two recent quantitative reviews, there is a need to clarify the extent of the impact of school-based sex education in abstinent behavior and explore the specific features of the interventions that are associated to variability in effect sizes.

The present study consisted of a meta-analytic review of the research literature on the effectiveness of school-based sex education programs in the promotion of abstinent behavior implemented in the past 15 years in the US in the wake of the AIDS epidemic. The goals were to: (1) synthesize the effects of controlled school-based sex education interventions on abstinent behavior, (2) examine the variability in effects among studies and (3) explain the variability in effects between studies in terms of selected moderator variables.

The first step was to locate as many studies conducted in the US as possible that dealt with the evaluation of sex education programs and which measured abstinent behavior subsequent to an intervention.

The primary sources for locating studies were four reference database systems: ERIC, PsychLIT, MEDLINE and the Social Science Citation Index. Branching from the bibliographies and reference lists in articles located through the original search provided another source for locating studies.

The process for the selection of studies was guided by four criteria, some of which have been employed by other authors as a way to orient and confine the search to the relevant literature ( Kirby et al ., 1994 ). The criteria to define eligibility of studies were the following.

Interventions had to be geared to normal adolescent populations attending public or private schools in the US and report on some measure of abstinent behavior: delay in the onset of intercourse, reduction in the frequency of intercourse or reduction in the number of sexual partners. Studies that reported on interventions designed for cognitively handicapped, delinquent, school dropouts, emotionally disturbed or institutionalized adolescents were excluded from the present review since they address a different population with different needs and characteristics. Community interventions which recruited participants from clinical or out-of-school populations were also eliminated for the same reasons.

Studies had to be either experimental or quasi-experimental in nature, excluding three designs that do not permit strong tests of causal hypothesis: the one group post-test-only design, the post-test-only design with non-equivalent groups and the one group pre-test–post-test design ( Cook and Campbell, 1979 ). The presence of an independent and comparable `no intervention' control group—in demographic variables and measures of sexual activity in the baseline—was required for a study to be included in this review.

Studies had to be published between January 1985 and July 2000. A time period restriction was imposed because of cultural changes that occur in society—such as the AIDS epidemic—which might significantly impact the adolescent cohort and alter patterns of behavior and consequently the effects of sex education interventions.

Five pairs of publications were detected which may have used the same database (or two databases which were likely to contain non-independent cases) ( Levy et al ., 1995 / Weeks et al ., 1995 ; Barth et al ., 1992 / Kirby et al ., 1991 /Christoper and Roosa, 1990/ Roosa and Christopher, 1990 and Jorgensen, 1991 / Jorgensen et al ., 1993 ). Only one effect size from each pair of articles was included to avoid the possibility of data dependence.

The exploration of study characteristics or features that may be related to variations in the magnitude of effect sizes across studies is referred to as moderator analysis. A moderator variable is one that informs about the circumstances under which the magnitude of effect sizes vary ( Miller and Pollock, 1994 ). The information retrieved from the articles for its potential inclusion as moderators in the data analysis was categorized in two domains: demographic characteristics of the participants in the sex education interventions and characteristics of the program.

Demographic characteristics included the following variables: the percentages of females, the percentage of whites, the virginity status of participants, mean (or median) age and a categorization of the predominant socioeconomic status of participating subjects (low or middle class) as reported by the authors of the primary study.

In terms of the characteristics of the programs, the features coded were: the type of program (whether the intervention was comprehensive/safer-sex or abstinence-oriented), the type of monitor who delivered the intervention (teacher/adult monitor or peer), the length of the program in hours, the scope of the implementation (large-scale versus small-scale trial), the time elapsed between the intervention and the post-intervention outcome measure (expressed as number of days), and whether parental participation (beyond consent) was a component of the intervention.

The type of sex education intervention was defined as abstinence-oriented if the explicit aim was to encourage abstinence as the primary method of protection against sexually transmitted diseases and pregnancy, either totally excluding units on contraceptive methods or, if including contraception, portraying it as a less effective method than abstinence. An intervention was defined as comprehensive or safer-sex if it included a strong component on the benefits of use of contraceptives as a legitimate alternative method to abstinence for avoiding pregnancy and sexually transmitted diseases.

A study was considered to be a large-scale trial if the intervention group consisted of more than 500 students.

Finally, year of publication was also analyzed to assess whether changes in the effectiveness of programs across time had occurred.

The decision to record information on all the above-mentioned variables for their potential role as moderators of effect sizes was based in part on theoretical considerations and in part on the empirical evidence of the relevance of such variables in explaining the effectiveness of educational interventions. A limitation to the coding of these and of other potentially relevant and interesting moderator variables was the scantiness of information provided by the authors of primary research. Not all studies described the features of interest for this meta-analysis. For parental participation, no missing values were present because a decision was made to code all interventions which did not specifically report that parents had participated—either through parent–youth sessions or homework assignments—as non-participation. However, for the rest of the variables, no similar assumptions seemed appropriate, and therefore if no pertinent data were reported for a given variable, it was coded as missing (see Table I ).

Once the pool of studies which met the inclusion criteria was located, studies were examined in an attempt to retrieve the size of the effect associated with each intervention. Since most of the studies did not report any effect size, it had to be estimated based on the significance level and inferential statistics with formulae provided by Rosenthal ( Rosenthal, 1991 ) and Holmes ( Holmes; 1984 ). When provided, the exact value for the test statistic or the exact probability was used in the calculation of the effect size.

Alternative methods to deal with non-independent effect sizes were not employed since these are more complex and require estimates of the covariance structure among the correlated effect sizes. According to Matt and Cook such estimates may be difficult—if not impossible—to obtain due to missing information in primary studies ( Matt and Cook, 1994 ).

Analyses of the effect sizes were conducted utilizing the D-STAT software ( Johnson, 1989 ). The sample sizes used for the overall effect size analysis corresponded to the actual number used to estimate the effects of interest, which was often less than the total sample of the study. Occasionally the actual sample sizes were not provided by the authors of primary research, but could be estimated from the degrees of freedom reported for the statistical tests.

The effect sizes were calculated from means and pooled standard deviations, t -tests, χ 2 , significance levels or from proportions, depending on the nature of the information reported by the authors of primary research. As recommended by Rosenthal, if results were reported simply as being `non-significant' a conservative estimate of the effect size was included, assuming P = 0.50, which corresponds to an effect size of zero ( Rosenthal, 1991 ). The overall measure of effect size reported was the corrected d statistic ( Hedges and Olkin, 1985 ). These authors recommend this measure since it does not overestimate the population effect size, especially in the case when sample sizes are small.

The homogeneity of effect sizes was examined to determine whether the studies shared a common effect size. Testing for homogeneity required the calculation of a homogeneity statistic, Q . If all studies share the same population effect size, Q follows an asymptotic χ 2 distribution with k – 1 degrees of freedom, where k is the number of effect sizes. For the purposes of this review the probability level chosen for significance testing was 0.10, due to the fact that the relatively small number of effect sizes available for the analysis limits the power to detect actual departures from homogeneity. Rejection of the hypothesis of homogeneity signals that the group of effect sizes is more variable than one would expect based on sampling variation and that one or more moderator variables may be present ( Hall et al ., 1994 ).

