The winding road to womanhood

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Research and development unit In primary Health Care, Södra Älvsborg County, Sweden

Section of Primary Health Care, Department of Public Health and Community Medicine, Institute of Medicine at Sahlgrenska Academy University of Gothenburg, Sweden and

Youth health centre in Lerum, Primary Health Care, Southern Älvsborg County, Sweden

The winding road to womanhood Adolescents´ attitudes towards menstruation, womanhood and sexual health - observational and interventional studies

by

Gun Rembeck

Göteborg 2008

 

Abstract Menarche is a unique marker of female maturation representing the transition from childhood to womanhood. When entering adolescence, children face a number of challenges in areas such as the parent-adolescent relationship, development of the self and identity, an expanding network of social relationships, pubertal changes and the development of sexuality. Education may improve attitudes toward menstruation among adolescents thus increasing their awareness of risks and enabling them to protect themselves accordingly. This thesis aims to provide better understanding of these phenomenons and is based on four studies: I.  Twelve-year-old girls’ experiences of early puberty were described using content analysis of data from focus group interviews. Four themes were revealed: “Growing up - awareness, transition, longing”, “Mother - a close and important relationship”, “Menarche - a personal and important occurrence”, and “Sex and relationships”. The girls had many questions about sex and physical changes but felt adults had failed them in providing answers. II.  Twelve-year-old girls’ attitudes, thoughts and feelings towards menstruation and their bodies as well the ability to communicate on aspects of womanhood womanhood was elucidated using a questionnaire. Postmenarcheal girls were less positive towards menstruation than premenarcheal. premenarcheal. Many girls did not reaffirm the statement “I like my body” and many claimed they had been verbally sexually harassed. Mothers were thought of as most easily “chatted” with about menstruation. III.  This study investigated the effect of a new, structured, interactive, multisensory, group learning education (IML) for 12-year-old girls compared with a standard intervention. Pre- and postmenarche postmenarcheal al girls answered accordingly adjusted questionnaires on attitudes toward menstruation before and six months after the intervention. If the girls received IML just prior to menarche it resulted in improvements in attitudes toward menstruation. IV.  Second-year adolescent high school students completed a questionnaire on sexual experience, sexual risk behavior and the impact of an educational  program on STI. Boys Boys took less responsibility responsibility for STI prevention tha thann girls. Furthermore, boys perceived themselves less influenced infl uenced by STI-education than girls. Girls had greater experience of same-sex sexuality than boys. ISBN 978-91-628-7493-3. 978-91-628-7493-3. Printed by Geson Hyltetryck, Göteborg, Göteborg, Sweden, 2008. Cover picture by Eva Almqvist. Copyright  Gun Rembeck 

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List of publications This thesis is based on the following papers referred to in the t he text by Roman numerals: I.

Rembeck, G I. Hermansson E. Transition to puberty. Experiences of 12-year-old Swedish girls. Submitted.

II. Rembeck G I. Möller M. Gunnarsson R K. (2006). Attitude Attitudess and feelings towards menstruation and womanhood in girls at menarche. Acta Paediatrica. 95:707-714. III. year-old Rembeck,girls' G I.attitudes Gunnarsson RK.menstruation. (2004). Improv Improving ing prepostmenarche postmenarcheal al 12toward Health Careand Women Int. Aug;25(7):680-98. IV. Rembeck, G I. Gu Gunnarsson nnarsson RK. Ro Role le of gender in sex sexual ual behavior and re response sponse to education in sexually transmitted infections in i n 17-year-old adolescents. Manuscript.

Papers have been reprinted with permission.

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Contents 1.

Abbreviations and definitions ................................................................... ......................................................................................... ...................... 6 1.1.   Abbreviations ......................................................................... .......................................................................................................... ................................. 6 1.2.   Definitions ............................................................................. .............................................................................................................. ................................. 6 2. Introduction ........................................................................... ..................................................................................................................... .......................................... 7 2.1.   Adolescence and puberty: an important transitional phase. .................................. 7 2.1.1. The concept of transition ............................................................................... ............................................................................... 7 2.1.2. Self-esteem and social relationships .............................................................. 8 2.1.2.1.  2.1.2.2. 

 Body-image and society ........................................................................ 8 Verbal abuse.......................................................................................... .......................................................................................... 9

2.1.3. Menarche and menstruation menstruation........................................................ ........................................................................... ................... 9 2.2.  Sexuality ................................................................... ............................................................................................................... ............................................ 10 2.2.1. Definitions of sexuality................................................................................ 10 2.2.2. Sex and the concept of gender .............................................................. ..................................................................... ....... 10 2.2.3. Sexual experience and sexual risk behaviour .............................................. 11 2.2.4. Sexually transmitted infections (STI) .......................................................... .......................................................... 11 2.3.   Educating adolescents in sexual health ................................................................ 11 2.3.1. Educating 12-year-old girls in menstruation and womanhood .................... 11 2.3.2. Sexual health prevention.............................................................................. 12 2.3.3. Forums of sexual health prevention prevention............................................................. ............................................................. 12 2.3.4. Learning and pedagogic theories ................................................................. 13 2.3.4.1.   Piaget´s cognitive development theory ............................................... 13 2.3.4.2.  Vygotskij´s sociocultural theory .......................................................... 13 2.3.4.3.   Marton´s variation theory ................................................................... 14 2.3.4.4.   Learning style and multisensory learning ........................................... ........................................... 14 2.3.5. Unresolved educational problems................................................................ 15 2.4.   Aims of the thesis ................................................................... .................................................................................................. ............................... 15 2.4.1. General aims ................................................................................................ ................................................................................................ 15 2.4.2. Specific aims................................................................................................ 15 3. Methods......................................................................................................................... 15 3.1.  Selection of participants (I-IV) ............................................................................. ............................................................................. 15 3.1.1. 12-year-old girls: focus group interviews (I) ............................................... 15 3.1.2. 12-year-old girls: descriptive and intervention study (II, III) ...................... 16 3.1.3. 17-year-old adolescents: descriptive study (IV) .......................................... 16 3.2.   Data collection (I-IV) ......................................................................... ........................................................................................... .................. 16 3.2.1. Focus group interviews (I) .......................................................... ........................................................................... ................. 16 3.2.2. Questionnaire: 12-year-old girls (II-III)....................................................... (II-III)....................................................... 16 Questionnaire: adolescents (IV) ............................................... 3.3.3.2.3. (III, IV)17-year-old    Interventions ............................................................................................ .......................................................................... .................. 17 3.3.1. Educational approach: 12-year-old girls (III) .............................................. 17 3.3.2. Education: 17-year-old adolescents (IV) ..................................................... 25 3.4.   Data analysis (I-IV) ............................................................................ .............................................................................................. .................. 26 3.4.1. Qualitative data (I) ............................................................ ....................................................................................... ........................... 26 3.4.2. Descriptive data (II) ..................................................................................... ..................................................................................... 26 3.4.3. Intervention data (III)................................................................. (III)................................................................................... .................. 27 3.4.4. STI-questionnaire (IV)................................................................................. 27 4. Results ........................................................................................................................... ........................................................................................................................... 27 4.1.  Transition to puberty: Experiences of 12-year-old girls (I) ................................. 27 4.1.1. Growing up: awareness, transition and longing........................................... 28 4.1.2. Mother: a close and important relationship ................................................. 28 4.1.3. Menarche - a personal and important occurrence ........................................ 29 4.1.4. Sex and relationships ........................................................................... ................................................................................... ........ 29 4.2. (II)  

 Attitudes and feelings towards menstruation and womanhood in 12-year-old girls

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4.2.1. Premenarcheal and postmenarcheal girls girls..................................................... ..................................................... 30 4.2.2. Experiences and feelings of their bodies ..................................................... 30 4.2.3. Who informed the girls and who they could talk to..................................... 31 4.3.   Improving pre- and post menarcheal, 12-year-old girls´ attitudes toward menstruation (III) .................................................................. .............................................................................................................. ............................................ 32 4.4.   Role of gender in sexual behaviour and response to education in sexually transmitted infections in 17-year-old adolescents (IV) ...................................................... 35 4.4.1. Gender differences in sexual experience and sexual risk behaviour............ 35 4.4.2. Students in programs preparing for university compared to vocational  programs 37 5. Discussion ..................................................................................................................... ..................................................................................................................... 37 5.1.   Methodological aspects ........................................................................................ ........................................................................................ 37 5.1.1. Qualitative method (I).................................................................................. 37 5.1.2. Choice of questionnaires (II, III, IV) ........................................................... ........................................................... 38 5.1.3. Potential problems when interpreting questionnaires (II, IV)...................... 38 5.1.4. Possible alternative explanations of intervention results (III)...................... 39 5.1.5. Statistical significance versus clinical relevance (II, III, IV)....................... 39 5.2.  Gender ...................................................................... .................................................................................................................. ............................................ 40 5.2.1. Gender differences in sexual risk behaviour and responsibilities (IV) ........ 40 5.2.2. Pornography and Internet............................................................................. 40 5.2.3. Same sex sexual experience and STI ........................................................... 40 5.3.   Influencing 17-year-old adolescents in sexual risk behaviour ............................. 41 5.4.  Girls in early puberty - a time of transition.......................................................... 41 5.4.1. 5.4.2. 5.4.3. 5.4.4. 5.4.5. 5.4.6. 5.4.7. 5.4.8. 5.4.9.

Life private in transition (I)...................................................................................... (I)........................................................................ .............. 42 41 The and secret (I) ............................................................. ............................................................................. ................ Awareness of sexuality (I, II)................................................................... II)....................................................................... .... 42 Attitudes toward menarche (II) (II)................................................................ .................................................................... .... 43 Anticipation of womanhood (II) ................................................................. 43 Self-esteem (II) .................................................................... ............................................................................................ ........................ 44 Verbal sexual harassment and teasing due to appearance (I, II).................. II) .................. 44 Persons influencing 12-year-old girls’ attitudes (I-II) ................................. 45 Educating and positively influencing attitudes toward menstruation (III)... 45 5.4.9.1.   Experienced benefits from active intervention .................................... 45 5.4.9.2.  The importance of timing .................................................................... 46 5.4.9.3.   Early-matured girls ............................................................................. ............................................................................. 46 5.4.9.4.   Late-matured girls ......................................................................... ............................................................................... ...... 47 5.5.   A new approach (III) ......................................................................... ............................................................................................ ................... 47 5.6.   Educational obstacles to overcome and future challenges................................... 47 6. 7. 8.

Summary and conclusions.................................................................................. conclusions............................................................................................. ........... 48 Acknowledgements ............................................................. ....................................................................................................... .......................................... 49 Appendix Appendix................................................................. ....................................................................................................................... ...................................................... 51 8.1.  Questionnaire part 1 for premenarcheal girls (II, III) ......................................... 52 8.2.  Questionnaire part 1 for postmenarcheal girls (II, III) ........................................ 57 8.3.  Questionnaire part 2 for girls (II, III) .................................................................. 62 8.4.  Questionnaire to 17-year-old adolescents (IV) .................................................... 65 9. References ..................................................................................................................... ..................................................................................................................... 70 10. Original publications................................................................................................. publications................................................................................................. 80

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1. Abbreviations and definitions 1.1.

Abbreviations

HIV AIDS STI UN UNAIDS WHO 1.2.

Human immunodeficiency virus Acquired immune deficiency syndrome Sexually transmitted infections United Nation The Joint United Nations Programme on HIV/AIDS World Health Organization Definitions

Adolesence Adolescent Menarche

The transitional period between childhood and maturity, occurring roughly between the ages of 10 and 19.   19. People aged 10-19 years Menstrual debut debut  

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2. Introduction I began working at youth health centres in 1990 where I met young people up to 25 years of age. Most were girls between 16 and 19 years of age just j ust entering a sexual relationship. Adolescents usually sought a nurse-midwife for help with contraception, sexual problems, concerns with their genitals and bodies, testing for f or sexually transmitted infections and pregnancy. Another common request was for free condoms. I soon became frustrated over the lack of knowledge of their sex organs and the negative and foreign attitudes towards their genitals and bodies. Even if the menstrual cycle is complicated and a woman’s genitals are nearly impossible for her to see, it was hard to accept their lack of words for their genitalia. Thus, I began to create words for women’s genitalia and pedagogical ways of describing them, their function and at the nature of a gynaecological examination in a way I felt young girls could grasp. I soon observed how their self-esteem increased when I supplied them with names for these body parts. The goals of the Swedish health authorities were to protect adolescents from sexually transmitted infections (STI), unwanted pregnancies and to strengthen a sense of identity during adolescence. Thus, in late 1980, youth health centres in southwestern Sweden were opened in most municipalities. The personnel had few guidelines allowing freedom to test different approaches. The youth health centre in Lerum cooperated with the research and development unit in primary pri mary healthcare in Lerum. This close cooperation was uncommon at other youth health centres in Sweden. Creativity through this cooperation led to the development of new ideas and methods. In 1995, I read of an approach to 12-year-old girls introduced by the nursemidwife Pia Höjeberg at the Tensta youth health centre in Stockholm. The method was inspired by the African Bemba tribal rituals in Zambia for girls reaching menarche. The question of helping girls on the threshold of adulthood was raised. Could such an approach prepare them for late adolescence? A 13-year journey had  begun. 2.1.

Adolescence and puberty: an important transitional phase.

Aside from the first two years of life, there are no other periods of human development as intense early adolescence [1].w Transition in early adolescence  been conceptualized conceptualized as aasde developmental velopmental period with ith fundamental changes cha nges in life has  patterns [2]. Transition is characterized by flow and movement movement and includes iden identity, tity, roles and relational skills [3]. When entering adolescence, children face many challenges in areas such as the parent-adolescent parent-adolescent relationship, development of the self and identity, the expanding network of social relationships, pubertal changes and the development of sexuality [4-6]. 2.1.1. The con concept cept of transition

When girls receive menarche and development of a new body begins they pass from one stage of life to another. This is an important transition. Transition is a passage from one phase of life, condition, or status to another. It engulfs multiple concepts embracing processes, time, and perception [7]. Transition is an ongoing process demanding awareness of the occurring changes. There is a general structure for transitional dimensions consisting of at least three phases: entry, passage and exit.

