319Surmach M, Tishchenko E. Reproductive health of teenagers as the research problem: the substantiation of methodology

Reproductive health of teenagers as the research problem: the substantiation of methodologyZdrowie rozrodcze nastolatków jako problem badawczy: uzasadnienie metodologii

Marina Surmach 1/, Eugeniusz Tishchenko 2/

1/ Chair of Public Health and Public Health Care, Grodno State Medical University, Belarus2/ Dean of Medical-Diagnostics Faculty, Grodno State Medical University, Belarus

Aim. To prove the medical-sociological technique of research of reproductive health of teenagers with the account of modern approaches to the understanding of health and the health-related quality of life.Method. Two ways of data selection are allocated in its frame: the analysis of factors, significant for health of teenagers from the point of view of adults; and research of factors, significant from the point of view of teenagers. Results. It was revealed that research of health of teenagers has the specificity connected with age factor. The social approach is the core from the positions of sociology of health. Quality of life connected with health can become the criterion of an estimation of state of health of children. But the basic methodological problem is the absence of a uniform questionnaire and methodology of estimation of results, which is crucial for reproductive health. The questionnaire developed by us allows to study factors of teenagers’ ways of life and life conditions, to reveal potential risk factors. The technique unites objective (physical activity, social functioning) and subjective (emotional status, teenager`s satisfaction with realization of health-related needs) criteria. Reproductive objectives of teenagers are investigated. We have included factors important for quality of life and reproductive health from the teenager’s point of view, and the factors which are not significantly important from the teenager’s point of view, but with real value for teenage reproductive health. The questionnaire passed preliminary test and was applied on the republican sample of teenagers.

Key words: reproductive health of teenagers, health-related quality of life, questionnaire, methodology of research

Cel pracy. Zbadanie medyczno-socjologicznej techniki badań nad zdrowiem rozrodczym nastolatków oraz współczesnego pojmowania zdrowia i jakości życia determinowanej stanem zdrowia.Metoda. W wyborze danych zastosowano determinanty socjologiczne – analizę czynników istotnych dla zdrowia nastolatków zarówno z punktu widzenia dorosłych, jak i młodzieży.Wyniki. Zdrowie nastolatków koreluje z czynnikiem wieku. Jakość życia w korelacji ze zdrowiem można uznać za kryterium oceny stanu zdrowia dzieci. Jednak podstawowym problemem metodologicznym jest brak standardowego kwestionariusza i metodologii oceny wyników. Kwestionariusz opracowany przez autorów pozwala na badanie warunków życia nastolatków i wykrywa potencjalne czynniki ryzyka. Nasz kwestionariusz łączy kryteria obiektywne (aktywność fizyczna, funkcjonowanie społeczne) oraz subiektywne (stan emocjonalny, satysfakcja z możliwości realizacji potrzeb zdrowotnych). Badane są cele rozrodcze młodzieży. Włączyliśmy czynniki istotne dla jakości życia i zdrowia rozrodczego z punktu widzenia nastolatków, a także czynniki, które młodzież ignoruje, a które wpływają istotnie na jakość życia i rozrodczość. Kwestionariusz został przetestowany i zastosowany w badaniu grupy białoruskich nastolatków.

Słowa kluczowe: zdrowie rozrodcze nastolatków, jakość życia determinowana stanem zdrowia, kwestionariusz, metodologia badań

Adres do korespondencji / Address for correspondenceAss. Prof. Marina SurmachGrodno State Medical UniversityGorkogo St 80, Grodno 230009e-mail: marina_surmach@mail.ru, Belarus

© Hygeia Public Health 2011, 46(3): 319-325

www.h-ph.pl

Nadesłano: 20.06.2011Zakwalifikowano do druku: 05.07.2011

Modern approaches to understanding health and methodological peculiarities of its studying

Modern definitions of health consider healthas «The condition providing the realization ofbiologicalandsocial functionsinfullvolume».Theprincipleofcompletenessofrealizationoffunctionsinthedefinitionofhealthhasbeenputattheheart

of the functional approach. Its founder was thefamoussociologistT.Parsons,whodefinedhealthas«Optimumpossibilitiesoftheindividualtocarryouteffectivelytherolesandproblemsforwhichhe/shehasbeensocialized». Changesinmodernapproachestounderstandinghealtharereflectedinthemethodologyofitsstudying.

