Vol.3, No.6, 370-377 (2011)
doi:10.4236/health.2011.36063
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Sexual and reproductive health needs of adolescent
girls from conservative and low-income families in
Erzurum, Turkey
Nesrin Reis1, Dilek Kilic2*, Raziye Engin2, Ozlem Karabulutlu2
1Bezmialem University, Health Sciences Faculty, Department of Nursing, Istanbul, Turkey;
2Ataturk University, Health Sciences Faculty, Department of Nursing, Erzurum, Turkey; *Corresponding Author: [e-mail]
Received 3 February 2011; revised 28 April 2011; accepted 5 May 2011.
ABSTRACT
The objective of this survey was to determine
the sexual and reproductive health needs of
conservative and/or economically challenged
adolescent girls. A total of 310 subjects (16.5 ±
2.2 years old), attending three private institutes
teaching Islamic matter and the holy Quran and
two private institutes teaching carpet-weaving
in Erzurum, Turkey, were interviewed between
November 2004 and February 2005. The ques-
tionnaire covered knowledge on reproductive
health and s exua l ma tter s to attain their feelings
prior to their first menarche, their practices
during menstruation, and their awareness of
gynecological and sexually transmitted dis-
eases as well as their attitudes toward and re-
sponsiveness to domestic violence. Their re-
sponses showed that these issues were con-
sidered taboo and/or embarrassing to share.
Also, a considerable percentage of the girls had
no or limited knowledge on reproductive health
and sexual matters and mismanaged gyneco-
logical problems and domestic violence. More-
over, those had knowledge revealed that their
sources were non-scientific information from
unprofessional individuals. In conclusion, the
conservative and/or economically challenged
adolescent girls who are not attending regular
high schools need professional lectures on re-
productive health and sexual matters.
Keywords: Reproductive Health; Sexual Health;
Adolescent Gi rls
1. INTRODUCTION
Of the world population in 2000, over one billion
people were adolescents (10 - 19 years old) and 85% of
them lived in developing countries, mainly Asian coun-
tries [1]. They will contribute to population growth in
next decades, suggesting that their education on sexual
and reproductive health and their needs are extremely
critical [2]. Moreover, they may be vulnerable to several
diseases and problems, such as HIV and sexually trans-
mitted diseases (STD) as well as experiencing unin-
tended pregnancies and maternal complications, if they
receive inaccurate or incomplete information on repro-
ductive h ealth. A survey conducted by Polish researchers
ascertained that adolescent girls were sexually active and
41.1% of them were referred to ineffective methods,
which led to withdrawal during sexual intercourse, re-
sulting in a higher rate of unwanted pregnancy, STD,
and other sexual and reproductive health problems [3].
In fact, it was reported that 70% of the people STDs
were at age ranging from 15 to 24 years [4]. Adolescent
sexual and reproductive health education is still a ne-
glected issue in many countries [5]. Especially the ado-
lescents from the rural part of the developing countries
are disadvantageous due to unavailability and/or inade-
quacy of reproductive health care services and trainings
[6-10]. While the reproductive and sexual health of ado-
lescents is acknowledged as good from developed coun-
tries to Western Europe cou ntries [11,12], there ar e stud-
ies reporting that the reproductive and sexual health of
adolescents in some European countries [13,14], Canada
[12,15], and America [15-17] are poor. Worldwide, so-
cietal shifts and behavioural patterns exacerbated by
unique developmental vuln erabilities create a confluen ce
of factors that place today’s adolescents at heightened
risks for poor health outcomes [16]. Therefore, World-
wide, all adolescents need sexual and reproductive
health education and legal acts [13,16]. International
Conference on Population and Development held in
Cairo in 1994 recognized the reproductive rights as fun-
damental human rights [9]. These rights cover that all
adolescents should receive health care services and that

N. Reis et al. / Health 3 (2011) 370-377
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
371371
they should be given a h igh-quality sexu al and reproduc-
tive health education . However, before provision of su ch
service, field surveys must be performed to determine
knowledge on and attitudes toward reproductive health
and sexual matters, which may vary the culture, relig ion,
economical and educational statues, and environmental
factors. Therefore, in this preliminary study, we con-
ducted a survey involving adolescent girls from conser-
vative and/or economically challenged families to de-
termine their knowledge on and attitudes toward repro-
ductive health and sexual matters and explore their
needs.
2. METHODS
2.1. Participants and Their Characteristics
This descriptive study included 220 adolescent girls
attending three private institutes teaching the Quran as
well as some Islamic issues and 90 adolescent girls at-
tending two private institutes teaching carpet-weaving in
Erzurum, Turkey. The subjects voluntarily participated
in this study from November 2004 to February 2005.