To examine the relationship between the study characteristics included as potential moderators and the magnitude of effect sizes, both categorical and continuous univariate tests were run. Categorical tests assess differences in effect sizes between subgroups established by dividing studies into classes based on study characteristics. Hedges and Olkin presented an extension of the Q statistic to test for homogeneity of effect sizes between classes ( Q B ) and within classes ( Q W ) ( Hedges and Olkin, 1985 ). The relationship between the effect sizes and continuous predictors was assessed using a procedure described by Rosenthal and Rubin which tests for linearity between effect sizes and predictors ( Rosenthal and Rubin, 1982 ).

Q E provides the test for model specification, when the number of studies is larger than the number of predictors. Under those conditions, Q E follows an approximate χ 2 distribution with k – p – 1 degrees of freedom, where k is the number of effect sizes and p is the number of regressors ( Hedges and Olkin, 1985 ).

The search for school-based sex education interventions resulted in 12 research studies that complied with the criteria to be included in the review and for which effect sizes could be estimated.

The overall effect size ( d +) estimated from these studies was 0.05 and the 95% confidence interval about the mean included a lower bound of 0.01 to a high bound of 0.09, indicating a very minimal overall effect size. Table II presents the effect size of each study ( d i ) along with its 95% confidence interval and the overall estimate of the effect size. Homogeneity testing indicated the presence of variability among effect sizes ( Q (11) = 35.56; P = 0.000).

An assessment of interaction effects among significant moderators could not be explored since it would have required partitioning of the studies according to a first variable and testing of the second within the partitioned categories. The limited number of effect sizes precluded such analysis.

Parental participation appeared to moderate the effects of sex education on abstinence as indicated by the significant Q test between groups ( Q B(1) = 5.06; P = 0.025), as shown in Table III . Although small in magnitude ( d = 0.24), the point estimate for the mean weighted effect size associated with programs with parental participation appears substantially larger than the mean associated with those where parents did not participate ( d = 0.04). The confidence interval for parent participation does not include zero, thus indicating a small but positive effect. Controlling for parental participation appears to translate into homogeneous classes of effect sizes for programs that include parents, but not for those where parents did not participate ( Q W(9) = 28.94; P = 0.001) meaning that the effect sizes were not homogeneous within this class.

Virginity status of the sample was also a significant predictor of the variability among effect sizes ( Q B(1) = 3.47 ; P = 0.06). The average effect size calculated for virgins-only was larger than the one calculated for virgins and non-virgins ( d = 0.09 and d = 0.01, respectively). Controlling for virginity status translated into homogeneous classes for virgins and non-virgins although not for the virgins-only class ( Q W(5) = 27.09; P = 0.000).

The scope of the implementation also appeared to moderate the effects of the interventions on abstinent behavior. The average effect size calculated for small-scale intervention was significantly higher than that for large-scale interventions ( d = 0.26 and d = 0.01, respectively). The effects corresponding to the large-scale category were homogeneous but this was not the case for the small-scale class, where heterogeneity was detected ( Q W(4) = 14.71; P = 0.01)

For all three significant categorical predictors, deletion of one outlier ( Howard and McCabe, 1990 ) resulted in homogeneity among the effect sizes within classes.

Univariate tests of continuous predictors showed significant results in the case of percentage of females in the sample ( z = 2.11; P = 0.04), age of participants ( z = –1.67; P = 0.09), grade ( z = –1.80; P = 0.07) and year of publication ( z = –2.76; P = 0.006).

All significant predictors in the univariate analysis—with the exception of grade which had a very high correlation with age ( r = 0.97; P = 0.000)—were entered into a weighted least-squares regression analysis. In general, the remaining set of predictors had a moderate degree of intercorrelation, although none of the coefficients were statistically significant.

In the weighted least-squares regression analysis, only parental participation and the percentage of females in the study were significant. The two-predictor model explained 28% of the variance in effect sizes. The test of model specification yielded a significant Q E statistic suggesting that the two-predictor model cannot be regarded as correctly specified (see Table IV ).

This review synthesized the findings from controlled sex education interventions reporting on abstinent behavior. The overall mean effect size for abstinent behavior was very small, close to zero. No significant effect was associated to the type of intervention: whether the program was abstinence-oriented or comprehensive—the source of a major controversy in sex education—was not found to be associated to abstinent behavior. Only two moderators—parental participation and percentage of females—appeared to be significant in both univariate tests and the multivariable model.

Although parental participation in interventions appeared to be associated with higher effect sizes in abstinent behavior, the link should be explored further since it is based on a very small number of studies. To date, too few studies have reported success in involving parents in sex education programs. Furthermore, the primary articles reported very limited information about the characteristics of the parents who took part in the programs. Parents who were willing to participate might differ in important demographic or lifestyle characteristics from those who did not participate. For instance, it is possible that the studies that reported success in achieving parental involvement may have been dealing with a larger percentage of intact families or with parents that espoused conservative sexual values. Therefore, at this point it is not possible to affirm that parental participation per se exerts a direct influence in the outcomes of sex education programs, although clearly this is a variable that merits further study.

Interventions appeared to be more effective when geared to groups composed of younger students, predominantly females and those who had not yet initiated sexual activity. The association between gender and effect sizes—which appeared significant both in the univariate and multivariable analyses—should be explored to understand why females seem to be more receptive to the abstinence messages of sex education interventions.

Smaller-scale interventions appeared to be more effective than large-scale programs. The larger effects associated to small-scale trials seems worth exploring. It may be the case that in large-scale studies it becomes harder to control for confounding variables that may have an adverse impact on the outcomes. For example, large-scale studies often require external agencies or contractors to deliver the program and the quality of the delivery of the contents may turn out to be less than optimal ( Cagampang et al ., 1997 ).

Interestingly there was a significant change in effect sizes across time, with effect sizes appearing to wane across the years. It is not likely that this represents a decline in the quality of sex education interventions. A possible explanation for this trend may be the expansion of mandatory sex education in the US which makes it increasingly difficult to find comparison groups that are relatively unexposed to sex education. Another possible line of explanation refers to changes in cultural mores regarding sexuality that may have occurred in the past decades—characterized by an increasing acceptance of premarital sexual intercourse, a proliferation of sexualized messages from the media and increasing opportunities for sexual contact in adolescence—which may be eroding the attainment of the goal of abstinence sought by educational interventions.

In terms of the design and implementation of sex education interventions, it is worth noting that the length of the programs was unrelated to the magnitude in effect sizes for the range of 4.5–30 h represented in these studies. Program length—which has been singled out as a potential explanation for the absence of significant behavioral effects in a large-scale evaluation of a sex education program ( Kirby et al ., 1997a )—does not appear to be consistently associated with abstinent behavior. The impact of lengthening currently existing programs should be evaluated in future studies.