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Most characteristic for transition is disconnectedness associated associated with disruption of the linkages on which feelings of security depend. Meaning attributed to transitional events varies between persons, communities, and societies thus influencing outcomes. Patterns of response are, for example, distress, irritability, anxiety, changes in self-concept, changes in role performance and self-esteem. Conditions that may influence the quality of the transitional experience and the consequences of transitions are meanings, expectations, levels of knowledge, skill and planning, environment, and emotional and physical well-being [8]. A successful transition implies achieving a period of greater stability. Indicators of successful transitions are subjective wellbeing, role mastering, and healthy relationships. To fully understand responses to transition, it is important to understand how perception of the transition  process and expectations expectations of outco outcomes mes affect the transition [7]. 2.1.2. Self-esteem and social relationships relationships

Self-esteem is built up throughout childhood, affected by many factors, primarily the early interplay within the family. Furthermore, self-esteem develops in an intimate interplay with the immediate environment [6]. Self-esteem is linked to t o body-esteem which is partly regulated r egulated during adolescence by bodily factors beyond individual control, such as the onset of puberty [1, 9]. Some adolescents show high levels of stability in their self-esteem, whereas others do not [10, 11]. High self-esteem is related to parental approval, peer support,  psycho-social adjustment, adjustment, academic ademic [4, succe success [12, 13]. Howeve However, r, self-esteem varies according to gender and and ac ethnicity 10,ss14, 15]. Adolescents, especially girls, often develop a decline in self-esteem in early adolescence and, compared to boys, show more negative attitudes toward themselves concerning physical appearance as they enter adolescence [4, 14, 16]. Contrary to claims that adolescence implies severe conflict in terms of personal identity and social relationships [17, 18] contemporary research points to the importance of a maintained parent-adolescent relationship [19-22]. Several  psychologists recognize recognize adolesce adolescents nts as gradually re reaching aching greater independence independence while maintaining relationships with parents for support and guidance [22, 23]. However, conflicts between adolescents and parents increases at the onset of puberty [24, 25]. Twelve-year-old adolescents usually do not agree with their parents on who decides what rules to follow [23]. As children move into adolescence, friendships evolve into more intimate, supportive, and communicative relationships [26, 27]. Adolescents choose friends with similar behavior, attitudes, and identities [28, 29]. Indeed, adolescents bring to their peer relationships many qualities developed early on in life as a result of socialization within the family [30]. Peers influence one another not through coercive pressure but through t hrough admiration and respect [4, 31]. There is some evidence that among girls, intimacy in friendship is fostered through conversation [14, 32]. 2.1.2.1.

Body-image and society

During physical development impulses initiating thoughts of becoming adult are sent to the young individual [6]. Body awareness and testing sexuality increase along with the development of puberty. Compared to boys, girls are earlier in their external  pubertal development development [6]. As body ma mass ss increases du during ring puberty, adolesc adolescent ent females may increase a negative body image [33].

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Girls are exposed to stressful societal expectations and mass medial pressure in terms of gender role expectations and ideals of beauty [9, 34, 35]. Girls in early adolescence receive many comments on their changing bodies and often feel stared at [35]. The body is for many girls an ongoing personal project with a lesser or greater possibility for self-influence [36]. The key is to try tr y and control the project through exercise, diet, hair removal, cosmetic surgery, or make-up, presenting the result as natural, with possibly devastating effects on self-esteem [34]. 2.1.2.2.

Verbal abuse

Insults reflect current values in society [37]. They are usually made under emotional stress to provoke and gain advantage [38]. The most devastating way of insulting women is by attacking their sexual morality and is often done through sexual verbal harassment [38]. Two common words used for the sexual verbal harassment of women are “whore” and “cunt” [38]. The former is usually considered more serious than the latter [38]. 2.1.3. Menarche and men menstruation struation

Menarche is a unique marker of female maturation representing the transition from childhood to womanhood [39]. Girls reach menarche at an average age of 12.0 – 13,4 years in different sudies [40-44]. Menarche seems to come slightly earlier in obese girls compared to slim girls [45]. The experience of menarche is partly dependant on previous expectations resulting in both positive and negative feelings [46-49]. However, most girls do not consider menarche as something to be happy about [48, 50]. Girls appear to have incorporated many of the prevailing cultural views of menstruation early in life. Unfortunately, most of these views are negative and non preparative for womanhood womanhood [48, 51]. Unlike the developed countries, countries, where menarche is treated mainly as a hygienic problem, menarche is celebrated in other societies with rituals as in, for example, the Bemba tribe [52, 53]and Navajo Indians [54]. Girls able to communicate about menstruation worry less than girls who can not [55]. Unfortunately, most girls cope by concealing menstruation. Furthermore,  postmenarcheal girls are more self-conscio self-conscious, us, embarrassed embarrassed,, and secretive aabout bout their  bodies compared compared to premenarcheal ggirls irls [49, 56-60]. Cons Consecuently, ecuently, Koff (1981 (1981)) found postmenarcheal that premenarcheal communicate with(1986) peers about menstruation while girlsgirls hadcould difficulty [46]. Dashiff reported that menstruating girls talked about physical and emotional symptoms [58]. However, they usually spoke only of the negative aspects of menstruation [58]. In most societies mothers play an important role in informing their daughters about menstruation. Subsequently, daughters view their mothers as an important source of support [60-63]. Thus, girls living apart from their mothers may have  problems finding other mature mature females to comm communicate unicate with [64]. Unfortuna Unfortunately, tely, misleading information can be transferred from mothers to daughters [65]. Fortunately, positive feelings toward menstruation exist among premenarcheal girls, 9-12 years old [48, 66]. Girls with positive feelings associated menstruation with growing up and being normal [48]. Some of them believed, however, menstruation to be an embarrassing nuisance that could not be controlled [48, 66].  Nowadays, media media plays an impo important rtant role in forming attitudes toward toward menstruation. Menstruation is often portrayed as odorous, painful, embarrassing, and shameful [67, 68]. According to the media, menstruating women are expected to act 9

 

normally while continuing daily routines [49]. 2.2.

Sexuality

2.2.1. Definitions of se sexuality xuality

Sexuality and sexual health are major themes at youth health centres. WHO defines sexuality as: Sexuality is a central aspectsexual of being human throughout and encompasses sex, gender identities and roles, orientation, eroticism,life pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires,  beliefs, attitudes, values, behaviors, practices, practices, roles and relationships. While sexuality sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical and religious and spiritual factors [69].

Furthermore, WHO defines sexual health as:  as:   Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled [69].

2.2.2. Sex and the concept of gender

The most common definition of sex refers to the biological characteristics which define humans as female or male. These sets of biological characteristics are not mutually exclusive as there are individuals who possess both, but these characteristics tend to differentiate humans as males and females. Another definition is that the term sex often means "sexual activity". In the context of sexuality and sexual health discussions, the first definition is preferred [69]. The concept of gender was first used at the end of 1980. There is no consensus for a detailed definition. However, existing descriptions of the term usually include gender as a construction of sex and relations between women and men in a social structure of power and hierarchy [70, 71]. Gender refers to the economic, social and cultural attributes and opportunities associated with being male or female at a particular point in time [69, 70]. While 70].  While sex is usually unchanged gender may change during a lifetime [70]. Gender equity means equality in the distribution of benefits and responsibilities  between women and men. It often requires requires women-specific programmes programmes and policies policies to end existing inequalities [69]. Gender discrimination refers to any distinction, exclusion or restriction made on the t he basis of socially constructed gender roles and norms preventing a person from enjoying full human rights [69]. If one defines girls by emphasising problems, there is a risk that this group will be subsequently stigmatised [72]. Structural powerlessness to deal with the problems  becomes hidden hidden while blame is placed placed instead on the the individual. Thus, working with groups of girls may result in ”improving” girls rather than liberating them. To avoid stereoptypes for boys and girls, gender and identity should be placed in a greater and more dynamic perspective [72].

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2.2.3. Sexual experienc experience e and sexual risk behaviour

The average age for sexual debut in Sweden is approximately 16.5 years for both sexes. [73-75]. A recent study showed both girls and boys in vocational programs sexually more advanced showing greater risk behavior than those in university preparatory programs [76, 77]. Subseque Subsequently, ntly, girls in vocational pprograms rograms had a significantly higher frequency of STI [76]. Boys in general take greater sexual risks than girls [76]. Early puberty in boys and menarche before age 11 in girls are associated with early sexual debut. For boys it was also related to general adolescent risk-taking behavior [75]. 2.2.4. Sexually transmitted infection infections s (STI)

The estimated number of persons living with human immunodeficiency virus (HIV) worldwide in 2007 was 33.2 million [78]. More than 6800 persons daily are infected  by HIV and more than 5700 persons persons die from acquired immune deficiency syn syndrome drome (AIDS). During the initial phase of an epidemic, HIV will typically infect people at high-risk: prostitutes, injecting drug users, men who have sex with men, or persons with other sexually transmitted infections (STI). Factors influencing the possible “bridging” of HIV to the general population include the frequency of male utilization of prostitutes, sexual patterns in the general population, condom usage, age differences between partners, the prevalence of STI other than HIV, frequency of sexual violence, women’s empowerment, access to HIV/AIDS treatment and the capacity of the health care system [79, 80]. The number of cases of HIV in Western Europe continues to increase among heterosexuals and among men who have sex with men [81]. Aside from being a marker for sexual risk behavior, STI other than t han HIV enhances transmission of HIV [79, 80, 82]. One of the t he most common STIs is Clamydia trachomatis. The prevalence of C. trachomatis has increased in Sweden and in other Europeén countries [83, 84]. Since 1997 the number of C. trachomatis cases in Sweden has more than doubled and the increase in registered cases is highest among women 15 to 25 years of age. There are several explanations for this increase such as greater number of sexual  partners, more casual casual sex, less us usee of condoms [85-87], later family building [88 [88]] increased use of drugs [78], travel [89] and immigration [81, 90]. 2.3.

Educating adolescents in sexual health

2.3.1. Educating 12-year-old girls in menstruation an and d womanhood

Chisungu is an initiation ceremony for girls of the African Bemba tribe in Zambia when a girl receives her first menstruation [52, 53, 91, 92]. This is an initiation rite for girls where older women in the t he village gather round the girl and teach her how to  be a woman according according to the cu culture lture of the Bemba tribe. Th Thee rite includes spec special ial dances and songs along with holy figures fi gures and symbolic paintings. They emphasise  possessing female female genitals is som something ething to be proud of. T The he older women uutilise tilise the knowledge that what is heard, seen, felt, done and tasted will not be forgotten. At the t he end of the month-long ceremony the girls are initiated into the t he tribe as women with a great celebration. At the end of the celebration the girl’s father f ather is involved by giving her presents, usually clothing. The girls learn to feel that becoming a woman is something to celebrate. This is a form of education that is recognized r ecognized as cumulative cumulative.. A girl may have little intellectual understanding of what is being done at the time of her chisungu, but she may be in a highly emotional state where she is likely li kely to be 11

 

suggestible to the general emphasis placed on the importance of marriage and childbirth. They will recall this and in the future return and seek more knowledge. In many western countries girls are taught about the body and puberty at school. When a girl receives her first menstruation she usually turns to her mother to receive help in managing the hygienic aspects of menstruation. She emphasizes that it is normal and natural to menstruate and provides sanitary napkins. Furthermore, the girls and her parents receive a free sample of sanitary napkins and instructions from manufacturers at age 12. The message thus being that menarche is nothing other than a hygienic problem. This situation in western society is not optimal for enhanceme enhancement nt of learning about menstruation and sexual health. If girls fail to learn about the basics of menstruation, it will be even more difficult to teach them the risks of unprotected sexual activity [93]. Some authors suggest menarche as the best opportunity to intensify efforts to educate girls concerning risks associated with unprotected sexual intercourse [39, 94]. Previous research shows that teaching methodologies, language language and timing must be on a level with the capacity for understanding [57, 95], [39]. 2.3.2. Sexual health prevention

Sexual health needs of adolescents remain poorly understood in many parts of the world. This is a considerable challenge for many countries [96]. There is a consensus for reaching adolescents by preventive interventions for HIV/AIDS. This includes schools, health services, mass media and outreach  programs targeting young young people [97]. 2.3.3. Forums of s sexual exual health prevention

Historically, sex education was introduced in schools earlier in Sweden than in other western countries, dating back to the late 19th century [98]. A law passed in 1955 made sex education compulsory. In Sweden, girls are taught about the body in natural science courses. Furthermore, school nurses provide information about  puberty and menstruation menstruation [99]. In general, pupils pupils in Sweden are taught about the human body chiefly at the ages of 8, 11 and 14. Subjects include puberty and the reproductive organs. In many areas, school nurses teach these subjects as well. A  problem is that formal education education focuses on functions but no nott on emotions an andd worries concerning these functions. Furthermore, formal education does not take into consideration maturing early are unprepared forthinking the onsetmay of menarche. Girls who havethat notgirls yet developed the ability for abstract have difficulties in understanding conventional education for these issues [100]. The purpose of Swedish school healthcare is to t o promote student health [101]. This includes preventive medicine, health maintenance and “working toward a healthy lifestyle” for the students. The national board of health and welfare has given school healthcare services directives to cooperate with local youth health centres  particularly for STI and unwanted unwanted pregnanc pregnancies. ies. Youth health centers were opened in the 1970s and established in all Swedish communities by the late 1980s [102]. Youth health centers provide help for youths up to 25 years of age based on a holistic view, utilizing medical, social and  psychological competence. competence. Youths Youths meet individually aand nd in groups with a nursemidwife, social worker, psychologist or doctor from the youth health center. Methods for creating a positive forum where youths can talk about becoming women or men have been developed in youth health centers throughout Sweden. However,

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the best method has not yet been established. The Swedish youth health centers task is to cooperate with others working with youths and health problems. Swedish authorised nurse-midwives work in the areas of sexual and reproductive health [103-105]. A nursing degree is a prerequisite for specialising as a nursemidwife. The profession of nurse-midwife places large demands on the ability to work independently based on scientific and multicultural knowledge and professional responsibility. The national board of health and welfare describes three areas of competence for the Swedish nurse-midwife [105]: •  Sexual and reproductive health •  Research, development and education •  Management and organization According to the new abortion legislation from 1975, nurse-midwives were authorized to prescribe oral contraception and insert intrauterine i ntrauterine devices [105]. Preventing undesired pregnancies and the incidence and spread of STIs are important aims for midwives working with sexual and reproductive health at youth health centres [102, 104]. 2.3.4. Learning an and d pedago pedagogic gic theories

According to Pilhammar Andersson [106] Tell me, and I will forget. learning is identified as a transformation of Show me, and I may remember. knowledge and valuation. Learning includes Involve me, and I will understand. understanding, new perspectives and finally, - Confucius, 450 B.C.  personal change. change. Learning is see seenn first and foremost as a quest for meaning [107]. Pedagogy is the art or science of being a teacher. Pedagogic theories are of prime importance when constructing educational programs for sexual health and STI prevention for adolescents. adolescents. 2.3.4.1.

Piaget´s cognitive development theory

Jean Piaget (1896-1980) was a pedagogue and philosopher from Switzerland. His cognitive development theory consists of four stages, the fourth being the formal operational stage occurring at 11 years of age. At approximately 12 years of age children develop the ability for abstract reasoning where they can think with the aid of a hypothesis in addition to the tangible situation [108-111]. 2.3.4.2.

Vygotskij´s sociocultural theory

Lev Semenovich Vygotskij (1896-1934) was a pedagogue a pedagogue and philosopher. He stated that words words contain generations of human thought and knowledge. When a child understands words she also understands the thoughts associated with those words. Learning language provides access to an understanding of the world as perceived by mankind throughout history [112]. According to Vygotskij (1934) knowledge is not something that exists by itself, apart from reality, but a construction of reality, created to understand and describe the world around us. Vygotskij saw surroundings and human interaction (people, surroundings, nature, society etc.) as decisive for individual development and ability. Increase of knowledge occurs not within the individual alone but through interaction  between individuals. Vygotskij (1934) concludes that learning is more about tools and surroundings. It demands an active student, an active teacher and an active environment. The

13

 

environment influences the pupil by being active and dynamic and the teacher has an important role in organizing the environment. According to Vygotskij learning is first and foremost a social process demanding participation and experience. The teacher’s main task is to t o provide beneficial and stimulating assignments and to  provide opportunities for for interaction. While Vygotskij emphasized emphasized the importance of society and surroundings, he also emphasized the importance of individualising learning. Thus, the dialogue between pupil and teacher is i s of great importance. The teacher must utilise the student’s abilities and find the positive in each student. Imagination, playfulness and creativity are important key words in terms of learning. 2.3.4.3.

