Improving quality of sexual and reproductive health education: Pilot intervention with lower secondary school teachers and pedagogical students in some educational institutions in Viet Nam

176 HNUE JOURNAL OF SCIENCE DOI: 10.18173/2354-1059.2017-69 Chemical and Biological Science 2017, Vol. 62, Issue 10, pp. 176-184 This paper is available online at IMPROVING QUALITY OF SEXUAL AND REPRODUCTIVE HEALTH EDUCATION: PILOT INTERVENTION WITH LOWER SECONDARY SCHOOL TEACHERS AND PEDAGOGICAL STUDENTS IN SOME EDUCATIONAL INSTITUTIONS IN VIETNAM Nguyen Thi Hong Hanh, Do Thi Nhu Trang, Nguyen Thi Trung Thu, Le Thi Tuyet, Nguyen Phuc Hung and Duong Thi Anh Dao Faculty of Biology, Hanoi National University of Education Abstract. This study examined training modules for lower secondary school teachers and pedagogical students in order to improve their knowledge and motivation in sexual and reproductive health (SRH) education in their schools. An intervention study was conducted from 2013 to 2016 with 128 lower secondary school teachers and 100 pedagogical students. The pilot intervention was designed with 5 lessons providing knowledge on SRH and one lesson on interactive training skills. Pre- and post- tests were designed to measure the improvement in knowledge and attitude of the participants. After intervention, the rate of participants with at least 25/30 correct answers for the test on SHR knowledge has increased significantly, accounting for 91.2% among intervention group while remains at 4.8% among control group (P < 0.001). The gap between Hanoi city, Thai Binh – a rural province and Dien Bien – a mountainous province regarding the awareness on SRH importance was shortened after intervention (P < 0.05). Students had significantly higher motivation to integrate SRH into subject lessons than teachers (60.0% vs. 47.7% in pre-test, 99.0% vs. 78.9% in post-test, P < 0.05). The intervention results recommend that it will be more effective to train teachers when they are in pedagogical universities rather than after their graduation. The combination of knowledge and skills of training modules was helpful to increase motivation for SRH integration into subject lessons. Keywords: Teachers, pedagogical students, sexual and reproductive health education. 1. Introduction As the world becomes more interconnected than ever before, Vietnamese youth communicate about their own sexuality more openly and boldly [1]. So, they are requesting credible and accessible information on sexual and reproductive health (SRH) [2]. In order to respond to their needs, a number of reproductive health professionals, clinics, and non-governmental organizations have developed and implemented some programs Received November 25, 2017. Revised December 14, 2017. Accepted December 21, 2017. Contact Nguyen Thi Hong Hanh, e-mail address: hanhnth@hnue.edu.vn Improving quality of sexual and reproductive health education: pilot intervention with teachers 177 aimed at providing SHR education and at preventing sexually transmitted infections (STIs). However, only a small number of Vietnamese youth have had been accessed to these programs, their sources of knowledge are mainly from the internet. As a result, Vietnamese youth is facing a threat of sexual ill-being. Female adolescents are at higher risk of experiencing unintended premarital pregnancy [2]. The abortion rate of Vietnamese adolescent is in the top 5 of Southeast Asia with approximately 4,600 cases in 2016 (Ministry of Health) [3]. Both male and female adolescents are at higher risk of contracting an STI. According to the Health Ministry's statistical yearbook 2014, there were 3,956 children under 15 years old infected with STIs. Especially, half of all new HIV infection cases in Vietnam were at young people ages 15-24 [4]. Notably, in Vietnam, formal SRH education has not been compulsory yet in schools. So, SRH education quality depends heavily on teachers‟ intention. SRH issues are integrated into several subjects‟ curriculums but teachers sometimes do not include these topics in their lessons because they feel uncomfortable and not confident when talking about this very sensitive matter [5]. Consequently, SRH education quality in Vietnam is uneven and does not meet the objectives of general education by Ministry of Education and Training (MOET) [6]. On the other hand, according to Hailonga (2005) [7], the most important influencing factor on impeding adolescents from benefiting from school-based SHR education and the quality of SHR education is teachers‟ attitudes towards the subject. In addition, the research results of Mkumbo (2012) [8] pointed out that most teachers in both urban and rural Tanzania expressed difficulties and discomfort in teaching most of the key sexuality education topics. This has a huge impact on their willingness to teach sexuality education programs in schools. Therefore, in order to improve the quality of education, changing the perception of teachers on this issue should be a top concern. The study examined training modules for lower secondary school teachers and pedagogical students since aiming to improve their knowledge and motivation in SRH lessons delivered in schools. 
