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Adolescent sexually transmitted diseases knowledge, attitudes, and behavior

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Title:
Adolescent sexually transmitted diseases knowledge, attitudes, and behavior
Creator:
Sereeter, Erdenechimeg
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
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Language:
English
Physical Description:
91 leaves : ; 28 cm

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Subjects / Keywords:
Sexually transmitted diseases -- Study and teaching -- Mongolia -- Ulaanbaatar ( lcsh )
Teenagers -- Attitudes -- Mongolia -- Ulaanbaatar ( lcsh )
Teenagers -- Sexual behavior -- Mongolia -- Ulaanbaatar ( lcsh )
Sex instruction for teenagers -- Mongolia -- Ulaanbaatar ( lcsh )
Sex instruction for teenagers ( fast )
Sexually transmitted diseases -- Study and teaching ( fast )
Teenagers -- Attitudes ( fast )
Teenagers -- Sexual behavior ( fast )
Mongolia -- Ulaanbaatar ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 88-91).
Thesis:
Integrated sciences
General Note:
Integrated Sciences Program
Statement of Responsibility:
Erdenechimeg Sereeter.

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|University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
57707743 ( OCLC )
ocm57707743
Classification:
LD1190.L584 2004m S47 ( lcc )

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Full Text
ADOLESCENT SEXUALLY TRANSMITTED DISEASES KNOWLEDGE,
ATTITUDES, AND BEHAVIORS
by
Erdenechimeg Sereeter
B.S., The National Medical University in Mongolia, 1998
M.D., The National Medical University in Mongolia, 1998
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Integrated Science
2004


This thesis for the Master of Integrated Science
degree by
Erdenechimeg Sereeter
has been approved
by
Susan Dreisbacfi
Q jqAjJL lij
^ Date


Erdenechimeg Sereeter (M.I.S)
Adolescent Sexually Transmitted Diseases Knowledge, Attitudes, and Behaviors
Thesis directed by Research Assistant Prof. Susan Dreisbach
ABSTRACT
By the late 1980s the socialist system collapsed and Mongolia has been
experiencing changes in its political, economic, social, and cultural structures.
One of the changes has been a dramatic increase in sexual activity among
adolescents, which has led to increased numbers of STDs. Since sexuality
education is new in Mongolia, very little information is available about teenagers'
sexuality, especially teenagers' sexual behaviors and their knowledge and attitudes
about STDs other than HIV/AIDS. Thus, it was important to address this issue,i
especially between those students who continue their education beyond 8th grade
and those who do not. Different sexuality education curriculums are offered in 8th,
9th, and 10th grades and only 10th graders leam about STDs in school.
This study of 342 8th, 9th, and 10th grade students selected from three urban
schools in the capital city, Ulaanbaatar, Mongolia describes their sexual
behaviors, measures their knowledge, and identifies their attitudes about STDs
other than HIV/AIDS.
The results of this study indicate that students who had more sexuality education
in schools or were in higher grades were more knowledgeable about STDs other
than HIV/AIDS and they were also more concerned about STDs and had
traditional beliefs about sexual relationships that could encourage teenagers to
be abstinent from casual sexual relationships. However, students in higher grades
had more risky sexual behaviors that put them at high risks for STDs. The
findings can be used to improve and develop appropriate sexuality education
programs for schools.
This abstract accurately represents the content of the candidate's thesis. I recommend
its publication.
Signed
Susan Dreisbach
in


ACKNOWLEDGEMENT
Many thanks to my wonderful advisor Dr. Dreisbach, for all her help in the
writing of this thesis and for her patience with me during past one year. I would
also like to thank the other members of my thesis committee, Dr. Kimbrough and
Dr. Janes, for their insights and comments. A special thank you to the staff of the
Graduate School for their support and understanding.


CONTENTS
Figures...................................................vii
Tables....................................................viii
CHAPTER
1. INTRODUCTION.............................................1
Specific Aims.........................................3
2. A REVIEW OF LITERATURE AND SEXUALITY
EDUCATION IN MONGOLIA....................................6
A Review of the Relevant Literature..................6
The Status of Sexuality Education in Mongolia........13
3. THE METHOD SECTION......................................19
The Setting..........................................19
Inclusion Criteria and School Selection..............19
Recruitment..........................................21
The Subjects.........................................22
Instrumentation......................................26
Survey Administration................................27
Data Analysis........................................27
Human Subjects Considerations........................28
4. THE PRESENTATION OF FINDINGS............................29
v


Sexuality Education Programs in Schools...........29
Information Resources about STDs other than AIDS..30
Teenagers' Knowledge about STDs other than AIDS...32
Attitudes and Beliefs.............................44
Teenagers' Sexual Risk Behaviors..................48
Sexual Intercourse..........................49
Age at First Sex............................50
Number of Sexual Partners...................50
Alcohol Use Before Sex......................51
Drug Use Before Sex.........................53
Condom Use..................................55
5. DISCUSSION AND CONCLUSION..................57
Discussion........................................57
Limitations.......................................67
Conclusion........................................68
APPENDIX
A. HUMAN SUBJECTS RESEARCH COMMITTEE AT THE
UNIVERSITY OF COLORADO AT DENVER APPROVAL............72
B. SURVEY QUESTIONNAIRE................................73
C. COMPULSORY SEXUAL HEALTH EDUCATION TOPICS
IN THE FORMAL SCHOOL CURRICULUM IN MONGOLIA..........84
D. GLOSSARY OF ACRONYMS................................86
E. GLOSSARY OF MONGOLIAN WORDS.........................87
REFERENCES....................................................88
vi


FIGURES
Figure
2.1 Percentage of abortions among women under 20.............................9
2.2 Prevalence of STDs in Mongolia per 10,000 population, 1990-2000..........11
3.1 The 8th graders' answers about continuing study...........................23
3.2 The participants' grades by grade level...................................24
4.1 Information resources about STDs other than AIDS.........................30
4.2 The participants' average knowledge scores...............................32
4.3 The best-known STDs by gender.............................................35
4.4 The best-known STDs by grade level........................................36
4.5 Options to prevent STDs..................................................40
4.6 Intimate helpers by grade level..........................................48
4.7 Gender and grade level of sexually active participants....................49
4.8 Sexually active students' alcohol use.....................................52
4.9 Sexually active students' drug use........................................53
4.10 Drug use by grade levels................................................54
4.11 Sexually active participants condom use................................55
vii


TABLES
Table
3.1 Gender of the participants by grade level................................22
4.1 The participants' perception of sexuality education in school............29
4.2 The participants' knowledge score by grade levels and gender.............33
4.3 The number and proportion of students who identified up to 6 STDs.........34
4.4 The students who knew one or more common symptoms by gender...............37
/
4.5 The proportions of students who correctly identified up to 5 common
symptoms of STDs by grade level..........................................37
4.6 Proportion of students who identified common symptoms of STDs............38
4.7 Students' choices of avoiding STDs by gender.............................40
4.8 Students' choices of prevention methods for STDs by grade level..........41
4.9 Misconceptions about STDs................................................43
4.10 Summary of 3 statement agreement questions..............................44
4.11 The students' worry about getting an STD.................................45
4.12 The students' worry about getting an STD by grade level..................46
4.13 The students' worry about getting an STD by gender.......................46
4.14 The students intimate helpers by gender.................................47
viii


CHAPTER 1
INTRODUCTION
The following two stories from the Mongolian Adolescent Reproductive
Health Project (2002) are common cases for Mongolian teenagers.
"...I met with him at the summer camp. We had fireworks at that
day and everybody was-so excited. Then we drank some beer. When
we were in the forest, he told me that we loved each other, so we
had to prove each other. Finally, he asked me "How about having
sex?" At that time, I had no doubt about having sex because also he
said to me that if I did not have sex with him, he was ready to sleep
with another girl..."
A 16 year-old teenager girl who had an abortion
"...I was a pregnant. I suspected that my husband slept with another
woman. One day I had really bad discharge from my vagina. The
discharge looked like pus. I knew that something was wrong.
However, I believed that I did not need to see a doctor, so I used
various kinds of medicines and injections for getting rid of it..."
A 19 year-old teenage mother
Yes, nowadays, everything is changed. When I was a teenager, a boy would
meet his girlfriend after school, carry her backpack, and take her to a movie. The
most exciting thing to hear was that someone kissed someone.
Mongolia, located between China and Russia, is a country with a unique
history and culture. The Mongolian land territory is large but the total population is
1


only 2.4 million. Twenty-five percent are adolescents aged 10 to 19 (WHO, 2003, p.
7 & 10). Mongolia was a part of the socialist system until the late 1980s. For
centuries, before and during the socialist system, discussion of sexuality was a taboo
subject. By the late 1980s the socialist system collapsed and Mongolia began to
experience changes in its political, economic, social, and cultural structures. One of
these changes has been a dramatic increase in sexual activity among adolescents,
which has led to increased numbers of sexually transmitted diseases (STDs),
unwanted pregnancies as well as a heightened risk for infection by the human
immunodeficiency virus (HIV) (International Women's Health Coalition, 2004).
When the Ministry of Health and Social Welfare (MOHSW) became aware of the
health problems facing Mongolian youth, it stepped forward to respond to this
problem by proposing sexuality education as a mandatory component of health
education in the school setting. Since sexuality education is a relatively new concept
in Mongolia, very little information is available about teenagers' sexuality, especially
teenagers' sexual risk behaviors and their knowledge and attitudes about STDs other
than Acquired Immunodeficiency Syndrome (AIDS). Consequently, I am concerned
about teenagers' knowledge and attitudes about STDs other than AIDS and their
sexual risk behaviors, including alcohol and drug use as these relate to sexual
activity. It is very important to assess teenagers' knowledge and attitudes about STDs
other than AIDS and their sexual behaviors in Mongolia in order to develop
2


interventions to decrease risky sexual behaviors and in turn decrease the number of
STDs in this population.
Specific Aims
The specific aims of this study were:
1. To describe 8lh, 9th, and 10th grade teenagers' sexual risk behaviors, to measure
their knowledge, and to identify their attitudes about STDs other than AIDS.
2. To compare 8th, 9th, and 10th grade teenagers' sexual risk behaviors, their
knowledge, and attitudes about STDs other than AIDS.
It was important to evaluate teenagers' knowledge and attitudes about STDs
other than AIDS and their risk behaviors because STDs are, in reality, a greater risk
for teenagers than AIDS in Mongolia. According to the statistics of the National
Research Center for Infectious Diseases (NRCFID), approximately 20,000 patients
have been screened for HIV infection every year since 1987. As of 2001, two patients
were positive: one acquired HIV in another country, and the second is thought to
have acquired HIV through contact with an African person visiting Mongolia
(Ebright, Altantsetseg, & Oyungerel, 2003, p. 1512). Thus, nowadays, HIV/AIDS is
not as big a problem among Mongolian teenagers as other STDs.
It was important to compare 8th, 9th, and 10th grade teenagers' knowledge and
attitudes about STDs other than AIDS and their risk behaviors because many
Mongolian youth do not progress beyond the 8th grade and may not be learning about
3


the risks of STDs and how to prevent them. The Mongolian general education
structure has two kinds of systems; the 10-year system and the 8-year system.
According to the most recent data up to 40% of the eighth graders do not continue
their studies beyond grade 8 (Ministry of Science, Technology, Education, and
Culture (MOSTEC), 2002)). Students have the right to finish their study until 8th
grade and generally, continuation of study depends on students grades. That fact is
important to this study because different sexuality education curricula are offered in
8th, 9th, and 10th grades (see Appendix C). For example, the eighth graders are taught
about pregnancy, fertility, how to protect themselves from unwanted pregnancies, as
well as testicular and breast-self examination. The curricula for ninth graders include
information about sexual identity and orientation and safer sex. Only the curricula for
tenth graders includes information about STDs, so those students who do not
continue past the eighth grade do not have a chance to leam about STDs in school.
However, we have to prepare these adolescents for family life also. Furthermore,
teenagers become sexually active at these ages.
This thesis consists of five chapters, including the introduction: a review of
the relevant literature and the status of sexuality education in Mongolia, methods, the
presentation of findings, and a conclusion. The literature review explores the main
issues concerning adolescents' reproductive health, including STDs in the United
States of America (USA) and Mongolia and presents some studies regarding
Mongolian teenagers' knowledge and attitudes about STDs other than AIDS.
4


Moreover, this chapter gives the background on school-based sexuality education in
Mongolia. The next chapter presents the setting, the inclusion criteria, the school
selection process, the recruitment, the data collection technique as well as the
subjects. The presentation of findings is based on a survey of 342 students who were
recruited from the three urban schools.
In the conclusion, I summarize the main findings. This chapter also includes
discussion and limitations. In the discussion section, I compare my findings to other
studies and note my thoughts.
5


CHAPTER 2
A REVIEW OF LITERATURE AND SEXUALITY
EDUCATION IN MONGOLIA
A Review of the Relevant Literature
Adolescence is a period of sexual maturation between ages 10 and 19 that
transforms a child into a biologically mature adult capable of sexual reproduction and
vulnerable to the consequences of sexual activity. (Gubhaju, 2002, p .3). The
reproductive health of adolescents is of growing concern today for several reasons.
First, the size of the adolescent population in the world commands attention.
Adolescents numbered nearly 1.1 billion in 1995 of which 913 million lived in
developing countries and 160 million in developed countries. In other words, one in
every five people in the world is an adolescent, and 85 of every 100 adolescents live
in developing counties (Takemi Program in International Health Harvard School of
Public Health, 1998, p. 4). In Mongolia, adolescents (ages 10-19) numbered 581,188
or 25% of the total population of 2.4 million in 1998. Of all Mongolian adolescents,
38% were between the ages of 14-17 (WHO, 2003, p. 7 & 10).
Second, the onset and pace of adolescence are changing, making it a
particularly vulnerable period of development. Moreover, demographic,
6


epidemiological, and socio-economic trends in many countries, including Mongolia,
are combining to create different life styles for adolescents that add to their
vulnerability.
Nowadays, there is a clear trend among young men and women in many
countries to marry later in their lives and to engage in sexual relations prior to
marriage. For instance, in the United States, sexual activity among adolescents 15 to
19 years of age increased from 32% in 1971 to 45% in 1995 (Jordan, Price, &
Fitzgerald, 2000, p. 338). In addition, the nationwide survey of Youth Risk Behavior
Surveillance United States indicates that in 2001,45.6% of high school students had
ever had sexual intercourse (National Library of Medicine, 2004). A 1996 study in
Mongolia, found that 26% of adolescents aged 17 to 18 years had had sex. However,
this figure has increased in the last four years and in 1999, 34.5% of adolescents 17-
18 years old report having had sexual intercourse (WHO, 2003, p. 13). The period of
exposure to sexual activities before marriage also becomes longer because the
. average age at menarche continues to decline (Takemi Program in International
Health Harvard School of Public Health, 1998, p. 14).
Political, social, and economic changes, including the collapse of the socialist
system, urbanization, industrialization, increase of education needs, and western
media influences have eliminated many of the traditional restraints on early sexual
activity outside marriage and have exposed many adolescents to the risks of
unintended pregnancies, abortions, and sexually transmitted diseases (STDs), which,
7


in turn, increase the risks to their reproductive health and well-being (Takemi
Program in International Health Harvard School of Public Health, 1998, p. 14).
First, I would like to discuss unintended pregnancies among teenagers. The
United States still has the highest rate of adolescent pregnancy in the developed
world. Each year as many as one million American teenagers become pregnant. The
vast majority of these teenagers say they never intended to get pregnant (Buckingham
& Derby, 1997, p. 11). In Mongolia, the rate of giving birth among adolescents has
increased in the last ten years. According to the Reproductive Health Survey, in 1998
about 9% of 15-19 years old girls gave birth (NSOM & UNFPA, 1999, p. 38).
Moreover, according to the 1996-1998 statistical data, 8.3% of maternal deaths from
pregnancy and delivery were adolescents between the ages of 15-19, which is twice
as high as the percentage of deaths among the 20-29 age group (WHO, 2003, p. 14).
Second, the rate of abortion is important because it indicates that young
women are having unprotected sex that results in unplanned or unwanted
pregnancies. For most teenagers, abortion is a personal and complex decision. About
one third of all teenagers who become pregnant each year in the United States choose
to terminate their pregnancy (Buckingham & Derby, 1997, p. 105). In Mongolia,
6.3% of women aged 13-20 became pregnant. Of these, 43.3% pregnancies were
unwanted and 18% had abortions. Those who had attained merely a primary
education had the highest pregnancy rates in comparison with those who had attained
the education level of grade 10. According to health statistics, the percentage of
8


abortions among women under 20 in Mongolia has increased significantly (WHO,
2003, p. 14) (see Figure 2.1). In 1998, about 9,135 women had an induced abortion in
Mongolia. Of these 5.5% were under 20 years old. The number did not include cases
of abortion in private hospitals, which were estimated at 18% among women ages 15-
24 and 2% among women ages 35-39. The reported rate was underestimated because
abortions in private hospitals were neither registered nor reported to the health and
statistical offices (WHO, 2003, p. 15).
Figure 2.1 Percentage of abortions among women under 20
Source: National Statistical Office of Mongolia. (2001). p.28.
Finally, it is estimated that more than 15 million new cases of sexually
transmitted infections are diagnosed each year in the United States. Approximately
one fourth of these new infections occur among teenagers (Planned Parenthood
Federation of America, 2004). Chlamydia, gonorrhea, and genital warts (also known
as HPV human papillomavirus) are most common among American teenagers
9