Marton´s variation theory

Marton pointed out the following requirements for learning [107]: • Knowledge must be rele relevant vant • Knowledge should be dis distinct tinct • Variation enhances learning • Involvement of all senses Learning involves an interactive process whereby both pupil and teacher learn. Learning is double-edged involving two or more individuals with differing knowledge bases. This implies that all parties take a stand on “why” and “for what  purpose” knowledge knowledge is important. Re Relevance levance and ddistinctiveness istinctiveness of kno knowledge, wledge, the “what”, and variation to stimulate the senses in learning, the “how”, become meaningful for the result [107]. Learning, thus involves the three didactical concepts of “what”, “how” and “why”, as well as the concepts of relevance, distinctiveness and variation. The actual environment where learning takes place also plays an important part in learning and the exchange of experience [106].An isolated, calm, pleasant and secure environment with adequate time allotted and access to pedagocical aids provide a firm basis for learning. Teaching can also be enhanced by creating a positive  physical and mental mental atmosphere. T The he patient/youth sho should uld feel free to ask and and has the right to receive answers to these questions. This can be achieved by tearing down the hierarchy to enable the pedagogical meeting. 2.3.4.4.

Learning style and multisensory learning

Learning style is the way in which each student begins to t o concentrate, process, and retain new and difficult information [113, 114]. This interaction is different diff erent for different individuals. All people utilise a mixture of learning styles. Some may find they have one dominant style of learning, with far less use of other styles. Others may find they use different styles in different circumstances. By involving more channels into the brain during learning, we remember more of what we learn. Examples of available channels are [115]: •  •  •  •  •  •  • 

Visual (spatial). Prefering pictures, images, and spatial understanding. Aural (auditory-musical). Preferring sound and music. Verbal (linguistic). Preferring words, both in speech and writing. Physical (kinesthetic). Preferring your body, hands and sense of touch. Logical (mathematical). Preferring logic, reasoning and systems. Social (interpersonal). Preferring to learn in groups or with other people. Solitary (intrapersonal). Preferring to work alone and use self-study.

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Combining Gardner’s and Dunn Dunn and Dunn’s [113, 114, 116 116,, 117], [118] learning styles results in modern multisensory learning. 2.3.5. Unresolved educational problems

When entering adolescence, children face a number of challenges in areas such as the  parent-adolescent relationship, relationship, developm development ent of the self and identity, an expanding expanding network of social relationships, pubertal changes and the development of sexuality [4-6]. Despite the importance for preparing girls in the t he transitional phase of early  puberty it is difficult to obtain representative representative resea research rch from the girl’s perspe perspective. ctive. A  better understanding of girls’ personal expe experiences riences would be helpful to guide se service rvice  provision, clinical recommendations recommendations and educational policy. Prior research has shown that sex-education in school and health services is important but more  practical interventions and and evaluations are needed [76, 79, 80, 119-123 119-123]. ]. 2.4.

Aims of the thesis

2.4.1. General aims

The aim of the present thesis was to provide better understanding of the experiences of early adolescence and to evaluate an active, educational, group program held at youth health centers for 12-year-old girls. Furthermore the aim was to investigate  potential sexual risk behavior and perception perception of being affec affected ted by an educational educational  program for STI in second-year second-year high sco scool ol students. 2.4.2. Specific aims

Describe 12-year-old girls’ experience of early puberty (I). •  Elucidate early adolescent girls’ attitudes towards menstruation and their thoughts and feelings towards their bodies. Furthermore, the aim was to see if there were differences in these attitudes and feelings between premenarcheal and postmenarcheal girls (II). •  Compare the effect of an active, educational, group program held at youth health centers with the present standard education on 12-year-old girls´ attitudes toward menstruation (III). gender differences in seco second-year nd-year high sch school ool student •  Investigate gender adolescents with respect to sexual risk behavior and perception of being • 

affected by differences an educational program aboutinSTI. A secondary aim was to investigate between students university-preparatory gymnasium programs compared to those in vocational programs

3. Methods 3.1.

Selection of participants (I-IV)

3.1.1. 12-year-old girls: foc focus us group in interviews terviews (I)

Participants in this study were eighteen 12-year-old sixth-grade girls, in a municipality in southwestern Sweden (population 36 000). After group education (in study III) at the youth health centre [102] led by nurse-midwifes, girls were asked to  participate. All girls, parents and guardians received received verbal an andd written information. Informed wasEthics received from parents and guardians to participate in the study. Theconsent Scientific Committee, Göteborg University, approved the study.

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3.1.2. 12-year-old girls: d descriptive escriptive and intervention study (II, III)

Sixth grade girls from eight schools were invited to participate in the study in late 1999. Most of these girls were 12 years old. The study area consisted of three nearby geographical areas from three municipalities in southwestern Sweden. The municipalities were a mixture of urban, village and rural populations. In one (Lerum), all schoolgirls were invited, while in the other two (Härryda and Skara), it was limited to girls from two schools in each area. Verbal and written information on the study was provided at the schools. Participation was voluntary and written consent was obtained from children, parents and guardians. Headmasters and schoolteachers were also informed. A questionnaire was filled in individually at school. The Scientific Ethics Committee, Göteborg University, University, approved the study. In the intervention study (III) girls were assigned to two different interventions. Due to practical reasons related to school schedules, it was necessary to use different methods to assign pupils to active or standard intervention. In both Härryda and Skara, one school was designated to receive active intervention and one school to receive standard intervention. The schools in Härryda and Skara were comparable in housing environment. However, in four schools in Lerum, classes within the same school were designated to active or standard intervention. 3.1.3. 17-year-old adoles adolescents: cents: descriptive study (IV)

In the fall of 2005, second-year students from two counties in southwestern Sweden were invited to participate in the study. Participants were approximately 17 years old. Headmasters were informed. Teachers were not present when the study took place. An ethical discussion took place at the research and development unit for primary health care in Southern Älvsborg County and the study was considered ethically acceptable. During compulsory 50-minute, STI-educational sessions lead by the youth center’s personnel, verbal and written information for the study was provided. Although STI-education was compulsory, participation in the study was voluntary. The questionnaire was filled in voluntarily and individually following the sessions. 3.2.

Data collection (I-IV)

3.2.1. Focus group interv interviews iews (I)

Data was obtained focus group interviews [124].from The the aimprevious of the focus groups was partly to followfrom up ordinary educational sessions week, and  partly to bring forth participants’ participants’ experiences of early early puberty. The present present study focuses only on the latter aim. Four groups of 4 to 5 girls were interviewed in the  presence of an observer. Guided by open-ended interviews participants were simply asked to relate their experiences of puberty. Broad, open-ended questions, such as "tell me your experience of being a 12-year-old girl" were used. If irrelevant subject matter was raised, it was dealt with, when necessary, by guiding the interview back to relevant subjects [125]. Each focus group interview, lasting one hour, was recorded, transcribed, depersonalized depersonalized and read several times t imes before initiating the main analysis. 3.2.2. Questionnaire: 12-year-old girls (II-III)

Each girl was given a two-part questionnaire to answer confidentially. Part one explored thoughts and feelings toward menstruation using a questionnaire developed  by Morse [126] and translated by Lönn Lönnroth roth (Appendix 8.1 aand nd 8.2). It was a vvalid alid 16

 

and reliable instrument using Likert-scales to measure adolescent responses to menarche. The Swedish versions of the questionnaires were tested for f or verification. Part one was in two versions, for pre- and post-menarcheal girls. After instruction, the girls chose either the pre- or postmenarcheal postmenarcheal form. Both versions consisted of 58 items. 47 were identical and used in the study. The items were merged to six dimensions and a total score, according to Morse et al [126]. Part two of the questionnaire explored information sources and issues i ssues related to womanhood (Appendix 8.3). Furthermore, they were asked whether they had been verbally sexually harassed and what their reactions were if so. Part two of the questionnaire explored information sources and issues related to womanhood. The content validity of the questions in part two was tested t ested in discussions with other researchers. These questions were then tested on a small group prior to this study. In the intervention study (III) the girls girl s completed the questionnaire a second time, four and a half to six months later. In the intervention study the change in scores  between the first and second question questionnaires naires was the ba basis sis for further statistical analyses. 3.2.3. Questionnaire: 17 17-year-old -year-old adole adolescents scents (IV)

Each student was given a 22-item questionnaire (Appendix 8.4). The anonymous questionnaire contained items on sexual experience and risk behavior and questions evaluating the impact of the educational program (Table 9-11). The content validity of all items in the t he questionnaire was ensured by repeated discussions discussions with other researchers. 3.3.

Interventions (III, IV)

3.3.1. Educational approach: 12-ye 12-year-old ar-old girls (III)

In the active intervention study (III) a new structured, interactive, multisensory group learning education (IML) was compared to a standard intervention. Standard intervention consisted of lessons according to the established school curriculum but also included all other influences from family, peers, media, and society. Generally, Swedish pupils learn about the body at the ages of 8, 11 and 14. Subjects include  puberty and the reproductive reproductive organs. organs. Those girls receiving active intervation were were,, of course, also subjected to the standard intervention in addition to the active intervention. The active intervention may be described as follows: Participants in active intervention were informed of a visit to the youth health centre one or two weeks after the first questionnaires. A structured group session was conducted following a method described by Höjeberg [91] and further developed by Rembeck [63]. The group design was intended to strengthen the group [49, 72], thus increasing self-esteem [127, 128]. Meetings at the youth health centres established the centre as a future resource [102]. Prior to the meetings the nurse-midwife  prepared dialogues dialogues for the different phases phases of the IML. The ph physical ysical and  psychological changes changes during ppuberty uberty were the sub subjects jects included. Girls came to the youth health centre accompanied by their school nurse. Two hours were allotted together with the school nurse and nurse-midwife. The focus was on a dialogue based on their thoughts and questions. The girls were treated as young women and not as pupils. Furthermore, they were treated as subjects and not objects. The active intervention does not include passive forms of education, such as films or anatomical pictures. The pedagogical aids used in this active intervention seemed to capture attention, thus enhancing learning. Furthermore, the ambition was to use a 17

 

 jargon similar to their own [95]. [95]. The details of eve every ry meeting varied depending depending on the group’s responses. The goal was to give a favourable impression and stimulate curiosity towards womanhood. First, brief information about the youth health centre was provided. The meeting then had the following sections: 1.  Menarche a sign of potential 2.  Cultural exposé 3. 4.   The Signscontract of incipient womanhood 5.  Making the invisible visible 6.  Standing on the threshold of womanhood 7.  Functions in female genital organs 8.  Delicate words 9.  The rite 10. The gynaecological examination 11. Sexuality 12. Your body speaks 13. The hot seat 14. Closure  Menarche a sign of potential  

The meeting then began with the following text on a flip fl ip chart. GIRL

 WOM N



The nurse-midwife asks: “when does a girl become a woman?” The girls were encouraged to reflect and discuss. If the girls said “menarche” the nurse-midwife “jumped on board” by asking “what is i s possible when you have reached menarche?” “When is it natural to receive r eceive menarche?” The midwife then told them “menstruation is a sign that you are women with potential! When a girl receives menarche she has the potential of becoming a mother.” Cultural exposé

Stories of menstruation and of women from the past and other cultures were told. In In this context, pictures of girls from different cultures just receiving their first menstruation werehistorical shown. They were encouraged to discuss feelingsthe aroused by these stories. The and cultural exposé aimed to emphasize importance of being on the threshold of adulthood. The contract

After this introduction rules for the t he meeting were discussed. All were to feel free to question. No question was considered stupid and it was unacceptable to laugh at others in the group. This was intended to promote mutual respect. The midwife asked if they knew what secrecy was. They were given time to explain that all personnel were bound to secrecy. Nothing said to the personnell would be heard outside the group. A secrecy pact was made within the group.  Signs of incipient womanhood

The nurse-midwife encouraged the girls to write wri te down the physical and  psychological signs signs of a girl changing into a woman on a flip-chart. The nurs nursee-

18

 

midwife turned on music and left the room. r oom. After a short while the nurse-midwife reentered. The writings on the flip-chart were discussed and experiences shared. Among other things the girls always wrote about gaining weight. This was a good opportunity to talk about normal increase in body fat during puberty. The normal increase of girls’ hips for future pregancies needed to be discussed. Girls maturing early are at risk for perceiving themselves as ove overweight rweight whether they are or not.  Making the invisible visible

The girls were then told to close their eyes and touch themselves just under their  pant waists. The nurse-midwife asked if they felt a hard bone called the pubic bone. bone. They were then told to open their eyes. They learned that the uterus lay behind this  bone. If the girls seemed seemed ashamed when touching them themselves selves the nurse nurse-midwife -midwife asked the reason for this.  It was then time to present a “special person”, said the nurse-midwife. A life-size Waldorf doll was presented (figure 1).

Figure 1 – The life-size Waldorf doll  

Two girlswith werethe asked they would to open her abdomen. The dolltowas the floor girlsifbeside it. Thislike moment served as an icebreaker get put the on quiet

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girls to talk. The girls took out internal organs from inside the doll’s abdomen and gave them to the others. The internal sex organs presented were the uterus, fallopian tubes, and ovums (figure 2).

Figure 2 – The open Waldorf doll

Even the external genital organs are present on the doll, with vaginal opening, clitoris and pudenda. It was explained why the latter were also called “privates”. The girls were shown a passage from the genitals via vagina, uterus, and fallopian tubes to the abdomen. It was explained to the girls that they have very important organs and that they should take care of them. They then replaced the organs and the doll was placed  beside them in a chair. Standing on the threshold of womanhood

The nurse-midwife went to the and opened She stood the threshold of two rooms and asked: - “Where am door I standing?” She it. explained thatonwhen they entered the youth health centre they entered a room as young girls. They then went across a threshold to another room where they sat down. This represented their present stage in life. They then went on to become young women. They were told that the youth health centre contained many rooms, which they had not yet been in. This was comparable to life containing many future “rooms” to discover. The nurse-midwife explained that; “Just as I now stand on a threshold you also stand on a threshold in life. You are on the threshold of womanhood.” A dialogue about dreams and role models took place.  Functions in female genital organs

The girls were asked to place their tongues on the sides of their t heir mouths and asked  what it was that was wet?  The girls answered and the function of saliva was discussed. The nurse-midwife informed them of mucous membranes in the walls of the uterus and vagina and between the labia and that discharges there have, to some 20

 

extent similar functions as saliva. Thus, all mucous membranes need to be moist. They then talked about the use of soap. They were asked if they had ever had soap in their mouths and how that felt and that consequently it was just as unsuitable to use soap when washing their genitals as for washing their mouths. Thus, they were recommended not to use soap for the genitals. In case of problems such as local irritation they were encouraged to sleep without underwear. The menstrual cycle was described in detail. Menstruation was described as the uterus repapering with wallpaper flowing out from the uterus via the vagina. Menstruation includes the mucous membrane, egg and blood. Irregular menstruation the first year is common and menstruation generally ceases ceases at around 50 years of age. All girls were encouraged to participate in the dialogue. Pedagogical aids used during the dialogue were full-scale clay models of the uterus, fallopian tubes and ovums (figure 3). The uterus was presented as a muscle. The difference between menstruation and ovulation was explained.