As it has been stated, the exploration of moderator variables could be performed only partially due to lack of information on the primary research literature. This has been a problem too for other reviewers in the field ( Franklin et al ., 1997 ). The authors of primary research did not appear to control for nor report on the potentially confounding influence of numerous variables that have been indicated in the literature as influencing sexual decision making or being associated with the initiation of sexual activity in adolescence such as academic performance, career orientation, religious affiliation, romantic involvement, number of friends who are currently having sex, peer norms about sexual activity and drinking habits, among others ( Herold and Goodwin, 1981 ; Christopher and Cate, 1984 ; Billy and Udry, 1985 ; Roche, 1986 ; Coker et al ., 1994 ; Kinsman et al ., 1998 ; Holder et al ., 2000 ; Thomas et al ., 2000 ). Even though randomization should take care of differences in these and other potentially confounding variables, given that studies can rarely assign students to conditions and instead assign classrooms or schools to conditions, it is advisable that more information on baseline characteristics of the sample be utilized to establish and substantiate the equivalence between the intervention and control groups in relevant demographic and lifestyle characteristics.

In terms of the communication of research findings, the richness of a meta-analytic approach will always be limited by the quality of the primary research. Unfortunately, most of the research in the area of sex education do not employ experimental or quasi-experimental designs and thus fall short of providing conclusive evidence of program effects. The limitations in the quality of research in sex education have been highlighted by several authors in the past two decades ( Kirby and Baxter, 1981 ; Card and Reagan, 1989 ; Kirby, 1989 ; Peersman et al ., 1996 ). Due to these deficits in the quality of research—which resulted in a reduced number of studies that met the criteria for inclusion and the limitations that ensued for conducting a thorough analysis of moderators—the findings of the present synthesis have to be considered merely tentative. Substantial variability in effect sizes remained unexplained by the present synthesis, indicating the need to include more information on a variety of potential moderating conditions that might affect the outcomes of sex education interventions.

Finally, although it is rarely the case that a meta-analysis will constitute an endpoint or final step in the investigation of a research topic, by indicating the weaknesses as well as the strengths of the existing research a meta-analysis can be a helpful aid for channeling future primary research in a direction that might improve the quality of empirical evidence and expand the theoretical understanding in a given field ( Eagly and Wood, 1994 ). Research in sex education could be greatly improved if more efforts were directed to test interventions utilizing randomized controlled trials, measuring intervening variables and by a more careful and detailed reporting of the results. Unless efforts are made to improve on the quality of the research that is being conducted, decisions about future interventions will continue to be based on a common sense and intuitive approach as to `what might work' rather than on solid empirical evidence.

References marked with an asterisk indicate studies included in the meta-analysis.

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

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• least-squares analysis
• sex education

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Effectiveness of Sex Education Interventions in Adolescents: An Overview

Affiliations.

• 1 Equity-in-Health Group, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
• 2 School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
• 3 School of Human Sciences, Universidad Nacional de Colombia, Bogotá, Colombia.
• PMID: 32048888
• DOI: 10.1080/24694193.2020.1713251

The objective of this overview was to identify and evaluate the effectiveness of sex education interventions aimed at reducing sexual risk behaviors in adolescents. A search was conducted of systematic reviews in English, Spanish and Portuguese from 1946 until July 2018 in the following databases: MEDLINE (Ovid), EMBASE, Scopus, PsyArticles, Cochrane Central Register of Controlled Trials, LILACS and additional resources. The extraction and analysis of data was synthesized in a narrative mode describing intervention, population, and key outcomes such as decreased risky sexual behavior, decreases in sexually transmitted infections, and adolescent pregnancy. There were 2289 potentially relevant studies, of which 31 systematic reviews related to adolescent interventions were included. It was demonstrated that interventions involve parents and the community as participants, are based on audiovisual media and school workshops, and their emphasis is on information and training in school. Different reviews framed in methods of psychosocial intervention based on community groups and the home as a fundamental axis were reported. Finally, a large amount of scientific evidence related to the subject was identified. New directions are presented for interventions in sexual education for adolescents based on the combination of actions and techniques, the implementation of digital technology, and socio-cultural and contextual adaptations.

Keywords: Sexual health; adolescent; school health services; sex education; sexuality.

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• Published: 30 August 2024

Early neonatal mortality in Ethiopia from 2000 to 2019: an analysis of trends and a multivariate decomposition analysis of Ethiopian demographic and health survey

• Fekadeselassie Belege Getaneh   ORCID: orcid.org/0000-0001-8729-1784 1 ,
• Lakew Asmare 2 ,
• Abel Endawkie 2 ,
• Alemu Gedefie 3 ,
• Amare Muche 2 ,
• Anissa Mohammed 2 ,
• Aznamariam Ayres 2 ,
• Dagnachew Melak 2 ,
• Eyob Tilahun Abeje 2 &
• Fekade Demeke Bayou 2  

BMC Public Health volume  24 , Article number:  2364 ( 2024 ) Cite this article

Metrics details

Early neonatal deaths, occurring within the first six days of life, remain a critical public health challenge. Understanding the trends and factors associated with this issue is crucial for designing effective interventions and achieving global health goals. This study aims to examine the trends in early neonatal mortality in Ethiopia and identify the key factors associated with changes in early neonatal mortality over time.

This study utilized five consecutive Ethiopian Demographic and Health Survey datasets from 2000 to 2019. To investigate the trends and identify factors influencing changes in early neonatal mortality over time, conducted a trend analysis and a logit-based multivariate decomposition analysis. Data management and analyses were performed using STATA version 17/MP software. All analyses were weighted to account for sampling probabilities and non-response. Statistical significance was determined at a two-sided p -value threshold of less than 0.05.

The analysis included a total of 12,260 weighted women from the 2000 survey and 5,527 weighted women from the 2019 survey. Over the study period, there was an overall downward trend in early neonatal mortality, decreasing from 34 deaths per 1000 live births in 2000 to 27 deaths per 1000 live births in 2019. The annual rate of reduction was estimated to be 1.03%. Approximately 45% of the observed decline in early neonatal mortality rate can be attributed to changes in population characteristics or endowments (E) during the study period. Factors such as the mother’s age, maternal education, marital status, preceding birth interval, types of pregnancy, and the sex of the child significantly contributed to the compositional change in the early neonatal mortality rate.

Over the past two decades, Ethiopia has seen a modest decline in early neonatal mortality, but this progress falls short of the Sustainable Development Goal (SDGs) targets. To achieve the SDGs, the Ministry of Health and its partners should intensify efforts to reduce early neonatal mortality. Strategies like preventing early/late pregnancies, promoting appropriate marriage timing, and prioritizing education could help further reduce early neonatal deaths. Further research is also needed to explore the factors driving this issue.