(Planned Parenthood Federation of America, 2004). Although rates of STDs other
than syphilis and gonorrhea have been going up, teenagers still have higher rates of
gonorrhea than do sexually active men and women aged 20-44 (Alan Guttmacher
Institute, 1999). During the 1980s, genital chlamydia became the most prevalent STD
in the USA and in 1996 there were an estimated 3 million new cases diagnosed. This
made chlamydia the most frequently reported infectious disease in the country
(Planned Parenthood Federation of America, 2004). In some settings, 10-29% of
sexually active teenage American women and 10% of teenage American men tested
for STDs have been found to have chlamydia (Alan Guttmacher Institute, 1999).
HPV infections have risen as well, with estimated incidence of 5.5 million new
infections each year. HPV infections of the cervix and vagina are now the most
common STDs among sexually active young women (Planned Parenthood Federation
of America, 2004). In some studies, up to 15% of sexually active teenage women
have been found to be infected with HPV, many with a strain of the virus linked to
cervical cancer (Alan Guttmacher Institute, 1999).
STDs have become an increasing problem since Mongolia became fully
independent of Soviet control in 1990. This increase may relate partly to temporary
loss of central governmental control as well as the decreased economic base for the
country. It is estimated that every year about 7,000-8,000 people are getting infected
with STDs in Mongolia. About 49-58% of STD patients are under 25 years of age
(WHO, 2003, p. 15). Data for syphilis show a decreasing trend from 1983 to 1993
10


with a decline in cases from 700 to 18/100,000 population, followed by a rise in cases
to 32/100,000 population in 1995. Data suggest a 1.5-3.0 fold higher rate of syphilis
for ages 15-24 than any other group. Data for gonorrhea show an upward trend in rate
of cases, from 51/100,000 population in 1983 to 142/100,000 in 1995. The majority
of cases are aged 15-44 (Purevdawa et al., 1997, p. 398-401 & Ebright, Altantsetseg,
& Oyungerel, 2003, p. 1509 & 1511-1512) (see Figure 2.2).
Figure 2.2 Prevalence of STDs in Mongolia per 10,000 population, 1990-2000
Syphilis --i$ Gonorrhea
Source: National Statistical Office of Mongolia. (2001). p. 31.
Trichomonias rates also show an upward trend in the number of cases, from
47/100,000 population in 1983 to 155/100,000 cases in 1995. Like gonorrhea the
majority of cases are in the 15-44 year age range. In addition, for children aged 0-14,
the 1983-1993 rate remained below 4.5/100,000; however, in 1994 and 1995 the rate
increased reaching 53 and 48/100,000 respectively (Purevdawa et al., 1997, p. 398-
401 & Ebright, Altantsetseg, & Oyungerel, 2003, p. 1509 & 1511-1512).
11


These are official statistics of NRCFID, So the above rates are entirely underestimates
because STD cases in private hospitals were neither registered nor reported to the
health and statistics offices.
STDs are responsible for a variety of acute and chronic health problems, and
can have especially serious consequences for adolescents, such as pelvic
inflammatory disease, ectopic pregnancy, infertility, and cervical cancer.
Consequently, it is very important to assess teenagers' knowledge and
attitudes about STDs other than AIDS and their sexual behaviors in Mongolia. Since
sexuality education is a relatively new program in Mongolia, very little information is
available about these issues. However, there are a few studies, such as a 1999 survey,
"Reproductive Health and Sexuality: Knowledge, Attitudes, and Behaviors" by the
UNFPA, the MOHSW, the MOSTEC, and other international organizations
(Adolescent Reproductive Health Project, 2002). About 1400 rural and urban school
students, aged 11-18, participated in this study. To assess teenagers' knowledge, the
study asked three questions about each reproductive health topic such as anatomy and
physiology, puberty changes, conception, pregnancy, contraception, sexual
orientation, sexual coercion, and STDs. It is impossible to assess teenagers' real
knowledge about STDs based on only three knowledge questions. In addition, The
World Health Organization (WHO), the UNFPA, and the Mongolian government and
some of its organizations conducted a study together, "Adolescent Behaviors and
their Living conditions" (National Statistical Office, 2002). About 3,600 4th to 10th
12


graders and 400 young people not in school from both rural and urban areas
participated in this study. The main purposes of this study were to examine the
implementation of the Adolescent Reproductive Health Project and to evaluate
adolescent living conditions rather than assess teenagers' knowledge about STDs
other than AIDS. Furthermore, in 1996, the UNFPA and the MOHSW conducted
another study named, "Adolescent Reproductive Health Knowledge, Attitudes and
Practice" (MOHSW & UNFPA, 1996). The sample included 4,674, young people
aged 13-20. The study included only four questions to assess teenagers' knowledge
about STDs other than AIDS which were very general. For example: "Have you ever
heard about STDs? Yes or No and "Do you know about symptoms of STDs? Yes
or No.
Consequently, there is no study to my knowledge that focuses on Mongolian
teenagers' sexual risk behaviors and their overall knowledge and attitudes about
STDs other than AIDS.
The Status of Sexuality Education in Mongolia
In response to the growing problems, in 1997, the MOHSW and the
MOSTEC established a joint initiative to promote the country's new commitment to a
preventive approach to public health care. A key part of the initiative was to design a
primary and secondary school health education program that would address the most
pressing public health concerns facing young Mongolians. In partnership with the
13


WHO, the Mongolian government identified ten thematic areas to include in a
comprehensive health education curriculum; one of these areas was reproductive
health. In addition, the resolution of the International Conference on Population and
Development, held at Cairo in 1994, had great influence on the Mongolian
governments decision. One of the topics discussed in this conference was that of
adolescent sexuality education. Initially, the MOHSW encountered some resistance
from the MOSTEC about reproductive health and, in particular, the idea of school-
based sexuality education. For centuries, Mongolians had avoided public (and much
private) discussion of these issues. The hesitation was based in part on a concern that
such education would result in promiscuity. Extensive dialogue, joint participation in
international meetings, and a review of the literature on this topic led, however, to a
consensus that the culture was already in transition, and that effective education
could reduce rates of unwanted and unsafe sex. During that time, policy makers
believed that because of changes in politics and life of the society, sexual activity
among teenagers, the risk of STDs, and unwanted pregnancies were greatly
increasing. Reproductive health education is one way of addressing these issues.
However, when ministry officials asked themselves what adolescents needed to know
if they were going to reduce their risk of unwanted pregnancy, STDs, and physical
abuse, they did not have any clue. Also, they realized that there were no sexuality
education experts in Mongolia. Nevertheless, some school-based sexuality education
programs have been implemented since 1998 under the guidance of the UNFPA,
14


WHO, and other international organizations in Mongolia. One such project is the first
Mongolian Adolescent Reproductive Health Project, nicknamed PO Zorgaa1, which
refers to UNFPA Project number 06. Since 1998 the UNFPA has supported the
longest running school-based project in Mongolia. The project has a budget of
US$743,890. It is being managed by the Margaret Sanger Center International
(MSCI) and is being implemented by the MOHSW and the MOSTEC. The project
has four components (Population Council, 2002, p. 11 & Asia and Pacific Regional
Bureau for Education UNESCO Bangkok & UNFPA, 2004):
1. Formal education:
A curriculum that was piloted in 12 schools that is now offered in 60% of all
schools (100% of all urban schools). When more experience has been gleaned and if
the government expands the number of hours (currently, 5-6 hours a year of sexuality
education) for reproductive and sexual health education, a second edition of the
curriculum will be produced and distributed nationally.
2. Informal education :
The project staff has been working with non-governmental organizations
(NGOs) in order to reach teenagers out of school. The project conducted a three-week
training course for NGO staff and volunteers in 1999 and distributes materials such
1 It means in Mongolian number six.
15


as a newspaper "UerkheLove"2 to the NGOs. Moreover, "Hotline 312151" offers
advice to adolescents in the areas of reproductive health and sexuality. In the first
eight months of 1999, the hotline service of "Adolescence Future Center" provided
answers to 560 people on about 600 questions. Eighty-three percent of all the
customers were adolescents. Because of financial constraints, however, this element
of the project has not yet been developed.
3. Information and communications:
Understanding that the classroom is only one avenue for transmitting
messages about sexuality, and, given the need to reach out-of-school young people,
the project also has an information, education, and communication component,
making use of the popular media (both electronic and print) to reach adolescents and
complement the school-based education. In 1998, the project developed a newspaper
called "UerkheLove" for adolescents. The MSCI proposed two educational videos of
20 minutes. The topics of these videos are human sexuality and parental dealings
with adolescents. Also, the project developed two textbooks to complement the
curriculum.
2 The first reproductive health project for Mongolian adolescence, which is sponsored by the UNFPA
and MSCI developed this newspaper. The projects name in Mongolian was long, so it quickly came
to be called by the nickname PO Zorgaa, which refers to UNFPA Project number 06. It helps to
educate teenagers, allows them to present issues in their own voices, increases teen involvement and
participation, and advocates teen issues. This newspaper is published 3-4 times an year.
16


4. Clinical services:
There are few places in Mongolia where teenagers feel comfortable about
seeking reproductive health care services. Although the existing clinics technically
are open to adolescents, most teenagers report that they are concerned about their
privacy because the local population is small and "people talk." Currently, PO Zorgaa
staff are cooperating with a sister project, also funded by the UNFPA, to open
adolescent-friendly pilot clinics.
Sex education is a new activity in Mongolia, thus, considerable time and
effort are required to build up the expertise and experience for curriculum
development and teachers' training. Under this aspect, the MSCI has organized
training of master trainers since October 1998. The governmental goal is to provide
each of the 683 schools in Mongolia with at least one qualified sexuality educator on
staff. As of early 2002, the master trainers have trained about 300 school teachers;
however, at least an equal number of teachers are using the curriculum without the
benefit of training. Another important achievement has been the project's
collaboration with the MOSTEC to institutionalize sexuality education in teacher
training programs. The Pedagogical University in Ulaanbaatar has begun to offer a
course on reproductive health and sexuality education for biology teachers
(Population Council, 2002, p. 22).
Mongolia is beginning to receive the attention it deserves for the first stages
of its reproductive health and sexuality education program. In order to reach its goals,
17


we need a lot of research to improve and develop better sexuality education programs
to be taught in schools. The findings of my study will help to determine if there is a
gap in the knowledge of STDs between those students who discontinue their
education after 8 years and those who continue on to the 10-year system. The
findings can be used to improve and develop appropriate sexuality education
programs to be taught in schools. In particular, the findings may help to identify
which topics should be addressed in sexuality education programs for different grade
levels.
18


CHAPTER 3
THE METHOD SECTION
The Setting
This study was conducted in three urban secondary schools that offered a
standard health class curriculum in the capital city of Mongolia, in September and
October 2003. The study was conducted before the tenth graders had been taught
about STDs in the 2003-2004 school year.
Inclusion Criteria and School Selection
In 2000 there were 683 primary and secondary schools in Mongolia
(Population Council, 2002, p. 21). Although sexuality education programs are
relatively new in Mongolia, almost all urban secondary schools are regularly
involved in school-based sexuality education programs. In other words, the sexuality
education is taught by a teacher trained in this subject area and a standardized
sexuality education program is included in the main curriculum for all students.
There are two main school curricula related to school-based sexuality education
programs: one is called the family ethics class and the other is called the health class.
The family ethics class has been taught since 1994 only for ninth and tenth graders.
19


The family ethics class includes a few topics related to human sexuality, including
STDs, but it includes more topics related to social ethics, for example desirable
individual qualities, how to behave and communicate in a social environment,
divorce and its consequences, and harmful habits, including smoking and drinking.
In contrast, the health class has been taught since 1998 for all grades from 3rd
to 10th. This class focuses more on topics related to health, including human
reproductive health. Consequently, only schools that offered the health class were
eligible for this study.
School inclusion:
Be schools that have implemented health class curriculum
Be schools that offer health classes in the first semester of the 2003-2004 school
year
Be schools that have 8th, 9th, and 10lh grade levels
Be schools that are located in the capital city
Have agreement of school administrators and teachers
Three hundred and forty-two male and female eight, ninth, and tenth grade
students aged 14-18 years were recruited from three urban schools to participate in
this study.
Students' inclusion:
Be at least 14 and not older than 19 years old
Be male or female
A participant's permission
20


Eighth, ninth, and tenth graders were selected for inclusion because many
students are becoming sexually active at these ages. Also, it was important to include
8th graders because up to 40% of students do not continue their education past that
grade.
Recruitment
Generally, the Mongolian general education system has four semesters.
Usually secondary schools themselves arrange which semester the health class is
taught. During October 2003, of the urban secondary schools that offered the
standard health class curriculum, only 12 schools offered the health class in the first
semester. Three of these 12 schools were randomly selected using the lottery method.
By chance, all three schools were on the outskirts of the city where families with
lower educational level and lower incomes live. The researcher could contact the
schools easily with the assistance of her Mongolian advisor who works at the
Educational Office and is a supervisor responsible for biology and chemistry
teachers. The researcher and her Mongolian advisor introduced the purpose of the
study to school administrators and teachers and received their permission to conduct
this research in their schools and classrooms. For each school, one health class or
class work3 for each grade level was selected for participation using the lottery
J It is a separate class in which students and teachers can freely discuss whatever they want.
21


method. The study was verbally explained to students and their voluntary
participation was requested.
There was a lot of interest in participants and eagerness to be part of a study. Students
were informed of their right to skip any questions they did not want to answer and
their right to end participation at any time. No student ended participation before
completing the survey.
The Subjects
Three hundred and forty-two male and female eighth, ninth, and tenth grade
students aged 14-18 years were recruited from the three urban schools to participate
in this study. The participants in this study included: 119 students from the eighth
grade, 101 students from the ninth grade, and 122 students from the tenth grade. Ages
of the students ranged from a maximum of 18 to a minimum of 14 with an average
age of 15.99 (SD=0.97). As shown in Table 3.1, there were more females than males
in all grades with 61.1% (209) female and 38.9% (133) were male.
Table 3.1 Gender of the participants by grade level
Female Male Total
8th grade 69 50 119
9th grade 61 40 101
10lh grade 79 43 122
Total 209 133 342
22


Of the 119 eighth grade students, the majority 56.3% (67) reported that they
would like to continue on to 9th grade whereas 4.2% (5) of students were not
interested in continuing their studies past 8th grade. Moreover, 39.5% (47) reported
that they did not know. Figure 3.1 summarizes the 8th grade students answers about
continuing their studies beyond 8th grade.
Figure 3.1 The 8th graders' answers about continuing study
The researcher was interested in the students grades to see if academic
achievement was related to knowledge of STDs other than AIDS. Of the 318 (93%)
respondents, most students reported that they got B (40.6%) and C (39.6%) grades
last year. Average grades were higher in the 9th and 10th graders as would be expected
since continuing students are selected from the top students.
23


