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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 50-58

Is what is known enough? Knowledge, perception and competencies on reproductive and sexual health issues of nursing students from a Metropolitan City, Karnataka

1 Professor-Nursing, Division of Epidemiology and Population Health, St John's Research Institute, Bangalore, Karnataka, India
2 Free-lance Consultant, St John's Research Institute, Bangalore, Karnataka, India
3 Director-Pledge Academy, St John's Research Institute, Bangalore, Karnataka, India
4 Senior Resident, Division of Biostatistics, St John's Research Institute, Bangalore, Karnataka, India

Date of Submission26-May-2020
Date of Decision06-Jun-2020
Date of Acceptance22-Jun-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Maryann Washington
Division of Epidemiology and Population Health, St. John's Research Institute, Bengaluru - 560 034, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_47_20

Rights and Permissions

Nurses, by nature of their training and experience, are expected to be proficient in addressing sensitive issues, including reproductive and sexual health (RSH). However, health-care professionals are known to struggle with their personal and professional views with respect to these concerns. It is important to determine what young nursing students know and perceive about RSH issues and how they assess their own abilities to address these issues. Cross-sectional sample of 723 1st year nursing students of the undergraduate and diploma programmes, enrolled in eight institutions in a metropolitan city in Karnataka, South India, were selected purposively for this survey. Data were obtained through a self-administered questionnaire under four main sections as follows: (i) baseline information of the student; (ii) assessment of knowledge on 'growing up issues', 'prevention of pregnancy' and 'sexually transmitted infections including HIV;' (iii) understanding perceptions of students on RSH and (iv) self-assessed competency of students. Overall knowledge scores of students were below average (<50%). Responses of students to statements related to their perceptions indicated they required clarification on various RSH issues. Students assessed their personal and professional competency to deal with RSH issues, as a little above average (56%). Cognizance of these gaps in knowledge, perceptions and self-assessed competency on RSH issues of 1st year nursing students, necessitates educators to address these gaps early in their program as they, within 6-month of being enrolled for nursing, have clinical and community postings for a considerable duration of time.

Keywords: Competencies, knowledge, nurses, perception, reproductive and sexual health

How to cite this article:
Washington M, Hartley S, Tavares J, Pushparaj M, Selvam S, Mony PK. Is what is known enough? Knowledge, perception and competencies on reproductive and sexual health issues of nursing students from a Metropolitan City, Karnataka. Indian J Cont Nsg Edn 2020;21:50-8

How to cite this URL:
Washington M, Hartley S, Tavares J, Pushparaj M, Selvam S, Mony PK. Is what is known enough? Knowledge, perception and competencies on reproductive and sexual health issues of nursing students from a Metropolitan City, Karnataka. Indian J Cont Nsg Edn [serial online] 2020 [cited 2022 Aug 20];21:50-8. Available from: https://www.ijcne.org/text.asp?2020/21/1/50/295044

  Introduction Top

Nurses are indispensable to healthcare. Their expansive training in bio-physiological, social and behavioural sciences, as well as their continual contact with clientele in varied settings, puts them in a unique position to demystify health-related information and promote healthy behaviours in the community.[1],[2] Student nurses in India undergo rigorous training of 3–4 years, which incorporates theoretical and practical experiences through direct patient care in the hospital, community and schools from the 3rd month of enrolment. They learn basic clinical skills, including obtaining a clinical history and facilitating critical physical and mental assessments, which is a key competency in acute and chronic care settings.[3] They are thus expected to be proficient in establishing trusting relationships that is key to also conducting brief reproductive and sexual health (RSH) counselling.

Yet there have been speculations about a nurse's competence in handling such concerns personally as well as professionally. Experience with capacity building of seasoned nurses on HIV/AIDS in India showed that they were embarrassed to talk about these issues. Findings from the literature [4],[5] suggest that educational programs are needed to help nurses introspect and question strongly held attitudes, which might act as barriers when responding to personal and professional RSH concerns.[6],[7],[8],[9],[10] There is an evident need to bring awareness on how cultural, religious and traditional value systems could affect and prevent good quality RSH services.[11] Therefore, providing an opportunity for young nursing students to examine their values, attitudes, perceptions and personal behaviours on RSH in a neutral environment, is assumed, would potentially help them respond in an appropriate, non-judgemental and unbiased manner, to any related issues in their professional or personal lives.