 2. Content 2.1. Research methodology * Study population An intervention study was conducted from 2013-2016 with 68 secondary school teachers (23-34 years old) in Hanoi and 60 secondary school teachers (24-33 years old) in Dien Bien province; and 50 pedagogical students (19-22 years old) in Hanoi National University of Education and 50 pedagogical students (19-22 years old) in Thai Binh Pedagogical College with a retention rate of 100%. The same sample size was applied for control groups in all sites. 87.7% of them are Kinh, the main ethnic group in Vietnam. * Intervention design Pilot intervention was designed with 5 lessons (250 minutes) providing knowledge on SRH and 1 lesson (50 minutes) on interactive training skills with the theme of each lesson as follows: (1) Adolescent reproductive health, (2) Contraceptive methods, (3) Safe and unsafe abortion, (4) Sexually transmitted diseases and HIV/AIDS, (5) Maternal and child health care, (6) Methods of teaching, integrating, extracurricular activities on SRH. N. T. H. Hanh, D. T. N. Trang, N. T. T. Thu, L. T. Tuyet, N. P. Hung and D. T. A. Dao 178 All lessons used the cognitive and capacity approach such as role-play, group discussion, project work, problem-solving. Learners are the center of the learning process in which learners were encouraged to share their opinions and their decisions. Meanwhile, the control learned about SHR by themselves. Training educators are lecturers in the Department of Human and animal physiology, Faculty of Biology and experts in Reproductive Health Education and Family Planning Center, Hanoi National University of Education. Before program implementation, training educators participated in a training session, where materials were reviewed and teachers‟ concerns were addressed and clarified. * Assessment Knowledge: Pre- and post- test were designed to measure changes in knowledge and attitude of the participants. Each participant was taken two tests before and after intervention within 15 minutes. Each test included 30 multiple-choice questions about SHR knowledge (about human reproduction, contraception methods, STIs and HIV/AIDS.) that was approved by Reproductive Health Education and Family Planning Center, Hanoi National University of Education. Awareness, intention, and motivation: Participants were asked to answer a prepared questionnaire about awareness on SRH importance; intention and motivation to teach and integrate SHR in their lessons. The scale used as a measure of awareness on SRH importance included two items: (1) the importance of learning SRH for children and (2) the importance of teaching SRH. Learners answered each statement using a three-point scale ranging from „agree‟, „not sure‟ and „disagree‟. The scale used as a measure of intention and motivation included two items. One assessed the teacher's confidence in teaching, integrating SRH knowledge into future lectures using a three point scale ranging from „not confidence‟, „not sure‟ and „confidence‟ and another related to their intention to teach, integrate and organize extra-curricular activities on SRH in the future using a two point scale including „yes‟, and „no‟. These scales were approved by Reproductive Health Education and Family Planning Center, Hanoi National University of Education. Participants also are required to design their lectures at the end of the training program. * Statistical analysis Categorical variables were expressed as percentages. Continuous variables were expressed as means ± SD if variables were normal distribution. Chi-square test or one- way ANOVA or independent-sample t-test was used when appropriate. The statistical analyses were done with the statistical software package SPSS16.0 (SPSS Inc., Chicago, Illinois). P-values < 0.05 were considered as significant. Crude DiD (difference-in-differences) index that permits the comparison of differences in outcomes, before and after an intervention was calculated by the formula: DiD = (Y1[D = 1] – Y0[D = 1]) – (Y1[D = 0] – Y0[D = 0]) Note: Y0[D = 0]: The value of the control group at t0 (before intervention) Y0[D = 1]: The value of the control group at t1 (after intervention) Y1[D = 0]: The value of the intervention group at t0 (before intervention) Y1[D = 1]: The value of the intervention group at t1 (after intervention) Improving quality of sexual and reproductive health education: pilot intervention with teachers 179 The completed test was assessed and classified into three levels as follows: „high‟ for 25 to 30 correct answers (> 75 th percentiles), „medium‟ for 16 to 24 correct answers (25th - 75 th percentiles), „low‟ for under 16 correct answers (< 25th percentiles). Each correct answer was given one point. * Ethical considerations During the intervention, the teachers and students had the right to stop participating in the study at any time. The personal information was kept secretly. 