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Introduction

Neonatal mortality, defined as the number of deaths among live-born infants before 28 completed days, is a critical indicator of a country’s socioeconomic development and quality of life [ 1 ]. Within the neonatal period, early neonatal mortality specifically refers to the probability of dying during the first six days of life per 1000 live births [ 2 ].

Unfortunately, global estimates indicate that over 5.0 million children under the age of five and 2.4 million infants died in 2020, with newborns accounting for half of these deaths [ 1 ]. Alarmingly, nearly 3 million children worldwide die within the neonatal period, with a staggering 99% of these deaths occurring in low and middle-income countries [ 3 ]. Moreover, within the neonatal period, the majority of deaths (75%) occur within the first week of life, with a substantial proportion (25–45%) occurring within the first 24 h after birth [ 2 ].

While Ethiopia has made overall progress in reducing under-five and infant mortality rates, the country has experienced an unfortunate increase in neonatal deaths, with the neonatal mortality rate rising from 29 deaths per 1,000 live births in 2016 to 33 deaths per 1,000 live births in 2019. This reversal in the trend is a significant public health concern that requires urgent attention. However, the factors contributing to the rising neonatal mortality rates in Ethiopia are not well-understood [ 4 ].

The Sustainable Development Goals (SDGs) prioritize the reduction of under-five child mortality rates globally. To achieve this goal, it is crucial to address neonatal mortality rates, particularly in high-risk nations, where 98% of neonatal deaths occur ( https://ethiopia.un.org/en/sdgs/3 ). The SDGs have set targets to lower newborn mortality to 25 and under-five mortality to 12 per 1,000 live births by 2030 [ 5 ]. Achieving these objectives necessitates a concerted effort to decrease early neonatal mortality rates, especially in developing nations.

Fortunately, evidence suggests that up to 50% of neonatal deaths can be prevented through cost-effective interventions that can be implemented before, during, and after delivery [ 6 ]. These interventions play a crucial role in reducing early neonatal mortality rates and improving the survival chances of newborns. However, the lack of understanding of the specific drivers of neonatal mortality in Ethiopia hampers the development of targeted policies and interventions.

Therefore, this study aims to investigate the trends and factors associated with neonatal mortality in Ethiopia. By identifying the contributing factors and understanding the underlying causes, policymakers and healthcare professionals can develop targeted interventions and strategies to effectively reduce early neonatal mortality rates and achieve the SDG targets. The findings of this study will fill an important research gap and provide critical insights to guide the efforts towards improving neonatal health and survival in Ethiopia.

Methods and materials

Study area, period, and design.

Ethiopia is located in the horn of Africa, with its geographical coordinates ranging between latitude 3° and 14°N and longitude 33° and 48°E. The country spans a total area of 1,100,000 square kilometers ( https://ethiopianembassy.org/overview-about-ethiopia/ ) and is divided into nine regional states, namely Tigray, Afar, Amhara, Gambela, Benishangul-Gumuz, Harari, Oromia, Somali, and Southern Nations Nationalities and Peoples of Region, along with two city administrations (Addis Ababa and Dire Dawa). The analysis utilized data from the Ethiopian Demographic and Health Surveys (EDHS) conducted in 2000, 2005, 2011, 2016, and 2019. The study employed a community-based cross-sectional study design.

Source and study population

The source population for this study consisted of all women of reproductive age who had given birth within five years before each survey. The study population included reproductive-age women who had given birth within five years preceding each survey in the selected enumeration areas (EAs). The surveys utilized nationally representative samples drawn from birth records, with the following weighted numbers of women participating: 12,260 in 2000, 11,163 in 2005, 11,872 in 2011, 11,022 in 2016, and 5,527 in 2019.

Data collection tools and procedures

The data collection process for each survey year involved two stages. Stratification was carried out based on urban and rural areas within each region of the country. In the first stage, a specific number of enumeration areas (EAs) were selected: 539 EAs in 2000, 535 EAs in 2005, 596 EAs in 2011, 643 EAs in 2016, and 305 EAs in 2019 for the EDHS. In the second stage, a fixed number of households were selected within each EA using systematic sampling. For the detailed sampling procedure, can refer to the EDHS reports available on the Measure DHS website ( https://dhsprogram.com/Data/terms-of-use.cfm ) for each specific survey.

Outcome variable

Dependent variables : Early neonatal mortality (Yes, No).

Early neonatal mortality refers to the mortality of newborn babies within the first six days of life. For regression analysis, newborn babies who experienced mortality within the first six days were coded as ‘1’, while newborn babies who survived beyond six days were coded as ‘0’.

Independent variables : Socio-demographic characteristics (age of the women, maternal educational status, marital status, place of residency and region), Maternal and Neonatal characteristics (high-risk fertility, antenatal care, place of delivery, mode of delivery, postnatal care, birth interval, birth order, types of pregnancy and sex of the baby).

Decomposing variable : Survey year was used to decompose (2000 labeled as “0” and 2019 labeled as “1”).

Operational definition

Early neonatal mortality refers to the deaths of newborn babies that occur within the first six days of their postnatal age, as recorded in the dataset.

Risk fertility behavior refers to the characteristics of mothers who exhibit behaviors associated with higher risks in terms of fertility. These behaviors include being too young (under the age of 18) or too old (over the age of 34), having short birth intervals (less than 24 months between the preceding birth and the current pregnancy), and having a high parity (having more than three children).

Data management and analysis

The data were extracted, edited, coded, and verified by using STATA version 17/MP software. Descriptive statistics were conducted to understand the variables. The trends were analyzed separately for each survey period. Before conducting statistical tests, the data was weighted using sampling weight, primary sampling unit, and strata to ensure the survey’s representativeness. The trend in early neonatal mortality rate was estimated by calculating the rate difference and annual rate of reduction. The annual rate of reduction (ARR) was used to describe the decrease in mortality rate per year. In this study, ARR was calculated as follows:

• r1 = mortality rate for the year of the survey used as a baseline

• r2 = mortality rate in the year of the final survey

• t = number of years between the first and second survey

A recently developed statistical technique called multivariate decomposition was employed in this study to analyze the differences in a distribution statistic between two groups or its change over time. This approach allows for the decomposition of the components of a group difference or change into various explanatory factors. The technique utilizes regression models to separate the factors contributing to the differences in a statistic, such as a mean or proportion, between groups. These factors include compositional differences between groups, differences in characteristics (endowments), and differences in the effects of characteristics (differences in coefficients). This analysis technique is also useful for examining changes over time, as it can partition the components of change into those attributable to changing composition and changing effects [ 7 ]. In this particular study, a non-linear multivariate logit decomposition model was used to assess the contribution of changes in proportion to the early neonatal mortality rate over the past two decades.

The proportion difference in early neonatal mortality rate between 2000 and 2019 EDHS surveys can be decomposed as:

For the log odds of early neonatal mortality rate, the proportion of the model is written as.

The component ‘E’ is the difference attributable to endowment change, usually called the explained component. The ‘C’ component is the difference attributable to coefficients (behavioral) change, usually called the unexplained component.