Figure 3.2 The participants' grades by grade level
8th grade 9th grade 10th grade
Mostly As Mostly Bs Mostly Cs Mostly Ds Mostly Fs
The participants' socioeconomic status was measured using three indicators:
fathers education, mothers education, and family's approximate monthly income.
The educational level of the population in Mongolia is high in comparison
with other developing countries. Of the 326 students who responded to the question
about father's education, 27.9% reported that they did not know. Thirty-two point
eight percent of the respondents' fathers had completed high school4 and an
additional 34.7% completed college5 and university6. Only 4.6% of the respondents
reported that their fathers had less than high school education.
4 High school education is the basic education and study term is 10 years.
5 Study term is usually less than 4 years and to get degree in vocational training, such as a nurse, a
plumber, and an electrician.
6 Study term is usually 4-6 years and to get degree in higher education, such as a medical doctor, an
engineer, and a lawyer.
24


Of the 331 students who responded to the question about mother's education,
16.6% said that they did not know. Thirty-five percent of the respondents' mothers
had completed high school and 45.6% of the respondents' mothers had completed
college and university. Only, 2.7% of the respondents reported that their mothers had
less than high school education. Mothers were better educated than fathers in this
population.
Family income of the participants was compared to the lowest guaranteed
living standard established every year by the National Statistical Office of Mongolia
for the capital city, Ulaanbaatar and other aimags7 8. For 2003, the standard was set at
o
25,600 tugrugs per month (National Statistical Office, 2003). Families with incomes
near or below this level would be considered poor. Based on this information, most
teenagers (63.1%) lived in families with higher incomes than the lowest guaranteed
living standard (30,001-100,000 tugrugs). Only 10.1% of the participants reported
that their families approximate monthly incomes were less than or equal to 30,000
tugrugs. Another 10.1% of the students lived in families with relatively higher
incomes of greater than 100,001 tugrugs per month.
7 Aimag provinces, with a total population of 50,000-150,000.
8 The Mongolian banknote, approximately 1,000 tugrugs = 1 US dollar.
25


Instrumentation
The participants completed a self-reported questionnaire that included a total
of 46 questions: 11 demographic questions, 17 knowledge questions about STDs, 7
attitude questions, and 11 questions about teenagers sexual risk behaviors (See
Appendix B). The instrument incorporated questions from published and unpublished
resources such as the Colorado 1999 Youth Risk Behavior Survey, Colorado Youth
Survey, and knowledge, attitudes, beliefs and behaviors (KABB) surveys. The survey
was initially developed in English. Because of differences between the Mongolian
and English languages, translation and back-translation were conducted by the
researcher and her Mongolian advisor. A pilot test was conducted with volunteer
Mongolian teenagers similar to those in the study sample. Six 8-10th grade students (3
males and 3 females) participated in the pilot test and the researcher interviewed the
students afterwards. The purpose of the pilot test was to identify unclear questions
and to estimate the amount of time needed to complete the survey. As a result, three
questions were changed: one question about a familys approximate income and two
questions about STD treatment. For the income question, we modified only the
categories. For the treatment questions, because of translation problems we combined
two questions into one. After the researcher discussed the needed changes with her
advisors, the changes were made on the questionnaire.
26


Survey Administration
The questionnaires were administered on days selected by the researcher in
October, 2003, to 342 students during health class or the class work. The self-
reported questionnaire took 20-25 minutes to complete and was administered in the
classroom by the researcher. No identifying information was included on the surveys.
The completed surveys were collected by the researcher. Following survey
administration, the researcher, a Mongolian physician, provided students with
information about STDs and answered their questions for the remainder of the class
time.
Data Analysis
The data were entered into SPSS and EXCEL and analyzed using descriptive
statistics. The analysis of variance (ANOVA) test and t-tests were used for
comparing the knowledge scores for three groups. The findings were described using
appropriate tables and figures.
27


Human Subjects Considerations
The research protocol was reviewed and approved by the Human Subjects
Research Committee at the University of Colorado at Denver. Both male and female
students participated voluntarily in this study. The purpose of the study, rights of
participants, and the survey instructions were explained verbally to students as a
group. Students were informed of their option to end their participation at any time.
Furthermore, we made every effort to keep the students answers private by not
requesting or using any names or other identifying information on the survey.
Individual answers were kept private and were not shared with their parents, teachers,
or friends.
28


CHAPTER 4
THE PRESENTATION OF FINDINGS
Sexuality Education Programs in Schools
Although only schools with sexuality education were selected to participate in
this study when the survey asked the participants if they had sexuality education in
their schools, only 60.5% of participants reported that they had sexuality education in
their schools. Totally, 41.8% students reported that they had been taught about STDs
other than AIDS in their schools. Table 4.1 represents the students overall
assessment of sexuality education programs in their schools by grade levels.
Table 4.1 The participants perception of sexuality education in school
Have you had sexuality education in school? Have you ever been taught about STDs other than AIDS in school?
Yes No Not answer Yes No Not sure Not answer
8th grade 34.4% 60.5% 5.1% 22.7% 51.5% 22.7% 3.1%
(41) (72) (6) (27) (61) (27) (4)
9th grade 76.2% 21.8% 2% 52.5% 31.7% 12.8% 3%
(77) (22) (2) (53) (32) (13) (3)
10,h grade 72.9% 25.4% 1.7% 51.6% 21.3% 26.2% 0.9%
(89) (31) (2) (63) (26) (32) (1)
Total 60.5% 36.5% 3% 41.8% 34.8% 21% 2.4%
(207) (125) GO) (143) (119) (72) (8)
29


As would be expected from the health class curriculum (see Appendix C), higher
grade levels, 9th and 10th grades had more students who reported having sexuality
education in school (76.2% and 72.9%). Similarly, 9th and 10th grade levels had more
students who reported being taught about STDs other than AIDS in school (52.5%
and 51.6%).
Information Resources about STDs other than AIDS
The survey asked the participants to note which of nine information
resources common among teenagers they used to leam about STDs other than AIDS.
The participants also had a chance to add other sources of information. The main
sources of information on STDs were television (35%, N=120), friends (30%,
N=102), newspapers or magazines (27%, N=92), and teachers or school programs
(24%, N=82) (see Figure 4.1).
Figure 4.1 Information resources about STDs other than AIDS
teacher or school prog
newspaper or magazines
friends
television
0% 5% 10% 15% 20% 25% 30% 35% 40%
i i i i ; i
3mm fSSVl I i
j i i :

- : 1 ; !

1 i ! !

i i i j i i ;
30


In addition, a few students reported that they obtained information on STDs from the
Internet and public places, such as overhearing conversations on a bus. Also, it is
interesting to note that 6 students responded that an adolescent newspaper,
UerkheLove, was their main source of information on STDs. Only 7% of the
participants reported that they got some information about STDs from their parents or
relatives.
When asked about needing additional information, 71.1% responded that they
wanted more information about STDs. Ninth grade students were most interested in
receiving more information (80.2%) as compared to the 10th grade students (70.5%)
and 8th grade students (63.9%). Students who wanted additional information listed the
following topics they were interested in learning about:
How can I prevent STDs? Are there any special methods or drugs?
What are common and classic symptoms of STDs?
Is it possible for me to get most STDs from touching toilet seats, moist towels, or
clothes?
Is it possible for me to get an STD the first time I have a sex?
If I have a problem with STDs, who can help me? Are there any special
organizations or hospitals for teenagers?
31


Teenagers' Knowledge about STDs other than A TPS
An overall knowledge score was calculated based on the percentage of correct
responses to the 17 knowledge questions. There were 35 points possible. Using the
sum of scores from the 17 knowledge questions, the participants were scored as
having poor, moderate, or excellent knowledge about STDs other that AIDS (80%-
100% = excellent; 60%-79% = moderate; 59% or less correct = poor). Overall, the
participants knowledge about STDs other than AIDS was poor. The average
knowledge score was 10.29 (SD=5.73) or 28.6% with scores ranging from zero (0%)
to 25 (71%). As shown in Figure 4.2, only 19 students (5.5%) were scored as having
moderate knowledge and the rest of the 323 students (94.5%) were scored as having
poor knowledge about STDs other than AIDS.
Figure 4.2 The participants' average knowledge scores
32


Table 4.2 represents the students knowledge scores about STDs other than AIDS by
their grade levels and gender. Of the 19 students who were scored as having
moderate knowledge, 11 (57.89%) were males and 8 (42.11%) were females and all
were in the 9th and 10th grades except for one male student in the 8th grade.
Table 4.2 The participants knowledge score by grade levels and gender
Scores 8th grade 9th grade 10lh grade Total
Male Female Male Female Male Female
Average score 8.92 7.67 12.15 10.88 12.7 10.82 10.29
35-28 scores = excellent 0 0 0 0 0 0 0
27-21 scores = moderate 1 0 4 4 6 4 19
20 or less = poor 49 73 37 58 31 75 323
Total 342
An independent samples t-test showed that the male students average
knowledge score (M = 11.07, SD = 5.81) about STDs other than AIDS was
significantly higher than the female students average knowledge score (M = 9.78,
SD = 5.63, p = 0.04). It is interesting that the knowledge scores for students who said
they have had sex (M = 11.76, SD = 5.55) were significantly higher (t (333) = 2.39, p
= 0.02) than the scores for students who said they have not (M = 9.88, SD = 5.69).
A one-way analysis of variance (ANOVA) was conducted to evaluate the
difference in knowledge scores between students in the three grade levels. A
significant difference was found (F (4, 339) = 14.83, p < 0.0001) between the three
33


grades with the 10lh grade students having a significantly higher knowledge score (M
= 11.54, SD = 5.90), followed by the 9th graders (M = 11.39, SD=5.80), and finally
the 8th graders (M=8.07, SD=4.79).
Additional t-tests indicated that there was a significant difference between the
8th and 9lh (t (218) = -4.65, p<0.0001), and between 8th and 10th grade scores (t (239)
= -5.01, p<0.0001). However, there was no significant difference between the 9lh and
10th grade scores (t (221) = -0.19, p = 0.84).
These findings suggest that knowledge about STDs other than AIDS is greater
for those students who continue their education beyond 8th grade, and among those
who are older or have initiated sexual intercourse. However, the vast majority of
these scores still fall in the poor range.
The survey asked teenagers to select the names of STDs from a list of 12
disease names, including other disease names, such as cystitis, appendicitis, and
hemorrhoids. Of the 334 (97.6%) students who responded to this question, about one
third (32.3%) said that they did not know. Nobody identified all 8 STDs. Table 4.3
shows the proportion of students who identified up to 6 STDs correctly.
Table 4.3 The number and proportion of students who identified up to 6 STDs
6 STDs 5 STDs 4 STDs 3 STDs 2 STDs 1 STD
correctly correctly correctly correctly correctly correctly
1.5% 5.7% 7.2% 17.7% 18.6% 17.0%
(5) (19) (24) (59) (62) (57)
34


Only 14.4% could identify 4 or more STDs. The three best-known STDs
among the respondents were syphilis (59.9%), gonorrhea (44%), and herpes genitals
(19.8%). Nobody knew that hepatitis was a sexually transmitted disease.
In general, more female respondents (36.5% vs 25.9%) than males said that
they did not know any STDs, so, more male students (56.5% vs 51.1%) than females
checked 1-3 correct STDs. The two best-known STDs among both male and female
teenagers were syphilis and gonorrhea (see Figure 4.3).
Figure 4.3 The best-known STDs by gender
Similar to the findings in other areas of STD knowledge, 9,h and 10th grade
students were better able to correctly identify the names of STDs than were 8th
graders. Nevertheless, there was agreement among all grades that the two best-known
STDs were syphilis and gonorrhea. As shown in Figure 4.4, with increasing grade
35


levels, the proportion of students who identified the two best-known STDs increased
dramatically.
Figure 4.4 The best-known STDs by grade level
8 th grade 9 th grade 10th grade
cr

Participants were asked to select which of 10 symptoms were common
symptoms of STDs. The choices included some symptoms related to other diseases,
for example weight loss or weight gain, bleeding hemorrhoids, and nausea and
vomiting. Of the 334 respondents, 56% reported that they did not know any common
symptoms of STDs. Only 2.7% of the respondents checked all 5 common symptoms
of STDs correctly whereas 11.9% checked only one symptom. The proportions of
students who reported that they did not know any symptoms of STDs were similar
for each gender (55.7% males vs 56.2% females). In general, females were slightly
36


more knowledgeable with 23.5% knowing three or more symptoms in comparison to
only 19% for the males (see Table 4.4)
Table 4.4 The students who knew one or more common symptoms by gender
Students who knew all 5 symptoms Students who knew 4 symptoms Students who knew 3 symptoms Students who knew 2 symptoms Students who knew 1 symptom
Male 3.8% (5) 7.6% (10) 7.6% (10) 9.9% (13) 15.3% (20)
Female 1.9% (4) 10.8% (22) 10.8% (22) 10.3% (21) 9.8% (20)
Sixty-seven percent, of the 8th graders, 48% of the 9th graders, and about a half (52%)
of the 10th graders reported that they did not know any common symptoms of STDs.
The 9th and 10th graders were more knowledgeable with 29% and 28.9% respectively
knowing three or more symptoms in comparison to only 7.9% for the 8th graders (see
Table 4.5).
Table 4.5 The proportions of students who correctly identified up to 5 common
symptoms of STDs by grade level.
All 5 symptoms 4 symptoms 3 symptoms 2 symptoms 1 symptom
8th grade 0.9% (1) 2.6% (3) 4.4% (5) 8.8% (10) 15% (17)
9th grade 5% (5) 12% (12) 12% (12) 14% (14) 9% (9)
10th grade 2.5% (3) 14% (17) 12.4% (15) 8.3% (10) 11.6% (14)
37


The most common symptoms of STDs identified by the respondents were:
abnormal discharge from penis or vagina (28.7%), painful urination (27.8%),
appearance of blisters and sores (22.5%), itching or burning in genitals (21.3%), and
pelvic pain or pain in lower abdomen (11.4%)
In general, a higher proportion of females than males identified common
symptoms of STDs. As with other knowledge questions the 9th and 10th graders were
more likely to know common symptoms of STDs (see Table 4.6).
Table 4.6 Proportion of students who identified common symptoms of STDs
Common symptoms of STDs -gtS grade pth grade "To* grade Male Female
1. Painful urination .12.4% (14) 39% (39) 33% (40) 29.7% (39) 26.6% (54)
2. Abnormal discharge from penis or vagina 15% (17) 34% (34) 37.2% (45) 28.2% (37) 29% (59)
3. Itching or burning in genitals 8.8% (10) 29% (29) 26.4% (32) 19.8% (26) 22.2% (45)
4. Some blisters and sores appear 11.5% (13) 28% (28) 28.1% (34) 16.8% (22) 26.1% (53)
5. Pelvic pain or pain in lower abdomen 9.7% (11) 16% (16) 9% (11) 9.9% (13) 12.3% (25)
The survey asked if it is necessary to seek a health professionals help if a
person has an STD. Of the 340 respondents, the vast majority (85.6%) reported that
they would need to seek medical professionals help if they had an STD. A few
(6.7%) respondents mistakenly believed that the need to seek medical professionals
help for an STD depended on the STD. Only one eighth grader reported that she
would treat an STD herself if infected. There was not any difference between male
38


and female students or between grade levels for knowledge about the need to seek
medical care for STDs.
When asked Can you avoid STDs? the majority (71.7%), of the respondents
said that avoiding STDs is possible whereas only 3.9% reported that STDs could not
be avoided. Almost a quarter (24.3%) responded they did not know. More males than
female students reported that avoiding STDs was possible (81.1% and 65.8%
respectively). As would be expected from the lower overall knowledge scores of
females, more female students (28.7%) than male students (17.3%) reported that they
did not know if STDs could be avoided. The percentage of students who said that
avoiding STDs was possible increased with advancing grade levels (60.7% for the 8th
graders, 76.5% for the 9th graders, and 78.2% for the 10,h graders). Likewise, with
advancing grade levels, the percentage of students who responded that they did not
know decreased (19.3% for the 10th graders, 23.5% for the 9th graders, and 30.3% for
the 8th graders).
The survey asked those respondents who thought avoidance was possible to
choose which of five possible prevention options they should adopt (see Survey in
Appendix B). Participants could select more than one option. Seventy-two percent
(N=169) reported that using a condom was a possible prevention option. Over one
third (36.8%, N=87) reported they should not have sex and also just over one third
(34.7%, N=82) responded that limiting the number of partners was a possible option
to avoid STDs. Moreover, 30.5% (N=72) students considered not using drugs as
39


another option to prevent STDs. Only 3 (1.3%) 8th grade students mistakenly
believed that avoiding kissing is a possible way to prevent STDs. Figure 4.5 shows
the students responses about possible options to avoid STDs.
Figure 4.5 Options to prevent STDs
As mentioned earlier, that only 3 eighth graders reported that avoiding kissing was a
possible choice to prevent STDs, so the next table does not include this option. There
were major differences between male and female students' choices of prevention
options as noted in Table 4.7.
Table 4.7 Students choices of avoiding STDs by gender
Avoid sex Use a condom Limit # partners Avoid drugs
Male 24.3% (25) 82.5% (85) 34.9% (36) 28.2% (29)
Female 46.6% (62) 63.2% (84) 34.6% (46) 32.2% (43)
40