2.2. Results 2.2.1. Awareness of participants on SRH importance The gap among Hanoi city, Thai Binh and Dien Bien regarding awareness on SRH importance was shortened after the intervention (Fig.1). In the pre-test, the percentage of teachers in both control and intervention groups saying that “SRH education was very importance” was significantly higher in Hanoi compared to those in Dien Bien. Similarly, the number of students in Hanoi had the same answer was greater than that in Thai Binh in both control and intervention groups (P < 0.05). After intervention, the percentages of participants aware of the importance of SHR among intervention groups were significantly higher than those in control groups (75% vs. 38.3% in teachers in Dien Bien P < 0.05; 88.2% vs. 61.8% in teachers in Hanoi P < 0.05; 98% vs. 74% in students in Hanoi, P < 0.05; 98% vs. 52% in students in Thai Binh, P < 0.001). Crude DiD (difference-in-differences) index in teachers in Dien Bien, teachers in Hanoi, students in Hanoi, students in Thai Binh groups were 40.1% (P < 0.001), 23.3% (P < 0.05), 20.0% (P < 0.05), and 48.0% (P < 0.001), respectively. Figure 1. Awareness of participants on SRH importance * P < 0.05; ** P < 0.001, P-values obtained by Chi-square test N. T. H. Hanh, D. T. N. Trang, N. T. T. Thu, L. T. Tuyet, N. P. Hung and D. T. A. Dao 180 Thus, the level of change of teachers in Dien Bien and students in Thai Binh groups was higher than teachers in Hanoi and students in Hanoi groups, although after intervention, the data was the same between students in Hanoi and students in Thai Binh (98%) and the proportion of participants aware of the importance of SHR among teachers in Hanoi was slightly higher than that of teachers in Dien Bien (88.2% vs. 75%, P = 0.079). 2.2.2. Knowledge of participants on SRH Before intervention, there were no differences between intervention and control groups regarding knowledge on adolescent reproductive health, contraceptive methods, unsafe abortion, sexually transmitted diseases and HIV/AIDS (Table 1). The average mark in control group and intervention group was 16.8 and 17.0, respectively (P = 0.759). DiD of the average mark was 7.1 (P < 0.001). The proportion of participants with high knowledge (at least 25/30 correct answers) was similar between control and intervention groups (6.1% and 4.4% respectively, P = 0.523). After intervention, the rate has increased significantly among intervention group (91.2%) while remains at 4.8% among control group (P < 0.001). Table 1. Average marks and categories Classifications Pre-test Post-test Control Group (n=228) Interventi on group (n=228) P Control Group (n=228) Interventio n group (n=228) P Average mark a 16.8 2.9 17.0 3.1 0.579 17.7 3.3 25 2.4 <0.001 High (25-30 correct answers) b 10 (4.4) 14 (6.1) 0.523 11 (4.8) 208 (91.2) <0.001 Medium (16-24 correct answers) b 148 (64.9) 151 (66.2) 157 (68.9) 20 (8.8) Low (0-15 correct answers) b 70 (30.7) 63 (27.7) 60 (26.3) 0 (0) a Data are presented as mean±SD, P-value obtained by Student T-test. b Data are presented as n (%), P-values obtained by Chi-square test. Notably, after intervention, there was a difference between the teachers and the students about the post-test results in intervention group (Fig.2). The percentage of students who had high marks was 96%, while that of teachers was 87.5% (P = 0.024). Improving quality of sexual and reproductive health education: pilot intervention with teachers 181 Figure 2. Comparison of post-test result between intervention teachers and students 2.2.3. Intention and motivation to teach and integrate SHR After intervention 100% participants (n = 228) were confident about lessons planning to integrate SRH and interactive training methods in comparison to only 45.6% (n = 104) before intervention. Figure 3. The percentage of participants intending to teach, integrate and organize extra-curricular activities on SRH in the future * P < 0.05, NS. Non-significant, P-values obtained by Chi-square test Students had significantly higher motivation to integrate SRH into subject lessons than teachers (Figure 3). When asked: „Do you intend to teach, integrate and organize extra-curricular activities on SRH in the future?