Hygeia Public Health 2011, 46(3): 319-325

320 Hygeia Public Health 2011, 46(3): 319-325

The sociological method becomes the integral andbasicmethodatthepresentstage. Priorities in methodology of studying healthof teenagers from a position of sociology of healthhavechangedinparallelwiththechangeofaccentofresearchesfrombiologicalfactorstopsychologicaland,atlast,tosocial.Biological,cognitive,psychosexualandsocialapproacheshavebeendeveloped[1,p.10]. Thesocialapproachtohealthofteenagersprevailsduring recent years in the sociology of health. It isdirectedtowardstheresearchofabilityofteenagersto understand social relations and to understandotherpeople.Complexityanddurationofprocessofacquisition of social knowledge is underlined. Theapproachisbasedonphysical,psychologicalandsocialpeculiaritiesofateenager:activehormonalprocesses,dependence on the big number of micro-socialfactors of environment (family, school, immediateenvironment) and macro-social factors (society,culture),activeknowledgeofapersonalroleinthesocietyandwaysofitsrealization,perceptionofvitalvalues and behavioral norms into various spheres,including the sphere of health. Not being able toestimate objective processes, the teenager is rathervulnerabletotheinfluenceofsocialandinformationalenvironment[2,3]. Within the limits of the social approach tohealth (in the frameworks of sociology of health)wecanallocatetwowaysofdataselection[8,p.19].The first consists of the selection and the analysisof factors, significant for health of teenagers fromthepointofviewofadultpeople–parents,relatives.It is characteristic that conclusions, as a rule, areconnectedwithteenagers’indifferenceincareabouthealthandinsufficientsensiblenessoffactorsnegativefor health. The second way provides the researchof factors significant for health from the point ofviewofteenagersthemselves.Withthereferencetoreproductivehealth,I.V.Zhuravlyovaincludesinsuchfactorstheteenagers’knowledgeaboutreproductiveand sexual health, the data about the place of theteenagerinthesociety,intheadultlife,aboutwaysofadaptationtoit.Theunderstandingandsupportoftheteenagerbyparents,contemporaries(inotherwords,socialsupport)playsanimportantrole[4,5]. Methodologicalapproachestostudyingthehealthofteenagersintheclinicalmedicinearecharacterizedin modern conditions by the increase of socialorientation. TraditionallythehealthofteenagersisestimatedintheclinicalpracticeinBelarusbythetechniqueofcomplex estimation of state of health of children, atmasspreventivemedicalexaminations.Thetechniquewasdevelopedmorethan30yearsagobytheInstituteofHygieneofchildrenandteenagersoftheMinistryofHealthoftheUSSRundermanagementofS.M.Grombah

[6].ByS.M.Grombah’stechnique,indicatorsofhealthofchildrenarethefollowing:theabsenceofdiseases,normal condition of the basic functions, timely andharmonious development, high reactance of anorganism. According to the condition of indicatorsrevealed at a complex medical-preventive survey, thechildqualifiesforoneoffivegroupsofhealth. The author of the methodology S.M.Grombahnoticed later thatbiologicalestimationalone isnotenoughforthecomplexapproachtotheproblem,asmany children who from purely medical positionscannotbeconsideredhealthy,inthepracticearequitesufficientinthesocialfunctionsand,hence,arequitehigh-grade members of the society. S.M.Grombahspecifiedthattherewasanecessityofmoredetailedcharacteristics of health, the estimation of its levelshouldbebasedonthedegreeofrealizedpossibilities,i.e.onthedegreeofsocialcapacity,orsocialadaptation.Forthefirsttimethescientistshadachancetodividechildrenintosocialgroupsofhealthwhichcannotcoincidewithtraditionalclinicalgroups. Inthelastyears,leadingpediatriciansofdifferentcountriesstatedthenecessityofinclusionofresearchofqualityoflifeforanestimationofstateofhealthofchildren.AsV.J.AlbitskyandI.V.Vinjarskajamark:«Theindicatorofqualityoflifewhichvaluesaperson’sjudgmentofownphysical,psychologicalandsocialwell-beingcanbecomethenewcriterionofhealthofchildren»[7,p.16].Theconcept«thequalityoflifeconnectedwithhealth»opensaconceptofhealthwiththefunctionalapproachdevelopedinthesociologyofhealth.So,V.J.Albitskyspecifiesthat:«Introductionof an indicator of quality of life as the additionalcriterionwillallowtomodifyanexistingtechniqueofcomplexestimationofstateofhealthofchildrenandtomakeitatanew,modernlevelwiththeapplicationoftheinternationalapproaches,anduseofastandardtoolkitwillmakeresearchcomparableinanyterritory»[7,p.17].