Background characteristics of the study population

Table  1 provides information on the distribution of individual characteristics of women who gave birth in the five years preceding each survey conducted between 2000 and 2019. The average age of respondents was 29.5 years (+ 6.9) in 2000 and 28.6 years (+ 6.5) in 2019, indicating a slight decrease over the study period. In terms of maternal education, the percentage of uneducated mothers decreased from 82.07% in 2000 to 53.58% in 2019, showing a significant decline. This suggests an improvement in educational attainment among women over time.

These findings highlight several positive changes in individual characteristics and healthcare utilization among women giving birth in Ethiopia between 2000 and 2019. In both survey years, the proportion of males among the newborns was approximately 51%, indicating a relatively balanced sex ratio. Furthermore, there was a notable increase in the utilization of antenatal care services and institutional delivery. The proportion of women receiving the recommended fourth or more antenatal care visits increased by 4.2 times, indicating an improvement in access to prenatal care. Similarly, the percentage of women giving birth in a healthcare facility (institutional delivery) increased by nearly 10 times, reflecting an enhanced utilization of healthcare facilities during childbirth. The increase in educational attainment, antenatal care visits, institutional deliveries, and Cesarean section deliveries signifies progress in maternal and newborn health services (Table  2 ).

Trends of early neonatal mortality in the five survey years

The early neonatal mortality rate in Ethiopia showed a significant decrease from 2000 to 2019. During Phase I (2000 to 2016) and Phase III (2000 to 2019), there was an overall decline in the early neonatal mortality rate, decreasing from 34 per 1000 live births in 2000 to 27 per 1000 live births in 2019 (Fig.  1 ), with an annual rate of reduction of 1.03%. However, in Phase II (2016 to 2019), there was a slight increase in the early neonatal mortality rate, rising from 22 to 27 per 1000 live births (Table  3 ).

Trends of early neonatal mortality in Ethiopia; 2000–2019

The rate of decline in early neonatal mortality varied among different background characteristics of the study participants. Among the eleven regions included in the analysis, only four regions (Tigray, Amhara, Oromia, and Southern nation nationality) showed a significant reduction in early neonatal mortality rates. The Southern nation nationality region exhibited the largest annual rate of reduction (ARR) in early neonatal mortality rates with the total reductions of 67 deaths per 1000 live births, respectively, from 2000 to 2019.

The rate of reduction was highest among participants who had home deliveries (2.4 per annum), received no antenatal care visits (2.29 per annum), had twin pregnancies (2.05 per annum), were uneducated (2.03 per annum), and were currently not married (1.93 per annum). Conversely, the lowest average annual rate of reduction was observed in the Somali region (-85.71% per annum), Dire Dawa (-12.5% per annum), and among mothers who gave birth in a healthcare institution and through cesarean section delivery (-49.6 and − 38.6 per annum, respectively) (Table  3 ).

Across all surveys, the early neonatal mortality rate showed a decline for mothers living in rural areas, uneducated women, those with a single high-risk fertility factor, women who delivered at home, and women with twin pregnancies. However, the Somali region recorded an increase of 119 deaths per 1000 live births in early neonatal mortality throughout 2000 to 2019.

These findings underscore the varying trends in early neonatal mortality rates across different regions and population groups in Ethiopia. It highlights the need to target interventions and resources to regions and populations where early neonatal mortality rates remain high or have experienced an increase. By addressing the factors contributing to these trends, further progress can be made in reducing early neonatal mortality and improving overall neonatal health in Ethiopia.

• Decomposition analysis

The early neonatal mortality rate in Ethiopia has seen a significant reduction of 8 per 1000 live births from 2000 to 2019. A multivariate decomposition logistic regression analysis reveals that approximately 45% of the observed mortality difference can be attributed to the characteristics of the surveyed women, known as compositional factors (Table  4 ).

Several compositional factors were found to have a notable impact on the change in early neonatal mortality. These factors include the age of the mother, maternal education, marital status, preceding birth interval, types of pregnancy, and the sex of the child. The analysis indicates that certain changes in these factors positively or negatively contributed to the decline in early neonatal mortality rates.

The reduction in early neonatal mortality rates was significantly influenced by an increase in the proportion of women aged 20 to 34 years, married women, and those with primary or higher education. Conversely, compositional factors that remained relatively stable or unchanged exhibited a negative correlation with the decline in early neonatal mortality rates. These factors include birth intervals of 24 months or more, singleton pregnancies, and male infants.

After accounting for the effect of compositional factors, it was found that 55% of the change in early neonatal mortality between 2000 and 2019 in Ethiopia can be attributed to behavioral change factors or the effects of specific characteristics, rather than the structural composition of the two cohorts. However, this difference was not statistically significant (Table  4 ). These findings underscore the importance of considering various compositional factors (endowments) rather than coefficients when analyzing changes in early neonatal mortality rates. Understanding the specific contributions of these factors can provide valuable insights for designing effective interventions and policies to further reduce neonatal mortality rates in Ethiopia.

Early neonatal mortality is a crucial measure of newborn health and has a strong association with neonatal and under-five mortality rates. It poses a significant challenge, especially in low-income countries such as Ethiopia, where efforts to reduce early neonatal mortality are of utmost importance. Therefore, this study aims to examine the pattern and multivariate decomposition of early neonatal mortality in Ethiopia over the past two decades.

The early neonatal mortality rate in Ethiopia has shown a significant decrease from 34 per 1000 live births in 2000 to 27 per 1000 live births in 2019. This decline is in line with Ethiopia’s commitment to achieving the Sustainable Development Goals (SDGs) and its efforts to reduce neonatal mortality ( https://www.scribd.com/document/518384802/Annual-Performance-Report-2012-2019-2020 ). The Ethiopian government, along with development partners and organizations, has implemented several initiatives aimed at improving access to healthcare, enhancing maternal and child health services, and increasing community awareness of newborn care. These interventions have played a crucial role in addressing the factors contributing to early neonatal mortality [ 8 ]. However, despite the decline, the early neonatal mortality rate in Ethiopia remains high compared to global standards. To achieve the SDG targets for neonatal survival, further interventions are necessary. These include strengthening health systems, enhancing the capacity of healthcare professionals, promoting evidence-based practices, and addressing socio-cultural barriers [ 9 ].

Multivariate decomposition logistic regression analysis revealed that 45% of the observed early neonatal mortality difference is attributed to maternal characteristics (compositional factors) between the surveys. This highlights the importance of considering women’s characteristics when examining changes in early neonatal mortality rates. Specifically, the compositional change in maternal age, marital status, and education level have made important contributions to the decrease in early neonatal mortality rates in Ethiopia over the last twenty years.

Compositional change in maternal age makes an important contribution to the decrease in early neonatal mortality rate in Ethiopia over the last twenty years. Previous studies have shown that both younger and older maternal ages are associated with an increased risk of early neonatal mortality [ 10 , 11 , 12 ].