In India, enrolment for nursing programmes generally occurs by those primarily in their late adolescence period at the age of 17–18 years, soon after intermediate studies (Grade 12). Young people's knowledge on RSH was found to be limited, non-existent, inappropriate or known to begin when they began to have sex.[12] A study of young people between 15 and 24 years in Nepal revealed that [13] A review on the health problems of adolescents in India indicated a high prevalence of high-risk sexual behaviour among young people (15–24 years), which needed to be addressed to prevent related health problems.[14] A critical analysis of nursing students [15] curricula and an assessment of their perceptions on related RSH issues [16] revealed curricula and competency gaps that hinder confidence in responding appropriately to these issues in the field.

Preparing young nurses to meet the specific knowledge needs on RSH is, therefore, a challenge requiring planned activities within the curriculum. The present curricula [1] of the undergraduate nursing diploma and degree programmes in India (2005–2006) have prescribed units on RSH within a biomedical-disease framework. While nursing students must be prepared to care for individuals with treatments that might affect RSH such as mastectomy, prostatectomy, radiation therapy, chemotherapy, palliative care; etc.;[6],[7],[17] these experiences could trigger changes in their own life as nurses and often they could struggle with differences between their personal and professional values on various RSH issues.[18]

This article is the initial part of a quasi-experimental study where a survey of the knowledge, perceptions and self-assessed competencies of the 1st year nursing students enrolled in institutions within a metropolitan city on RSH issues was done. This city is home to at least 203 and 167 institutions providing degree and diploma nursing, from a total of 513 and 302 nursing institutions, respectively, in Karnataka State alone that are recognised by the State Nursing Council. The findings of this survey provided insights to tailor curricula contextually for young nursing students in the selected institutions and to test the impact of this curricula on students' knowledge, perceptions and self-assessed competency on RSH issues.

  Materials and Methods Top

A cross-sectional survey of nursing students enrolled in nursing institutions located in a city of Karnataka, India, was performed before an interventional study. Twelve nursing institutions were identified purposively based on their management type (government, private or minority), whether they had an affiliation to a hospital, and if they offered either or both the Diploma and Degree Nursing program. Ethical clearance was obtained from the Institutional Ethics Committee (Ref No 137/2013). The study was also registered in the Clinical Trials Registry of India (CTRI/2017/04/008353). Official permission was obtained from the administrative heads of the institutions for the conduct of the study. Eight of the twelve institutions gave permission for the study, while four required a separate ethical clearance from their own institutions and thus were excluded due to time constraints. Thus, in all, we had one government, four minority, three privately managed institutions for the baseline study. The sample size calculated for this baseline survey was a minimum of 200 (at 95% of confidence interval, 5% precision and design effect of 2).

The study began in January 2017. Data was collected in March-April 2017 for the baseline survey before the intervention. In total, 856 1st year nursing students between ages 18–38 years were addressed in groups at their respective institutions. All students below 18 years, those who did not consent to participate in the study and those not available on the day of data collection were excluded. Although the needed sample size for the survey was only 200, all students who gave consent were recruited in the survey stage since all consented students had to be included for the intervention stage later. The students were given an introduction to the study, its purpose and what was expected of them and the researchers. They were asked to complete the survey in the classroom if they consented to participate in the study. It took approximately 45 min for the survey to be completed.

The survey had four sections. It was adapted from available instruments, based on the experience of the study team and validated by three experts in the field. The reliability of the tool was not checked due to the tight timeline for completion of the study. The first section provided baseline information of the student. The second section consisted of 33 statements to assess the students' knowledge on themes such as 'growing up issues', 'prevention of pregnancy' and 'sexually transmitted infections (STIs) including HIV' to which they had to respond either 'true', 'false' or 'do not know'. This section was scored based on responses to statements. Scores were arbitrarily categorised as below average if scores were <50%; 51%–60% was considered as average; 61%–80% as good and scores >80% as excellent. The third section was used to understand perceptions of students on RSH. It consisted of 15 statements where students had to respond on a 5-point scale to strongly agree', 'agree', 'undecided', 'disagree' or 'strongly disagree'. This section was not scored, but the proportions of students were presented based on their responses indicating their views on specific RSH aspects. The fourth section was used to measure self-assessed competency of students. It consisted of statements to which the nursing students had to rate their level of confidence on a scale ranging from 1 to 5 representing 'very confident', 'confident', 'some confidence', 'little confident', or 'not confident at all'. This section was scored based on the students' responses to their self-assessed level of confidence.

  Results Top

Of the total 856 nursing students from eight institutions enroled in the 1st-year nursing program, the response rate was 84%, with data from 723 students analysed; whereas the remaining 16% (133 students) were either not present or <18 years or had not consented to participate. Since the items on the questionnaires received from the students were incomplete on a few baseline variables, the number (n) of students differs by variables.

