Effects of mobile health education on sexual and reproductive health information among female school-going adolescents of rural Thailand

Introduction

Adolescent pregnancy is a well-known reproductive health problem in the teenage population of Thailand. Moreover, this age group is more prone to pregnancy due to their active sexual and biological health.¹ Studies have found that 41% of adolescents were sexually active, and about 20% were engaged in risky sexual behaviors.^1,2 The reported data showed that, annually, about 47 childbirths occurs in 1,000 adolescent mothers in the world.³ The United Nations Children's Fund data from Thailand, 2016–2017, found that the prevalence of adolescent pregnancy in the age group of 15–19 years was 51%.⁴ Moreover, other sources also revealed that the birth rates among adolescents aged 15–19 years during in 2013, 2014 and 2015 was 51.1, 47.9 and 44.8 per 1,000 adolescents women, respectively.^5,6 In 2018, the childbearing rate among adolescents aged 10–19 years increased to 12.9%, which is an alarming signal for policy makers in sexual and reproductive health in the country.⁷ Hence, the situation of adolescent pregnancy has become a predominant problem in Thailand that needs urgent interventions.⁸ Moreover, it has been observed through the evidence that the this number of adolescent pregnancy is more in the southern part of Thailand including Chumpon province, Krabi province, and Nakhon Si Thammarat province.⁹ This problem of adolescent pregnancy has not yet been resolved. Moreover, proper information and knowledge for adolescents on sexual health literacy, early aged pregnancy, sexually transmitted diseases (STD), childbearing information and care are highly needed.¹⁰

Sexual health literacy is very effective approach for improving an individual's cognitive and social skills that result in developing a positive behavior.¹¹ Sexual health literacy implies the achievement of knowledge levels, personal skills, and confidence to take action for personal and community health improvement by changing personal lifestyles and living conditions. Improving adolescents' access for sexual and reproductive health information, and their capacity to use it effectively, sexual health literacy should be provided and tested among the younger population of Thailand. Therefore, this study was conducted to evaluate the effects of mobile messages to improve sexual health literacy among secondary School female students of rural Thailand.

Methods

Results

Sociodemographic characteristics of the respondents of both the health education and observation groups are explained in Table 1. The comparison of general characteristics between the two groups were not different in terms of grade point average, age, allowance, and parent's marital status. Most of the female students were 14-year-old students of grade 8, and obtained grade point average over 3.0. The characteristics between two groups were not statistically different in term of grade point average (p = 0.439), age (p = 0.312), monthly income (p = 0.220), living condition (p = 0.410), and their parent's marital status (p = 0.465). Hence, both groups have similar socio-demographic information selected for the study.

The level of sexual health literacy scores calculated as per index score mentioned in the method section among secondary school female students of both groups shows statistical significant difference in mean, SD and range (p = 0.000) after the health education. Group with health education was observed with significant changes with domains like; sufficient (76%), problematic (22%) and inadequate only (2%). However, the observation group remained the same without any change. The health education group reported only 1 (2%) participant with inadequate but on other hand, observation group showed all their participants with inadequate sexual health literacy group (Table 2).

Both groups were compared through average mean score measured by calculation of all four domains like: accessing, understanding, appraising and applying. The observation group remained the same at both measurements: pre and post (p = 0.521). However, the health education group showed statistically significant differences in all four domains (p = 0.000). This shows that the health education group has received positive information as compared to observation group that remained same (Table 3).

The magnitude of change in the mean score of sexual health literacy scores was significantly higher in the health education group than the observation group (Figure 1).

Figure 1. Estimated marginal means of index score.

Discussion

Students with good educational record perceived health education messages in better way as compared to those who had poor academics performance. This is consistent with a study showed that adolescents who attended school in urban setting had significantly higher score on sexual health literacy and knowledge.^12,13 Female adolescents who are in the middle of psychosocial development phases, they undergo various changes in terms of their physical, cognitive, emotional, and sexual development at this stage.¹⁴ These changes can lead to major risk factors for premarital sexual behaviour, adolescent pregnancy, abortion, and sexually transmitted infections. Health literacy is also effected by factors such as education, ethnicity, gender, age, profession, income, culture, language, and social support.^15,16 However, this study focused on several variables including age, grade point average, average allowance, parent's marital status, and living with parents that also indirectly affected the sexual and reproductive health of the respondents. This can be assumed that students who are performing well in school may have higher knowledge and understanding toward sexual health literacy.

It was found that the measurement of the sexual health literacy scores (index) of the health education group in the baseline and endline had increased respectively through duration of the health education. There were statistically significant changes of the overall index scores before and after the health education program of the health education group. These findings are consistent with a study conducted on sex education program and prevention among grade 8 female students, where it was found that the experimental group had significantly higher levels of knowledge about preventing sexually transmitted disease and unwanted pregnancy, attitudes towards sexual behavior, self-efficacy in prevention of undesirable sexual behaviors, self-esteem, and sexual behaviors. This can be explained by the score of female students who received program information that was relevant to sexual health literacy which is consistent with accessing, understanding, appraising, and applying. Comparison of sexual health literacy scores (index) of the health education and observation groups at different time of measurement showed that the health education group's sexual health literacy scores had changed as compared to baseline. However, the observation group's sexual health literacy scores did not change and remained same in both pre and post measurements. This can be explained by that the observation group did not receive the program; moreover, people can improve their literacy skills through intensive health education. The mean scores in the comparison group gradually declined in all four domains. The increasing trend in scores from the baseline to endline can be explained by the health education activities that comprised all four domains of sexual health literacy. Moreover, the health education group received health education through social media model plus line messages. In addition, the program designed was based on information, motivation and behavioral skills health education that is relevant to sexual health literacy and cover assessing, understanding, appraising and applying in display of info-graphic and animations. Participants randomly received rewards when joining the activities through LINE. This is similar to the health education study which found that the mean scores of health literacy were higher than those in the observation group after receiving the Sex Must Safe Program, the health education program, which included all the elements of health literacy.¹⁶

Conclusion

This study concluded that the mobile messages are proved to be effective among adolescents to increase their sexual and reproductive health literacy and this could be replicated in similar settings of the country to promote sexual and reproductive health and control the teenage pregnancy issues in the country.

Limitations and recommendations

The sample size of this study was small and population in the study was secondary school female students only. The areas of the study were purposively selected; hence the results of the study may not be generalizable to other locations and population. This Social Media Model should be recommended to policy makers in order to be applied in the prevailing situation. Implementation and modification of the Social Media Model's contents should be performed by relevant government authorities in order to be applicable for general population; especially for a rapid observation and prevention of teenage pregnancy. Limited time of measurements in the intervention group could have an effect on the knowledge of the participants in medium or long term knowledge, hence this study focuses on a short-term evaluation.

Data availability