The compositional change in marital status has also been identified as a contributing factor for decrement in early neonatal mortality rate in Ethiopia. This finding highlights the protective role of marriage in early neonatal health outcomes. This might be because married women often have access to emotional and financial support from their spouses, which can contribute to improved health-seeking behavior and better utilization of healthcare services during pregnancy and childbirth. This supportive and stable environment reduces maternal stress which can lead to adverse pregnancy outcomes [ 13 , 14 ]. Kebede et al. (2021) also found that married women had lower early neonatal mortality rates compared to unmarried or single women [ 15 ].

Additionally, the compositional change in the education level of mothers has significantly contributed to the decrease in early neonatal mortality. Educated individuals are more likely to adhere to healthcare recommendations, adopt healthier habits, have better access to media, and have greater decision-making power within their households, all of which contribute to improved neonatal health [ 16 , 17 ]. Their enhanced financial capacity also plays a crucial role in ensuring adequate care for their newborn babies [ 18 ].

However, the data also revealed minimal changes in the composition of women’s birth intervals, which had a substantial negative effect on the rate of early neonatal mortality decline. Longer birth intervals may be associated with factors like delayed access to prenatal care, increased maternal age, or other underlying health conditions that increase the risk of early neonatal mortality [ 19 ]. Further research is needed to explore the underlying causes and mechanisms behind this negative impact.

Furthermore, slight decrements in the composition of women with singleton pregnancies and being female were also negatively associated with the change in early neonatal mortality rate. This may be due to women with singleton pregnancies and being female having a higher chance of survival compared to their counterparts [ 20 , 21 ], potentially due to improved access to healthcare services, better prenatal care, or biological factors that confer a survival advantage [ 22 ].

Strengths and limitations

This study utilized a nationally representative dataset with a large sample size, providing robust statistical power to analyze the characteristics of the study population. The findings have implications for healthcare professionals and policymakers in identifying influential factors and designing interventions to reduce early neonatal mortality in Ethiopia. However, it is important to note that certain variables, such as gestational age, comorbidities, NICU admission history, treatment-related characteristics, and details about antenatal and postnatal care, were not included in the analysis due to limited availability or a high number of missing values in the data collected through the EDHS. This limitation restricts the comprehensive examination of these factors’ impact on early neonatal mortality. Moreover, the data collected through the DHS surveys rely on self-reported information, which may be subject to recall bias or social desirability bias. This potential for bias should be considered when interpreting the findings of the study.

Conclusion and recommendations

Over the past two decades, there has been a modest decline in early neonatal mortality in Ethiopia, but the rate remains unacceptably high. Approximately 45% of the overall reduction in early neonatal mortality can be attributed to changes in the characteristics of women during this period. Factors such as the age of the mother, maternal education, marital status, preceding birth interval, type of pregnancy, and the sex of the child have played a role, either positively or negatively, in influencing the change in early neonatal mortality in Ethiopia. To further reduce the early neonatal mortality rate, it is beneficial to encourage pregnancies among women between the ages of 20 and 34, promote marriage, and continue to prioritize education among the population. Additionally, interventions are needed to address the issue of short birth intervals, which has been identified as a significant barrier to delayed initiation of breastfeeding in Ethiopia over the past decade. Lastly, to achieve the Sustainable Development Goals, the Ministry of Health and other stakeholders should continue their efforts to decrease early neonatal mortality. Furthermore, further research is necessary to gain deeper insights into the underlying factors and mechanisms driving early neonatal mortality in Ethiopia.

Data availability

The datasets used during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Annual rate of reduction

Antenatal care

Cesarean section

Demographic health survey

Enumeration areas

Ethiopian demographic and health survey

Early neonatal mortality rate

Neonatal intensive care units

Sustainable Development Goals

Southern nation’s nationalities and peoples

United Nations international children’s fund

World health organization

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Acknowledgements

We owe the DHS program for granting us access to the data.

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and affiliations.

Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences, Wollo University, P.O. Box 1145, Dessie, Ethiopia

Fekadeselassie Belege Getaneh

Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Lakew Asmare, Abel Endawkie, Amare Muche, Anissa Mohammed, Aznamariam Ayres, Dagnachew Melak, Eyob Tilahun Abeje & Fekade Demeke Bayou

Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Alemu Gedefie

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FSB, LA, AA, and AE were involved in this study from the inception to design, acquisition of data, data cleaning, and data analysis. AG, DM, AMH, and AM were involved in data analysis, interpretation, drafting, and revising of the manuscript. ET and FD were involved in supervising the final manuscript. All authors read and approved the final manuscript.

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Correspondence to Fekadeselassie Belege Getaneh .

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Under the ethical principles outlined in the Declaration of Helsinki, the authors took all necessary steps to adhere to guidelines for medical research. Due to the authors’ limited direct contact with neonates and their families, obtaining informed consent was not feasible. The data sets utilized in this study are accessible through the Ethiopian Statistical Agency and the Ministry of Health. The authors submitted the proposed title and study aim to the online DHS website to download and utilize the data. The EDHS program granted authorization for data access, which was then used in the current study.

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Getaneh, F.B., Asmare, L., Endawkie, A. et al. Early neonatal mortality in Ethiopia from 2000 to 2019: an analysis of trends and a multivariate decomposition analysis of Ethiopian demographic and health survey. BMC Public Health 24 , 2364 (2024). https://doi.org/10.1186/s12889-024-19880-1

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Does Contract Farming Improve Income of Smallholder Avocado Farmers? Evidence from Sidama Region of Ethiopia

• Published: 28 August 2024

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• Tibebu Legesse   ORCID: orcid.org/0000-0003-4821-3198 1 ,
• Mesfin Gensa 2 ,
• Abera Alemu 3 ,
• Aneteneh Ashebir 1 &
• Zerhun Ganewo 1  

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Contract farming is considered the most effective income-generating strategy for smallholder farmers and a significant source of foreign currency in Ethiopia. Avocado farmers in the study area made a contract agreement with the Savando avocado oil processing company, which is part of the Yirgalem agro-processing industry. The main aim of this research was to look at the factors influencing avocado producers’ decision to participate in contract farming and how it would affect their income, using data collected from 413 avocado producers in Dale district, Sidama region, Ethiopia. The cross-sectional research design and multi-stage sampling procedure were used to choose the study’s representative sample. The data were analyzed using descriptive statistics, inferential statistics, and propensity score matching model. The findings of this study indicated that the age of the household head, sex of the household head, education level of the household head, family size, and proportion of the farmland allocated for avocado production influenced the avocado producers’ participation in contract farming under the agro-processing industry. Average treatment effect on treated (ATT) estimation showed that participation in contract framing had a substantial impact on avocado producer households’ income. The study suggests that local government should offer adult education to improve smallholders’ knowledge and attitudes towards the benefits of participation in contract farming schemes in the study area. Moreover, the district office of agriculture needs to work with farmers to allocate more land for avocado production.

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The datasets used and analyzed during this study are accessible upon request from the corresponding author.