Figure 3 – Full-scale clay models of the vagina, uterus, fallopian tubes and ovums

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Advice on suitable activities during menstruation, such as bathing and swimming were discussed. Sanitary pads and tampons were shown and the use of thin sanitary  pads was discussed. discussed. The latter we were re said suitable to absorbe absorbe menstrual bloo bloodd but not for discharges. Information about menstrual pain and possible treatment was  presented. The nurse-midwife also informed them of what help the yo youth uth health centre provided. They were taught when conception was possible. They were informed that the impregnated egg went from the end of the ovum to the t he uterus in 4-5 days. The clay uterine model was opened up to show a little hole inside. i nside. The mucous membrane within the uterus was described as a sheet that thickens during pregnancy and  becomes down-like down-like embedding the small fetus.  Delicate words

The flip chart was used again and the girls were encouraged to write names denoting female genitals, including nice, rude, childish or medical words (figure 4). The girls were then allowed to react to and talk about these words. They could mention if some words hurt when they were used as harrassement.

Figure 4 – Example of girls’ own names denoting female genitals (example in Swedish)

Among other words they were harassed with, words commonly mentioned were cunt, whore, slut, sow, hussy and bitch. They spoke of how it was common to be called different insulting names and how they felt when this happened. The words were then transformed by presenting the sources of the words. For example, the Swedish word “fitta” (cunt) originally had another meaning such as humid meadowland, little well or riverbed. These new meanings of the word disarmed the strong negative feeling of the words. The nurse-midwife asked if they could explain 22

 

what a “whore” was. If the girls said it was a prostitute a forum about what a  prostitute was was started. started. Then a disc discussion ussion about the word “whore” followed about who in their surroundings had been called “whore” and how they felt about it. In the continuing dialogue the nurse-midwife explained that in the past a “whore” was an unwed mother and that it was scandalous to be pregnant without a husband. The nurse-midwife: “It was also easy for the man to deny fatherhood if they were not married since there was no medical way of proving fatherhood. Today the word “whore” is used to insult girls but usually has nothing to do with pregnancy.” The dialogue continued depending on the girls’ responses to being harrassed. The content of the dialogue illustrated how those giving insults did not often understand that some words hurt more than others and did not realise r ealise that they hurt as much as they did. The dialogue also included the importance of supporting each other when insulted and recommended them to turn to a teacher, parents or other adult when harassed in this way. A contract was made in the group promising to help each other in these situations. The clear message was that nobody ever was a whore and should never accept being called one. The rite 

A bowl of pears representing the uterus and almonds shaped like the ovum was  placed before the girls (figure 5). They were to told ld that a fruit tree after expos exposure ure to sun and rain produces immature fruit that gradually ripens. The nurse-midwife: “This is analogous to the of the human requiresasfood, a place to live, a bed, love anddevelopment human contact to begin tofemale. mature She and evolve a woman.”

Figure 5 – Pears used to represent the uterus

Soft, relaxing, background music was played while the girls were invited to taste the uterus-sized sweetbyalmonds as ovaries. ended this part offruit the and meeting saying: formed “with this f ruit we The fruit at thenurse-midwife youth health centre

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wish you a good life as women”. The main purpose of this was to associate womanhood with positive feelings. Another purpose was to provide energy for the remainder of the session. The gynaecological examination 

The girls then gathered in another room where a gynaecological chair was demonstrated and the examination explained. The Waldorf doll (figure 1-2) was  placed on the gynaecological ch chair air to demonstrate a gynaecological eexamination. xamination. The nurse-midwife explained the importance of a gynaecologic gynaecological al examination and its importance for women’s health. The nurse-midwife said: “It deals with parts of your genitals that you do not see. But if something happens happens with the genital organs a nurse-midwife or gynaecologist can examine and help you to find out that everything is all right. It does not hurt and if you feel pain the examination can be stopped immediately. It usually takes only a few minutes.” The nurse-midwife further explained that before having sex with someone almost nothing happens with her genitals requiring a gynaecological examination and that an STI can only be acquired through sexual activity. They were reminded about the passage between the vagina and the abdomen with the risk for the spread of infection. Another clay model of the genitals was shown. The parts with names and functions were described. The model showed a full-size version of the outer and inner aspects of the pudenda, vaginal opening, urethra and clitoris (figure 3). The clitoris as providing sexual pleasure and touching or caressing the a clitoris was oftendescribed feels pleasant. The nurse-midwife describes the hymen by showing wrinkled hair band (figure 6).

Figure 6 – Wrinkled hair band representing the hymen

The hymen was described not as a membrane but rather as a wrinkled mucous membranous ring at the entrance of the vagina [129]. Here, they were informed it was possible to guide their fingers through the vagina to the top of the lower part of the uterus known as portio vaginalis, which felt like the tip t ip of the nose.

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Sexuality 

The girls were told that sexuality was threefold or that t hat it has three functions. First comes an innate sexuality and feelings of physical pleasure that can be aroused without the involvement of others: that when they touch and caress their own sexual organs it is usually pleasurable. They were told that masturbation is something  positive. Dialogue concerning concerning sexua sexuality lity was initiated from the girl’s resp responses onses to the question of how sexual lust felt. Secondly, they were told of sexuality involving another person. The girls were asked if they knew when it was time for a sexual experience with a partner. The dialogue continued by discussing a suitable time for a first sexual encounter. The nurse-midwife: “Some people feel attracted to persons of the same sex and others to people of the opposite sex. It is important to respect yourselves and your partner.” However, they were also told that having sexual activity with another person was not for children of their age. Thirdly, they were told of sexuality leading to reproduction. The nurse-midwife: “It often takes many years after menarche until a woman and her partner decide to be  parents. To have have intercourse is to kknow now that you can be a parent and to take responsibility for avoiding unwanted pregnancy.” The girls were asked if they knew of any contraceptives and a dialogue about contraceptives followed. Information was  provided about condom condom use and emergency con contraception. traception. Your body speaks  The nurse-midwife told the girls to listen to their bodies. The girls were requested to  point out where in their their bodies they felt it when something was righ rightt or wrong. They were given time to think and talk about how they could understand themselves by listening to their bodies. The unequivical message to the girls was that if they were uncertain of how they felt it was better to wait until they were sure. This could be applicable when considering when to start sexual activity with a partner. “The hot seat” 

After discussing the gynaecological examination and sexuality the girls were returned to the first room. Here they t hey played the “hot seat” game, a method dealing with attitudes. During this game the nurse-midwife made a statement and those in agreement stood up and switched chairs with others in agreement. This physical activity facilitated dialogue. The intention of this activity was to have the girls girl s take a stand and let them hear each other’s opinions. If someone wanted to change their opinion they could do so. Closure 

The girls were told that if i f they came upon something they did not want to discuss in front of the other girls they were welcomed back for a personal meeting. A calling card was given to them with the youth health centre’s telephone number. 3.3.2. Education: 17 17-year-old -year-old adoles adolescents cents (IV)

It was not intented to objectively evaluate the effect of the educational sessions given to 17-year-old adolescents. Focus was on comparing girls’ and boys’ subjective reactions or experiences of a given lesson.

25

 

The purpose of the 50-minute sessions was to provide information and discuss matters of STI including risk taking, sexual behavior, responsibility, condoms, Swedish law and contact tracing. Furthermore, information on testing and physical and psychological aspects of STI was provided. In a class of girls and boys, sessions began with a presentation by the center’s  personnel. The importance of STI-educa STI-education tion was explaine explainedd and a discussion discussion was initiated to establish sexuality as something positive, exciting, pleasurable and fun. Furthermore, emphasis was placed on risk, responsibility and prevention. Students were informed of symptoms, incubation time, testing, consequences and treatment. Information on the STI-protection law and contact tracing was provided. Students were then informed about how and where they could be tested. The educational process included encouraging students to relate their knowledge of STI whereby the personnel then provided additional information. During the session students were encouraged to ask questions. Thus, sessions were adapted to the student’s level of knowledge. Dialogue and discussion were encouraged. An STI  brochure and the youth center’s calling card were provided at the close of the sessions. 3.4.

Data analysis (I-IV)

3.4.1. Qualitative data (I)

The interviews were subjected to a method of qualitative content analysis in which  both the manifest and and the latent conten contentt was sought out [13 [130]. 0]. The transcribed interviews were first read for an overall understanding of the content related to the research question. Thereafter, meaning units relating to the aim of the study were identified, condensed, grouped and interpreted. The data was re-examined and reassessed. The transcripts were discussed with the co-author for comparison and validation [124]. Codes were identified, designated and grouped into sub-themes. The data was then further analyzed by reading the sub-themes searching for new associations and meanings. In the final stage, sub-themes were transformed to main themes according to Graneheim and Lundman [131].  3.4.2. Descriptive data (II)

Student’s t-test was used when comparing continuous data, such as age, between groups. Mann-Whitney’s testBecause was used in case skewed dataconsensus and for group comparison of ordinal data. there is noofinternational on how to  present ordinal scales scales or analyse their differences differences between groups we have presented data with both mean and median. Furthermore, when comparing groups we used both the parametric Students t-test and the non-parametric Mann-Whitney’s test, although the authors preferred the latter. For group comparison of dichotomous data Chi square with Yates correction was used. In covariance analysis at least one variable was measured by ordinal scale. Variables measured by ordinal scale were transformed tr ansformed to a rank variable. Logistic regression was performed in case the dependent variable in a covariance analysis was dichotomous. Items with ordered response alternatives (Table 3) had five response alternatives. When presenting them in Table 3 the understanding of data was simplified by

26

 

merging to three responses. However, when further analysing data in Table 3 with covariance analysis all five response alternatives were used. All P values ≤0.01 were considered statistically significant. The program SAS version 8.02 (SAS-institute) was used for covariance analysis and Epi Info version 3.2.2 – Windows version (CDC, Atlanta) for logistic regression. Epi-Info version 6.04d – DOS version (CDC, Atlanta) was used for other analyses. 3.4.3. Intervention data (III)

Changes in attitudes were constructed by calculating raw differences between the first and second questionnaire. Furthermore, these raw differences were transformed to improvement, worsening or unchanged, given the values +1, -1 and 0, respectively. This was performed for each of the six dimensions and total score (part 1 of the questionnaire). Differences in variance between groups were tested using Bartlett’s test for homogeneity of variance. Student´s t-test was not performed in case of different variances between groups. Because there was no international consensus on how to compare changes in ordinal scales between groups we used both the parametric Students t-test and the non-parametric Mann-Whitney’s test applied to both raw and transformed differences, although the authors preferred the latter [132]. 3.4.4. STI-questionnaire (IV)

Differences in proportions of girls and boys were analyzed with two-tailed chi-square with Yate’s correction (Table 9). Mean age differences for girls and boys were analyzed with Student’s t-test (Table 9). Differences in ordinal scales between girls and boys were analyzed with Student’s t-test and Mann-Whitney’s test (Table 9). To further analyze gender differences in the perception of STI-education a logistic regression was performed with sex as the dependent variable. Independent variables were “going steady”, “had experience of sexual intercourse”, “type of high school  program” and the item being evaluated evaluated.. Students in an ind individual ividual program were excluded. One regression was made for each evaluated item (Table 10). To further analyze differences between students in the two main educational  programs in their perception perception of STI-education a logistic regression wa wass performed with educational program as the dependent variable. Independent Independent variables were “going steady”, “hadinexperience of sexual intercourse”, sex and theanalysis. item being evaluated. Students an individual program were excluded in this One regression was made for each item evaluated (Table 11). The program Epi-Info version 3.3.2 (CDC, Atlanta) was used.

4. Results 4.1.

Transition to puberty: Experiences of 12-year-old girls (I)

In the following section 12-year-old girls’ experiences of entering puberty are  presented. Four themes themes were extracted from the data showing th thee variation of the experiences of first entering puberty (Table 1).

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Table 1 – Main themes and Sub themes from focus f ocus group interviews Main themes

Sub themes

Growing up - awareness, transition and longing

The new body •  Relationships •  Longing to decide for themselves

Mother – a close and important relationship

•  • 

• 

Mother close at hand A dynamic relationship •  Seeing themselves as mothers

Menarche - a personal and important occurrence

•  • 

Seeking someone to trust and confide in Menstruation: intimate and private

Expression of sex and feelings •  Observing boys’ sexual behaviour •  Knowledge of sex

• 

Sex and relationships

4.1.1. Growing up: a awareness, wareness, transition and longing

Twelve year-old girls were well aware of their own and other’s physical development. Some girls enteredGirls puberty and some later butmedia’s they always compared themselves to others. wereearlier impressionable and the image of young women’s appearance had a great influence on them. They reached out for new friends. They longed for the “free” life older girls appeared to have but deep down felt incapable of dealing with the responsibility. Developing a completely new body was experienced as strenuous. The girls were concerned about not knowing how their bodies would look later on. Some girls in this study expressed feeling that adults should more frequently inform them of their  physical development. development. The relationships were constantly changing with awareness that puberty strongly affected social lives. People of the same age developed differently where some entered puberty earlier and others later. The girls longed to behave like older girls. They attempted to influence parents and test limits. Some parents were more permissive than others. 4.1.2. Mother: a c close lose and impo important rtant relationship

In this study, girls often talked about their mothers. The girls described their mothers as someone close, someone they could talk to and trust. Mothers bore the brunt of the girls’ emotional outbursts and struggle towards independence. It also became apparent that the girls thought much about about what it would be like to be a parent. They  believed that it would be be both fun and tough. tough. For example, would they be ab able le to maintain a relationship while caring for the needs of a child? But to become a mother was something most saw as self-evident. It was evident that the girls longed l onged for a deep and warm relationship with their mothers. The girls wanted to be respected and listened to even if they had another opinion than their mothers. It was apparent that mother stood for security. A close mother-daughter relationship was important, but this was not conflictfree. The girls’ desire for independence sometimes put a strain on the relationship.

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They wanted to be in agreement and understand their mothers but to also have their own way. These conflicting feelings aroused a sense of guilt. Most girls in this study had positive expectations of being a mother. They were aware that a child-parent relationship influenced parenthood. The girls could see both the positive side of motherhood, at the proper age, and the difficulties. 4.1.3. Menarche - a p personal ersonal and important o occurrence ccurrence

Menarche was a very personal and important i mportant event. Most girls were very selective and discrete about discussing menarche with others, especially with the opposite sex. It was the mother the girls turned to in this situation. The girls felt they could trust and talk to their mothers about puberty and menstruation. They felt their mothers wanted to prepare them, were open and capable of communicating. The girls agreed that their mothers should be the first to know when they received menarche, but needed them to treat the questions of menstruation discreetly. Who took the initiative to dialogue differed. Sometimes it was the daughter and sometimes the mother. Menarche was a powerful experience entailing many emotions and thoughts. For many girls menarche was a mixture of excitement, anxiety, pride and embarrassment. 4.1.4. Sex and relationships

Girls were very interested in sex and were frustrated by not knowing more. They felt adults wanted to wait until the girls were older before talking about sex but couldn’t understand why. They felt sexuality physically and could also verbalize these feelings. The girls had observed that a boy’s way of expressing sex was different from their own. They observed that in the company of boys they were quieter and more discreet about sex. They were anxious about and resigned to frequent verbal sexual harassment. It came to light that girls thought considerably about sex, but didn’t talk about it  publicly. Most of the girls talked talked quite a lot abo about ut sex with their friends. The girls noticed while growing up that adults were disturbed when the girls touched their genitals. The girls wanted to talk about boys and their sexuality. They noticed a difference in how boys communicated about sex.  Knowledge of sex describes the need to talk about sex and discuss it to gain more knowledge. adultshasten avoided speaking and informing sex because The theygirls wereunderstood concerned that it would their sexual debut. The girlsabout were disappointed with teachers and adults who were not telling them about sex. However, the girls said most of the t he teachers could handle talking about sex.  4.2.