The majority adolescent girls attending these courses
had completed current the 8-year compulsory education
(elementary and intermediate school) imposed by law of
the state (n = 151, 82.9%). Some of them had only an
earlier the 5-year mandatory elementary school educa-
tion (n = 106, 34.2%). However, there also 16 subjects
who had no education (Ta b l e 1 ). Institutes teaching the
Quran and religious rheoretics were boarding institutes
where education, food, and shelter are provided. The
girls attending these courses were mostly from families
with low-income and/or had many children. Because
both kinds of institutes are regulated by the government,
families intend to take advantage of learning and prac-
ticing Islam in a proper environment and of making liv-
ing with their skills.
The mean age was 16.5 ± 2.2 years. All of them were
single and 82.9% of them had compulsory elementary
education. Majority were urban residents (78.7%) and
economically dependents (67.4%). Almost half the sub-
jects relied on the state social security system (SSS) due
to their parent’s employment in the government (37.7%)
and insurance system due to their parents’ private small
businesses (17.8%). The majority of the other half was
supported by the go vernment (33.5%) (Table 1).
2.2. Ethics
Written permission was taken from the related institu-
tions before the research. The aim of the research was
explained to the adolescent girls, and they were in-
formed that if they prefer not to continue, they could
withdraw from the study any time they wish. Further-
more, they were informed that their decision to partici-
pate into the research would not affect their attendance
to the course. They were assured that their names and
the names of their institu tions were confiden tial and th ey
were free to respond to whichever question(s) they
wanted.
Table 1. Socio-demographic characteristics of the adolescent girls.
N %
Educational status
Illiterate 27 8.7
Literate 16 5.2
Elementary school (5 years) 106 34.2
Intermediary sc hool (3 years) 151 48.7
High school (3 - 4 years) and university ( 2 - 6 yea rs) 10 3.2
Birth place
Urban 189 61.0
Rural 121 39.0
Current address
City centre 244 78.7
Suburb 66 21.3
Income status
Lower than outcome 209 67.4
Equal to outcome 85 27.4
Higher than outcome 16 5.2
Health insurance
SSS 117 37.7
Individual membership to the state insura nce system 55 17.8
Green card 104 33.5
No health insurance 34 11.0

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2.3. Procedure and Data Collection
Prior to the research, the researchers visited the insti-
tutes to evaluate facilities for pre-interviews with the
adolescent girls about the nature of the study. In this
meeting, the researchers focused upon sexuality, to a
large extent, the first menarche/pubertal changes, gyne-
cologic diseases, familial violence such as restric-
tions/prohibitions and verbal abuse.
The relevant literature was reviewed for the estab-
lishment of semi-structured questionnaire. Th e da ta were
collected with face-to-face interviews and included
demographic characteristics and sexual and reproductive
health needs of the adolescent girls. Each interview
lasted approximately 30 - 40 minutes.
2.4. Data Analysis
The PROC MEANS and UNIVARIATE procedures
were employed to determine descriptive statistics of
demographic characteristics and sexual and reproductive
health needs (SPSS, Version 10.0, Chicago, IL, USA).
Mean, standard deviation, range and frequency of re-
sponse variables were reported.
3. RESULTS
3.1. Knowledge and Management of
Menarche and Menstruation
One-third of the subjects had no knowledge prior to
their first menarche (Ta b le 2 ). Half of the subjects who
had knowledge about menarche (n = 209) received in-
formation from their family members, whereas only re-
ceived information from health professionals (n = 20, 9,
6). Moreover, majority of these girls had no knowledge
on menstruation physiology (79.7%). Feeling after ex-
periencing the first menarche was mix; 43% of the sub-
jects had uncomfortable feelings, such as anxiousness,
nervousness, and feeling dirty; 20% of them were happy
about considering them blooming; and 35.5% of them
had both feelings. Menstruation management practices
were hot application (38.7%), taking painkiller (16.1%),
and having more frequent bath (11.9%). While one-fifth
of the subjects practiced all these, almost other one-fifth
did not take any action to cope with menstruation.
3.2. Knowledge on Reproductive Health
Dysmenorrhea (23.9%) and irregular menses (18.1%)
were two most common gynecologic problems that
study subjects experienced (Tab le 3 ). Only one subject
(0.3%) had not experience their first menarche at time of
survey. More than one-third of the girls did not prefer to
share their gynecologic health status. Overall, 62.9% of
the girls acknowledged presence of gynecologic prob-
lems. However, majority of the adolescent girls (87.4%)
reported that they did not consider health unit for solu-
tion (87.4%) and preferred female doctor if they would
have to visit health unit (91.3%).
Table 2. Knowledge and management of menarche and menstruation of the adolescent girls.
