Study design and population
The study was implemented in two low performing areas: Nabiganj Upazila (sub-district) in the Sylhet division and four wards of Dhaka urban slum under Dhaka division of Bangladesh. The Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GoB), ranked districts and sub-districts based on four indicators using health and FP services utilization: percentage of pregnant women, crude birth rate, contraceptive-use rate, and coverage of two doses of vitamin A capsules. The MoHFW found that most low performing districts/sub-districts were located in Sylhet and Chittagong divisions. Nabiganj is a low performing sub-district under Sylhet division, and the slums in Dhaka city are also low performing areas. Therefore we selected Nabiganj and four slum areas of Dhaka City Corporation purposively for this study based on the above mentioned criteria. Both the areas are known as a low-performing areas with low RH indicators [13, 14]. The Population Council, Research Training and Management International (RTM International), John Snow International/Deliver Bangladesh and icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) were involved in implementation of this project. icddr,b evaluated the intervention activities through a baseline and end-line survey.
DBRHCP was an operation research (OR) project to improve the knowledge, and practice of targeted populations (married and unmarried) in order to meet their RH needs. Needs assessments were done at the beginning of the project to design the intervention strategies. RTM International and Population Council were involved for intervention activities in the project areas. They conducted the Behavior Change Communication (BCC) intervention for female unmarried adolescents. Under the BCC intervention, the activities were: i) formation of Community Support Groups (CSGs), ii) formation of peer promoters, iii) stage dramas, interactive jari gan and video shows. The objective of these activities was to increase awareness about RH and availability of RH services.
Community support group
Each CSG was consisted approximately 7–8 members, including elected representatives of the local government, field workers, religious leaders, teachers, social activists, unmarried females, and representatives of both rich and poor community members. A total 36 CSGs were formed. CSG members played an important role in improving the physical infrastructure of healthcare facilities as well as in cooperating with peer promoters to motivate unmarried females to seek services from trained service providers.
Married, unmarried, male and female-were selected as peer promoters to assist the field workers in their routine activities. Peer promoters organized group and one-to-one sessions at the community level to improve knowledge on RH and increase awareness about availability of services in healthcare facilities and RH services. The peer promoters played a bridging role between community members and the health facilities.
Stage dramas, interactive jari gan and video shows
The local cultural groups staged a total of 65 dramas where approximately 300 community members attended each time. Total 65 video shows were organized on reproductive health issues with the help of District Information Office and Department of Mass Communication. These shows were organized in the evening. The contents of the video show included safe motherhood, family planning, child health, gender, male involvement, services available in the service delivery center, etc. Ten jari gan events were held on reproductive health issues in the project areas. With the assistance of CSG members and field workers, a local cultural group organized a drama to increase awareness of family planning, reproductive health and maternal health care services.
This paper only highlights the changes of knowledge on selected RH issues among female unmarried adolescents over the intervention period as a part of evaluation of the large project.
Inclusion criteria required participants to be female, age 12–19 years and currently female unmarried adolescents. We excluded respondents if more than one female unmarried adolescent fulfilled the criteria from the same household. Female unmarried adolescents who were not residents in the area were also excluded. In households where potential participants resided but who were absent on the first attempted visit, up to three subsequent attempts were made to reach absentees.
At the initial stage of the study all households in the study areas were enumerated to collect basic information regarding age, sex, marital status, socio-economic condition, and other similar variables in order to develop the sampling frame under DBRHCP. According to this enumeration, there were 54,116 households in Nabiganj and 29,904 households in urban slum area of Dhaka city. After household enumeration, a baseline survey was conducted among female unmarried adolescents aged 12–19 years during November 2006 to March 2007. An end-line survey was done during November 2008 to March 2009. The sample size was 800 per site. The sample size was estimated based on a 95 % confidence with 90 % power and a 25 % non-response rate. The sample size calculation was based on prior research conducted by icddr,b in Abhoynagar and Mirsarai, which estimated that approximately 5 % of adolescents from the rural area utilized services from government facilities or NGOs . A total 800 female unmarried adolescents were selected independently for baseline and end-line survey from each study area by simple random sampling. The sample was drawn from the household enumeration list.
Survey measures and data collection
Experienced female interviewers who had previously worked in different public health research studies were recruited to serve as interviewers for this study. Selected interviewers received 1 month extensive training on adolescent health, reproductive health, menstruation, family planning methods, HIV and STIs, existing health service facilities and availability of services, and interview techniques. Trained interviewers interviewed female unmarried adolescents using a structured questionnaire. Each day after returning from the field, the interviewers crosschecked the completed questionnaires identify potential errors/mistakes. The field supervisors reviewed each of the questionnaires and conducted regular spot-checking to maintain data quality. An experienced field research manager coordinated the overall field activities.
The structured questionnaire was adopted from previous icddr,b studies, which also explored RH related knowledge among female unmarried adolescents. Prior to survey implementation, the study questionnaire was field tested and followed with a debriefing session to identify any errors or necessary corrections to the questionnaire. The questionnaire included items to assess knowledge and perception of menstruation, knowledge of family planning methods, perceptions of mode of transmission of HIV/AIDs including source of information, knowledge of STIs and reported STI symptoms, and utilization of health care facilities. STI-related symptoms included burning during urination, genital ulcer/sores, and excessive bleeding. These questions were prompted using the following two questions: “Have you heard about sexually transmitted diseases, what are those?” and “Have you experienced any of the following STI symptoms in the last 1 year?”.
Ethical approval for the study was obtained from the Ethical Review Committee (ERC) of icddr,b. The parents of female unmarried adolescents were asked for consent to allow their daughters to participate in the study. The study team received informed parental consent for all study participants including those under the age of 16. Once parental consent was obtained, the study team then approached the study participants. The parental non-response rate was 7 % in rural areas and 10 % in urban areas, but had already been corrected for in overall sample size estimation. None of the potential participants refused to participate. Data collection was anonymous and privacy was maintained during data collection. All interviews were conducted in a private corner/place of the household. To ensure confidentiality and anonymity, only identification numbers were used during data collection.
Descriptive analysis was conducted to estimate distributions of relevant characteristics of the sampled populations. A Bivariate analysis was done to compare baseline and end-line with respect to participant age, education, knowledge and perception of menstruation, knowledge of family planning methods, perceptions of mode of transmission of HIV/AIDs including source of information, knowledge of reported STI diseases and symptoms, and utilization of health care facilities. Proportions, 95 % confidence intervals (CIs), and p values were calculated for selected variables. SPSS version 10.0 (IBM Corp, Armonk, NY) was used for all statistical analysis. Chi square tests were used to see the difference in knowledge on selected RH issues between baseline and end-line among female unmarried adolescents.