Although the top choice for each gender was to use a condom for avoiding STDs the
male students' percentage was higher (82.5% males vs. 63.2% females). More
female students (46.6% vs.24.3%) reported that they would choose to avoid sex and
avoid drugs (32.2% vs.28.2%) for preventing STDs.
Table 4.8 Students choices of prevention methods for STDs by grade level
Avoid sex Use a condom Limit # partners Avoid drugs
8th grade 36.7% (25) 61.7% (42) 29.4% (20) 33.8% (23)
9th grade 36% (27) 73.3% (55) 45.3% (34) 22.6% (17)
10lh grade 37.6% (35) 77.4% (72) 30.1% (28) 34.4% (32)
As shown in Table 4.8 the proportion of students who responded that using a condom
was a possible way to prevent STDs increased with advancing grade levels. There
was not any differences between grade levels for the proportion of students who
responded that abstinence was a possible way to prevent STDs. Interestingly, more
9th grade respondents as compared to 8th and 9th grade respondents indicated that
limiting the number of sexual partners is something you should do to avoid STDs.
However, the proportion of students who chose avoiding drugs for preventing STDs
was the lowest for the 9th graders (22.6%).
There are a lot of misconceptions among teenagers about STDs other than
AIDS. For instance, some teenagers mistakenly believe that they can not get an STD
the first time they have sex, they can not get more than one STD at the same time,
41


and that taking birth control pills is an effective way to avoid STDs (Buckingham &
Derby, 1997, p. 16). In order to reveal any misconception among the participants the
survey asked several questions. Table 4.9 summarizes the students answers these
questions.
42


Table 4.9 Misconceptions about STDs
Questions % responding Yes No I do not know Conclusion
1. It is possible that if you are a virgin, you can get an STD the first time you have sex? (94.7%) 47.2% (153) 5.8% (19) 47% (152) A
2. It is possible that you can get more than one STD at the same time? (95.6%) 21.1% (69) 11.9% (39) 67% (219) A The proportion of students who reported that they did not know was almost split equally for each grade level.
3. Taking birth control pills is an effective way to avoid STDs. (92.7%) 13.9% (44) 35.6% (113) 50.5% (160)
4. Washing after intercourse is an effective way to avoid STDs. (93.6%) 16.6% (53) 28.8% (92) 54.6% (175) *
5. Some STDs do not have any symptoms. (91.8%) 12.1% (38) 18.8% (59) 69.1% (217) A Interestingly, the proportion of students who answered correctly was the highest for the 8th graders.
6. You can get STDs from touching toilet seats, moist towels, or clothes. (92.9%) 27% (86) 25.5% (81) 47.5% (151) A
7. You can tell by looking at and talking to a person if they have an STD. (93.8%) 2.8% (9) 71% (228) 26.2% (84)
Note: More females reported that they did not know.
A More males answered correctly.
With advancing grade levels, the proportion of students who answered correctly
increased.
A Higher graders were more likely to answer correctly.
There was not any differences between gender for the proportions of students who got right
answer.
Overall, the participants' knowledge of misconceptions about STDs other than
AIDS was poor. Male participants and students from higher graders were more
knowledgeable than females and the 8th graders. Yet, the percentages that did not
43


know the correct information (those who answered "I do not know" or incorrectly)
ranged from 52.8% to 87.9%.
Attitudes and Beliefs
The survey included 7 questions to identify the teenagers attitudes and
beliefs about STDs other than AIDS: 3 statement agreement questions, 1 worry
question, and 1 intimate helper question. Initially, responses were measured on a 5
point Likert scale. For analysis, responses were collapsed from 5 to 3 categories: I
agree, I disagree, and "I'm neutral or undecided."
Table 4.10 Summary of 3 statement agreement questions
Statement 1 agree I disagree I'm neutral Did not answer Results
1. STDs are a big problem among teenagers. 71.9% (246) 5.3% (18) 19.3% (66) 3.5% (12) - With increasing grade levels, the students were more likely to be concerned about STDs and less likely to be neutral. - More males agreed (78.7% vs. 71.9%).
2. Do not have sex until you are married. 60.5% (207) 14.9% (51) 21.7% (74) 2.9% (10) - More 8th and 10m graders agreed. - With advancing grade levels, the students were less likely to be neutral. - More females agreed (71.1% vs. 48.4%).
3. Do not have sex until you know a person very well. 77.2% (264) 4.1% (14) 14.6% (50) 4.1% (14) - The 9th and 10th graders were more likely to agree and less likely to be neutral. - More females agreed (85.7% vs. 72%).
44


To assess perceptions of personal risk all participants, not only those who
were sexually active, were asked how often they worried about getting an STD. Of
the 342 participants, 327 students (95.6%) answered this question. 60.9%, of the
respondents reported that they did not know if they would get an STD. Another
25.4% worried a lot. Only 2.7% reported that they never worried.
Table 4.11 The students worry about getting an STD
# of students Percent
Generally, I worry a lot. 83 25.4
I worry when I have sex. 15 4.6
I worry when I have unprotected sex. 21 6.4
I never worry. 9 2.7
I do not know. 199 60.9
Total 327 100.0
As shown in Table 4.12, with advancing grade levels, the proportion of
students who worried a lot increased. Likewise, with increasing grade levels, the
proportion of students who reported that they did not know decreased. In addition,
the 9th and 10th graders were more likely to worry when they had unprotected sex.
45


Table 4.12 The students worry about getting an STD by grade level
How much do you worry that you might get an STD? Total
Generally, I worry a lot I worry when I have sex I worry when I have unprotected sex I never worry I do not know
~8* grade 23.2% (26) 4.5% (5) 2.6% (3) 3.6% (4) 66.1% (74) 112
gth grade 24.5% (24) 4.1% (4) 9.2% (9) 2% (2) 60.2% (59) 98
10* grade 28.2% (33) 5.1% (6) 7.7% (9) 2.5% (3) 56.5% (66) 117
Total 83 15 21 9 199 327
According to the below table, the following findings were drawn:
- More males (33.9%) than females (20%) generally worried a lot about getting an
STD.
- More female students reported that they did not know (71.5% vs.44.1 %).
Table 4.13 The students worry about getting an STD by gender
Gender Total
Female Male
Generally, I worry a lot 20% (40) 33.9% (43) 83
I worry when I have a sex 3% (6) 7.1% (9) 15
I worry when I have an unprotected sex 3.5% (7) 11% (14) 21
I never worry 2% (4) 3.9% (5) 9
I do not know 71.5% (143) 44.1% (56) 199
Total 200 127 327
Participants were asked who they would go to first if they thought they had an
STD. They could choose from a list of potential intimate helpers9 or add their own
9 1-Parents, 2-Relatives, including brothers and sisters, 3-Friends, 4-Teachers, 5-Medical doctors and
other professionals of public clinics, 6-Medical doctors and other professionals of private clinics, and
7-Pharmacists
46


intimate helper. Nobody named any other intimate helpers. The 320 students who
responded said that they would seek help for an STD from: medical doctors and other
professionals of public clinics (29.4%), parents (29%), friends or peers (21.8%), and
medical doctors and other professionals of private clinics (16.2%).
As shown in Table 4.14 the students intimate helpers by gender.
Table 4.14 The students' intimate helpers by gender
For female students For male students
1. Parents-33% 2. Medical doctors of public clinics 27.3% 3. Friends 20.6% 4. Medical doctors of private clinics 17% 1. Medical doctors of public clinics 32.5% 2. Friends 23.8% 3. Parents 23% 4. Medical doctors of private clinics 15%
According to the above table, the female teenagers reported that they trusted the most
in their parents and medical doctors and other professionals of private clinics. In
comparison, the male students responded that they trusted the most in medical
doctors and other professionals of public clinics and in their friends.
47


Figure 4.6 Intimate helpers by grade level
8th grade 9th grade 1 Oth grade
40
Public clinics Parents Peers Private
clinics
With increasing grade levels, the proportion of students who trusted medical doctors
and other professionals of private clinics increased. In contrast, the percentage of
students who trusted their parents decreased from 34.6% in 8th grade to 25.2% in 10th
grade. In addition, the 9th graders placed greatest trust in medical doctors and other
professionals of public clinics (31.6%) whereas the 10th graders placed their greatest
trust in friends (23.5%) compared to other two grade levels.
Teenagers' Sexual Risk Behaviors
In this survey, the participants sexual risk behaviors were considered as two
overlapping but separate entities: behaviors over their lifetime and current behaviors
within the past three months.
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Sexual Intercourse
Of the 342 participants, 18.7% (64) responded that they had experienced
sexual intercourse during their lifetime (sexually active). Of these 64 students, 65.6%
(42) were males and 34.4% (22) were females. Sexual intercourse appeared to
increase with age as indicated in Figure 4.7. Also, for all grades, the male students
were more sexually active than the female students.
Figure 4.7 Gender and grade level of sexually active participants
Male El Female
20
8th grade 9th grade 10th grade
Participants were asked about having had sexual intercourse during the past 3
months. Of the 51 sexually active students who responded, 43.1% (22) reported not
having had sexual intercourse during the past three months. Of the 19 sexually active
female respondents, 42.1% (8) responded that they did not have sexual intercourse
during the past three months whereas this number was slightly higher (43.75%,
49


N=14) for the 32 male respondents. To compare grade levels, the number of students
who had not had sexual intercourse during the past three months was the highest for
the tenth graders (63.6%, N=14) and the lowest for the ninth graders (9.09%, N=2).
Age at First Sex
The age for first sexual intercourse ranged from 11 or younger to 16 for the
male students and 11 or younger to 18 or older for the female students. The mean age
for first having sex for the male students was 14.9 years (SD=1.12) and for the
female students it was slightly older at 15.3 years (SD=1.78).
Number of Sexual Partners
Teenagers who we surveyed were asked how many sexual partners they have
had during their life. Of the 63 sexually active participants who responded, almost
half46.03% (29) reported having had sex with only one person. Another 17.46% (11)
of the students reported having sex with two different partners. Therefore, most
students (63.49%, N=40) have had between 1 or 2 partners in their lifetime. An
additional 36.51% of the students have had 3 or more partners. The mean number of
partners for female students was 2 and for male students this number was slightly
higher (2.5). As would be expected, the survey showed with increasing grade levels,
that the mean number of partners increased: for the 8th graders 1.82; for the 9th
graders 2.3; and for the 10th graders 2.7 respectively.
50


Participants were asked how many sexual partners they had during the past
three months. Of the 51 sexually active students who responded, 56.9% (29) students
reported having sexual intercourse during the past three months. Sixty-five point five
percent (19) students reported having had sex with only one person during the past
three months. Another 17.2% (5) students reported having had sex with two different
partners. The remaining 17.3% (5) reported having had sex with more than two
different partners. In addition, 52.6% of the female students and 43.75% of the male
students had 1 or 2 partners during the past three months. Furthermore, 50% of the
sexually active eighth graders, 76.9% of the ninth graders, and 30.8% of the tenth
graders have had between 1 and 2 partners during the past three months.
Alcohol Use Before Sex
In accordance with the laws governing alcoholic consumption in Mongolia, it
is prohibited to use alcoholic beverages if a person is under 18 years old (State Great
Khural, 2001, 7.3.2 provision). Of the 64 students who reported having had sexual
intercourse, 95.3% (61) of the participants responded to the question about drinking
alcohol before sexual intercourse. As shown in Figure 4.8 9.8% (6) students usually,
34.4% (21) students sometimes, and 55.8% (34) students never drank alcohol before
sexual intercourse. Nobody reported always drinking alcohol before sexual
intercourse.
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Figure 4.8 Sexually active students' alcohol use
Forty-two point nine percent (21) of the sexually active female respondents
responded that they drank alcohol usually or sometimes before sexual intercourse as
compared to 45% (40) for the sexually active male respondents. In addition, one-
fifth (20%) of the 15 eighth grade respondents, half (50%) of the 18 ninth grade
respondents, and just over half (53.6%) of the 28 tenth grade respondents reported
that they usually or sometimes drank alcohol before sexual intercourse. In other
words, with increasing grade levels, the number of students who drank alcohol before
sexual intercourse increased.
The teenagers were asked about their alcohol use when they had sexual
intercourse the last time. Of the 64 students who had sexual intercourse, 90.6% (58)
responded to this question. Of these 58 students, 24.1% (14) reported that they drank
alcohol before they had sexual intercourse the last time. Twenty-one percent (4) of
the 19 female respondents and 25.6% (10) of the 39 male respondents reported
52


drinking alcohol before they had sexual intercourse the last time. Thirteen point three
percent (2) of the 15 eighth graders, 29.4% (5) of the 17 ninth graders, and 26.9% (7)
of the 26 tenth graders reported that they drank alcohol before they had sexual
intercourse the last time.
Drug Use Before Sex
Of the 64 students who reported having had sexual intercourse, 93.7% (60)
responded to the question about using drugs prior to sexual intercourse. As shown in
Figure 4.9, of these students, 8.3% (5) usually, 23.3% (14) sometimes, and 68.4%
(41) never used drugs before sexual intercourse.
Figure 4.9 Sexually active students' drug use
Fewer female respondents (23.8%, N=21) than the male respondents (38%, N=39)
reported that they usually or sometimes used drugs before sexual intercourse.
Moreover, 14.3% (2) of the 14 eighth grade respondents, 33.3% (6) of the 18 ninth
53


grade respondents, and 39.3% (11) of the 28 tenth grade respondents respectively
reported usually or sometimes using drugs before sexual intercourse. Therefore, the
survey showed with increasing grade levels, the number of students who used drugs
before sexual intercourse increased dramatically (see Figure 4.10).
Figure 4.10 Drug use by grade levels
When we asked about the teenagers drug use before they had sexual intercourse the
last time, of the 64 students who have had sexual intercourse, 92.2% (59) responded
to this question. Of these 59 students, the majority of students (86.4%, N=51)
reported that they did not use drugs before they had sexual intercourse the last time.
54


Condom Use
Although abstinence is the best and most foolproof method of protecting
oneself against contracting an STD, consistent condom use is the most effective and
simplest way to prevent STDs for those having sexual intercourse. Of the 64 students
who reported having had sexual intercourse, 89% (57) answered this question about
condom use. As shown in Figure 4.11, of the 18 female respondents, 72.2% (13)
reported using a condom "always" or "usually" whereas this number was slightly
higher (87.2%) for the 39 male respondents. Similarly, to combine answers always
and usually the ninth graders (70.6%) were the most likely to use a condom, followed
by the eighth graders (50%) and then the tenth graders (46.2%).
Figure 4.11 Sexually active participants condom use
55