‟, 47.7% of teacher (n = 61) and 60% N. T. H. Hanh, D. T. N. Trang, N. T. T. Thu, L. T. Tuyet, N. P. Hung and D. T. A. Dao 182 of students (n = 60) say „yes‟ before intervention while this rate was 78.9% (n = 101) and 99% (n = 99), respectively after intervention (P < 0.05). 2.2.4. Discussion Research results indicate that training helps teachers improve their knowledge of SHR, increase their awareness and motivation in teaching and integrating SRH. Kirby indicates that teachers‟ competence is a leading factor that should be placed in focus when conducting sexual education [9]. However, some studies confirm that teachers had limited knowledge, skills and confidence to deal with SRH issues, especially because of the difficult questions students ask [10, 11]. Besides, the school is one of the most suitable environments for SRH education because schools reach early adolescents with different socio-economic backgrounds, especially during puberty [12, 13]. Thus, SHR education programs in schools help to provide adolescents with the information and skills that they will need to make responsible decisions about their future sexual lives [14, 15]. According to research by Coyle [16] in a cohort of 3,869 students in 20 high schools in California and Texas, after 31 months, Safer Choices program was great effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants condom using, reducing the frequency of intercourse during the three months prior to the survey, reducing the number of sexual partners, and increasing use of condoms and other protection against pregnancy at last intercourse. When conducting a meta-analysis of 97 studies on the effectiveness of SRH educational programs, Kirby [14] also pointed out that 34% of 73 programs on the timing of the initiation of sexual intercourse delayed the initiation of sexual intercourse among young people. However, in Vietnam, reproductive health education programs in schools are limited. Most programs are pilot programs of non-governmental organizations financed primarily by international resources in some specific locations. Therefore, the sustainability of these programs is a matter of concern. Our research has shown that interventions help to increase awareness and motivation of teachers in teaching and integrating SRH knowledge. However, the effect of this program on their students has not been evaluated. Further research is needed in the future to improve the effectiveness of the program. Nowadays, in Vietnam, there is still a great gap in educational levels among upland provinces compared to delta provinces. The differences in SRH knowledge across regions are due to cultural barriers and limited access to information, education, and communication on these topics. However, this training program has helped to narrow the gap between Hanoi city, Thai Binh – a rural province and Dien Bien – a mountainous province regarding awareness on SRH importance. Our research is hopeful that the training for pedagogical students helps to raise future teachers' awareness in all regions of our country. In this study, we also found that students had significantly higher motivation to integrate SRH into subject lessons than teachers. This can be explained by traditional, and personal sensitivities of the teachers who teach in secondary schools. Meanwhile, pedagogical students are more open-minded young people who want to change because of their own needs. Improving quality of sexual and reproductive health education: pilot intervention with teachers 183 3. Conclusion The intervention result recommends that it will be more effective to train teachers since they are in pedagogical university rather than after their graduation. The combination of knowledge and skills of training modules is helpful to increase participants‟ motivation for SRH integration into subject lessons. Such training intervention is especially meaningful to teachers and pedagogical students who are teaching or will work in rural and mountainous areas. Acknowledgements. The authors would like to thank all teachers and students for the coordination during the study, and colleagues at the Reproductive Health Education and Family Planning Center and Hanoi National University of Education for their kind help and support. REFERENCES [1] Gammeltoft T., 2002. Being Special for Somebody: Urban Sexualities in Contemporary Vietnam. Asian Journal of Social Science, 30, No. 3, pp. 476-92. [2] Khuat T.H. 2003. 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