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Acknowledgements

The authors would like to thank the experts’ of the agriculture office of the district and the staff of Yirgalem integrated agro-processing industries for their patience and support in getting the required supplementary data. Besides, the authors would like to thank the respondents for their dedicated willingness to participate in this study

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Tibebu Legesse, Aneteneh Ashebir & Zerhun Ganewo

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The first author contributed for research proposal writing, data collection, and supervision. The second author assisted with data cleaning and feeding. The third, fourth and fifth authors contributed for data analysis and article writing. All authors read and approved the final manuscript.

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Legesse, T., Gensa, M., Alemu, A. et al. Does Contract Farming Improve Income of Smallholder Avocado Farmers? Evidence from Sidama Region of Ethiopia. J Knowl Econ (2024). https://doi.org/10.1007/s13132-024-02275-3

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Knowledge Attitude and Perception of Sex Education among School Going Adolescents in Ambala District, Haryana, India: A Cross-Sectional Study

Randhir kumar.

1 Assistant Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Anmol Goyal

2 Assistant Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Parmal Singh

3 Assistant Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Anu Bhardwaj

4 Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Anshu Mittal

5 Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Sachin Singh Yadav

6 Assistant Professor, Department of Community Medicine, MMIMSR, Mullana, Ambala, Haryana, India.

Introduction

Adolescence is a highly dynamic period characterised by rapid growth and development. Adolescents have limited knowledge about sexual and reproduction health, and know little about the natural processes of puberty, sexual health, pregnancy or reproduction. Sex education should be an integral part of the learning process beginning in childhood and continuing into adult life, because it is lifelong process.

This study was carried out to identify the knowledge and attitude of imparting sex education in school going adolescents in rural and urban area of Ambala district

Materials and Methods

A cross sectional study design was used to study the knowledge of reproductive and sexual health among school going children. A total of 743 adolescents from age group of 13-19 year were studied, using self designed semi-structured questionnaire to assess the knowledge regarding reproductive and sexual health among adolescents

The mean age of study subjects was 15.958±1.61 years, majority of adolescents i.e., 93.5% favour sex education. An 86.3% said sex education can prevent the occurrence of AIDS and 91.5% of adolescents prefer doctors should give them sex education followed by 83.0% school/teacher and least preference was parents 37.3%.

There were substantial lacunae in the knowledge about reproductive and sexual health. Students felt that sex education is necessary and should be introduced in the school curriculum.

The term adolescence comes from Latin word meaning “to grow to maturity” [ 1 ]. According to WHO 10-19 years is called adolescents [ 2 ]. It is the period when maximum amount of physical, psychological, emotional and behavioural changes take place [ 3 ].

Physical health, sexual and behavioural problems of adolescents are interrelated and these factors are related to unhealthy development in adolescents stem from the social environment. It also includes poverty, unemployment, crime, sexual harassment, gender and ethic discrimination and impact of social change on individual, family and communities. So adolescents need to provide preventive interventions for these behaviours are the same and all contribute to positive personal growth and development [ 4 ].

Adolescents need to know how to protect themselves from HIV/STDs and premature pregnancies, for this sex education is the best way, it should be a lifelong learning process based on the knowledge and skills and positive attitude, it helps to young people to enjoy sex and relationships that are based on qualities such as positive knowledge, mutual respect, trust, negotiation and enjoyment.

Age appropriate knowledge among youth and adolescents about the changes during puberty, sexuality, modes of transmission and prevention of sexually transmitted infections, HIV, and to maintaining a healthy and safe sexual life is important for the health and welfare and aware them to prevent unwanted pregnancies and of HIV/AIDS [ 5 ].

Sex education should be an integral part of the learning process beginning in childhood and continuing into adult life and its lifelong learning process. It should be for all children, young people and adults, including those with physical learning or emotional difficulties. It should encourage exploration of values and morale values, consideration of sexuality and personnel relationships and the development of communication and decision making skills. It should foster self-esteem, self-awareness, a sense of moral responsibility and the skills to avoid and resist sexual experience [ 6 ].

Health education plays important roles in human life and it is also a fundamental right. It can help to increase self-esteem, develop effective communication skills and encourage awareness about health and disease related knowledge. The mixture of myths/stigma secrecy, lack of knowledge, social disparity and negative media messages confuses young people and encourages poor self-esteem resulting in uninformed choices being made and it may lead to incorrect knowledge about sex, unprotected sex, unplanned pregnancy; STI’S including HIV/AIDS or deeply unhappy and damaging relationship [ 7 ].

Because of lack of clear protocol for sex education, like content, way of approaches, rules and regulation etc., for educational services and how these services should be fulfilled in different socioeconomic and cultural environments is not clear [ 8 ]. So, this study was done to identify the knowledge attitude and perception of sex education among school going adolescents.

A school based cross-sectional study was conducted among school going adolescents in a rural and urban area of district Ambala, Haryana for a period of six months from January 2015 to July 2015. Adolescent in the age group 13-19 years studying in class 9 th to 12 th were included and those who had not given consent and who had not completed questionnaires were excluded from study. The sample size was calculated on the basis of prevalence of knowledge regarding reproductive and sexual health with confidence limit 95% and margin of sampling error 10% by using the formula n=4pq/l 2 , to work out the required sample size the following equation was applied n=4pq/l 2 . Literature review reveals that the prevalence of knowledge regarding reproductive and sexual health among school going adolescents in India is 35% (WHO/MOHFW [ 9 ] and Mittal k et al., [ 10 ]). As the data on knowledge regarding reproductive and sexual health for Haryana state is not available, so the sample size was calculated by presuming the prevalence of knowledge regarding reproductive and sexual health in school going children in India to be 35% and thus the sample size for the study came out 743. These samples were divided into 4 strata rural/urban, government/private, class wise and sex wise were taken through stratified random sampling technique and then use simple random sampling technique to reach the total sample size. Ambala district has 224 higher and senior secondary schools only co-educational schools were taken for study. There were 134 government and 69 private co-educational schools in the six community development blocks of district Ambala. As the number government and private schools were in 2:1 ratio, so eight government and four private schools were selected randomly [ 11 ], and the number of students included in the study was 446 and 297 from government and private schools respectively. The number of schools in the government sector was more in rural areas and greater numbers of private schools were located in urban areas so the Probability Proportionate To Size (PPS) technique was used to cover the sample size of 743 student. One section of each class from selected school was included in the study, which was taken at random. Only those students were enrolled in the study those fulfilled the inclusion criteria, interview was continued till total sample were covered. Special care was taken to include the students in age group from 13-19 years by ensuring participation of all classes from 9 th to 12 th . A self designed, semi-structured, self-report pretested questionnaire was used to screen students regarding knowledge and attitude about sex education. The questionnaires were divided in to two groups. Part-1: Socio demographic profile and part-2: sexual health and knowledge, attitude and source of giving sex education. Most of the questions were structured with 3-5 options. Students were to answer one option unless specified otherwise. Open-ended question were given wherever description of answers was required. The questions were framed in English and translated into Hindi. Both Hindi and English questionnaires were used as per choice of the respondents. The study was conducted after obtaining written permission from district education officer, Ambala. Permission was also obtained from the principals of the selected schools. Informed and written consent was also obtained from parents during teacher- parents meeting. Completed questionnaires were compiled and entered into Microsoft Excel and analysed using Stastical Package of Social Sciences (SPSS) version 21, chi-square test and bar diagram.