Attitudes and feelings towards menstruation and womanhood in 12-year-old girls (II)

Of 403 pupils invited to participate in the study, 58 (14.4 %) chose not to participate.  Not all attended school school when the study took place, so ooff the remaining 345 ppupils, upils, 309 (90 %) participated and answered the questionnaires. Some did not answer all questions.  Name lists of the 403 invited girls revealed th that at 1.2% had Finish names and 8.4% 8.4% other non-Swedish names indicating possible non-Swedish origin. The corresponding figures for the 309 girls answering the questionnaire were 1.6% and 9.4%. The  proportion of girls with a possible possible non-Swedish origin did not differ between the invited girls and those t hose answering the questionnaire (p=0.82, chi-square). The girls’ 29

 

living accommodations were flats in 15.4%, town houses in 20.8% and houses in 63.8%. There were no statistically significant differences in living accommodations  between pre- and post post menarcheal ggirls. irls. 4.2.1. Premenarcheal and pos postmenarcheal tmenarcheal girls

Most girls 216/309 (70 %) had not reached menarche. The mean age (standard deviation, range) for girls not yet menstruating was 12.4 (0.35, 11.4-13.8) years and for girls who had had their first f irst period 12.6  12.6 (0.39, 11.8-14.3) years. Thus, girls not yet menstruating were slightly younger than girls who had had their first period (p=0.00003). In 57 of the 93 girls who experienced menarch menarchee we had reliable information on how long they had menstruated. They had menstruated for a mean of 0.58 years with SD 0.42 (median 0.5 with interquartile range 0.25-0.83). Postmenarcheall girls were less positive towards menstruation compared to Postmenarchea  premenarcheal girls (p=10 (p=10-6, Student’s t-test and Mann-Whitney’s test, Table 2). Table 2. Comparison of premenarcheal versus postmenarcheal girls´ attitudes towards menstruation (part one in questionnaire)  Number a  Meanb  Median  P -value -valuec  T -test Pred   Postd  Pre Post Pre Post -test M&W e Positive feelings   186 85 28.3 (7.55) 23.4 (6.83) 28.0 23.0 10-6  10-6   f   Negative feelings   186 81 38.8 (7.21) 38.8 (9.07) 39.0 38.0 1.0 0.82 Menstrual symptoms g   198 87 13.6 (2.28) 13.7 (3.65) 14.0 14.0 0.82 0.73  g 

Openness Acceptance  of menarcheh  Living with menstruationi  Total score j  a

    c   b

d e  f  g

h i  j

200 206 202 143

88 87 89 62

15.5 12.6 (3.49) (2.06) 22.3 (3.29) 141 (16.6)

16.1 (4.13) 13.1 (2.76) 22.7 (3.93) 136 (21.4)

15.0 13.0 22.0 142

16.0 13.0 22.0 139

0.24 0.062 0.38 0.065

0.25 0.049 0.42 0.17

Number of girls providing complete answers to the first questionnaire Mean score with standard deviation within paranthesis P-value for comparison of groups; T -test: -test: Students t-test; M&W: Mann-Whitney’s U-test Pre: Premenarcheal girls; Post: Postmenarcheal girls Ten questions with a maximum of 50 scores (high scores indicate more positive feelings) Thirteen questions with a maximum of 65 scores (high scores indicate less negative feelings) Five questions with a maximum of 25 scores (high scores indicate less symptoms or more openness) Four questions with a maximum of 20 scores (high scores indicate greater acceptance) Six questions with a maximum of 30 scores (high scores indicates easier living) Forty-seven questions with a maximum of 235 scores (high scores are more positive)

4.2.2. Experiences a and nd feelings o off their bodies

Many girls (43 %) did not affirm the statement “I like l ike my body” and almost one fourth stated being teased for their appearance (Table 3). In covariance analyses with Morse dimensions 1-6 (described in Table 2) as dependent variable, all statements according to Table 3, girl’s age, having experienced menarche or not and the possible housing conditions as independent variables (dimension and statements as rank variables, menarche and housing conditions as class variables) showed that the statement “I want to be an adult” was important. The more the girl agreed to this statement the greater positive feeling (p=0.0002, Covariance analysis) and the greater her openness (p<0.004, Covariance analysis). Another important statement was “I like that my body develops”. The more the girl agreed to this statement the higher positive feeling (p<0.0001, Covariance analysis) thestatement greater her“Iopenness analysis). The more they agreedand to the have been(p<0.004, teased forCovariance my appearance” the

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lower the score for negative feelings indicating more negative feelings (p=0.009, Covariance analysis). Table 3. Experiences and feelings among 12-year old girls about their bodies (part two in questionnaire)

I like my body I like my self I have been teased for my appearance I like that my body develops I want to be an adult I decide over my body

 N

Do not agree

Do not know

Agree

303 304 299 305 303 304

17.5% 9.9% 64.9% 9.8% 21.5% 8.6%

25.7% 18.4% 12.7% 36.4% 33.7% 20.4%

56.8% 71.7% 22.4% 53.8% 44.9% 71.1%

In this analysis adjusting for covariates it seemed that being pre- or postmenarcheal still remained as a variable correlated to the dimension positive feelings (p<0.001, covariance analysis) and also slightly to acceptance of menarche (p=0.058, covariance analysis). These p-values are almost the same as corresponding unadjusted p-values in Table 2. In covariance analyses with Morse dimensions 1-6 (described in Table 2) as dependent variable, all statements according to Table 3, girl’s age, having experienced menarche or not and the possible housing conditions as independent variables (dimension and statements as rank variables, menarche and housing conditions as class variables) showed that the statement “I want to be an adult” was important. The more the girl agreed to this statement the higher positive feeling (p=0.0002, covariance analysis) and the greater her openness (p=0.004, covariance analysis). Another important statement was “I like that my body develops”. The more the girl agreeds to this statement the higher positive feeling (p<0.0001, ( p<0.0001, covariance analysis) and the greater her openness (p=0.004, covariance analysis). The more they agreed to the statement “I have been teased for my appearance” the lower the score on negative feelings indicating more negative feelings (p=0.009, covariance analysis). In this analysis adjusting for covariates it seemed that being  pre- or postmenarcheal postmenarcheal still remained as a vvariable ariable correlated to the dimension  positive feelings (p<0.001, (p<0.001, covariance aanalysis) nalysis) and also slightly to accep acceptance tance of menarche (p=0.058, covariance analysis). These p-values are almost the same as corresponding unadjusted p-values in 3Table To investigate how items in Table were2.associated with each other a covariance analysis was performed with the item “I want to be an adult” as dependent variable. All other items in Table 3 and having experienced menarche or not were independent variables (items in Table 3 as rank variables and menarche as class variable). The only association found was that the more the girl liked that their body developed the more they wanted to be an adult (p<0.0001, covariance analysis). 4.2.3. Who informed the g girls irls and who they could talk to

Seventy-nine per cent stated they were informed about menstruation by their mothers (Table 4). Postmenarcheal girls felt they were more often informed i nformed by their mothers compared to premenarcheal girls (p=0.007, chi square). The mother was also cited the person they could most easily “chat” with about their period (Table 4). Female friends are, after mothers, the ones that girls “chat” most often with about menstruation (73 %) (Table 4). Male friends are not usually the ones girls talk to about menstruation, sex and relations (Table 4). Postmenarchea Postmenarcheall girls could talk 31

 

about menstruation with male friends to a greater extent compared with  premenarcheal girls (p=0.001, (p=0.001, chi square). In other covariance analyses with Morse dimensions 1-6 (described in Table 2) as dependent variable, all responses according to Table 4, girl’s girl ’s age, having experienced menarche or not and the possible housing conditions as independent variables (dimension as rank variable, response to items, i tems, menarche and housing conditions as class variables) showed that the dimension openness was highly correlated to several items in Table 4. Higher openness was correlated to being told about menstruation by female friend (p<0.0001, ( p<0.0001, covariance analysis), analysis), being told/informed about menstruation by magazines (p<0.0009, covariance analysis), can talk about menstruation with female friend (p<0.0001, covariance analysis), being informed about sex by TV-program (p<0.004, covariance analysis) being informed about sex by magazines (p<0.01, covariance analysis) and can talk about sex with female friend (p<0.004, covariance analysis). Lower openness was correlated to  being informed about about sex by no on onee (p<0.003, covarian covariance ce analysis) and can talk about relations with no one (p<0.01, covariance analysis). Being informed about menstruation by sister was associated with higher acceptance of menarche (p<0.01, covariance analysis). Being able to talk about menstruation with the father was associated with having less negative feelings (higher scores on the dimension negative feeling) towards menstruation. When analysing responses to items described in Table 4 for the 57  postmenarcheal girls girls for whom we had reliab reliable le records for the time ssince ince menarche we used a logistic regression model where response to item was the dependent variable and girl’s age and time since menarche were independent variables. Girls who had had menarche earlier were more likely to say yes to the t he statement that they could talk about relationships with male friends compared with girls having had menstruation later on (p=0.005, (p=0.005, logistic regression). regression). Time after menarch menarchee did not influence the responses for other items in Table 4. Table 4. Who told the girls and with whom could they talk (n=307) (part two in questionnaire) Was told about … by… Menstruation Sex

Could talk about … with … Menstruation Sex Relations

Mom Dad

79.1 % 4.9 %

34.9% 7.6%

83.1% 10.1%

44.6% 7.5%

63.0% 19.3%

Sister Brother TV-program Female friend Male friend Teacher School nurse Magazines Other person  No one

15.4 % 0.7 % 16.0 % 43.5 % 0.0 % 40.9 % 67.1 % 29.6 % 6.2 % 1.6 %

8.6% 2.3% 27.7% 58.4% 8.6% 32.5% 36.5% 33.9% 4.3% 9.5%

22.9% 2.0% --73.0% 2.6% 10.8% 46.6% --9.1% 1.3%

14.8% 3.0% --73.1% 9.2% 5.6% 27.2% --6.9% 8.2%

25.2% 8.2% --86.0 18.6% 5.1% 20.6% --8.8% 2.9%

4.3.

Improving pre- and post menarcheal, 12-year-old girls´ attitudes toward menstruation (III)

Of 403 pupils invited to participate in the study 58 (14.4 %) chose not to participate. Of the remaining 345 pupils, 283 (82 %) participated and were followed up with a

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second questionnaire. The follow-up rate was 80% in the active intervention group and 84% in the standard intervention group. Loss of follow-up was due to; sickness, relocation, attended special lectures, teachers neglecting to call students, incorrect questionnaires and incorrectly reported personal code numbers. The mean, standard deviation for the mean and median age  age were for the active intervention group 12.5, 0.37, and 12.5 respectively and for f or the standard intervention group 12.4, 0.36, and 12.4 respectively. The difference diff erence between groups was not statistically significant. At the time of the t he first questionnaire there were 111/159 (74 %) in the standard intervention group and 99/151 (66 %) in the active intervention group that had not reached menarche. These differences were not statistically significant. There was a small difference between the standard intervention group and the active intervention group in the “Acceptance of menstruation” dimension (Table 5). The two groups were otherwise comparable. Table 5. Baseline values for active and standard intervention groups  Number a  SId   AId   Positive feelingse 

Mean SI AI

Median SI AI

SDb  SI AI

 P -value -valuec  T-test

M&W

142

129

27.0

26.5

28.0

26.0

7.8

7.6

0.58

0.45

137 143 145 153

130 142 143 140

38.0 13.5 15.7 12.5

39.6 13.8 15.7 13.1

38.0 14.0 16.0 13.0

40.0 14.0 15.0 13.0

7.7 2.9 3.6 2.1

7.8 2.7 3.8 2.5

0.098 0.45 0.93 0.029

0.086 0.53 0.92 0.053

148

143

22.0

22.8

22.0

23.0

3.3

3.6

0.052

0.053

104

101

139

141

141

142

17.7

18.9

0.49

0.45

 f 

 Negative    g   Menstrualfeelings symptoms  g  Openness   Acceptance of menarcheh  Living with menstruationi  Total score j  a

  Number of girls providing complete answers to the first questionnaire Standard deviation of mean c P-value for comparison of groups; T -test: -test: Students t-test; M&W: Mann-Whitney’s test d    SI: Standard Intervention group; group; AI: Active Intervention group e Ten questions with a maximum of 50 scores (high scores indicate more positive feelings)  f Thirteen questions with a maximum of 65 scores (high scores indicate less negative feelings)  g Five questions with a maximum of 25 scores (high scores indicate less symptoms or more openness) h Four questions with a maximum of 20 scores (high scores indicate more acceptance) i Six questions with a maximum of 30 scores (high scores indicate easier living)  j Forty-seven questions with a maximum of 235 scores (high scores are more positive) b

Girls experiencing their first period between the two questionnaires showed greater improvement in their attitudes in the active intervention group compared to the standard intervention group. This favor for the active intervention group was seen in the “Positive feelings” and “Openness” dimensions (Table 6). It was also seen in tthe he total score (Table 6). In Lerum, we saw an even larger difference between the two groups in the “Positive feelings” (p=0.0050, t-test, p=0.019, Mann & Whitney’s test,  p=0.0037, Mann-Whitney’s Mann-Whitney’s test on transforme transformedd data) and “Ope “Openness” nness” dimen dimensions sions (p=0.014, t-test, p=0.0062, Mann-Whitney’s test, p=0.0072, Mann-Whitney’s test on transformed data).