Participants were asked if they or their partners used a condom when they had
sexual intercourse the last time. Of the 64 students who have had sexual intercourse,
93.75% (60) students responded to this question. Of these 60 students, just over half
(53.3%, N=32) reported that neither they or their partners used a condom. The
remaining 46.7% (28) reported that they or their partners had used a condom when
they had sexual intercourse the last time. More males (51 %) reported condom use
when they had sexual intercourse the last time than females (38.1%). The proportion
of students who said they or their partners used a condom the last time was the
highest for the ninth graders (50%), followed by the tenth graders (46.4%) and then
the eighth graders (42.8%).
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CHAPTER 5
DISCUSSION AND CONCLUSION
Discussion
This study of 342 eighth, ninth, and tenth grade students selected from three
urban schools in the capital city, Ulaanbaatar, Mongolia described their sexual risk
behaviors, measured their knowledge, and identified their attitudes about STDs other
than AIDS. The study revealed several important findings.
The participants' knowledge about STDs other than AIDS was poor. Knowledge
about STDs other than AIDS is greater for males, those students who continue
their education beyond 8th grade, and among those who are older or have initiated
sexual intercourse.
The participants from all grades showed insufficient knowledge about STDs
other than AIDS in general. For example, 32.3% of the respondents said that they
did know any names of STDs. The majority did not know that some STDs do not
have any symptoms, they were uncertain whether they could get more than one
STD at the same time, and believed that washing after intercourse is an effective
way to avoid STDs. Over half of the participants (56%) did not know any common
symptoms of STDs. Only 4 students (1.2%) knew that chlamydia was an STD and
57


nobody recognized hepatitis as an STD. These findings suggest that a successful
school-based sexuality education program (health class curriculum) in Mongolia
has to have more information about STDs, in general, and about chlamydia and
hepatitis specifically. This is especially important for two reasons. First, because
liver cancer caused by hepatitis B virus is the first leading cancer in Mongolia.
Second, because in most cases chlamydia infection will not have any symptoms. In
other words, it is a kind of silent infection in up to 20% of infected men and up to
80% of infected women (Daugirdas, 1991, p. 18). Consequently, special costly tests
must be performed to diagnose chlamydia. Due to limited financial resources in
Mongolia, early screening and diagnostic levels are low, so most people do not
know about this disease. However, knowing about chlamydia and hepatitis B might
help teenagers prevent these potentially serious diseases.
Finding insufficient knowledge about STDs in this study population was not
surprising or unexpected because sexuality education is a relatively new program in
Mongolia and teenagers do not have enough accurate sources of information about
STDs. This was shown in a 1999 study conducted by the Adolescent Reproductive
Health Project that assessed the participants' knowledge about reproductive health.
Eighty-five percent, of the participants got less than 30% of the questions correct.
The study indicated that the participants knew little about STDs and how to prevent
them (Adolescent Reproductive Health Project, 2002 p. 50). In addition, the
UNFPA and the MOHSW conducted another study called "Adolescent
58


Reproductive Health Knowledge, Attitudes, and Practice" in which only 30%, of
the participants reported that they knew some symptoms of STDs. (MOHS W &
UNFPA, 1996, p. 33). Furthermore, another study completed in 2002 showed that
the vast majority (63.3%) of participating students did not know whether or not all
STDs have some symptoms (National Statistical Office of Mongolia, 2002, p. 40).
This current study showed that although the teenagers who participated know
that abstinence is the best and most foolproof method of protecting oneself against
contracting an STD, the vast majority (71.6%) of respondents said using a condom
was a possible prevention option whereas only 36.8% reported they should not have
sex.
The participants agreed that STDs are a big problem among teenagers.
The vast majority of participants (71.9%) believed that STDs are a big problem
among Mongolian teenagers. The study showed that with advancing grade levels, the
number of students who thought STDs are a problem for teenagers increased.
The participants had "traditional" beliefs about sexual relationships that could
encourage teenagers to be abstinent from casual sexual relationships.
The majority (60.5%) believed it was best not to have sex before marriage.
Most participants (77.2%) also believed that they should not have sex until they
know a person very well. The study indicated that with increasing grade levels, the
number of students who had these "traditional" beliefs increased.
59


Some participants engaged in sexual behaviors that put them at high risks for
STDs.
In this study, 18.7% (64), of the participants were sexually active. Older
students and males were more likely to report being sexually active. These findings
are corroborated by other studies of youth in Mongolia (Adolescent Reproductive
Health Project, 2002, MOHSW & UNFPA, 1996, & National Statistical Office of
Mongolia, 2002). This study showed that the mean age for first having sex was 14.9
years for the male students and 15.3 years for the female students. Compared to a
1996 study, the average age at first sex for the students in this study was relatively
younger. The average ages for first having sex in the 1996 study were 16.76 years for
the male students and 17.22 years for the female students (MOHSW & UNFPA,
1996, p. 18). It is difficult to explain why these averages might be so different.
Maybe, the relatively younger age for first having sex is related to specific population
characteristics in this study. By chance, all three selected schools were on the
outskirts of the city where families with lower education level and lower incomes
tend to live. However, the 1996 study shows a demographic picture similar to this
study. It is unlikely that the average age of first sexual intercourse would have
declined so dramatically in six years. It would be important to further investigate this
discrepancy.
60


Our study found that 36.5%, of the sexually active participants reported
having had 3 or more partners. With advancing^grade levels, the mean number of
sexual partners increased. No data from other studies were available for comparison.
Although the law prohibits alcohol use by minors under 18 years of age,
alcohol use is high among Mongolian teenagers. A 1998 Assessment on Alcoholism
in Mongolia found that 51.2% of the entire population regularly drank alcohol and
were involved in various law violations. Seventy-one percent of adolescents under
age 20 and 54.7% under 16 tried to use alcohol during their life (not regularly).
Reasons for high rates of alcohol use include growing unemployment and poverty,
the widening gap between the rich and the poor, and declining standards of living
among the population in general (WHO, 2003, p. 17). The Adolescents' Needs
Assessment (2000) survey found that the average starting age for drinking alcohol
among respondents was 17.6 years for both urban and rural areas. However, urban
adolescents drank twice as much alcohol as rural adolescents (WHO, 2003, p. 17). In
this study, 44.2% reported that they usually or sometimes drank alcohol before sexual
intercourse. According to a 2002 study, conducted by the National Statistical Office,
44.2%, of the participants (about 3600 4th to 10th graders and 400 young people not in
school from both rural and urban areas) reported that they used alcohol, but this study
did not explore a relationship between sexual intercourse and alcohol use (National
Statistical Office of Mongolia, 2002, p. 28). In addition, another study conducted by
the Adolescent Reproductive Health Project (Adolescent Reproductive Health
61


Project, 2002, p. 34) indicated that with increasing ages, alcohol use and sexual
intercourse increased.
According to the most recent data from WHO, 2.2-2.3% of adolescents use
drugs of some kind, including pain-relieving drugs. The younger ones mostly sniff
petrol, polish or glue, and 10.1% of 17-20 year olds have tried drugs. There is little
information about injectable drugs, but there is no evidence that they are a problem
among adolescents (WHO, 2003, p. 17) A 2002 study found that 0.5% of the
participants (about 3600 4th to 10th graders and 400 young people not in school from
both rural and urban areas) reported using opium and 2.3% said they used pain
relievers. Another 5.9% reported that they inhaled polish, glue, or perfume (National
Statistical Office of Mongolia, 2002, p. 29-30). However, in the current study, 31.6%
of those who were sexually active reported that they usually or sometimes used drugs
before sexual intercourse. This number is surprisingly high and unexpected, in light
of the small number of students who report using drugs in other studies.
Nevertheless, for other studies, not only sexually active participants but also not
sexually active participants reported about their drug use. For the current study, it
was possible that the participants thought that tobacco and alcohol were drugs.
Maybe, we should have said illegal drugs in the question to make it more clear.
The number of students who used drugs before sexual intercourse increased
dramatically with advancing grade levels. Unfortunately, in our survey, we only
62


asked about using drugs before sexual intercourse, so we are unable to tell about drug
use in general.
It is important to note that all those youth who reported using drugs before
sex also said they used alcohol sometimes or usually before sex. Further research is
needed on teenagers' drug use in general, especially teenagers' knowledge about
drugs, what kinds of drugs are available for them, accesses to drugs, and the factors
that influence teenagers' drug use. Research on American teens indicates that youths
who participate in one risk behavior often participate in multiple risky behaviors
(DiClemente, Havsen, & Ponton, 1996, p. 3). More research is needed to see if risk
behavior clustering is evident among Mongolian teenagers also.
Although Mongolian teenagers have relatively unrestricted access to condoms
(free from family doctors and school doctors, free in adolescent clinics, and they can
buy one at a time from pharmacies), teens report inconsistent and infrequent condom
use. In the current study, just over one-third (36.8%) of sexually active students
reported that they always used a condom. Fifty-three percent reported that they or
their partners did not use a condom when they had sexual intercourse the last time. A
similar finding was found in a 1999 study. One-third of the sexually active
participants said that they did not use a condom when they had sexual intercourse the
last time because they never thought about the risk of getting an STD (Adolescent
Reproductive Health Project, 2002, p. 49).
63


The participants want more information about STDs other than AIDS.
The vast majority (71.1%) of participants wanted more information about
STDs. This finding is corroborated by several previous studies (Adolescent
Reproductive Health Project, 2002, p. 48 & MOHSW & UNFPA, 1996, p. 37). It is
very important to note that compared to the 9th and 10th graders (80.2% and 70.5%),
fewer 8th graders (63.9%) reported that they wanted more information about STDs
other than AIDS. Maybe, this is related to their lack of knowledge, so they do not
know what information they need.
The most frequently reported sources of information on STDs other than AIDS
are friends and media (television, newspapers, and/or magazines).
According to two previous studies (Adolescent Reproductive Health Project,
2002, p. 48 & MOHSW & UNFPA, 1996, p. 38), these sources of information on
sexuality and reproductive health are common among the Mongolian teenagers. Thus,
this finding suggests that television programming and printed materials may be used
to positively influence teenagers' knowledge, attitudes, and their sexual behaviors. In
addition, only 7% of the participants reported that they got some information about
STDs from their parents and relatives. However, when participants were asked who
they would go to first if they thought they had an STD, 29% chose parents as
potential intimate helper (parents were selected as the second most likely potential
intimate helper among the participants). The above two percentages (7% and 29%)
64


are relatively low, but there is a hope that the number of teenagers who want to
discuss with their parents sexuality topics, such as STDs will increase further.
Also, our study found that teenagers would seek help for an STD from medical
doctors and other professionals at public and private clinics, as well as from
parents and peers.
However, the percentages are relatively low (less than 30%) for each
category. These findings are similar to those in previous studies that found that
teenagers intended to seek help for reproductive health problems from medical
doctors (34.9%), peers (33.3%), and mothers (27.9%) (MOHSW & UNFPA, 1996, p.
21). With increasing grade levels, the proportion of students who trusted medical
doctors and other professionals of private clinics increased. In contrast, the
percentage of students who trusted their parents decreased. Developmentally, this
makes sense because as teens, they want to become more independent and they are
concerned about their privacy. Students in higher graders preferred private clinics
perhaps because private clinics do not require personal information. Today, many
teenagers and their parents do not feel comfortable discussing sexuality because for
long time discussing sexuality was a taboo in Mongolia. However, our study showed
that parents would be the second intimate helper for teenagers to seek help for an
STD. Consequently, it seems advisable to put greater investment into providing
parents with accurate information about sexuality and STDs since they never had
sexuality education in their schools. Parents may be able to make a valuable
65


contribution through talking with their teens about sexuality, but only if they know as
much or more about sexuality as their teenagers. Furthermore, the findings from our
study suggest that training peer educators might be a good way for teenagers to get
accurate information about STDs.
The STD education part of the health class curriculum in schools is
unsatisfactory.
Although only schools with sexuality education were selected to participate
in this study only 60.5% of the participants reported that they had sexuality
education in their schools. According to the health class curriculum, all grades
should not have learned something about STDs other than AIDS in the previous
school year (see Appendix C); however, 22.7% of the 8th graders, a half of the 9th
graders, and 41.8% of the 10th graders respectively reported that they had been
taught about STDs already. The study revealed that students in higher grades
reported having sexuality education in their schools and having been taught about
STDs other than AIDS more often than those in 8th grade which would be expected.
Similar findings were found in a 1999 study conducted by the UNFPA, the
MOHSW, the MOSTEC, and other international organizations; 50% of the
participants attending schools that provided sexuality education did not report
having any sexuality education in their schools (Adolescent Reproductive Health
Project, 2002, p. 9).
66


Limitations
Limitations existed in this study that could bias the results.
First, the study was conducted at the beginning of the 2003-2004 school year.
If the study were conducted at the end of school year, the findings would be different.
Students from all grades would have more knowledge about STDs other than AIDS
at the end of school year. For example, the knowledge demonstrator by the 9th grade
students in this study actually reflected what they learned in 8th grade or before. This
would be similar for all 3 grades. On the other hand, it is difficult to understand
because another factor is that only outstanding students continue their education
beyond 8th grade. Thus, in order to assess real knowledge, the sample should have
included other youth who did not continue their studies beyond 8th grade. Because of
limited time and financial difficulties, this study did not include this population.
Second, although sample size was large in this study the subjects were
selected from only the 12 schools that offered the health class in the first semester.
Also, by chance, all three selected schools were on the outskirts of the city where
families with lower educational level and lower incomes tend to live. Thus, the
results of the study can not be generalized to all Mongolian 8th, 9th, and 10th grades
teenagers.
67


Third, this study included only students who were in school. Further research
is needed on out-of-school students who did not study beyond 8th grade.
Fourth, due to the sensitive nature of the survey, some students may have
answered some questions in a socially desirable manner. The investigator tried to
minimize these threats to internal validity by promising to maintain respondent
confidentiality, by collecting no identifying information, by having surveys
completed without any teachers in the classroom, and by giving students extra paper
to hide their answers.
Fifth, although the survey format was necessary for assessing knowledge,
attitudes, and behaviors from a large sample, the closed-answer-format did not allow
for the collection of additional explanatory information from students. Thus,
teenagers' knowledge and attitudes about STDs other than AIDS and their sexual
behaviors may not have been fully addressed or investigated.
Finally, there is no standard test to assess teenagers knowledge about STDs
other than AIDS, so the responses of these teens can not be compared to the response
of other groups of teens.
Conclusion
Mongolia is a landlocked country in northeast Asia and has the total
population of 2.4 million. Twenty-five percent are adolescents aged 10 to 19.
Mongolia was a part of the socialist system. By the late 1980s the socialist system
68


collapsed and Mongolia has been experiencing changes in its political, economic,
social, and cultural structures. One of the changes has been a dramatic increase in
sexual activity among adolescents, which has led to increased numbers of STDs in
this population. Since sexuality education is new in Mongolia, very little information
is available about teenagers' sexuality, especially teenagers' sexual behaviors and
their knowledge and attitudes about STDs other than AIDS. Thus, it was important to
address this issue, especially looking at those students who continue their education
beyond 8th grade and those who do not. Because different sexuality education
curriculums are offered in 8th, 9th, and 10th grades and only 10th grade students leam
about STDs in school.
This study included 342 eighth, ninth, and tenth grade students selected from
three urban schools in the capital city, Ulaanbaatar, Mongolia. The study described
their sexual risk behaviors, measured their knowledge, and identified their attitudes
about STDs other than AIDS.
This study indicated that overall, the participants' knowledge about STDs
other than AIDS was poor and students who were in higher graders or had more
sexuality education in schools were more knowledgeable. The vast majority of
participants believed that STDs are a big problem in their community. Moreover, the
majority had "traditional" beliefs about having sexual relationships believing they
should wait until marriage and knowing a person very well to have sex. The study
showed that with increasing grade levels, the number of students who were
69


concerned about STDs and had "traditional" beliefs about having sexual relationships
increased. A minority of participants (mostly students in higher grades) engaged in
sexual behaviors that put them at high risks for STDs, such as having 3 or more
sexual partners, using alcohol and drugs before sexual intercourse, and not using a
condom regularly.
All grades (8th, 9th, and 10th) are an important period for sexuality education
because teenagers become increasingly sexually active at these ages. Thus, they all
have high risks for STDs. This study suggests that adolescents' acquired knowledge
about STDs other than AIDS from sexuality education and other sources is
unsatisfactory. Thus, it is necessary to look the health class curriculums for all grades
(8th, 9th, and 10th) and perhaps, make revisions. As a result of these changes, perhaps,
increasing the amount learned about STDs in 8th grade before 40% of Mongolian
teenagers complete their education. The findings will be very helpful for other
sources of information, for example what kinds of information should be covered
about STDs other than AIDS in TV programs and printed materials for teenagers.
Also, the findings might be important to school teachers because they have a clue
about what their teenagers really know about STDs. Finally, as a result of these, we
can prevent teenagers from STDs and decrease the number of STDs in this
population.
More research is needed on the full range of teenagers risk behaviors and
how those might be changing. Also, it would be important to study the
70


implementation of the sexuality education presented in the health class to understand
what teachers are teaching exactly for each grade level about STDs and why all
students do not recall learning about STDs in school.
71