The present study was a cross-sectional study conducted in rural and urban areas of district Ambala, Haryana. A total of 743 school- going adolescents studying in classes 9 th to 12 th in the selected government and private schools situated in different parts of urban and rural areas were included in the study. A total of 743 students of 13-19 years age-group those responded well, without hiding any problem were the subjects of the present study. [ Table/Fig-1 ] shows that 294(39.5%) of adolescents belonged to 15-16 year age group. The mean age of studied subjects was 15.958±1.61. Female were 358 (48.2%) and 385 (51.8%) were male. There were more students from government schools 446 (60%). More number of students were studying in class 10 th and 11 th i.e., 27.2% each, and in urban area 204 (53.5%) belongs to nuclear family and in rural area 198 (54.7%) belongs to joint family. Maximum 211 (28.4%) of adolescents belongs to SES class III and lowest number from class I 84 (11.3%). Whereas in rural area majority of adolescents belongs to SES class V and in urban area majority of adolescents belongs to class II. It was statistically highly significant (p<0.001).

[Table/Fig-1]:

Socio demographic profile of respondents.

Present study [ Table/Fig-2 ] reveals the association between different socio-demographic profile and perception of need of sex education among adolescents; it shows that majority of adolescents 695 (93.5%) favour sex education. However, boys 374 (97.1%) were more likely to favour sex education as compared to girls 321 (89.7%). It was found that adolescents with higher age group, belongs to urban area and private school with higher SES favours sex education in school. It was considered statistically significant.

[Table/Fig-2]:

Perception of sex education according to their socio-demographic profile of adolescents.

[ Table/Fig-3 ] reveals the reason for sex education among adolescents, out of 695 adolescents who are in favour of sex education, 600 (86.3%) said sex education can prevent the occurrence of AIDS, whereas 396 (57.0%) removes myth, 373 (53.7%) believe knowledge of sex makes future life easy, 275 (39.5%) thought that protects from other diseases and 102 (13.7%) don’t give any reason for sex education.

[Table/Fig-3]:

Perception of the reasons of sex education among adolescents (n=695).

(*Multiple responses)

[ Table/Fig-4 ] reveals that majority of adolescents thought 615 (86.9%) sex education and STDs, 581 (82.2%) menstruation and its hygiene, 512 (72.3%) changes occurring during puberty and 503 (71.0%) drug abuse was the most common topic that should be discussed in class. However, 349 (49.4%) urban adolescents thought menstrual and its hygiene topic and about 280 (39.5%) rural adolescents sex education and STDs related topic should discuss in class.

[Table/Fig-4]:

Perception of students about content of sex education.

[ Table/Fig-5 ] shows the area wise distribution of respondents according to their preference for getting sex education. It was found that majority 680 (91.5%) of adolescents prefers doctors should give them sex education followed by 617 (83.0%) school/teacher and least preference was parents 277 (37.3%). However, in urban adolescents most common preference for sex education was school/teacher i.e., 357(48.0%) and in rural area 347 (46.7%) doctor was the most common preference for getting sex education.

Distribution of respondents according to their preference for getting sex education.

This study has tried to assess the knowledge, attitude and practices regarding reproductive health and sexual problems, to assess the perception regarding reproductive and sexual health among adolescents and to identify the need of imparting sex education in school going adolescents (13-19 year) from urban and rural area of district Ambala Haryana.

Regarding the need of sex education among adolescents, it shows that majority of adolescents (93.5%) favour the sex education. However, boys (97.1%) were more likely to favour sex education as compared to girls (89.7%). A similar study was conducted by Jaideep K et al., in Chandigarh found that 95% of students were in favours of mainstreaming of sex education [ 12 ]. Another study done by Benzaken T et al., shows 90% favours sex education and study by Thakur HG et al., shows that 90% and 97% favours sex education, among boys 82.9% and among girls 75.6% respectively [ 13 , 14 ]. A study done by Dorle AS et al., from Karnataka found only 48% of student favours sex education in higher and senior secondary school and it was lower than our study it might be because of regional and cultural difference and also study was conducted five year back [ 15 ].

To find out the reason of sex education, 86.3% participants said that sex education can prevent the occurrence of AIDS, whereas 57.0% remove myth, 53.7% knowledge of sex makes future life easy, 39.5% protect from other disease and 102 (13.7%) don’t give any reason for sex education. A study done by Mueller TE et al., reported that majority of adolescents said sex education reduce the risks of potentially negative outcome from sexual behaviour such as fear and stigma of menstruation, unwanted and unplanned pregnancies and infection with STIs including HIV [ 16 ]. To know the preference for getting sex education, present study found that majority 680 (91.5%) of adolescents prefers doctors followed by 617 (83.0%) school/teacher and least preference was parents 277 (37.3%) respectively. A similar study was conducted by Jaideep K et al., in Chandigarh found that 76.74% students choose the teacher as the best source to provide sex education [ 12 ]. Similar observation was found by Wong WC et al., in Hongkong and Zhang L et al., in China [ 17 , 18 ]. All these variation might be because of regional and cultural difference. A study done by Dorle AS et al., from Karnataka found girls favours parents and boys favours friend as a source of information about sex [ 15 ]. A view point given by Datta SS et al., favours school and college should give sex education to adolescents [ 19 ].

This study suffers from the usual limitation of a cross-sectional study. We only include the co-education school so it cannot be generalizes to all school adolescent. As sex education is a sensitive topic, we cannot guarantee about the honest answers as it covered the sensitive issue i.e., recall bias. Participants may agree with statements as presented to them, especially when in doubt i.e., acquiescence bias and also social desirability bias.

Recommendation

Sex Education must be introduced in the school which should start from the primary school and brings about the age appropriate topics as they go through the high school. It should contain a package of information about life skills, reproductive health, safe sex, pregnancy and STI’s including HIV/AIDS. A socio cultural research is needed to find the right kind of sexual health education services for boys and girls separately from the teacher of same gender. It is the responsibility of parents, teachers, social workers, politicians, administrators, medical and paramedical profession so that adolescent girl or boy got legitimate due to education and empowerment and change over to adult men or women is smooth and streamlined with nil or least medical, social or psychological problems.

In this present study knowledge and perception of sex education was good, majority believe that sex education should implemented in school curriculum and majority of them gave good reason for sex education implementation in school. The most common preference for getting sex education was from doctor and teacher/school followed by friend respectively. Sex education and sexuality is unaccepted in many communities and also among some parents, adolescents feel shy and scared to talk about sex education, some adolescents hesitate to reply about sex education especially girls.

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