Health-related quality of teenage life: toolkit requirements. Peculiarities of reproductive health

The analysis of quality of life in pediatricsallowstoinvestigatenotonlyclinical,butalsosuchsocialaspectsofhealthofchildren,asperceptionofsurroundingworldby thechild, theattitudeof thechild to disease and treatment, rules of occurrenceof psychological and social problems in the familybecause of the disease at the child, condition of“optimumhealth”fromthepointofviewofthechildandhisparents[8]. It is especially important in the estimation ofreproductivehealth,becausetheaccountofknowledgeofteenagers,ofsocialandbehavioralfactorsofriskofearlysexualexperiencearenecessary.

321Surmach M, Tishchenko E. Reproductive health of teenagers as the research problem: the substantiation of methodology

However,theintroductionofthesocialapproachto studying health inpublic health service practiceencounters methodological problems. The mostsignificantproblemsinstudyingtheteenagequalityoflifeconnectedwithhealthcontaintheabsence:

–ofuniformRussian-speakingquestionnaire,–of the unified methodology of an estimation of

results,–andoftheaccountofspecificityofstudiedaspects

ofhealth(reproductivehealth,teenage).Any technique for studying health-related qualityoflifeofteenagersdevelopedbydomesticscientistshas not received the standard status till now. Atthe same time, a number of works as, for example,developed in the Belarusian Medical Academy ofPostgraduateEducation«TheMethodofestimationofindividualqualityoflife»[9],deservemoresteadfaststudying and wide circulation. The results receivedbyI.V.Mashchenko(withthehelpoftheMethod)atresearchofqualityoflifeof14-18-year-oldteenagersof Minsk and Molodechno have shown that theaverageindexofqualityoflifeislowandmakes23.5%.Leading factors of poor quality of life of teenagersareaconcernforhealthandqualityofsocialization.Self-estimationofhealthisoneofthemajorfactorsdetermininganindicatorofqualityoflife[9]. As E.V.Bahadova notes: «There is an importantaspectforanindividual inthedefinitionofqualityof life: it is a subjectivity of indicators from theadult or the child. The person can take an activeor passive position in the dyad «Health-Illness»,andcanregulatesubjectiveperceptionofqualityoflife. For the child this is much more difficult as itis still strongly dependent on external and familyfactors.Achildisnotinaconditiontoregulatemanyprocesses, including social and psychological. Thechild’s subjective perception of peculiarities of thefunctioning, health and quality of life is a seriousmoment for revealing of peculiarities of medical-biologicandsocialadaptation…Thebestperspectiveistheapproachtothedecisionofquestionofhealthanddegreeofillnessfromthepositionsofestimationofqualityoflife–bythesubjectiveperceptionofitsindicatorsfromthechildorhisparents»[10]. Thedataaboutresearchofqualityoflifeforthewhole population submit the big value for variousinstitutes of a society [11, p. 107]. Such standardindicatorsareavailableinalldevelopedcountriesoftheworldfromtheendof1990sthatbecamepossiblebyworkingoutandintroductionofthequestionnaireSF-36 [12]. This questionnaire is applicable for anagecategoryfrom15till85years.Thustheconsentof parents and their interrogation for teenagerespondentsarenotprovided.ThebasiclacklimitingpossibilitiesofapplicationofthequestionnaireSF-36forteenagersistheabsenceofsensitivitytospecificity