Appendix A Human Subjects Research Committee at the University of Colorado at
Denver Approval
University of Colorado at Denver
HUMAN SUBJECT RESEARCH COMMITTEE
University of Colorado at Denver
Campus Box 129, P.O. Box 173364
Denver, CO 80217-3364
MEMORANDUM
DATE: July 28, 2003
TO: Erdenechimeg Sereeter, MD
FROM: Deborah Kellogg, HSRC Chair
SUBJECT: Human Subjects Research Protocol #988 Adolescent STDs
Knowledge, Attitudes, and Behaviors
Your protocol, with changes, has been approved as non-exempt. This approval is
good for up to one year from this date.
Your responsibilities as a researcher include:
If you make changes to your research protocol or design you should
contact the HSRC.
You are responsible for maintaining all documentation of consent. Unless
specified differently in your protocol, all data and consents should be
maintained for three years.
If you should encounter adverse human subjects' issues, please contact us
immediately.
If your research continues beyond one year from the above date, contact
the HSRC for an extension.
The HSRC may audit your documents at any time.
Good Luck with your research.
72


Appendix B Survey Questionnaire
Adolescent STD Knowledge, Attitudes, and Behaviors
A survey of Mongolian adolescents sexual risk behaviors
and their knowledge and attitudes about sexually transmitted
diseases (STDs) other than AIDS
Thank you for agreeing to participate in this survey. This survey is about what you
know and think about sexually transmitted diseases (STDs) other than AIDS. You
will also be asked few questions about things you do that affect your health.
In order for this survey to be helpful, it is important that you answer each question
as thoughtfully and honestly as possible Do NOT write your name on this survey.
The answers you give will be kept private and used only for this study. The
information you give will be used to develop better sexuality education programs for
young people like you.
Completing the survey is voluntary. Your answers will not affect your grades and
will be not reported to your parents. If you are not comfortable answering a question,
just leave it blank.
Be sure to read the instructions below before you begin to answer.
Thank you very much for your help.
Instructio ns
1 .This is not a test, therefore, there is no penalty if you answer a question incorrectly.
Consequently, please answer each question the best you can.
2. For some questions, you have several options and for some questions you do not.
When you answer the questions, please read the notes.
3. Please use this kind of mark ( Male ).
Lets begin the survey.
The questions that ask about your background will only be used to describe the
types of students answering this survey. The information will not be used to identify
you or your answers.
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1. Are you:
o Female
o Male
2. How old are you?
o 14 years old or younger
o 15 years old
o 16 years old
o 17 years old
o 18 years old
o 19 years old or older
3. What grade are you in currently?
o 8th grade
o 9th grade
o 1 Oth grade
4. If you are an 8th grade student, are you planning to continue to 9th grade?
o Yes
o No
o I do not know.
5. What were your grades like last year?
o
o
o
o
o
Mostly As
Mostly Bs
Mostly Cs
Mostly Ds
Mostly Fs
6. What is the highest level of schooling your father completed?
o Less than high school
o Completed high school
o Completed college
o Completed university
o I do not know.
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7. What is the highest level of schooling your mother completed?
o Less than high school
o Completed high school
o Completed college
o Completed university
o 1 do not know.
8. What is your familys approximate monthly income? (by togrogs=it is the
Mongolian banknote)
o Up to 30,000
o 30,001-50,000
o 50,001-70,000
o 70,001-100,000
o 100,001 or more
9. Have you had sexuality education in school?
o Yes
o No
10. Have you ever been taught about sexually transmitted diseases (STDs)
other than
AIDS in school?
o Yes
o No
o Not sure
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11. Where do you get information about STDs? (Check one option on each
line)
Sources Always Usually Sometimes Never
1. Radio
2. Television
3. Newspapers, magazines
4. Posters
5. Medical doctors and other medical professionals
6. Religious organizations
7. Teachers and school programs
8. Friends
9. Parents and relatives
10. Other sources please list
For the following questions JUST DO YOUR BEST. If you are uncertain, you also
have the option of answering "/ do not know. REMEMBER YOU HAVE TO
THINK ABOUT ONLY OTHER STDs NOT AIDS.
12. Which of the following are the names of sexually transmitted diseases
(STDs)? (You may check several options)
o Pubic lice (crabs)
o Cystitis
o Candida (yeast)
o Trichomoniasis
o Syphilis
o Appendicitis
o Hemorrhoids
o Chlamydia
o Genital warts
o Gonorrhea
o Hepatitis
o Herpes genitals
o I do not know
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13. Which of the following are common symptoms of STDs? (You may check
several options)
o Painful urination
o Weight loss or gain weight
o Abnormal discharge from penis or vagina
o Itching or burning in genitals
o Bleeding hemonrhoids
o Some blisters and sores appear
o Frequent urination
o Nausea and vomiting
o Pelvic pain or pain in lower abdomen
o Fever
o I do not know.
14. Which of the following are common tests for revealing STDs? (You may
check several options)
o The blood test
o X-ray
o Swab tests
o Urinary test
o Microscope tests
o I do not know.
15. What causes STDs? ( You may check several options)
o Bacteria
o Viruses
o Pubic lice (crabs)
o All of the above,
o I do not know.
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16. Do you need a doctor to treat when you get an STD?
o Yes, I need medical professionals help to treat an STD.
o No, I can treat an STD myself,
o Depends on the STD.
o I do not know.
(Ifyou chose No", you can skip question # 17).
17. If you believe that you need medical professionals help to treat an STD,
what are they going to do for you?
o They can diagnose that I get an infection or not
o They do some treatment that can only reduce symptoms
o They do some treatment that can rid all infection off
o I do not know
18. Can you avoid STDs? (If you chose Yes", please answer question #19
also, otherwise skip to question #20)
o Yes, Im 100% sure I can.
o Yes, I usually can.
o No, it is not possible,
o I do not know.
19. If you believe that you can avoid STDs, what should you do? (Here you
may check several options)
o Avoid kissing
o Do not have sex.
o Use a condom,
o Do not have many partners,
o Do not use drugs,
o I do not know.
The next 9 questions are YES or NO. If the statement is correct, put the mark (X)
in the Yes box. If the statement is not correct, put the mark (X) in the No box.
You also have the option of answering I do not know.
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Questions r Yes ' No I do not know.
20. It is possible that if you are a virgin, you can get an STD the first time you have sex.
21. It is possible that you can get more than one STD at the same time.
22. Syphilis is usually checked for by a blood test.
23. Taking birth control pills is an effective way to avoid STDs.
24. Washing after intercourse is an effective way to avoid STDs.
25. Some STDs usually will go away on their own.
26. Some STDs do not have any symptoms.
27. You can get most STDs from touching toilet seats, moist towels, or clothes.
28. You can tell by looking at and talking to a person if they have an STD.
For the following questions, there are no right or wrong answers. Please give your
opinion. Let's answer these questions.
29. STDs are big problems among teenagers.
o I strongly agree (100%).
o I agree.
o Im undecided or neutral,
o I disagree.
o I strongly disagree (100%).
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30. What is your opinion about the statement Do not have sex until you are
married.
o I strongly agree (100%).
o I agree.
o Im undecided or neutral,
o I disagree.
o I strongly disagree (100%).
31. What is your opinion about the statement Do not have sex until you
know a person very well.
o I strongly agree (100%).
o I agree.
o Im undecided or neutral,
o I disagree.
o I strongly disagree (100%).
32. How much do you worry that you might get an STD?
o Generally, I worry a lot.
o I worry when I have sex.
o I worry when I have unprotected sex.
o I never worry,
o I do not know.
33. If you thought you had an STD, who would you go to first? (Please choose
only one answer)
o Parents
o Relatives (for example, brothers and sisters)
o Friends
o Teachers
o Medical doctors and other professionals of public clinics
o Medical doctors and professionals of private clinics
o Pharmacists
o Others please name...............................
80


34. Do you need more information about STDs? (If you answered Yes , please
answer question # 35)
o Yes
o No
o
35. What information would be helpful to you? (Please write your
answer)...................................................................
Please answer the following questions as honestly as possible. Remember, the
answers you give are anonymous, will be kept private and will be used only for this
study.
36. Have you ever had sexual intercourse?
o Yes
o No
37. How old were you when you had sexual intercourse for the first time?
o 11 years old or younger
o 12 years old
o 13 years old
o 14 years old
o 15 years old
o 16 years old
o 17 years old
o 18 years old or older
o I have never had sexual intercourse.
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38. During your life, with how many people have you had sexual
intercourse?
o 1 person
o 2 people
o 3 people
o 4 people
o 5 people
o 6 or more people
o I have never had sexual intercourse.
39. During the past 3 months, with how many people have you had sexual
intercourse?
o 1 person
o 2 people
o 3 people
o 4 people
o 5 people
o 6 or more people
o I have never had sexual intercourse.
40. How often do you drink alcohol before you have a sexual intercourse?
o Always
o Usually
o Sometimes
o Never
o I have never had sexual intercourse.
41. Did you drink alcohol before you had sexual intercourse the last time?
o Yes
o No
o I have never had sexual intercourse.
42. How often do you use drugs before you have a sexual intercourse?
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o Always
o Usually
o Sometimes
o Never
o I have never had sexual intercourse.
43. Did you use drugs before you had sexual intercourse the last time?
o Yes
o No
o I have never had sexual intercourse.
44. When you have a sexual intercourse how often do you use a condom?
o Always
o Usually
o Sometimes
o Never
o I have never had sexual intercourse.
45. The last time you had sexual intercourse, did you or your partner use a
condom?
o Yes
o No
o I have never had sexual intercourse.
46. If you unexpectly meet a nice guy or girl at a party, would you agree to
have sex with that person? (You check several options)
o Yes, if we were attracted to each other,
o Maybe if I had been drinking alcohol or using drugs,
o I would never agree,
o I do not know.
Thank you for your participation.
83


Appendix C Compulsory Sexual Health Education Topics in The Formal School
Curriculum in Mongolia
Grade (age) Topic Content
1 (7-8) No topics
2(8-9) No topics
3 (9-10) Human development Anatomy and physiology Society and culture Gender roles
4(10-11) Human development Physical and emotional changes in puberty Menstruation Wet dreams Relationships Feelings
5(11-12) Human development Self-esteem Relationships Friendships Personal skills Peer pressure and decision-making
6(12-13) Personal skills Communication: Basics Assertive communication Values Society and culture Society and messages about sexuality
84


Grade (age) 7(13-14) Topic Content Sexual health Rape Date rape Relationships Love Personal skills Communication and consent Managing stress Society and culture Diversity
8(14-15) Human development
Anatomy and physiology
Conception and pregnancy
Sexual behavior
Abstinence
Sexual health
Condoms
Contraception and other methods
Testicular and breast-self-examination
9(15-16) Human development
Sexual identity and orientation
Sexual behavior
Sexual relationships and behavior
Sexual health
Risk assessment
9 Safer sex and alcohol
Personal skills
Communication about safer sex and condoms use
Refusal skills
10(16-17) Human development
Prenatal care and childbirth
Sexual behavior
Sexuality through the lifecycle
Sexual health
STDs and HIV/AIDS consequences
STD prevention
Relationships
Marriage commitments and raising children
Personal skills
# Goal setting
85


Appendix D Glossary of Acronyms
AIDS.......................................Acquired Immunodeficiency Syndrome
ANOVA......................................................Analysis of Variance
HIV.............................................Human Immunodeficiency Virus
HPV.....................................................Human Papilloma Virus
MOHSW......................................Ministry of Health and Social Welfare
MOSTEC....................Ministry of Science, Technology, Education, and Culture
MSCI.......................................Margaret Sanger Center International
NGO.............................................Non-Go vemmental Organization
NRCFID............................National Research Center for Infectious Diseases
NSOM.......................................National Statistical Office of Mongolia
STD................................................Sexually Transmitted Disease
UNFPA...............................United Nations Fund for Population Activities
USA.....................................................United States of America
WHO...................................................World Health Organization
86


Appendix E Glossary of Mongolian Words
Aimag.....................A geographical subdivision, a province state of Mongolia
Tugrug.................................................The Mongolian banknote
Uerkhelove..................................The newspaper name for adolescents
Zorgaa.............................................................Number six
87


REFERENCES
Adolescent Reproductive Health Project. (2002). Reproductive health, sexuality:
Knowledge, attitudes, and behaviors, 1999. Ulaanbaatar, Mongolia: ARHP, UNFPA,
MOSTEC, MOHSW, & MSCI.
Adolescent Reproductive Sexual Health, (n.d.). Adolescent reproductive health and
sexuality in Mongolia. Accessed March 2003, from
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Alan Guttmacher Institute, (n.d.). Facts in brief-Teen sex and pregnancy. Accessed
March 2004, from http://www.agi-usa.org/pubs/fb teen sex.html.
Asia & Pacific Regional Bureau for Education UNESCO Bangkok & United Nations
Population Fund. (n.d.). Case studies: Mongolia. Accessed June 2003, from
http://www.unescobkk.org/ips/arh-web/demographics/mongolia.cfrn.
Brown, E. J., Simpson, E. M. (2000). Comprehensive STD/HIV prevention
education targeting adolescents: Review of an ethical dilemma and proposed ethical
framework. Nursing Ethics, 7 (4), 339-349.
Buckingham, R. W., & Derby, M. P. (1997). I'm pregnant, Now what do Ido?.
New-York: Prometheus Books.
Colorado youth survey. (1998) Colorado Department of Human Services Alcohol &
Drug Abuse Division.
Daugirdas. J (1991) Sexually transmitted diseases. Illinois: MedText, Inc.
DiClemente, R. J., Havsen, W. B., & Ponton, L. E. (1996). Handbook of adolescent
health risk behavior. New York: Plenum Press.
Do you understand your teenager boy or girl? 2003). The Newspaper of Reproductive
Health, 14, 2.
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Ebright, J. R., Altantsetseg. T., & Oyungerel. R. (2003). Emerging infectious
diseases in Mongolia. Emerging Infectious Diseases, 9 (12), 1509-1515.
Gubhaju, B. B. (2002). Adolescent reproductive health in Asia. The 2002IUSSP
Regional Population Conference "South-East Asia's Population in a Changing Asian
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Imperato, A. M. (1996) Acquired immunodeficiency syndrome and suburban
adolescents: Knowledge, attitudes, behaviors, and risks. Journal of Community
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International Women's Health Coalition, (n.d.). Sexuality education in Mongolia:
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Jordan, T. R., Price, J. H., & Fitzgerald. S. (2000). Rural parents' communication
with their teen-agers about sexual issues. Journal of School Health, 70 (8), 338-344.
Kann, L., Warren, C. W., Harris, W. A., Collins, J. L., Williams, B. I., Ross, J. G., et
al. (1996) Youth risk behavior surveillance-United States, 1995. MMWR, 45 (SS-4),
1-18.
Knowledge, attitudes, beliefs, and behaviors surveys. (1994) The United States
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Ministry of Health and Social Welfare & United Nations Population Fund. (1996).
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National Library of Medicine, (n.d.). Youth risk behavior surveillance United
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Full Text

PAGE 1

ADOLESCENT SEXUALLY TRANSMITTED DISEASES KNOWLEDGE, ATTITUDES, AND BEHAVIORS by Erdenechimeg Sereeter B.S., The National Medical University in Mongolia, 1998 M.D., The National Medical University in Mongolia, 1998 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Integrated Science 2004

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This thesis for the Master of Integrated Science degree by Sereeter has been approved by Susan Dreisbacfi Q f.A.J_ I '-{ J J_ l:lO<-f Date

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Erdenechimeg Sereeter (M.I.S) Adolescent Sexually Transmitted Diseases Knowledge, Attitudes, and Behaviors Thesis directed by Research Assistant Prof. Susan Dreisbach ABSTRACT By the late 1980s the socialist system collapsed and Mongolia has been experiencing changes in its political, economic, social, and cultural structures. One of the changes has been a dramatic increase in sexual activity among adolescents, which has led to increased numbers of STDs. Since sexuality education is new in Mongolia, very little information is available about teenagers' sexuality, especially teenagers' sexual behaviors and their knowledge and attitudes about S1Ds other than HIV/AIDS. Thus, it was important to address this issue). especially betWeen those students who continue their education beyond gth grade and those who do not. Different sexuality education curriculums are offered in gth, 9th, and loth grades and only lOth graders learn about STDs in school. This study of 342 8th, 9th, and 1Oth grade students selected from three urban schools in the capital city, Ulaanbaatar, Mongolia describes their sexual behaviors, measures their knowledge, and identifies their attitudes about STDs other than HIV/AIDS. The results of this stUdy indicate that students who had more sexuality education in schools or were in higher grades were more knowledgeable about STDs other than HIV/AIDS and they were also more concerned about STDs and had "traditional" beliefs about sexual relationships that could encourage teenagers to be abstinent from casual sexual relationships. However, students in higher grades had more risky sexual behaviors that put them at high risks for STDs. The findings can be used to improve and develop appropriate sexuality education programs for schools. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. Signed lll

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ACKNOWLEDGEMENT Many thanks to my wonderful advisor Dr. Dreisbach, for all her help in the writing of this thesis and for her patience with me during past one year I would also like to thank the other members of my thesis committee, Dr. Kimbrough and Dr. Janes, for their insights and comments. A special thank you to the staff of the Graduate School for their support and understanding.