Nearly two-thirds of the students, 62% (447/723) were enroled in the degree programme and 276 (38%) in the diploma program. Majority (79% - 555/701) of the students surveyed were below 20 years of age. The students' age ranged from 18 to 38 years, with a mean of 19.05 (±1.69) years. Three students were 30 years and one, 38 years old. Almost all, 95% (688/722) of students were females. One did not mention gender. Of all the students, nearly two third 60% (434/723) were Christian, one third 29% (211/723) were Hindus, 7% (48/723) were Buddhists and 4% (30/723) were from other religions including Muslims, Donyi Polo and other indigenous groups. Majority of the students, 79% (574/716) of them, lived with both parents, 10% (72/716) with only the mother and 7% (53/716) with other family members. A very small proportion 2% (17/716) lived with their father only. The rest of the students had not mentioned about their living type.

Ninety-three percent (675/723) of the students were of Indian nationality and the remaining 7% (48/723) were foreign nationals. Of the foreign nationals 15% (7/48) reported themselves as foreign nationals hailing from Tibet, but settled in Indian states such as Uttarakhand, Himachal Pradesh, Karnataka and Sikkim. Those of Indian nationality came from all regions/zones [Figure 1] of the country with the most, 56% (385/664) from South India, and then 22% (147/664) from North Eastern states. All states of India were represented except for Haryana. However, the only union territory represented was Delhi. The most represented state was Kerala 34% (224/664) followed by Karnataka 17% (111/664). Eleven students had mentioned as Indians but did not mark their state.
Figure 1: Number of nursing students from different zones of India (n = 664)

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Two third, 62% (445/723) of all the students surveyed had attended a class on sexuality prior to being enrolled for their nursing course. The most common session that was covered during these classes was on prevention of STIs and HIV, as reported by 67% (298/445) who had attended classes.

Students reported that they mostly discussed issues on sexuality with their mother (62% - 446/723), then with peers (50% - 359/723) and siblings (19% - 140/723) and least with their father (3% - 19/723). While they reported to have received information on sexuality most commonly from a teacher (64% - 460/723), mother (42% - 306/723) and peer (32% - 231/723) [Figure 2]. When asked to mention the infectious disease they were most worried about as part of their professional work, HIV was the most common cause for concern among 73% of the students, followed by sexually transmitted diseases (21%) and tuberculosis (20%). The least feared disease reported included malaria (47%), dengue (33%) and tuberculosis (9%).
Figure 2: Source of information and person with whom students discussed RSH Issues before enrolling for nursing program (n = 723).

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Knowledge on reproductive and sexual health issues

Overall knowledge mean scores of students on RSH issues were below average, 46% (±13.98). Their mean knowledge scores on 'growing up issues' (48 ± 18), 'prevention of pregnancy' (44 ± 18) and 'STIs including HIV' (45 ± 17) was also below average (<50%) [Figure 3].
Figure 3: Knowledge scores of student nurses on RSH issues.

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Knowledge scores related to 'growing up issues' [Table 1] was not dependent on age, nationality or living arrangements (P > 0.05). However, degree students had significantly higher scores on this aspect than the diploma students (P < 0.001); female students scored significantly higher than male students (P < 0.01); students who had attended an RSH class prior to enrolling in the institution scored higher than those who had not (P < 0.05). A significant difference in knowledge score was also seen between students from different religions.
Table 1: Knowledge scores of student nurses on growing up issues according to baseline variables

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Knowledge scores related to 'prevention of pregnancy' [Table 2] did not differ significantly based on the type of program or their gender (P > 0.05). However, students >20 years scored higher than those <20 years of age; non-Indian students had better scores than Indian students, and those who attended a class on sexuality before being enrolled in the nursing program had higher scores (P < 0.05). In addition, scores of students, differed significantly based on their religion; and with whom they were living with. Students who lived with guardians other than their parents scored higher than those who lived with either or both parents (P < 0.05).
Table 2: Knowledge scores of student nurses related to prevention of pregnancy according to baseline variables

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The scores on knowledge related to 'STIs and HIV' [Table 3] differed significantly based on program, gender (P < 0.05) and prior attendance of a sexuality class (P < 0.001). The degree students had better scores than diploma students; males better than females, and students who had attended scoring higher than those that had not a class on sexuality prior to enrolling for the nursing program. Scores did not differ based on age, religion, nationality or living arrangement.
Table 3: Knowledge scores of student nurses on sexually transmitted infections including HIV/AIDS according to baseline variables