ofteenage,and,asaconsequence–theinsufficientaccount of peculiarities of teenagers and theirreproductivehealthasthesubjectandtheobjectofresearch.Atthesametimeitisknownthatadisplayofeachofcomponentsofqualityoflifedependsontheageofthechild:inparticular,atschoolagequestionsofacomponentofsocialfunctioningarebasedontheactivityofthechildatschoolandconnectedwithhis/heradaptationinthecollective,skilltocommunicate[11,p.233].Reproductivehealthanditsinfluenceonthequalityoflifeoftheteenagerishighlyspecific,andthatshouldbereflectedinthequestionnaire. The questionnaires applied in the pediatricpracticereflectspecificityofchildandteenage.Atthesametime,they(inanoverwhelmingmajority)assumeparticipationintheresearchaschildrenandparents,namelythecomplexapproachconsideringinaggregateopinionofthechild(self-report)andparents(proxy-report)[11,p.232].Impossibilityofapplicationofthestandardinternationalquestionnaires(mostknownamongthemare“ChildHealthQuestionnaire”and“PedsQL”) in our research «Teenager: reproductivehealth and behavior» is connected first of all withthe methodology of research. It is not assumingthe participation of parents because that wouldlower the reliability of the information receivedfrom the teenager concerning behavioral factors ofreproductive health – as unconditional display ofa «proxy-problem» or a«cross-informant variance»phenomenon[13,14]),butalsowiththe fact thatthegivenquestionnairesdonotallowtoreceivetherequiredinformationaboutreproductivehealthinfullvolume.Besides,theculturalandlanguageadaptationand subsequent validation of questionnaires fromanotherlanguageisaratherdifficultandexpensiveprocedure. In generalizing techniques of research of thehealth-relatedqualityoflifeofteenagers,itisnecessarytonoticethattheyunitetwotypesofcriteriaandaredirectedtowardsstudyingthephysical,psychologicaland social functioning with their interrelations.Objectivecriteriaincludephysicalactivity,thefactorsconnectedwithsocialfunctioning–study,adaptationinthecollective.Subjectivecriteriacontainfactorsoftheemotionalstatus,satisfactionwithvariousaspectsoflife,thestateofhealthandself-estimationofhealth-related factors – in other words, degrees of teenageperceptionoftowhatdegreehis/herrequirementsforhealtharesatisfiedandtowhatdegreethepossibilitiesnecessaryforitaregiven. The basic questionnaire requirements for theresearchofqualityoflifeinmedicineincludereliability(accuracyofmeasurement),validity(abilitytomeasureauthenticallythecharacteristicsinthequestionnaire)andsensitivity(abilitytorevealchangeindynamics)[11,p.40-41].Therequirementsforthequestionnaires

322 Hygeia Public Health 2011, 46(3): 319-325

appliedinpediatricsaresimilar[15,p.28].Hence,theaccountofthespecifiedrequirementsbytheauthor`squestionnairewillallowtoprovideitssuitabilityforobjectivesoftheresearch. Thequestionnaire«Teenager:reproductivehealthandbehavior»(fig.1)containsthesectionsallowingto characterize factors of way of life of teenagers(nutrition, dreams, physical activity, apsycho-emotional background, prevalence of smoking,peculiaritiesofbehavior inrelationtoalcohol); lifeconditionsofteenagers(suchsocialcharacteristicsasfamilytype,quantityofchildren,residing,educationofparents,financialconditionsoffamily);presenceof potential risk factors (familiarizing with drugsand other psychoactive substances, risk of crisispsychological conditions, of risky sexual behavior(contraceptive behavior, pregnancies); medicalactivity of teenagers (attitudes to medical aid,including gynecological or urological), knowledgeaboutpossibilitiesofmedicalaiduse). Reproductiveobjectivesarestudiedquantitatively.By mark scales are investigated such factors as:estimation and self-estimation of state of health,self-estimationofnutrition,physicalactivity,psycho-emotional status, financial position of family,possibilities of social realization in the future,knowledgeaboutreproductivehealth. Wehave includedfactors important forqualityof life and reproductive health from the point ofviewof theteenager,andthe factorswhicharenotsignificantlyimportantfromtheteenager’spointofview, butwith real value for reproductivehealthofteenagers(vitalvalues,sourcesofinformationaboutreproductivehealth,somefactorsconnectedwiththeorganizationofmedicalandpsychologicalhelp). Thus,advantagesofbothwaysofselectionofdatainasociologicalresearchofhealthofteenagersareused,subjectiveandobjectivecriteriaofresearchofqualityofalifeareunited,specificityofindicatorsofbehaviorinthefieldofreproductivehealthisconsidered. The questionnaire is balanced by the quantityofquestions(58closed andhalf-closed questions),made with the account of staging of interview, haspassed a preliminary test at carrying out a “flight”research. Recommendations about the necessity of„anunderstandingposition”whenthemaintenanceof questions should consider values dominatingamong respondents are taken into consideration attheformulationofquestions[16].