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Table 6. Change in attitudes for girls experiencing menarche during the interval between the two questionnaires  Number a  SId   AId   Positive feelings  Negative feelings Menstrual symptoms Openness Acceptance of menarche Living with menstruation Total score

Mean SI

AI

Median SI AI

SD b  SI AI

 P -value -valuec  T-test

M&W

MWT

20

12

-3.4

+0.4

-2.0

+2.0

6.0

6.5

0.11

0.14

0.043

22

14

+0.77

+2.6

0.0

+3.0

6.7

6.8

0.94

0.43

0.56

18

12

-1.0

+0.92

-0.50

+1.0

3.1

3.1

----e 

0.11

0.18

22

15

+0.32

+2.9

0.0

+3.0

3.8

4.2

0.060

0.027

0.073

25

13

+1.1

+1.5

+1.0

+1.0

3.0

3.6

0.73

0.49

0.27

24

14

+1.2

+1.4

0.0

+1.5

3.2

2.7

0.80

0.60

0.40

8

8

-2.1

+10.3

+2.0

+10.0

13.5

4.0

----e 

0.013

0.063

a

  Number of girls providing complete answers to the first questionnaire Standard deviation of mean c P-value for comparison of groups; T-test: Students t-test; M&W: Mann-Whitney’s test MWT: Mann-Whitney’s test using transformed data b

d  e

  Variances SI: Standard Intervention group; group; AI: Active Intervention group differ between groups

When focusing on all pre-menarcheal girls at the first questionnaire, which also included girls that were pre-menarcheal at the time of the second questionnaire, no differences could be seen between groups (Table 7). Table 7. Change in attitudes for all girls who were pre-menarcheal at first questionnaire  Number a  SId   AId   Positive feelings  Negative feelings Menstrual symptoms Openness Acceptance of menarche Living with menstruation Total score

Mean

SDb 

Median

SI

AI

SI

AI

SI

AI

 P -value -valuec  T-

test

M&W

MWT

81

71

+0.21

+0.24

0.0

0.0

5.9

5.9

0.64

0.41

0.47

77

74

+0.74

+0.84

0.0

+0.50

6.3

6.2

---e 

0.87

0.98

82

83

-0.62

-0.012

0.0

0.0

2.6

2.4

0.12

0.26

0.64

86 94

85 84

+1.1 +0.70

+1.3 +0.31

+1.0 0.0

+1.0 0.0

3.2 2.4

3.2 2.2

0.63 0.26

0.71 0.22

0.73 0.29

92

79

+1.5

+1.5

+1.0

+2.0

3.3

3.5

0.91

0.51

0.81

43

51

+2.9

+4.9

+2.0

+6.0

13.9

10.3

0.43

0.49

0.11

a

  Number of girls providing complete answers to the first questionnaire Standard deviation of mean c P-value for comparison of groups; T-test: Students t-test; M&W: Mann-Whitney’s test MWT: Mann-Whitney’s test using transformed data d    SI: Standard Intervention group; group; AI: Active Intervention group e Variances differ between groups b

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Girls who had had menarche before the first questionnaire improved more in the “Living with menstruation” dimension in the standard intervention group compared to the active intervention group (Table 8). Table 8. Change in attitudes for girls who had h ad had menarche before first questionnaire  Number a  SId   AId   Positive feelings  Negative feelings Menstrual symptoms Openness Acceptance of menarche Living with menstruation Total score

Mean SI

AI

Median SI AI

SDb  SI AI

c

T-test

M&W

MWT

 P -value -value  

30

39

-1.4

+0.62

-1.5

+1.0

6.9

5.3

0.18

0.11

0.15

31

36

+1.0

-0.44

+2.0

-2.5

8.4

6.3

0.42

0.19

0.12

29

37

-1.1

-1.4

-1.0

-1.0

3.6

3.9

0.76 0.76

0.74

0.81

32

41

+0.94

+0.93

+1.5

+1.0

3.6

3.0

0.99

0.89

0.96

36

41

-0.056

+0.20

0.0

0.0

2.9

3.0

0.71

0.68

0.64

34

39

+2.1

+0.26

+2.0

+1.0

3.3

3.0

0.018

0.022

0.16

18

19

-2.6

-2.8

-1.0 - 1.0

-6.0

15.0

14.3

0.96

0.73

0.68

a

  Number of girls providing complete answers to the first questionnaire Standard deviation of mean c P-value for comparison of groups; T-test: Students t-test; M&W: Mann-Whitney’s test MWT: Mann-Whitney’s test using transformed data d    SI: Standard Intervention group; group; AI: Active Intervention group b

4.4.

Role of gender in sexual behaviour and response to education in sexually transmitted infections in 17-year-old adolescents (IV)

610 second-year students in the two schools were listed. Of these, 451 attended schools the lecture the questionnaire was distributed. Two non-Swedish speaking exchange students were excluded. Of the 449 students invited, five fi ve returned blank questionnaires. Some of the remaining 444 students chose not to answer all questions. 237 (53.4%) students were preparing for higher studies, and 195 were in vocational programs (43.9%) while 12 (2.7%) were in individual programs. 4.4.1. Gender differences in sexual experien experience ce and sexua sexuall risk behaviour

Girls attended programs preparing for higher studies more frequently than boys (Table 9). Girls had greater experience of sexual intercourse than boys (Table 9). Furthermore, girls had more frequent f requent sexual experiences with someone of the same sex (Table 9). Girls tested for STI more often than boys (Table 9). The most common STI test was for C. Trachomatis. HIV was rarely tested for. Boys used condoms more often than girls (Table 9).

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Table 9. Gender differences in sexual experience and sexual risk behavior a  Item b 

Female

Male

 P

Preparing for study at university (194/195 c; 238/239c) Going steady (199/200a; 241/244a) Going steady with someone of the same sex (70/75d; 56/63d)

62 % 38 % 5.7 %

49 % 26 % 5.4 %

0.011 0.013 0.62

8.1 % 64 % 15.2 (1.0) 6.1 %

8.1 % 54 % 15.2 (1.2) 1.7 %

0.82 0.046 0.74 0.014

64 % 1.6 (1.1)g  2 (0-3)g  8.1 %

22 % 1.9 (1.0)g  2 (1-3)g  8.1 %

< 10-10  0.012g  0.015g  0.82

Sexual experience

Experience of oral sex (124/200a; 124/244aa) Experience of sexual intercourse (199/200 ; 241/244a) Age at first sexual intercourse – Years (SD) (126/127 e; 119/130e) Had sex with someone of the same sex (197/200a; 238/244a) f 

Sexual risk behavior

Tested for STI (95/94 ; 86/86f ) Used condom for protection (126/127d; 125/130d) Had intercourse in a foreign country (124/127 d; 124/130d) a  b

c d e f

g

444 questionnaires returned by 200 female students and 244 male students. Estimation of response rate: If replying “no” to some items they were encouraged to skip some other items. Response rate for each item is given within parenthesis (actual number of responses for females / theoretical number for females if all answered; actual number of responses for males / theoretical number for males if all answered) Twelve students in a special program not preparing for university and not studying at a vocational  program were excluded. 5 females, 6 males and 1 unidentified sex.  Only those first answering “yes” to the question “are you going steady with someone?” were encouraged to answer if they went steady with someone of the same sex.  Only those with experience of sexual intercourse were to answer tthis his item.  Only those with experience of sexual intercourse not always using condom were encouraged to answer this item. As seen, slightly more than 100% of those encouraged to answer this item did so. Apparently one girl misunderstood the instructions.  Students were encouraged to describe their use of condoms in a four-grade ordinal scale; 0=Never, 1=Rarely, 2=Sometimes, 3=Always. First line is mean (SD) and p-value calculated with Student’s t-test. Second line is median (interquartile range) and p-value calculated with Mann-Whitney’s test. 

Boys, far less than girls, percieved that STI-education influenced them (Table 10). Table 10. Odds ratio for boys compared to girls responding to education about sexually transmitted infectionsa Item b  STI-education is of valued (418/444) STI-education will influence my sexual behavior e (412/444) I will follow advice given in STI-education f  (418/444) STI-education increases propensity for testingg (353/368) a  b

c

d

e f g

Odds ratioc 

 P

0.51 (0.37- 0.70) 0.50 (0.38-0.65) 0.41 (0.29-0.58) 0.55 (0.41-0.75)

< 10-4  < 10-4  < 10-4  0.0001

444 questionnaires returned by 200 female students and 244 male students. All students were encouraged to answer these items. In the last item the response “don’t know” (provided by 76 students) was removed before analysis. Within parenthesis actual number of responses / theoretical number if all answered.  For first three items students were encouraged to answer using a four-grade ordinal scale. For the last item a three-grade scale was used. Odds ratio for each increasing step in ordinal scale is given. 95% confidence interval for odds ratio is given within parenthesis.   The ordinal scale was; 0=Of no importance, 1=Little importance, 2=Great importance, 3=Greatest importance.  The ordinal scale was; 0=Not at all, 1=Little, 2=Much, 3=Greatly.  The ordinal scale was; 0=Never, 1=Rarely, 2=Sometimes, 3=Always. The ordinal scale was; 1=No, 2=Probably, 3=Yes 36

 

4.4.2. Students in programs preparing for university compared to vocational programs

Type of study program did not affect the perception that STI-education influenced them (Table 11). Table 11. Odds ratio for students in programs preparing for higher studies compared to students in vocational programs responding to education about sexually transmitted infectionsa Item b  STI-education is of valued (418/444) STI-education will influence my sexual behavior e (412/444) I will follow advice given in STI-education f  (418/444) STI-education increases propensity for testingg (353/368) a  b

c

d e f g

Odds ratioc 

 P

0.84 (0.62-1.14) 0.95 (0.74-1.23) 1.26 (0.92-1.73) 0.79 (0.58-1.08)

0.26 0.71 0.15 0.14

444 questionnaires returned by 200 female students and 244 male students. All students were encouraged to answer these items. In the last item the response “don’t know” (provided by 76 students) was removed before analysis. Within parenthesis is given actual number of responses / theoretical number if all answered.  For first three items students were encouraged to answer using a four-grade ordinal scale. For the last item a three-grade scale was used. Odds ratio for each increasing step in ordinal scale is given. 95% confidence interval for odds ratio is given within parenthesis.   The ordinal  scale was; 0=Of no importance, 1=Little importance, 2=Great importance, 3=Greatest importance. The ordinal scale was; 0=Not at all, 1=Little, 2=Much, 3=Greatly.  The ordinal scale was; 0=Never, 1=Rarely, 2=Sometimes, 3=Always. The ordinal scale was; 1=No, 2=Probably, 3=Yes

5. Discussion Twelve-year-old girls were characterized by transition (I). It is important to inform these girls of their sexuality and of the transition t ransition to womanhood. Girls in early adolescence require attention and understanding in their quest for independence independence.. Parents, particularly mothers are, in this respect, of the utmost importance. In the descriptive study (II) it was shown that 12-year-old girls seek information about menstruation and sex from a variety of sources, indicating a need for information. The fact that a large proportion not like their bodies may indicate that their transition into womanhood will notdid be optimal. An education based on multisensory learning (III) may facilitate this transition. In 17-year-old adolescents (IV) boys did not test for presence of STI as much as girls. Furthermore, it was seen that boys to a lesser extent perceived that they were affected by STI-education than girls. 5.1.

Methodological aspects

5.1.1. Qualitative method (I)

In the first study the aim was an open data collection. Thus, a qualitative (empiricholistic) approach was chosen instead of a questionnaire. For this particular type of  participant and considering considering the sensitive topic, focus group interviews as data collection seemed to have several advantages compared to individual interviews. In a group discussion they could refrain from questions they felt too sensitive. On the other hand, participants tend to open up more easily in focus group interviews 37

 

whereby anxiety can be shared and thus reduced [124]. Data collection by focus group interview gained strength through the utilization of two persons cooperating during interviews. Furthermore, participants in this study shared similar backgrounds and experiences, which was a help throughout the t he interviews. Content analysis was originally applied exclusively to text interpretation but has  been developed developed into a research m method ethod for the analy analysis sis of data in regard to expressive contents, symbols and meanings. Of possible approaches content analysis was considered slightly more appropriate than phenomenology to analyse data from focus group interviews. Furthermore focus was on identifying emerging patterns but not specifically a life world perspective, as in phenomenology, or social intercations, as in grounded theory. Furthermore, since there was no aim to combine main themes to a theory, content analysis became the choice. One cannot claim that these results are the only way to describe the phenomenon but the result can be applied under similar circumstances with people in the same situation. 5.1.2. Choice of questionnaires (II, III, IV)

For the descriptive study (II) a questionnaire with two parts was used. Part one was the same as the questionnaire used in the intervention study (III). Part one did not cover all areas of interest. A preexisting questionnaire covering all these areas was not found. Thus new items were constructed and put in part two. Before use the questionnaire was thoroughly discussed with several other researchers and tested in a small group of girls before launching the study. In the intervention study (III) focus was to evaluatethe new intervention (IML), compared to a control group with standard intervation. For this purpose a quantitative (empiric-atomistic) approach with a questionnaire using items it ems that easily transformed to a measure was an obvious choice. The questionnaire used in the intervention study was particularly useful for comparisons in pre- and post-intervention measures for influencing attitudes through health and sexual education programs [126]. However, the questionnaire did not measure attitude influences in all aspects of the active intervention, such as towards names for the external genitals, aspects of maturation unrelated to menstruation, and information about a gynecological examination. examination. Thus, there might have been an effect of the active intervention in areas not measured by the questionnaire. In the STI-education study (IV) a quantitative approach was chosen because the aim strongly on the comparison between sexesother and different directions. A focused qualitative approach may have provided valuable educational information but would not have fulfilled the study goals. No previously validated questionnaire encompassingg both risk taking and how an STI-education was perceived to affect encompassin  behavior was found. found. Thus, a new questionnaire was constructed. Construct Construct validity was ensured by extensive discussions with experienced researchers prior to data collection. The questionnaire used in this study did not measure dimensions constructed through combining responses from several items. The unique situation of the interactive STI-education was not reproducible r eproducible within the same group of students. Thus, measurement of test-retest reliability of the questionnaire was not  possible. 5.1.3. Potential problems when interpreting questionnaires (II, IV)

In other studies, older sisters often provided important support [55]. However, we could not confirm this in the descriptive study (II) (Table 4). One possible reason for this might be that fewer girls in our study actually had a sister compared to the study

38

 

 by Frank et al [55]. Unfortunately we did not not ask them if they ha hadd brothers, sisters oorr  parents still living, thus we could not comp compensate ensate for this possible bias. Since many statistical calculations were performed in the descriptive study (II)  p<0.05 might be found found purely by chan chance. ce. Thus, p-va p-values lues 0.02-0.05 we were re ignored and only p-values ≤0.01 were considered statistically significant. Questionnaires in the descriptive study (II) were answered confidentially but not anonymously. One might imagine that some girls of non-Swedish origin would have agreed to answer the questionnaire if knowing that they would be totally anonymous, whereas they would perhaps hesitate to answer if they were to be treated only confidentially. Unfortunately ethnicity was not asked for in the questionnaire. However, name lists of students invited to participate and students actually answering the questionnaire suggest that this potential methodological error was very small. In the STI-education study (IV), the item at the t he bottom of Tables 10 and 11 initially had an extra “I do not know” response alternative. Responses Responses to this alternative were excluded prior to analysis because they could not naturally be fitted into the ordinal scale. In the STI-education study (IV) in i n Table 9, the response rate for the item on oral sex was low. The sex educators discovered that many avoided this question. We then decided to divide the pages lifting this item it em to the top of the following page. Avoidance could also be explained by uncertainty of the question’s implications. Thus, the results from this item were unreliable. In the STI-education study (IV) The item concerning intercourse in Table 9 might  be subject to different interpretations. interpretations. It was uncle unclear ar if adolescents re referred ferred to intercourse as vaginal or anal penetration or as oral sex. Although we are not certain of their interpretation of the word intercourse, the figures presented in Table 9 indicate the proportions of girls and boys involved in risk activities for acquiring an STI. 5.1.4. Possible alternative explanations o off intervention results (III)

All information and the questionnaires prior to the active intervention may have influenced results. It is possible that girls in the standard intervention group began a  process affecting attitudes attitudes on menarche menarche that would not hav havee otherwise occu occurred. rred. This might have diminished the outcome differences between the active and standard intervention groups. Thehave different methods employed to assign pupils to active or standard intervention might affected the results. In schools having classes receiving both the active and the standard intervention, information may have been exchanged between the groups. This might have diminished the differences in outcome between the groups. 5.1.5. Statistical significance v versus ersus clinical relevanc relevance e (II, III, IV)

In the descriptive study (II), the intervention study (III) and the STI-education study (IV) there were several findings that were statistically significant. However, the actual clinical relevance of these finding f inding were not always obvious. In covariance analysis (II) the dependent variable consisted of ordinal data and as such was transformed to their rank. This was a problem when regression coefficients (β) were to be interpreted and are therefore not presented. Thus, p-values for regression coefficients measuring the statistical significance are provided while a numerical measure indicating clinical relevance is not. The favourable statistical findings in the intervention study (III) were comparison of changes between groups in ordinal scales. They cannot be given a plain clinical

39

 

interpretation other than that the difference in change favours the new active education. In the STI-education study (IV) odds ratio for the differences between boys and girls (Table 10) may be interpreted as a measure of clinical relevance indicating that the gender difference was large. 5.2.