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Overall knowledge scores [Table 4] were not significantly different based on age, gender, nationality and living arrangement. However, students in the degree programme scored better than those in the diploma programme; those who attended a prior class on sexuality significantly scored better than those who had not(P < 0.001); and religious background of students had an impact on overall knowledge scores of students (P < 0.05).
Table 4: Overall knowledge scores of student nurses according to baseline variables

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Perceptions of nursing students towards reproductive and sexual health issues

Perceptions related to RSH were determined by the nursing students' responses to statements that were developed based on literature review and validated by experts. The aim was to understand their views with regard to personal and professional RSH behaviours before a planned sensitisation or training program. The statements were not scored because perceptions of students on these behaviours are personal and could depend on their knowledge, values and socio-cultural or religious background. [Table 5] is colour coded based on the proportion of students choosing a response, with the darkest shade indicating the largest proportion of students and the lightest shade indicating the least proportion.
Table 5: Perceptions of student nurses on reproductive and sexual health issues

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Students showed a definite direction of disagreeing to statements such as 'it is okay for people my age to have sex with different people' (80%) and 'Having sexual intercourse at my age is 'cool' thing for a girl or boy' (74%). Nearly a third of the students were unsure if 'Having sex with a virgin can cure AIDS' (29%), but two-thirds of them were leaning towards disagreeing with the statement (59%). The students showed a direction of agreeing to statements such as 'Condoms should be used if a person who is of my age is sexually active' (65%), 'Premarital sexual intercourse for young people is unacceptable for me' (57%), 'It is important to talk to your parents or counsellors about your sexual doubts' (86%) and 'Sexual intercourse should only occur between two people who are married to each other' (70%). Nearly a quarter of the students were unsure of the statement 'I can refuse to have sex with a person if I want' (23%), but the nearly two-thirds agreed to it (55%). Responses of students to other statements such as 'Girls can be safe from being raped if they dress properly' 'I believe a girl can have an abortion if the pregnancy was not wanted' 'All information on sex can be best obtained from the internet or watching movies or talking to my peers' are divided between the two ends of the scale. The following statements 'I would refuse to have sexual intercourse without a condom' (35%), 'Masturbating is safe and will not transmit HIV' (54%), 'People who get HIV/STD deserve it' (29%) had a quite a proportion of students in the unsure category.

A comparison of how these perceptions changed after a year of implementing a planned capacity building initiative using the life skills approach with the intervention and comparison group was studied, and results will be presented in another article.

Self-assessed competency scores

Self-assessed competency scores of students based on their response to the 12 items on the investigator developed tool was a little above average, with a mean score of 56% (±15.8) [Table 6]. Self-assessed competency scores did not differ on baseline variables such as age, gender and type of programme. However, students outside India had higher self-assessed competency scores compared to Indian students (P < 0.05). Determinants of self-assessed competency scores of students to address RSH issues personally and professionally were religious background, if they had attended a class before being enrolled in the nursing program and with whom they were living with (P < 0.05).
Table 6: Self-assessed competency of student nurses according to baseline variables

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  Discussion Top

Adolescent health is shaped by multifactorial psycho-socio-cultural and biological factors. Only a third of the nursing students surveyed reported to have had a class on sexuality prior to being enroled to the nursing programme, two-third discussed issues related to RSH with their mothers; two-thirds received information from their teachers on these issues. The survey clearly shows that young nursing students, coming from various states of the country and different religious backgrounds with the majority in their late adolescent period, have considerable gaps in knowledge and competencies related to sexual and reproductive health issues– growing up issues, prevention of pregnancy and STIs. Adolescents are known to lack knowledge regarding health and disease, health-related behaviours, risk and protective factors and social determinants of health.[19] The gaps in these RSH issues of nursing students need to be of concern not only to their parents but to their teachers and health-care providers as it indicates that adolescents are not being reached by interventions as intended by programme planners.[20] The fact that adolescents are not being reached adequately is evident from this study that shows only two-thirds of the students received orientation on topics regarding sexuality during their intermediate studies, with the most common topic being STIs. It would also raise concerns as to whether 'fear' is being instilled while orienting adolescents on these topics related to sexuality. The expression of sexuality is a natural process, and just like children and adolescents are guided to achieve and develop various physical, mental, social milestones as they grow, sexuality must be inculcated factually and non-judgementally through guidance by parents, teachers and others of social significance as part of normal growing up.