Probation of the questionnaire: “flight” research, design of the republican sample of teenagers

The questionnaire probation in the researchof100teenagerswhovisitedtheGrodnoCenterofhealth of teenagers was made in 2009. The results

have confirmed the reliability and validity of thequestionnaire. The basic interview was made inthe spring of 2010. We used a casual selection ofrespondentsinthepointsofdatagathering. According to the report of the WHO researchgroup«Healthofyouthisthecareofsociety»(Geneva,1989), the“teenage” is theperiod from10till19years,theterm„youth”isusedconcerningpeopleof15-25years,„youngmen”–personsof10-24years[17,18,p.5].TheLawAboutMarriageandFamilyoftheRepublicofBelarusdefinesthepersonfromthemomentofbirthuntil18yearsofageas“theminor”,until14years-as“juvenile”,thepersonattheagebetween 14-18 years - as “the teenager” [19]. It isnecessarytonoticethattheearlyteenage(10-14years)isclosersociallyandpsychologicallytochildren’sage,andconsiderablydiffersfrommoreadultagegroups.Thegroupofpersonsofearlyteenage(10-14years)in the sample designing has been lowered, as thepotential medical-sociological information receivedfromthisgroupofrespondentscannotbegeneralizedwith the research data from more mature persons,besides,thediscussionofquestionsofreproductionandsexualityatchildren’sandearlyteenageshouldbestrictlyregulatedpsychologicallyandpedagogically.Wegeneratedthesamplereflectingrepresentativelythegeneralteenagepopulationforsexualandterritorialdistribution. The calculated volume of the samplecorrespondstoaraisedreliabilityofresearch. So, the data about the mid-annual populationof the Republic of Belarus have allowed to defineparitiesinthesamplebetweenthecityandcountrypopulations,betweencitieswithadifferentnumberofpopulation(citieswiththepopulationofmorethan50 thousand people and cities with the number ofpopulationoflessthan50thousandpeople),betweenpartsofthesamplefromseparateadministrativeandterritorial units. According to the official statisticaldataaboutdistributionofresidentpopulationoftherepublicbythegender,theparityof1,05boysto1,0girlshasbeenestablished. ThedesignproceduresofferedbyU.Kokrenareused.ThevolumeofthesamplefordefinitionoftheshareofsomesignXinthegeneraltotalityiscalculatedundertheformula[20,p.90]:

n =+

1∆2

t2 v(1-v)1N

(1)

Where N is the volume of general totality, n – thevolumeofthesample,t–thefactorcorrespondingtoconfidentialprobabilityp(isdefinedunderStudent`stables,forp=0.95,t=2),v–theproportionofthesignXinthegeneraltotality,Δ–thesizeofanadmissibleerror. Our research «Teenager: reproductive healthandbehavior»assumedtoinvestigatethecomplexof

323Surmach M, Tishchenko E. Reproductive health of teenagers as the research problem: the substantiation of methodology

Fig. 1. Author’s questionnaire «Teenager: reproductive health and behavior»

324 Hygeia Public Health 2011, 46(3): 319-325

factors,valueofwhichisnotknown.Theinformationaboutthesizeofsign{v intheformula(1)}inthegeneral totality are not present for the majority ofthem. Inthesituationofimportanceofsuchafactorastheeconomicefficiencyofthesample,itisrecommended«tobeguidedbyachievementofaccuracyfirstofallforthemostimportantsignsfromthepointofviewoftheresearchobjectives»[21,p.463].Atthesametime,itisdifficulttorangestudiedfactorsinadvanceontheimportance for purpose achievement at the searchcharacterofresearch.So,itisobvious,thatatv=0.5thesizeofv(1-v)ismaximum,hence,nismaximumalso.Therefore,ifvisequaltovalue0.5intheformula(1),wewillreceivetheformulawhichcanbeusedatanyvaluesoftheproportionofthesigninthegeneraltotality[22,p.81]. Results of the medical-statistical research areauthentic at the value of confidential probabilityofpnotlessthan0,95(thust=2).Havingappliedthe specified values, we will receive the formularecommendedforcalculationofthevolumeofcasualsample:

n =+

1

∆2 1N

(2)

whereN–isthevolumeofthegeneraltotality,n–thevolumeofthesample,Δ–thesizeofanadmissibleerror. V.V.Paniottospecifiesthatatthesampleplanningitisnecessarytohaveinmindthattheformula(2)allowstoreceivethesetaccuracyatthesampleanalysisasawhole,whenitwillnotbedividedintoparts[22,p. 82]. Considering the necessity of account of thegender factor influenceonthestudiedsigns,at theplanningofresearchwestartwiththeprinciple,thatpartsofthesampleofteenagers,allocatedonthebasisofthegender,shouldbesufficientonthevolume. Attheconfidentialprobabilityofpnotlessthan0.95,thesizeofanadmissibleerrorΔshouldmakenomorethan0,05.Havingappliedthespecifiedvalue,andalsousingdataaboutthenumberofyoungmenandgirlson01.01.2009asvaluesN,wewillreceivethatvolumeofthesampleofboys,includedinthesubsequentanalysis,shouldmakenotlessthan400persons.Accordingtotheparityofboysandgirls,asampleofgirls,whosedatawillbeincludedinthesubsequentanalysis,shouldhavethevolumeofnotlessthan420persons.Hence,thevolumeofthewholesampleofteenagersthatrepresentativelyreflects the general totality of Belarusian teenagersmakesnotlessthan820persons. AccordingtoA.V.Reshetnikov,asmuchaspossibleanadmissiblepercentofreturnofquestionnairesshouldbenotlessthan85%,otherwisethesamplestructureisbroken[23,p.213;24].Havingthemaximumpercentof „safety factor” of the sample (15%), we receivethat its planned volume should make 943 persons

(460boysand483girls).Consideringthespecificityof teenagers as the object of studying [1,p.5], anadditional „safety factor” for questionnaires filledcarelessly has been added. Thus, the volume of thesampleplannedforthequestionnairehasmade1052persons. The percentage of return of questionnairesappeared maximum (about 100%) in the Gomelarea, minimum (less than 85%) – in Minsk andVitebsk. In this connection 100 questionnaires forMinskandVitebskwereduplicated.Thepercentageofquestionnairesfilledcarelesslyandnotincludedinthefurtheranalysishasmadeabout10%. ThesampleofteenagersreflectingrepresentativelythegeneraltotalityofBelarusianteenagers,whosedataare included in the further analysis, has made 949persons:463girlsand486boys(tableI). Thus,thesamplerepresentativelyreflectingthegeneral sample of teenagers according to genderandterritorialdistributionhasbeengenerated.Thesampleallowstoinvestigatestudiedfactorswiththeresultsaccuracycorrespondingwiththeprobabilityoferrorbylessthan0.05.Thecalculatedvolumeofthesamplecorrespondswiththeraisedreliabilityoftheresearch.

Conclusions

Validityoftoolkit,useofa“flight”questionnaireanditssubsequentprobationinscalesofacarefullydesignedsampleallowtoassumethevalidityofthemethodology developed by us for the research ofreproductivehealthofteenagers.

Table I. Sample of Belarusian teenagers, whose questionnaire data are used in the further analysis

Administrative-territorial part of the republic

Settlement Girls Boys Teenagers, total

Minsk and Minsk area Minsk 88 91 179

Borisov 13 14 27

Kopyl, Volozhin 25 26 51

Country population 31 33 64

Brest and Brest area Brest 15 16 31

Kamenets, Pinsk 30 31 61

Country population 24 25 49

Vitebsk and Vitebsk area Vitebsk 16 18 34

Orsha, Dubrovno 27 28 55

Country population 17 18 35

Gomel and Gomel area Gomel 23 25 48

Rogachev, Zhlobin 28 28 56

Country population 20 21 41

Grodno and Grodno area Grodno 16 17 33

Lida, Volkovysk 20 21 41

Country population 17 17 34

Mogilev and Mogilev area Mogilev 17 19 36

Bobrujsk, Gorki 23 24 47

Country population 13 14 27

Teenagers, total 463 486 949

325Surmach M, Tishchenko E. Reproductive health of teenagers as the research problem: the substantiation of methodology

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