Gender

5.2.1. Gender differences in sexual risk be behaviour haviour and respo responsibilities nsibilities (IV) Awareness in Sweden of the risk of acquiring C. trachomatis is much higher than for

HIV/AIDS [86]. However, the experience at youth centers has been that fear of acquiring C. trachomatis has been low. This is probably because C. trachomatis has  been perceived perceived as easily cure cured. d. The low fear of HIV/AIDS in Sweden is probab probably ly due to low Swedish prevalence [86]. A greater awareness that acquisition of C. trachomatis also increases the risk for acquiring HIV might increase responsibility and decrease sexual risk behavior. Girls learn about menstruation and their reproductive organs early on from their mothers (study II) and take responsibility for  prevention of pregnancy pregnancy [133-135]. Th This is concern brings them to the nurse-midwives nurse-midwives at the youth center mainly through the need for contraception. They are informed at the youth center of the importance of taking an STI test. Thus, girls take an STI test more often than boys [84, 136]. Traditionally, Swedish boys do not have their sex organs examined at the youth centers to the same extent as girls. Furthermore, boys seeking help are perceived as weak [137]. This and Christenson’s study suggests that boys avoid responsibility and rely on girlfriends to take necessary tests [134]. Christiansson’s study (2003) showed that girls felt they were bearers of C. trachomatis while boys were chiefly concerned with where they were infected. More time with young men is required to encourage them to take sexual responsibility. It is, thus, important to increase awareness and understanding of increased risk for STI and urge them not to jeopardize their health and the health of others [138]. 5.2.2. Pornography and Internet

Pornography is one of the most sought after topics on the Internet, and is i s easily available formen anyone, including children and adolescents [139]. Among 18-year-old adolescents (98%) consumed more pornography than women (72%) [140].   Many had contradictory feelings towards pornography and felt that ssexuality exuality was separated from intimacy [139]. However, pornography has an impact on sexual  behaviour for both young young women [141] [141] and men [142 [142]. ]. Data collection for study I occurred between 1998 and1999. Data collection for study II occurred between 1999 and 2000. At that time the Internet was not as widely used as it is today. Thus, pornography on the Internet was not a topic in i n study I-II. However, information on TV such as cable TV was asked about in study II. Data collection for study IV took place autumn 2005. However, pornography or other sources of information were not in focus in this study and was thus not included. 5.2.3. Same sex sex sexual ual experience a and nd STI

Female-to-female transmission of STI including HIV is a research field with wide knowledge gaps [143]. Even if it has been suggested that the overall probability of

40

 

female-to-female transmission is lower than male-to-female, investigators have identified several STIs among lesbians [144-146]. Girls, more often than boys, have same-sex sexual experiences (Table 9). From  prior studies we know know that girls have a more permissive attitude toward homosexuality than boys [86]. However, both girls and boys have had the same extent of experience of “going steady” with some someone one of the same sex (Table 9). Our results suggest that homosexual girls in similarity to heterosexual girls start sexual relationships earlier compared to boys. These results may indicate that same-sex sex is an experience girls have without defining themselves as either homosexual or heterosexual. 5.3.

Influencing 17-year-old adolescents in sexual risk behaviour

The romantic ideology of the 17th century where sexual activity belonged exclusively to the realm of marriage is now being challenged [147]. A consequence consequence of this is that the weakened connection between sexuality and reproduction has lead to an increase in risk behaviour for STI. It is important for sex-educators and health services to focus more on sexual practice, such as vaginal or anal intercourse, than on sexual identity, such as homosexuality or heterosexuality, when assessing risk for STI [143]. In the STI-education study (IV) it seems to be important i mportant to analyze how boys catch the educators’ message and find out how to reach boys learning styles. It appears that STI-education used in our study might not have appealed to boys’ learning styles as it did to girls’. Knowledge of different learning styles may help to change this [116, 118]. Girls’ learning styles are reported as more self-motivated, responsible and conforming while boys´ are more kinesthetic dynamic and learn by doing [148]. One major question is whether girls and boys should be separated during STI-education. In a prior intervention study where this was the case, condom use increased [149]. Thus, some differences in STI-education for girls and boys seem  justified. However, since since learning styles m may ay differ more between individuals than  between girls and boys boys [148] the cha challenge llenge of develop developing ing an improved S STI-education TI-education is not an easy task. 5.4.

Girls in early puberty - a time of transition

5.4.1. Life in transition (I)

The focus group study (I) showed that participants were in transition and that when  puberty began social social life was affected ccreating reating a need fo forr increased social rela relations. tions. This was in agreement with earlier studies [4, 150]. At the end of puberty, girls should be able to deal with their new lives with greater well-being while maintaining functional relationships [6, 8]. The girls in the study were on their way to discovering new roles and relationships while trying to maintain self-esteem. The ability to deal with feelings and physical well-being eases this transformation. In clinical work parents and professionals should take heed to the phases of development [151]. Girls turn to their mothers for testing their wills and extending  boundaries. This challenges challenges a m mother’s other’s ability to be distinct; firm but sensitive. sensitive. This dynamic relationship is an important step towards independence. Almost all girls longed to become mothers which could be interpreted as a desire to become adult. Girls who had experienced a rift between their parents or saw them t hem  burdened by too much responsibility responsibility were aware that paren parenting ting was not always easy

41

 

 but could still consider becoming becoming parents which is in agreement with a prior study [35]    

.

5.4.2. The private and secre secrett (I)

For a positive transformation t ransformation during adolescence girls need to feel meaningfulness while possessing knowledge of what is happening to them [3, 8]. The girls in the focus group study (I) sought someone close who they could trust to help them place menstruation and puberty in of a wider It became apparent thatmixed the girls that the happiness and pride havingperspective. a properly functioning body was withfelt thoughts of menstruation as embarrassing [35]. It would be reasonable to assume that girls would benefit from an open atmosphere both inside and outside the home to gain support in this phase of life. Almost all the girls said that mother was the person to turn to when they reached menarche which was in agreement with previous studies [60, 93, 152] (II). Mothers and daughters sought ways of communicating on these intimate inti mate questions. The girls were sensitive and felt their mothers went beyond the boundaries of integrity by telling others of their daughter’s menarche without permission. This study confirmed other research results that when a girl reached menarche her genitalia became  became her own, both private and secret [48]. Most girls in the focus group study (I) wanted to keep males outside the discussion of menstruation [62]possibly due to their cultural inheritance [153] and an ambivalence toward their own physical development (study II). Chrisler & Zittel´s study from 1998 showed cultural differences in the experience and impact of menarche on girls´ lives [154]. 5.4.3. Awareness of sexuality (I, II)

It was seen in the focus group study (I) how girls physically experienced their sexuality and their awareness of it. They were curious, wanting to know more and talking often to each other about sex. It appeared that there were gender differences regarding communication of sexuality. The girls were aware of social codes where it was not acceptable to talk about sex in the same manner as boys. This behaviour was so integrated that it was considered normal. Earlier studies have shown that teenage girls constantly communicate and interact with those around them concerning sex [155]. Forsberg (2005) found that it was important for girls gir ls to not lose their respectability [156]study or status rumours The descriptive (II) through and earlier studies{155]. have shown that girls who had been victims of verbal sexual harassment felt hurt [157]. However, most of the 12-yearold girls in the descriptive study had someone to talk to about this type of verbal sexual harassment. Another way of dealing with this was seen in Ambjörnssons [158] study of girls taking initiative and incorporating harassment words as their own to destigmatise them [158]. Unlike older girls in Ambjörnssons´s study, a 12-yearold is more vulnerable during the early stage of pubertal development. Having been exposed to verbal sexual assaults can negatively affect self-esteem and the experience of the new body. Girls have a need of adult support to help them sort their feelings of sexuality, but feel neglected and let down when this fails to occur. One way to t o deal with these questions is for the nurse-midwife [105] at the youth health centre [102], to use an educational model employing conversation and simple and concrete pedagogic means to provide answers to the girls’ questions as was used in the intervention study (III).

42

 

5.4.4. Attitudes towa toward rd menarch menarche e (II)

A century ago, girls received menarche approximately 2-4 years later in life than today’s girls [42, 153]. Furthermore, the number of pregnancies were higher in the 19th century compared to the 20th and 21th century, so the number of menstruations in life were less than in today’s Western society [159]. Thus, maturity has become more involved withThus, physical and sexual than with reproduction andin early motherhood. for some girls, development it may be puzzling to receive menarche adolescence and not supposed to become mothers until 28 [160, 161]. The increasing gap between menarche and motherhood makes menstruation a symbol not of motherhood but of sexuality. Girls in the descriptive study (II) were on average 12.5 years old, subsequently only 30% had reached menarche. Menarche signals that the body is functioning  properly and makes makes girls feel more grown grown up [48]. Usually, ggirls irls prefer to have menarche at the same time as their peers [47]. Although the descriptive study (II) found no difference in self-esteem between premenarchea premenarcheall and postmenarcheal girls, the latter seemed to better accept menstruation (Table 2). Thus, our results indicate that postmenarcheal girls accept menstruation, which might indicate that they are in some way prepared. However, premenarcheal girls were more positive to menstruation than postmenarcheal girls (Table 2) [51]. This indicates that experiencing menarche might worsen their attitude. Thus the question arises whether they could be even better prepared? Girls who were able to talk about menstruation with their fathers were associated with less negative feelings towards menstruation. It seemed to be important to engage fathers to take the opportunity and responsibility to talk openly with their daughters about menstruation. Fathers might thereby prevent anxiety and destructive concern that someone notices they have begun to menstruate.  Negative beliefs about about menarche aand nd menstruation ex exist ist in many countries aand nd cultures [51, 58, 152]. Should we, as in other cultures, introduce an initiation rite for girls receiving menarche menarche [52-54, 92]. The intervention stud studyy (III) suggests that we should. 5.4.5. Anticipation of womanhood (II)

It to ask t he(II) the question – must the girls want to between become adult? The in istheimportant descriptive study indicated a strong association wanting to results be an adult and openness in discussion issues around menstruation. Furthermore, openness in this study was associated with having greater communication with others while girls remaining uninformed were less open. Our assumption is that not wanting to  become an adult adult indicates a risk of po potential tential future problems. In the descriptive study (II), the majority of the girls were uncertain about  becoming adults. The transition from childhood childhood to womanhood womanhood is comparable to the transition from womanhood to motherhood. Something new, unknown and incomprehensible occurs. Girls in early puberty need to t o understand what’s happening to them and place it in a meaningful context [162]. Girls need to have influence over their lives and not feel like “victims”. They also need support support to verbalise their feelings. They must dare to ask questions such as: “What does it mean to be a woman? What is expected of me?” Women close to the girl, are especially important as models for girls with no mother living close to them [64].

43

 

5.4.6. Self-esteem (II)

From the descriptive study (II) we may conclude that self-esteem, especially bodyesteem, is lower than expected (Table 3). We saw no major difference in overall selfesteem or physical self-esteem between premenarcheal and postmenarcheal girls. This is in concordance with McGrory´s findings [163]. Why do some girls have high self-esteem and others not? During puberty, awareness of the 165]. body Furthermore, and its development contribute to the formation of self-esteem [164, development of their bodies will have consequence consequencess for how they are perceived by others. The prevailing western culture prefers girls to be small and feminine and the responsibility for being so lies wholly on themselves [48, 166]. Developing a more rounded, mature, body collides with the prevailing culture in their age group [9]. The results in the descriptive study (II) is that 12-year-old girls felt f elt ambivalent to their maturing bodies and were insecure. Images in the media of ideal body shapes are not in concordance with the body the girl is developing. Movies usually present female  bodies from a male male perspective, thus forc forcing ing girls to view female bo bodies dies from this male perspective [167]. During puberty, girls must frequently find their own way of accepting themselves [9, 165]. Fifteen-year old girls with a positive body attitude have high self-esteem whereas low self-esteem is linked li nked to unhealthy habits and overweight [168]. However, it is not as simple as just liking l iking or disliking the body [9]. The joy of a healthy body may quickly change to discouragement discouragement in front of the mirror. The maturation process is difficult, even if considered natural. It is a long process where self-esteem goes up and down before finally f inally achieving high self-esteem. Female identity is contradictory, both attractive and frightening [9]. These issues are important where low self-esteem might lead to increased risk-taking. 5.4.7. Verbal sexual haras harassment sment and teasing due to appearance appearance (I, II)

The focus group study (I), the descriptive study (II), and earlier studies, confirm that many girls are exposed to and frustrated by verbal insults with sexual harassment [37, 169, 170]. It is therefore necessary to find strategies to cope with harassment. It seems that girls unexposed to insults fear harassment more strongly than exposed girls. Thus, fear of harassment is worse than harassment itself. Some girls gradually adjust to it untilprocess harassment loses its [ 158]. Oneofimportant [158]. mechanism in the immunization is probably theeffect transformation feelings into words and sharing them with others. The descriptive study (II) suggests that a majority found a way of coping with harassment. School is the most likely place for verbal harassment [171], usually without  parental knowledge. knowledge. International studies of of sexual harass harassment ment in school sshow how that a “hostile” environment correlates with self-confidence [169, 172]. Girls harassed in school are less inclined to study, have lower self-esteem and expect less of their future careers. Adults have a central role of initiating discussion, and intervening in the occurrence of verbal harassment with sexual connotations [171, 173]. Teachers´ attitudes toward verbal aggression is important because they contribute to legitimatising or condemning it [169, [ 169, 170, 173]. Education, proactive intervention and prevention helps identify, conceptualize and decrease the occurrence of sexual harassment in school [37].