N %
Getting inform a t i on before the f i r s t menarche
Yes 209 67.4
No 101 32.6
The source of informa tion
Friend 39 18.7
Mother 58 27.7
Sister 41 19.6
Health staff 20 9.6
Other (book, media, etc.) 15 7.2
Multiple (friend, sister and medi a) 36 17.2
Knowledge on menstruation
Yes 63 20.3
Not knowing 247 79.7
Feelings at the first menarche
Unfavorable feelings (anxiousness, n e rvousness, fear, dirtiness, etc.) 136 43.9
Favorable feelings (to be on the verge of becoming a young girl, etc.) 64 20.6
Mix feeling 110 35.5
Menstruation man agement
Showering 37 11.9
Taking painkillers 50 16.1
Hot application 120 38.7
Others (more than one application) 61 19.7
No action 42 13.6

N. Reis et al. / Health 3 (2011) 370-377
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373373
Table 3. Gynecologic health needs of the adolescent girls.
N %
Gynecologic problems
Irregularity of menses 56 18.1
Dysmenorrhea 74 23.9
Over bleeding 10 3.2
No menses 1 0.3
Genital infections 17 5.5
Two or more problems 37 11.9
No response 115 37.1
Reference to a health unit for the problems
Yes 39 12.6
No 271 87.4
Preference of doctor’s gender
Female 283 91.3
Male 2 0.6
Either 25 8.1
Almost half of the subject had no know ledge on sexu-
ality and almost another half did not want to share their
knowledge on sexuality (Table 4). Information source
was highly variable; being elder sister and/or close
friend the major source. Likewise, more than half of the
subjects were not willing to share their information
source (55.1%) preferred to keep silent and did not an-
swer the question, whereas the other half (18.7%,
14.5%). Frequency of subjects that were aware of sexu-
ally transmitted diseases (STD) was similar to frequency
of the subjects who had general knowledge on sexual
matters. Only 13.2% of the subjects had knowledge on
STD’s and almost half of them did no t want to talk about
this issue. More than half of the subjects were not will-
ing to express their opinion on birth control (52.6%).
Other half had knowledge on contraceptive methods.
One percent of the subjects were aware of traditional
methods such as coitus interruptus and vaginal douching.
3.3. Experience of and Attitude toward
Domestic Violence
Three quarters of the subjects did not want to talk
about familial violence (Table 5). Others we re witness to
verbal abuse (12.9%), social abuse (9.4%), physical as-
sault (2.9%), and sexual violence (1.0%) between their
parents. Half of the subjects did not prefer to express
their feeling about domestic violence. Those expressed
their feeling were approval (6.1%), disapproval (hatred,
fear, fury) (24.2%), and ignorance (20.0%). Interestingly,
none of the subjects shared domestic violence with
health or security personnel and 15.1% of them did not
share it with anybody. Other family members (17.4%)
and friends (12.6%) were the primary contacts to men-
tion domestic violence. Again, more than half of the
subjects did not want to answer who was the person to
share domestic violence.
4. DISCUSSION
The Turkish education system is secular and “health
science” is a mandatory in high school curriculum.
However, conservative and low-income family or fami-
lies living in rural may prefer especially their daughters
to continue on their education in some institutes offering
religious program or skills. We assumed that these
groups of adolescent girls might need more assistance to
improve their know ledge and awareness on reproductiv e
health and sexual matters because their current curricu-
lum does not cover these issues. Ta b le 1 indicated that
our study gro up was not on ly conserva tive but also were
educationally deficient and from low-income families.
The majority were either hesitant to talk about their first
menarche experience and menstruation cycle or not in-
formed at all/improperly informed before the first men-
arche and during menstruation and did not know how to
manage their menstruation cycle. Instead of perceiving
these as a result of a health physical and physiological
development, they were swamped with depression signs
(Table 2). Similar information source and feelings at
pubertal age by the girls were also reported in other sur-
veys conducted in India [18] and Pakistan [6]. These
suggest that such education should be emphasized in
schooling adolescents effectively by teachers and com-
pensated in nonschooling adolescents through regular
workshops by local health care providers.
Despite presence of gynecological discomforts and
needs for professional assistance, our study subjects
were not willing to consult health unit. In case they
wanted to visit a doctor, female doctor was preferred

N. Reis et al. / Health 3 (2011) 370-377
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374
(Ta b le 3). This could be due to considering clinics dis-
turbing and non-confidential [6], unavailability of such
service [19], not knowing to get help from health cabi-
nets [8]. Young people need access to quality clinical
services that offer effective treatments and vaccines as
well as proper sexual education. Mbonye reported that
the adolescents with gynecological problems were free
of these problems and learned how to manage these
problems upon consulting health units in Uganda [20].
These findings emphasize the necessity of the youth
development programs covering health education and
care to economically challenged adolescents.