At present, in the Indian undergraduate nursing curricula, factual biomedical information on all these RSH issues is covered in the 3rd or 4th year of enrolment in the program.[15] However, it is important to plan for initial sensitisation on these issues for adolescent and young nursing students in their 1st year primarily because they are exposed to the clinical area as early as within 3 months of their enrolment.[16] They are thus likely to be faced with questions on these topics as they interact with their clientele either in the acute care setting or in the community. The facts that in this survey most (73%) of the students feared HIV and nearly a quarter of them about STIs (21%) are an indication that they probably lack information on how they could be protected from these infectious diseases, while caring for clientele with these infectious diseases. In addition, one could postulate that orientation on sexuality in the intermediate education period is driven by fear and disease-risk rather than on it being provided in a non-biased positive manner and as part of normal growing up. More than two-thirds (67%) mentioned they were sensitised about STIs before being enrolled to the nursing programme. This finding is similar to another study done with medical and nursing students from Fiji.[21],[22]

Many young people have their sexual debut in adolescence and gaps in their knowledge and self-assessed competencies related to RSH could place them at risk for adverse outcomes.[23] Sexuality education is the process of acquiring information and forming attitudes and beliefs about sex, sexual identity, relationships and intimacy. It needs to be done in a non-judgemental manner, providing avenues for clarification in a neutral environment. In this study from among those who were exposed to some sexuality education before being enroled for the nursing programme, 40% reported that they were oriented about contraception, 45% on growing up issues, 30% on pregnancy, indicating they do have some orientation on these issues. Yet, it is important to explore the methods used to cover these topics. In addition, whether these topics are covered from a rights framework or a moralistic perspective is important to explore. It is thus important that all adolescents, more so health care providers in their pre-service training are exposed to sexuality education as early as possible within the framework of their RSH and rights,[24] so that they could in turn deal with their clientele with this orientation. Considerations such as contextualising the information provided is needed, since it is obvious from this study that age, type of nursing program, previous exposure to a class on RSH and religious background of the students had an impact on their knowledge and self-assessed competency on RSH.

Nurses today are the first point of contact for clientele and are seen as important stakeholders for improving RSH across different settings– the hospital, community, acute and public health-care clinics, schools, and other institutions, particularly of adolescents themselves.[1],[21] However for this, they require appropriate, factual and contextual knowledge that addresses risky behaviours and strengthens protective factors. They also need to hone their skills to deliver evidence-based unbiased counselling and services to their clientele be it, patients, in acute care or adolescents, adults in various settings.[16],[20] Thus taking cognisance of the gaps in knowledge and self-assessed competencies related to RSH, it is important that nurse educators and education programs are responsive to facilitate and fill these gaps during the early years of young nursing students' education.[16],[25] Evidence-based contextual and experiential methods over a prolonged period by experts would benefit students since it could facilitate introspection, and thus enhance their self-confidence and comfort to address these issues. These methods could also facilitate practice of their counselling and communication skills in a safe classroom environment [26] before they attempt to counsell other adolescents in need. Individuals make choices to engage in specific behaviours based on what they know, believe and can do. Literature highlights the need to deliver interventions over a prolonged period of time for sustained effect on knowledge and behaviours.[20],[27]

The study is limited in that it depended on self-report to assess competencies of students to deal with RSH issues. Institutions were selected purposively, and this could limit the generalisability of findings, although the study subjects were from different zones of the country. These preliminary findings are part of a study that aimed to test if 1st year nursing students were exposed to RSH information with life skills integrated through participatory, reflective methods would express more knowledge, change in perceptions and increase in self-assessed competencies to deal with RSH issues at a personal and professional level.

  Conclusion Top

This paper clearly shows gaps in knowledge, perceptions and self-assessed competencies of nursing students on RSH issues in their 1st year of enrolment to the undergraduate nursing programme. Given the impetus on nurses to take the initiative and implement both parent-based adolescent RSH counselling [26] as well as independent or inter-professional collaborative health services, it would be helpful to reflect on how much is enough for professional nurses, then address these gaps using participatory reflective methods to address misconceptions, and competency gaps, in the early years of their pre-service training.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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1 Impact of a capacity-building initiative for first-year student nurses on reproductive and sexual health: A quasi-experimental study in Bangalore city, Karnataka, India
Sharon Hartley, Jennifer Tavares, Mercy Pushparaj, Sumithra Selvam, Prem Mony, Maryann Washington
Indian Journal of Continuing Nursing Education. 2022; 23(1): 86
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