44

 

5.4.8. Persons influen influencing cing 12-year-old girls’ attitudes (I-II)

Girls and women’s attitudes towards and behavior associated with menstruation is developed in a complex interplay of cultural beliefs, socialization factors, and actual experience [51, 153, 174]. The female informant’s attitudes toward menstruation and their body-esteem affect the message content delivered to the girl seeking information. Girls put their trust in many people at the time of menarche, such as mothers,  peers, school nurses and and nurses teach teachers (Table[55]. 1, 4).The Pee Peers rs withinhowever, or outside sc school hool important as individuals asers a group mother, is the mostare important person for information and discussion [46, 152] (Table 4). Although school nurses are very important informant, the descriptive study (II) indicates their importance decreases slightly after menarche in favour of mothers and female friends. Independence from adults is gradually reinforced by closer relations to peers, thus making peers more important [6, 9, 32]. Seventeen per cent of girls stated they were not informed by their mothers (Table 4). Since premenarcheal girls stated that they were informed by their mothers to a lesser l esser extent compared to postmenarchel postmenarchel girls, it may be concluded that some mothers witheld information until menarche. Other possible explanations might be that not all mothers understand their importance. Mothers may have difficulties with communication about these issues or they may miss the optimal opportunity for such discussions. Perhaps mothers more should actively inform their daughters prior to menarche. It is, however, important to discuss the content and quality of this information. A reasonable explanation is also that some girls do not live close cl ose to their mother [64]. As in prior studies our findings in study I indicated that girls felt embarrassed about telling their fathers about menarche [175]. At the same time study II showed that being able to talk to their fathers about menstruation could reduce concern that menstruation should be concealed. Adult informants, fathers and mothers in particular, should be both aware of their importance and encouraged to obtain adequate information to assure that positive and realistic expectations are transferred to the girl. Well-informed girls with high selfesteem will provide preparedness in the future when it is time to help their own daughters. It is important that schools, youth health centers and families realize this and influence group dynamic processes so that the transformation to womanhood may become a positive experience. Achieving this may help to reduce sexually transmitted diseases, teenage pregnancies and increase quality of life. 5.4.9. Educating and positively influencing attitude attitudes s toward menstruation (III)

Active intervention given to premenarchea premenarcheall girls jjust ust before menarche improved some of their attitudes towards menstruation. However, 12-year old girls´ change in attitudes as a result of active intervention, differed, depending on the time of menarche. These finding may have implications for the t he development of educational  programs. 5.4.9.1.

Experienced benefits from active intervention

Previous research has concluded that girls seem to have incorporated many of the  prevailing cultural views of menstruation menstruation early in life [93 [93,, 174]. Most of these these views are negative and do not prepare girls for womanhood. Girls “totally” unprepared usually have more negative attitudes. The media conveys a negative message concerning menstruation [67, 68]. Despite the prevailing cultural views, the active 45

 

intervention increased positive attitudes towards menstruation and womanhood. This caused a positive change in attitudes towards maturing and menstruation. This entailed pride in menstruating, eagerness to have their first period and happiness about their first menstruation. Overall, they felt better and more pleased toward menstruation with the active intervention compared to the standard intervention. In the intervention study (III), “negative feelings” such as fear others would notice menstruation was difficult to influence [174]. It might be easier to t o affect “negative feelings” if teaching both positivetoas wella as the negative aspects of menstruation [46, 57,emphasizes 59]. It might be the important offer balanced view of menstruation with some problems such as dysmenorrhoea [176]. The “Openness” dimension used in the intervention study (III) embraces the attitude towards communicating with peers about menstruation and feeling more comfortable/less embarrassed when talking about menstruation. The combination of increased openness and increased positive feeling found in this study might enhance improved  body image. 5.4.9.2.

The importance of timing

We learned from the intervention study (III) that best results were achieved when active intervention was given just before menarche to girls having their menarche on time. The active intervention improved attitudes in the on-time matured girls. If we want to improve attitudes in early-matured girls as well, we will probably have to reach them earlier. Further research is needed to determine if girls under 11 or 12 are  psychologically ready ready for this active interv intervention. ention. Girls need to feel accepted in the classroom and by peers independent of their stage of development. The best approach might be to educate girls gradually over several years beginning when premenarcheal [1, 39, 62]. That kind of approach has not yet been scientifically evaluated. 5.4.9.3.

Early-matured girls

At the beginning of the intervention study (III), 32 % of the girls had already had their first period. If the active intervention is given to girls during their 12 th year, we may reach the “on-time” menarcheal girls with an understandable education. However, we will not reach girls who already had their first menstruation. This may have implications since these girls reacted r eacted differently to active intervention compared to on-time girls. Early development implies that they, their parents and their neighborhood  perceive them as older [46]. Early-matured girls have have more extern externalizing alizing problems with a riskier life-style, such as earlier sexual debut, earlier alcoholic debut and lower scholastic achievement achievement [47, 177, 178] [177]. Furthermore, early-matured girls also have more internalizing problems such as higher scores on depressive feelings, sadness, psychosomatic psychosomatic symptoms and perceived instability of self [47, 178, 179]. Early-matured girls generally have lower self-esteem compared to boys and non pubertal girls [178, 180]. 180]. Girls` dissatisfaction with weight, weight, a great problem in western countries, seems to follow pubertal maturation. Some authors assert that this worry affects early maturing girls more than other girls [47, 181-184]. We know that early-matured girls may have a lack of cognitive ability and complex abstract thinking at the time of menarche [108, 109, 111, 185-188]. Before the age of 11 to 12, the t he child does not realize what menstruation actually entails [55]. If an intervention similar to the active intervention in this study is given before the early-matured girls receive menarche will they also change their attitudes? The early-

46

 

matured girls probably require earlier intervention to change their attitudes positively [59]. Furthermore, we can assume that educating early-matured girls must take consideration to their undeveloped, abstract thinking. 5.4.9.4.

Late-matured girls

In the intervention study (III), girls who were pre-menarcheal also at the time of the second questionnaire did not improve their attitudes. atti tudes. Since investigation was terminated after the second questionnaire, not know if theFurthermore, active intervention had a positive effect that would have been we seendoafter menarche. would the effect of the active intervention be even greater if received later? In contrast to early-matured girls, no authors suggest that late-matured girls experience life-styles problems. On the contrary, late-matured l ate-matured girls have a higher level of education and career than early-matured girls [47]. Furthermore, latematured girls worried less about menstruation while having more positive experience of menarche than other girls [49, 55]. Late-matured girls have developed an abstract thinking which might help them understand and accept menarche in a positive way [108, [ 108, 109, 111, 185-188]. 5.5.

A new approach (III)

The experience of the “fruit session” during the active intervention  intervention is a good example of the new approach. The girls were quiet and listened intensely. They gently took the pears and almonds one at a time. It was experienced as a ceremony and an important occasion. The new approach (IML) utilizes utili zes multisensory learning, variation and different learning styles. All these seemed to be important keys in reaching early adolescent girls. Presumably, most prevailing education on menstruation, sexuality and womanhood given to early adolescent girls has not contained these components. Thus, more effort should be put into incorporating these components in the future. It is reasonable to assume that this is also important for younger girls. 5.6.

Educational obstacles to overcome and future challenges

The IML for 12-year-old girls (III) (II I) has been presented for nurse-midwives at 60 Swedish youth health centres and at five seminars for school nurses from about 80 different schools. Lack of resources may complicate implementation and spreading of this Themethod. intervention described for 12-year-old girls (III), or parts of it, has been used for boys, intellectually i ntellectually challenged adolescents and the visually handicapped handicapped.. However, it remains to evaluate the effect on these groups of individuals. It seems that 17-year-old boys do not take responsibility in STI-prevention as fully as girls do. Present STI-education has not succeeded in reaching them. Another educational model, similar to the t he model developed for the12-years-old girls (study III), should be developed for older adolescents.  The Örebro Prevention Program (ÖPP) developed at Örebro University [189] was a succesfull programme for the prevention of alcohol intoxication and crime for youth. Short parent meetings were carried out every half year at schools with pupils in grades 7-9 (aged 13-16 years). This raises the interesting question of whether  parental involvement involvement in STI-education could could affect sexual risk behaviour behaviour in adolescents.

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6. Summary and conclusions The period around 12 years was characterized by transition. The girls were fully aware of their ongoing physical and social changes and were in need of attention and understanding of occurrences in this phase of life. They longed for a deep and close relationship with their mothers but also tested their independence on them. The relationship to people around them changed and they longed for new social relationships. When receiving menarche they experienced a greater need for integrity, not always understood by their t heir mothers. The girls expressed a need to know more about sexuality and felt that adults in their surroundings had failed them in this regard. They felt sexuality physically and had many advanced questions about sex and their bodily changes. It is important to inform girls of their sexuality at an early age which is in agreement with a prior pri or study Girls in early adolescence require attention and understanding in their quest for independence.. Parents, particularly mothers, should be informed and supportive independence whereby their roll is of the utmost importance. To better support girls in early  puberty we need to developed m methods ethods and provide knowledge of wh what at they consider important. The professional role of school nurses and nurse-midwifes provides an excellent opportunity to meet these needs in i n early puberty. Further research r esearch is needed to gain more knowledge of girls’ transitional processes from an individual  perspective. An unacceptable proportion disliking their bodies may indicate i ndicate the transformation to womanhood will not be optimal. Wanting to be an adult and liking their body develops seems to be associated with a more positive feeling towards menstruation. Furthermore, mothers and others timing and ability to communicate attitudes around menstruation and the body are important. Adolescence is a time of rapid change and psychological adjustment. Education may improve understanding and attitudes towards menstruation, thus making girls more aware of risks enabling them to protect themselves accordingly. This addresses  problems of increased increased teenage pregnancy pregnancy and ssexually exually transmitted infec infections. tions. Controlled trials evaluating different interventions are rare. This study of a new group intervention is one of the first controlled trials tr ials evaluating approaches to educating girls in the transformation to womanhood. We compared the effect of an active intervention with a standard intervention on attitudes towards menstruation. If .

the active intervention was given to premenarcheal girls just before menarche, it seemed beneficial. Our interpretation of these results is that girls should be reached actively by offering group education, if possible, just prior to menarche. Education should be held in groups, interactive, concrete and based on multisensory learning. Because early and late-matured girls` attitudes attit udes remained unchanged towards menstruation using our approach, further research is needed. When planning STI-education it is important to focus more on sexual practice than on sexual identity. It is also important to consider gender traditions and learning styles where reaching boys presents the greatest challenge. If we are unsuccessful in reaching boys with STI-education we will not be able to see a decrease in infection rates. Further research is needed to develop and evaluate methods in the STIeducation area to specifically influence boys’ behavior. A result in decreased risk  behavior is not easily easily achieved. Time Time and proper educational educational resources will always  be needed and and there are no sh shortcuts ortcuts for achieving the these se goals.

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7.  Acknowledgements I wish to express my warm and sincere gratitude to those who in various ways have contributed to making this work possible: • 

To my husband Christer for all his love, understanding, patience, for making life meaningful and happy.

• 

To my wonderful children Lisa, Martin and Amanda: thanks for your caring encounters and encourageme encouragement. nt.

• 

To my mother Berit for everything she has given me, for unconditional love and support. 

• 

To all the fantastic adolescents, it has been my pleasure to meet YOU. 

• 

To Ronny Gunnarsson, my chief advisor, who has believed in and guided me with unfailing enthusiasm and patience.

• 

To Evelyn Hermansson, my advisor, who with involvement and willingness lead me through the qualitative method and strongly promoted the midwifery  perspective.

• 

To Margareta Möller, my advisor and “sparring partner” who inspired me to strive forward.

• 

To Pia Höjeberg my “sister-in-arms” who also burns with enthusiasm for the girls and nurse-midwives. Always spurring me on and refusing to let me give up my research.

• 

To Bengt Mattsson och Cecilia Björklund, Lolo Humble, and others at the department of primary health care for their support.

• 

To Anna Westerståhl for advice regarding heteronormativity issues.

• 

To Mark Rosenfeld for enthusiastically and skillfully editing and translating  both the clean and and dirty Swedish words in the studies an andd thesis to English and for many good laughs and discussions along the way.

• 

To Pia Gustafsson and Åsa Jansson at the youth health centre in Skara and Eva Södergren at the youth health centre in Härryda for their enthusiasm in educating the 12-year-old girls and for help the questionnaires.

• 

To all the school nurses at Lerum, Härryda and Mölnlycke who have been involved in this research and who have helped me so much with the many heavy administrative tasks involved. Also humble thanks for standing by me in the important work with the girls.

• 

To Kristina Lindquist, Agneta Lundstedt at Alingsås youth health centres, Frida Gustafsson Helen Odzic-Pohl at the youth health centres in Borås who collected questionnaires and enthusiastically educated the 17-year-old youths.

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• 

• 

• 

• 

To the headmasters and teachers at the Lerum, Härryda and Skövde schools, Alströmer school in Alingsås and Sven Erikson school in Borås for their kind cooperation. To Solveig Kärrman and Ulla Sandwall who have always had the youngsters  best interest at heart and and for supporting my visions and amb ambitions. itions. To all personell at the youth health centre in Lerum who throughout the years gave me so much encouragement and feedback. To Kristina Dalenius, Gun-Britt Eriksson for their cooperation in running a  project for youth health centers och sschool chool healthcare aand nd realizing a researcher’s third mission- to make known the results of research. Also thanks to the municipalities Lerum, Alingsås, Vårgårda and Herrljunga för financial support to make known the results of research.

• 

To all nurse-midwives and school nurses through out Sweden that have been working with the IML method and have shown interest in my results. This has inspired me to carry on.

• 

To Leila Lönnroth, Bengt Höjer and Björn Nilsson for valuable advice, Erika  Nettelbladt and Martin Rembeck Rembeck for registering data and Ulla Wessma Wessmann for transcribing the interviews.

• 

To Bengt Dahlin who introduced me to the world of research and development.

• 

To Annika Billhult, Göran Jutengren at the research and development unit of  primary health care Södra Södra Älvsborg for prep preparing aring me with question questionss during the preliminary hearings and kindly answering all sorts of research questions these last years.

• 

To Eva Almqvist at the research and development unit of primary health care Södra Älvsborg for her excellent photos for the cover and pages of the thesis.

• 

Greta Jonasson and Jörgen Månsson for preparing me with questions during the preliminary hearings.

• 

Special thanks to the research and development council and primary health care in Södra Älvsborg for financial support.

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8. Appendix On the following pages these t hese appendix are found: Appendix 8.1: Questionnaire part 1 for premenarcheal girls (II, III) Appendix 8.2: Questionnaire part 1 for postmenarcheal girls (II, III) Appendix 8.3: Questionnaire part 2 for girls (II, III) Appendix 8.4: Questionnaire to 17-year-old adolescents (IV)

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8.1.

Questionnaire part 1 for premenarcheal girls (II, III)

52

 

Enkät 8.1 sida 1

53

 

Enkät 8.1 sida 2

54

 

Enkät 8.1 sida 3

55

 

Enkät 8.1 sida 4

56

 

8.2.

Questionnaire part 1 for postmenarcheal girls (II, III)

57

 

Enkät 8.2 sida 1

58

 

Enkät 8.2 sida 2

59

 

Enkät 8.2 sida 3

60

 

Enkät 8.2 sida 4

61

 

8.3.

Questionnaire part 2 for girls (II, III)

62

 

Enkät 8.3 sida 1

63

 

Enkät 8.3 sida 2

64

64

 

8.4.

Questionnaire to 17-year-old adolescents (IV)

65

 

Enkät 8.4 sida 1

66

 

Enkät 8.4 sida 2

67

 

Enkät 8.4 sida 3

68

 

Enkät 8.4 sida 4

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10. Original publications I.

Rembeck, G I. Hermansson E. Transition to puberty. Experiences of 12-year-old Swedish girls. Submitted.

II. Rembeck G I. Möller M. Gunnarsson R K. (2006). Attitude Attitudess and feelings towards menstruation and womanhood in girls at menarche. Acta Paediatrica. 95:707-714 III. Rembeck, G I. Gunnarsson RK. (2004). Improv Improving ing pre- and postmenarche postmenarcheal al 12year-old girls' attitudes toward menstruation. Health Care Women Int. Aug;25(7):680-98. IV. Rembeck, G I. Gu Gunnarsson nnarsson RK. Ro Role le of gender in sex sexual ual behavior and re response sponse to education in sexually transmitted infections in i n 17-year-old adolescents Manuscript.

Paper II and III have been reprinted with permission by the journals.

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