The half of our study subjects was no t willing to share
their knowledge, knowledge source on sexual matters
and STD as well as birth control methods. The other half
were either not knowledgeable or had limited knowledge
(Table 4). Naturally, it is the duty of families to give
information to adolescents on sexuality, STD’s and con-
traception, but families of our study group perhaps did
not know or were not aware of these issues. Surprisingly,
other studies also show that children/adolescents rarely
receive information on their sexual matters from their
parents [21,22], which may be account for performing
risky behavior due to possible variation of accuracy in
knowledge from various sources [23]. Girls with a
longer period of training were shown to conduct less
risky sexual behavior than those with a shorter period of
training [24]. In another study, it was shown that Nige-
rian girls lacking sexual education at school and home
tended to perform malicious sexual behaviors such as
involuntary pregnancy and injuries and infections in
genital system [10]. In Turkey, pre-marriage sex is not
acceptable adolescent girls. Upon marriage, some rela-
tives or honored friends inform the couple about sexual
matters including pregnancy and birth control. In case of
extra-marital pregnancy, criminal act of honor killin gs or
committing suicide may be encountered, especially in
communities where feudalism is still exits. Such percep -
tion, sometimes may lead improper places or methods to
abort in case of unauthorized marriages. In Kenya and
Zambia [7], it was reported that referred unmarried
pregnant girls to abortion. De Jong et al (2005) have
shown that in Arabic and Iranian communities, it is a
taboo to discuss sexuality and the young are unable to
receive knowledge concerning these subjects at a satis-
fying and adequate level. Overall, these studies suggest
that cultural and religious factors, inadequate informa-
tion, limited usage of services of reproductive health
usually appear to make the adolescent girls prone to
some diseases including STD’s and HIV-AIDS and so-
cially unacceptable cases including unwanted and un-
planned pregnancy, personal sexual and reproductive
health problems [20,26]. Disadvantaged groups exists
among adolescents in terms of sexual and reproductive
health despite presence of the sexual and reproductive
health services and training programmes directed at
adolescents in developed countries [11,12,16]. It is re-
ported that the age of their first sexual experience, the
Table 4. Reproductive health needs of the adolescent girls.
N %
Knowledge on sexual matters
Yes 41 13.2
No 138 44.5
No response 131 42.3
Information on sexual matters
Elder sister/Female friend 58 18.7
Various books 45 14.5
Magazine and journals 9 2.9
Television 21 6.8
Multiple communication resources (Friends, journals, TV, etc.) 6 2.0
No response 171 55.1
Knowledge on sexually transmitted diseases
Yes 41 13.2
No 138 44.5
No response 131 42.3
Awareness of contraceptive method s
At least 1 effective method 72 23.2
Two or more effective methods 72 23.2
Traditional methods 3 1.0
No response 163 52.6

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Table 5. Experience of and attitude toward domestic violence of the adolescent girls.
N %
Types of familial violence
Verbal violence 40 12.9
Physical violence 9 2.9
Imposition of restrictions 29 9.4
Sexual violence 3 1.0
No response 229 73.8
Feelings towards the one who conducts violence
Love 19 6.1
Hatred 39 12.6
Fear 11 3.5
Fury 25 8.1
Nothing 62 20.0
No response 154 49.7
Person choice to talk about violence
Fami ly membe r 39 12.6
Friend 54 17.4
Relative 3 1.0
Professional (health and/or security) 0 00.0
Nobody 47 15.1
No response 167 53.9
pregnancy rate, the use of contraception, HIV knowledge,
and STI rate from one population to another in these
groups, as well as adolescents portray high risk repro-
ductive health behaviour [11,12]. Therefore, it is impera-
tive to provide optimal sexual and reproductive health
education. It is recommended to apply a peer-based ap-
proach in reproductive health and sex education to the
adolescents [17,27,28]. Strategies should consider de-
velopmental needs of age of the adolescents and their
social context [29,30].
Our study population did not want to share domestic
violence and majo rity did not notify this to authorities in
case it happened (Ta ble 5). Domestic violence can ad-
versely affect adolescents’ attitudes on sexual matters
and mental and behavioral health as well as destroys the
development of self-concept and body image [31-34].
Information and counseling service should be provided
to parents especially when their girls become adolescent,
to facilitate establishment for their happy and health
marriages in future.
In conclusion, our survey revealed that conservative
and/or economically challenged adolescent girls with up
to intermediate education were in need of accurate and
professional education on sexuality and reproductive
health. However, at this point, we were unable to indi-
cate what characteristics of these adolescents (religion,
low education, or low-income) could be attributed to
their responses. Teachers and health professionals should
be facilitated by authorities to provide proper reproduc-
tive health and sex education to adolescents attending
institutes whose curriculum does not cover this topic.
Cross-cultural studies involving adolescents from dif-
ferent economic and education background should be
performed to determine factors underlying different atti-
tudes toward sexu a lity.
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