PAGE 5

CONTENTS Figures .............................................................................. vii Tables ............................................................................... viii CHAPTER 1. INTRODUCTION .............................................................. 1 Specific Aims ............................................................... 3 2. A REVIEW OF LITERATURE AND SEXUALITY EDUCATION IN MONGOLIA .............................................. 6 A Review of the Relevant Literature .................................. 6 The Status of Sexuality Education in Mongolia ...................... l3 3. THE METHOD SECTION .. ................................................ 19 The Setting ................................................................ 19 Inclusion Criteria and School Selection ............................... 19 Recruitment. .............................................................. 21 The Subjects ............................................................... 22 Instrumentation ............................................................ 26 Survey Administration ................................................... 27 Data Analysis ............................................................. 27 Human Subjects Considerations ........................................ 28 4. THE PRESENTATION OF FINDINGS ................................... 29 v

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Sexuality Education Programs in Schools ............................ 29 Information Resources about STDs other than AIDS ............... 30 Teenagers' Knowledge about STDs other than AIDS ............... 32 Attitudes and Beliefs .................................................... .44 Teenagers' Sexual Risk Behaviors .............................. . ... . 48 Sexual Intercourse .............................................. .49 Age at First Sex .................................................. 50 Number of Sexual Partners .................................... 50 Alcohol Use Before Sex ........................................ 51 Drug Use Before Sex ........................................... .53 Condom Use ................................................ ...... 55 5. DISCUSSION AND CONCLUSION ...................................... 57 Discussion ................................................................. 57 Limitations ................................................................ 67 Conclusion ................................................................. 68 APPENDIX A. HUMAN SUBJECTS RESEARCH COMMITTEE AT THE UNIVERS11Y OF COLORADO AT DENVERAPPROVAL. ........ 72 B. SURVEY QUESTIONNAIRE .............................................. 73 C. COMPULSORY SEXUAL HEALTH EDUCATION TOPICS IN THE FORMAL SCHOOL CURRICULUM IN MONGOLIA ...... 84 D. GLOSSARY OF ACRONYMS ............................................. 86 E. GLOSSARY OF MONGOLIAN WORDS ................................ 87 REFERENCES .............................................................................. 88 vi

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FIGURES Figure 2.1 Percentage of abortions among women under 20 ................................... 9 2.2 Prevalence of STDs in Mongolia per 10,000 population, 1990-2000 ........... 11 3.1 The 81h graders' answers about continuing study ................................... 23 3.2 The participants' grades by grade level ............................................. 24 4.1 Information resources about STDs other than AIDS .............................. 30 4.2 The participants' average knowledge scores ....................................... 32 4.3 The best-knowu STDs by gender. ................................................... 35 4.4 The best-known STDs by grade level.. ............................................. 36 4.5 Options to prevent STDs ............................................................. .40 4.6 Intimate helpers by grade level. ..................................................... .48 4.7 Gender and grade level ofsexuaiiy active participants ........................... .49 4.8 Sexually active students' alcohol use ................................................ 52 4.9 Sexually active students' drug use ................................................... 53 4.10 Drug use by grade levels ............................................................ 54 4.11 Sexuaiiy active participants' condom use ......................................... 55 vn

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TABLES Table 3. I Gender of the participants by grade level ........................................... 22 4.1 The participants' perception of sexuality education in school.. .. ................ 29 4.2 The participants' knowledge score by grade levels and gender .................. 33 4.3 The number and proportion of students who identified up to 6 STDs .......... 34 4.4 The students who knew one or more common symptoms by gender ........... 37 / 4.5 The proportions of students who correctly identified up to 5 common symptoms of STDs by grade level ................................................... 3 7 4.6 Proportion of students who identified common symptoms of STDs ............ 38 4. 7 Students' choices of avoiding STDs by gender .................................... .40 4.8 Students' choices of prevention methods for STDs by grade level.. ............ .41 4.9 Misconceptions about STDs ......................................................... .43 4.10 Summary of 3 statement agreement questions ................................... .44 4.11 The students' worry about getting an STD ....................................... .45 4.12 The students' worry about getting an STD by grade level.. ................... .46 4.13 The students' worry about getting an STD by gender. ......................... .46 4.14 The students' intimate helpers by gender. ........................................ .4 7 Vlll

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CHAPTER 1 INTRODUCTION The following two stories from the Mongolian Adolescent Reproductive Health Project (2002) are common cases for Mongolian teenagers. ... I met with him at the summer camp. We had fireworks at that day and everybody was-so excited. Then we drank some beer. When we were in the forest, he told me that we loved each other, so we had to prove each other. Finally, he asked me "How about having sex?" At that time, I had no doubt about having sex because also he said to me that if I did not have sex with him, he was ready to sleep with another girL." A 16 teenager girl who had an abortion .. .I was a pregnant. I suspected that my husband slept with another woman. One day I had really bad discharge from my vagina. The discharge looked like pus. I knew that something was wrong. However, I believed that I did not need to see a doctor, so I used various kinds of medicines and injections for getting rid of it ... A 19 teenage mother Yes, nowadays, everything is changed. When I was a teenager, a boy would meet his girlfriend after school, carry her backpack, and take her to a movie. The most exciting thing to hear was that someone kissed someone. Mongolia, located between China and Russia, is a country with a unique history and culture. The Mongolian land territory is large but the total population is 1

PAGE 10

only 2.4 million. Twenty-five percent are adolescents aged 10 to 19 (WHO, 2003, p. 7 & 10). Mongolia was a part ofthe socialist system until the late 1980s. For centuries, before and during the socialist system, discussion of sexuality was a taboo subject. By the late 1980s the socialist system collapsed and Mongolia began to experience changes in its political, economic, social, and cultural structures. One of these changes has been a dramatic increase in sexual activity among adolescents, which has led to increased numbers of sexually transmitted diseases (STDs), unwanted pregnancies as well as a heightened risk for infection by the human immunodeficiency virus(HIV) (International Women's Health Coalition, 2004). When the Ministry of Health and Social Welfare (MOHSW) became aware of the health problems facing Mongolian youth, it stepped forward to respond to this problem by proposing sexuality education as a mandatory component of health education in the school setting. Since sexuality education is a relatively new concept in Mongolia, very little information is available about teenagers' sexuality, especially teenagers' sexual risk behaviors and their knowledge and attitudes about STDs other than Acquired Immunodeficiency Syndrome (AIDS). Consequently, I am concerned about teenagers' knowledge and attitudes about STDs other than AIDS and their sexual fisk behaviors, including alcohol and drug use as these relate to sexual activity. It is very important to assess teenagers' knowledge and attitudes about STDs other than AIDS and their sexual behaviors in Mongolia in order to develop 2

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interventions to decrease risky sexual behaviors and in turn decrease the number of STDs in this population. Specific Aims The specific aims of this study were: 1. To describe 81h, 9th, and 101h grade teenagers' sexual risk behaviors, to measure their knowledge, and to identify their attitudes about STDs other than AIDS. 2. To compare gth, 9th, and lOth grade teenagers' sexual risk behaviors, their knowledge, and attitudes about STDs other than AIDS. It was important to evaluate teenagers' knowledge and attitudes about STDs other than AIDS and their risk behaviors because STDs are, in reality, a greater risk for teenagers than AIDS in Mongolia. According to the statistics of the National Research Center for Infectious. Diseases (NRCFID), approximately 20,000 patients have been screened for HN infection every year since 1987. As of2001, two patients were positive: one acquired HIV in another country, and the second is thought to have acquired HN through contact with an African person visiting Mongolia (Ebright, Altantsetseg, & Oyungerel, 2003, p. 1512). Thus, nowadays, HIV/AIDS is not as big a problem among Mongolian teenagers as other STDs. It was important to compare gth, gth, and 101h grade teenagers' knowledge and attitudes about STDs other than AIDS and their risk behaviors because many Mongolian youth do not progress beyond the gth grade and may not be learning about 3

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the risks of STDs and how to prevent them. The Mongolian general education structure has two kinds of systems; the 1 0-year system and the 8-year system. According to the most recent data up to 40% of the eighth graders do not continue their studies beyond grade 8 (Ministry of Science, Technology, Education, and Culture (MOSTEC), 2002)). Students have the right to finish their study until 81 h grade and generally, continuation of study depends on students' grades. That fact is important to this study because different sexuality education curricula are offered in 81h, 91 \ and 101h grades (see Appendix C). For example, the eighth graders are taught about pregnancy, fertility, how to protect themselves from unwanted pregnancies, as well as testicular and breast-self examination. The curricula for ninth graders include information about sexual identity and orientation and safer sex. Only the curricula for tenth graders includes information about STDs, so those students who do not continue past the eighth grade do not have a chance to learn about STDs in school. However, we have to prepare these adolescents for family life also. Furthermore, teenagers become sexually active at these ages. This thesis consists of five chapters, including the introduction: a review of the relevant literature and the status of sexuality education in Mongolia, methods, the presentation of findings, and a conclusion. The literature review explores the main issues concerning adolescents' reproductive health, including STDs in the United States of America (USA) and Mongolia and presents some studies regarding Mongolian teenagers' knowledge and attitudes about STDs other than AIDS. 4

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Moreover, this chapter gives the background on school-based sexuality education in Mongolia. The next chapter presents the setting, the inclusion criteria, the school selection process, the recruitment, the data collection technique as well as the subjects The presentation of findings is based on a survey of 342 students who were recruited from the three urban schools. In the conclusion, I summarize the main findings. This chapter also includes discussion and limitations In the discussion section, I compare my findings to other studies and note my thoughts. 5

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CHAPTER2 A REVIEW OF LITERATURE AND SEXUALITY EDUCATION IN MONGOLIA A Review of the Relevant Literature Adolescence is a period of sexual maturation between ages 1 0 and 19 that transforms a child into a biologically mature adult capable of sexual reproduction and vulnerable to the consequences of sexual activity. (Gubhaju, 2002, p .3). The reproductive health of adolescents is of growing concern today for several reasons. First, the size of the adolescent population in the world commands attention. Adolescents numbered nearly 1.1 billion in 1995 of which 913 million lived in developing countries and 160 million in developed countries. In other words, one in every five people in the world is an adolescent, and 85 of every 100 adolescents live in developing counties (Takemi Program in International Health Harvard School of Public Health, 1998, p. 4). In Mongolia, adolescents (ages 10-19) numbered 581,188 or 25% of the total population of 2.4 million in 1998. Of all Mongolian adolescents, 38% were between the ages of 14-17 (WHO, 2003, p. 7 & 1 0). Second the onset and pace of adolescence are changing, making it a particularly vulnerable period of development. Moreover, demographic, 6

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epidemiological, and socio-economic trends in many countries, including Mongolia, are combining to create different life styles for adolescents that add to their vulnerability. Nowadays, there is a clear trend among young men and women in many countries to marry later in their lives and to engage in sexual relations prior to marriage. For instance, in the United "States, sexual activity among adolescents 15 to 19 years of age increased from 32% in 1971 to 45% in 1995 (Jordan, Price, & Fitzgerald, 2000, p. 338). In addition, the nationwide survey of Youth Risk Behavior SurveillanceUnited States indicates that in 2001, 45.6% ofhigh school students had ever had sexual intercourse (National Library of Medicine, 2004). A 1996 study in Mongolia, found that 26% of adolescents aged 17 to 18 years had had sex. However, this figure has increased in the last four years and in 1999, 34.5% of adolescents 17-18 years old report having had sexual intercourse (WHO, 2003, p. 13). The period of exposure to sexual activities before marriage also becomes longer because the average age at menarche continues to decline (Takemi Program in International Health Harvard School ofPublic Health, 1998, p. 14). Political, social, and economic changes, including the collapse of the socialist system, urbanization, industrialization, increase of education needs, and western media influences have eliminated many of the traditional restraints on early sexual activity outside marriage and have exposed many adolescents to the risks of unintended pregnancies, abortions, and sexually transmitted diseases (STDs), which, 7

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in tum, increase the risks to their reproductive health and well-being (Takemi Program in International Health'Harvard School ofPublic Health, 1998, p. 14). First, I would like to discuss unintended pregnancies among teenagers. The United States still has the highest rate of adolescent pregnancy in the developed world. Each year as many as one million American teenagers become pregnant. The vast majority ofthese teenagers say they never intended to get pregnant (Buckingham & Derby, 1997, p. 11). In Mongolia, the rate of giving birth among adolescents has increased in the last ten years. According to the Reproductive Health Survey, in 1998 about 9% of 15-19 years old girls gave birth (NSOM & UNFP A, 1999, p. 3 8). Moreover, according to the 1996-1998 statistical data, 8.3% ofmatemal deaths from pregnancy and delivery were adolescents between the ages of 15-19, which is twice as high as the percentage of deaths among the 20-29 age group (WHO, 2003, p. 14). Second, the rate of abortion is important because it indicates that young women are having unprotected sex that results in unplanned or unwanted pregnancies. For most teenagers, abortion is a personal and complex decision. About one third of all teenagers who become pregnant each year in the United States choose to terminate their pregnancy (Buckingham & Derby, 1997, p. 1 05). In Mongolia, 6.3% of women aged 13-20 became pregriant. Of these, 43.3% pregnancies were unwanted and 18% had abortions. Those who had attained merely a primary education had the highest pregnancy rates in comparison with those who had attained the education level of grade 10. According to health statistics, the percentage of 8

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abortions among women under 20 in Mongolia has increased significantly (WHO, 2003, p. 14) (see Figure 2.1). In 1998, about 9,135 women had an induced abortion in Mongolia. Of these 5.5% were under 20 years old. The number did not include cases of abortion in private hospitals, which were estimated at 18% among women ages 1524 and 2% among women ages 35-39. The reported rate was underestimated because abortions in private hospitals were neither registered nor reported to the health and statistical offices (WHO, 2003, p. 15). Figure 2.1 Percentage of abortions among women under 20 8 7 6 5 4 3 2 I 0 ... L.":l 1996 1998 Source: National Statistical Office ofMongolia. (2001). p.28. __..7.6 2000 Finally, it is estimated that more than 15 million new cases of sexually transmitted infections are diagnosed each year in the United States. Approximately one fourth of these new infections occur among teenagers (Planned Parenthood Federation of America, 2004). Chlamydia, gonorrhea, and genital warts (also known as HPV human papilloma virus) are most common among American teenagers 9

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(Planned Parenthood Federation of America, 2004). Although rates ofSTDs other than syphilis and gonorrhea have been going up, teenagers still have higher rates of gonorrhea than do sexually active men and women aged 20-44 (Alan Guttmacher Institute, 1999). During the 1980s, genital chlamydia became the most prevalent STD in the USA and in 1996 there were an estimated 3 million new cases diagnosed. This made chlamydia the most frequently reported infectious disease in the country (Planned Parenthood Federation of America, 2004). In some settings, 10-29% of sexually active teenage American women and 1 0% of teenage American men tested for STDs have been found to have chlamydia (Alan Guttmacher Institute, 1999). HPV infections have risen as well, with estimated incidence of 5.5 million new infections each year. HPV infections of the cervix and vagina are now the most common STDs among sexually active young women (Planned Parenthood Federation of America, 2004). In some studies, up to 15% of sexually active teenage women have been found to be infected with HPV, many with a strain ofthe virus linked to cervical cancer (Alan Guttmacher Institute, 1999). STDs have become an increasing problem since Mongolia became fully independent of Soviet control in 1990. This increase may relate partly to temporary loss of central governmental control as well as the decreased economic base for the country. It is estimated that every year about 7,000-8,000 people are getting infected with STDs in Mongolia. About 49-58% of STD patients are under 25 years of age (WHO, 2003, p. 15). Data for syphilis show a decreasing trend from 1983 to 1993 10

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with a decline in cases from 700 to 18/100,000 population, followed by a rise in cases to 32/100,000 population in 1995. Data suggest a 1.5-3.0 fold higher rate of syphilis for ages 15-24 than any other group. Data for gonorrhea show an upward trend in rate of cases, from 51/100,000 population in 1983 to 142/100,000 in 1995. The majority of cases are aged 15-44 (Purevdawa et al., 1997, p. 398-401 & Ebright, Altantsetseg, & Oyungerel, 2003, p. 1509 & 1511-1512) (see Figure 2.2). Figure 2.2 Prevalence of STDs in Mongolia per 10,000 population, 1990-2000 I___.... Syphilis I 9.8 ... . .. -" .... 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Source: National Statistical Office ofMongolia. (2001). p. 31. Trichomonias rates also show an upward trend in the number of cases, from 47/100,000 population in 1983 to 155/100,000 cases in 1995. Like gonorrhea the majority of cases are in the 15-44 year age range. In addition, for children aged 0-14, the 1983-1993 rate remained below 4.5/100,000; however, in 1994 and 1995 the rate increased reaching 53 and 48/100,000 respectively (Purevdawa et al., 1997, p. 398401 & Ebright, Altantsetseg, & Oyungerel, 2003, p. 1509 & 1511-1512). 11

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These are official statistics ofNRCFID, so the above rates are entirely underestimates because STD cases in private hospitals were neither registered nor reported to the health and statistics offices. STDs are responsible for a variety of acute and chronic health problems, and can have especially serious consequences for adolescents, such as pelvic inflammatory disease, ectopic pregnancy, infertility, and cervical cancer. Consequently, it is very important to assess teenagers' knowledge and attitudes about STDs other than AIDS and their sexual behaviors in Mongolia. Since sexuality education is a relatively new program in Mongolia, very little information is available about these issues. However, there are a few studies, such as a 1999 survey, "Reproductive Health and Sexuality: Knowledge, Attitudes, and Behaviors" by the UNFPA, the MOHSW, the MOSTEC, and other international organizations (Adolescent Reproductive Health Project, 2002). About 1400 rural and urban school students, aged 11-18, participated in this study. To assess teenagers' knowledge, the study asked three questions about each reproductive health topic such as anatomy and physiology, puberty changes, conception, pregnancy, contraception, sexual orientation, sexual coercion, and STDs. It is impossible to assess teenagers' real knowledge about STDs based on only three knowledge questions. In addition, The World Health Organization (WHO), the UNFPA, and the Mongolian government and some of its organizations conducted a study together, "Adolescent Behaviors and their Living conditions" (National Statistical Office, 2002). About 3,600 41h to 101h 12

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graders and 400 young people not in school from both rural and urban areas participated in this study. The main purposes of this study were to examine the implementation ofthe Adolescent Reproductive Health Project and to evaluate adolescent living conditions rather than assess teenagers' knowledge about STDs other than AIDS. Furthermore, in 1996, the UNFPA and the MOHSW conducted another study named, "Adolescent Reproductive Health Knowledge, Attitudes and Practice" (MOHSW & UNFPA, 1996). The sample included 4,674, young people aged 13-20. The study included only four questions to assess teenagers' knowledge about STDs other than AIDS which were very general. For example: "Have you ever heard about STDs?" Yes or No and "Do you know about symptoms of STDs?" Yes or No. Consequently, there is no study to my knowledge that focuses on Mongolian teenagers' sexual risk behaviors and their overall knowledge and attitudes about STDs other than AIDS. The Status of Sexuality Education in Mongolia In response to the growing problems, in 1997, the MOHSW and the MOSTEC established a joint initiative to promote the country's new commitment to a preventive approach to public health care. A key part of the initiative was to design a primary and secondary school health education program that would address the most pressing public health concerns facing young Mongolians. In partnership with the 13

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WHO, the Mongolian government identified ten thematic areas to include in a comprehensive health education curriculum; one of these areas was reproductive health. In addition, the resolution of the International Conference on Population and Development, held at Cairo in 1994, had great influence on the Mongolian government's decision. One of the topics discussed in this conference was that of adolescent sexuality education. Initially, the MOHSW encountered some resistance from the MOSTEC about reproductive health and, in particular, the idea of school based sexuality education. For centuries, Mongolians had avoided public (and much private) discussion of these issues. The hesitation was based in part on a concern that such education would result in promiscuity. Extensive dialogue, joint participation in international meetings, and a review ofthe literature on this topic led, however, to a consensus that the culture was already in transition, and that effective education could reduce rates of unwanted and unsafe sex. During that time, policy makers believed that because of changes in politics and life of the society, sexual activity among teenagers, the risk of STDs, and unwanted pregnancies were greatly increasing. Reproductive health education is one way of addressing these issues. However, when ministry officials asked themselves what adolescents needed to know if they were going to reduce their risk of unwanted pregnancy, STDs, and physical abuse, they did not have any clue. Also, they realized that there were no sexuality education experts in Mongolia. Nevertheless, some school-based sexuality education programs have been implemented since 1998 under the guidance of the UNFP A, 14

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WHO, and other international organizations in Mongolia. One such project is the first Mongolian Adolescent Reproductive Health Project, nicknamed PO Zorgaa 1 which refers to UNFPA Project number 06. Since 1998 the UNFPA has supported the longest running school-based project in Mongolia. The project has a budget of US$743,890. It is being managed by the Margaret Sanger Center International (MSCI) and is being implemented by the MOHSW and the MOSTEC. The project has four components (Population Council, 2002, p. 11 & Asia and Pacific Regional Bureau for Education UNESCO Bangkok & UNFPA, 2004): 1. Formal education: A curriculum that was piloted in 12 schools that is now offered in 60% of all schools (100% of all urban schools). When more experience has been gleaned and if the government expands the number of hours (currently, 5-6 hours a year of sexuality education) for reproductive and sexual health education, a second edition of the curriculum will be produced and distributed nationally. 2. Informal education : The project staffhas been working with non-governmental organizations (NGOs) in order to reach teenagers out of school. The project conducted a three-week training course for NGO staff and volunteers in 1999 and distributes materials such 1 It means in Mongolian number six. 15

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as a newspaper "UerkheLove"2 to the NGOs. Moreover, "Hotline 312151" offers advice to adolescents in the areas of reproductive health and sexuality. In the first eight months of 1999, the hotline service of "Adolescence Future Center" provided answers to 560 people on about 600 questions. Eighty-three percent of all the customers were adolescents. Because of financial constraints, however, this element of the project has not yet been developed. 3. Information and communications: Understanding that the classroom is only one avenue for transmitting messages about sexuality, and, given the need to reach out-of-school young people, the project also has an information, education, and communication component, making use of the popular media (both electronic and print) to reach adolescents and complement the school-based education. In 1998, the project developed a newspaper called "UerkheLove" for adolescents. The MSCI proposed two educational videos of 20 minutes. The topics of these videos are human sexuality and parental dealings with adolescents. Also, the project developed two textbooks to complement the curriculum. 2 The first reproductive health project for Mongolian adolescence, which is sponsored by the UNFPA and MSCI developed this newspaper. The project's name in Mongolian was long, so it quickly came to be called by the nickname PO Zorgaa, which refers to UNFPA Project number 06. It helps to educate teenagers, allows them to present issues in their own voices, increases teen involvement and participation, and advocates teen issues. This newspaper is published 3-4 times an year. 16

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4. Clinical services: There are few places in Mongolia where teenagers feel comfortable about seeking reproductive health care services. Although the existing clinics technically are open to adolescents, most teenagers report that they are concerned about their privacy because the local population is small and "people talk." Currently, PO Zorgaa staff are cooperating with a sister project, also funded by the UNFP A, to open adolescentfriendly pilot clinics. Sex education is a new activity in Mongolia, thus, considerable time and effort are required to build up the expertise and experience for curriculum development and teachers' training. Under this aspect, the MSCI has organized training of master trainers since October 1998. The governmental goal is to provide each of the 683 schools in Mongolia with at least one qualified sexuality educator on staff. As of early 2002, the master trainers have trained about 300 school teachers; however, at least an equal number of teachers are using the curriculum without the benefit of training. Another important achievement has been the project's collaboration with the MOSTEC to institutionalize sexuality education in teacher training programs. The Pedagogical University in Ulaanbaatar has begun to offer a course on reproductive health and sexuality education for biology teachers (Population Council, 2002, p. 22). Mongolia is beginning to receive the attention it deserves for the first stages of its reproductive health and sexuality education program. In order to reach its goals, 17

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we need a lot of research to improve and develop better sexuality education programs to be taught in schools. The findings of my study will help to determine if there is a gap in the knowledge of STDs between those students who discontinue their education after 8 years and those who continue on to the 10-year system. The findings can be used to improve and develop appropriate sexuality education programs to be taught in schools. In particular, the findings may help to identify which topics should be addressed in sexuality education programs for different grade levels. 18

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CHAPTER3 THE METHOD SECTION The Setting This study was conducted in three urban secondary schools that offered a standard health class curriculum in the capital city of Mongolia, in September and October 2003. The study was conducted before the tenth graders had been taught about STDs in the 2003-2004 school year. Inclusion Criteria and School Selection In 2000 there were 683 primary and secondary schools in Mongolia (Population Council, 2002, p. 21 ). Although sexuality education programs are relatively new in Mongolia, almost all urban secondary schools are regularly involved in school-based sexuality education programs. In other words, the sexuality education is taught by a teacher trained in this subject area and a standardized sexuality education program is included in the main curriculum for all students. There are two main school curricula related to school-based sexuality education programs: one is called the family ethics class and the other is called the health class. The family ethics class has been taught since 1994 only for ninth and tenth graders. 19

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The family ethics class includes a few topics related to human sexuality, including STDs, but it includes more topics related to social ethics, for example desirable individual qualities, how to behave and communicate in a social environment, divorce and its consequences, and harmful habits, including smoking and drinking. In contrast, the health class has been taught since 1998 for all grades from 3rd to 1 01 h. This class focuses more on topics related to health, including human reproductive health. Consequently, only schools that offered the health class were eligible for this study. School inclusion: Be schools that have implemented health class curriculum Be schools that offer health classes in the first semester of the 2003-2004 school year Be schools that have 81 \ 91h, and 101 h grade levels Be schools that are located in the capital city Have agreement of school administrators and teachers Three hundred and forty-two male and female eight ninth, and tenth grade students aged 14-18 years were recruited from three urban schools to participate in this study. Students' inclusion: Be at least 14 and not older than 19 years old Be male or female A participant's permission 20

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Eighth, ninth, and tenth graders were selected for inclusion because many students are becoming sexually active at these ages. Also, it was important to include gth graders because up to 40% of students do not continue their education past that grade. Recruitment Generally, the Mongolian general education system has four semesters. Usually secondary schools themselves arrange which semester the health class is taught. During October 2003, of the urban secondary schools that offered the standard health class curriculum, only 12 schools offered the health class in the first semester. Three of these 12 schools were randomly selected using the lottery method. By chance, all three schools were on the outskirts of the city where families with lower educational level and lower incomes live. The researcher could contact the schools easily with the assistance of her Mongolian advisor who works at the Educational Office and is a supervisor responsible for biology and chemistry teachers. The researcher and her Mongolian advisor introduced the purpose of the study to school administrators and teachers and received their permission to conduct this research in their schools and classrooms. For each school, one health class or "class work"3 for each grade level was selected for participation using the lottery 3 It is a separate class in which students and teachers can freely discuss whatever they want. 21

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method. The study was verbally explained to students and their voluntary participation was requested. There was a lot of interest in participants and eagerness to be part of a study. Students were informed of their right to skip any questions they did not want to answer and their right to end participation at any time. No student ended participation before completing the survey. The Subjects Three hundred and forty-two male and female eighth, ninth, and tenth grade students aged 14-18 years were recruited from the three urban schools to participate in this study. The participants in this study included: 119 students from the eighth grade, 1 01 students from the ninth grade, and 122. students from the tenth grade. Ages of the students ranged from a maximum of 18 to a minimum of 14 with an average age of15.99 (SD=0.97). As shown in Table 3.1, there were more females than males in all grades with 61.1% (209) female and 38.9% (133) were male. Table 3.1 Gender of the participants by grade level Female Male Total 81 h grade 69 50 119 91 h grade 61 40 101 101n grade 79 43 122 Total 209 133 342 22

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Ofthe 119 eighth grade students, the majority 56.3% (67) reported that they would like to continue on to 9th grade whereas 4.2% (5) of students were not interested in continuing their studies past gth grade. Moreover, 39.5% (47) reported thatthey did not know. Figure 3.1 summarizes the gth grade students' answers about continuing their studies beyond gth grade. Figure 3.1 The gth graders' answers about continuing study Do not know 40% 4% Yes 56% The researcher was interested in the students' grades to see if academic achievement was related to knowledge of STDs other than AIDS. Of the 318 (93%) respondents, most students reported that they got B (40.6%) and C (39.6%) grades last year. Average grades were higher in the 9th and 101h graders as would be expected since continuing students are selected from the top students. 23

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Figure3.2 The participants' grades by grade level I 8th grade 0 9th grade D 1Oth grade I 40% +------1 30% +----20% +-----10% Mostly As Mostly Bs Mostly Cs Mostly Ds Mostly Fs The participants' socioeconomic status was measured using three indicators: father's education, mother's education, and family's approximate monthly income. The educational level of the population in Mongolia is high in comparison with other developing countries. Of the 326 students who responded to the question about father's education, 27.9% reported that they did not know. Thirty-two point eight percent of the respondents' fathers had completed high school4 and an additional34.7% completed college5 and universitl. Only 4.6% ofthe respondents reported that their fathers had less than high school education. 4 High school education is the basic education and study term is 10 years. 5 Study term is usually less than 4 years and to get degree in vocational training, such as a nurse, a plumber, and an electrician. 6 Study term is usually 4-6 years and to get degree in higher education, such as a medical doctor, an engineer, and a lawyer. 24

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Of the 331 students who responded to the question about mother's education, 16.6% said that they did not know. Thirty-five percent of the respondents' mothers had completed high school and 45.6% of the respondents' mothers had completed college and university. Only, 2.7% of the respondents reported that their mothers had less than high school education. Mothers were better educated than fathers in this population. Family income of the participants was compared to the lowest guaranteed living standard established every year by the National Statistical Office of Mongolia for the capital city, Ulaanbaatar and other aimags7 For 2003, the standard was set at 25,600 tugrugs8 per month (National Statistical Office, 2003). Families with incomes near or below this level would be considered poor. Based on this information, most teenagers (63.1 %) lived in families with higher incomes than the lowest guaranteed living standard (30,001-1 00,000 tugrugs). Only 10.1% of the participants reported that their families' approximate monthly incomes were less than or equal to 30,000 tugrugs. Another 1 0.1% of the students lived in families with relatively higher incomes of greater than 100,001 tugrugs per month. 7 Aimag-provinces, with a total population of 50,000-150,000. 8 The Mongolian banknote, approximately 1,000 tugrugs = 1 US dollar. 25

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Instrumentation The participants completed a self-reported questionnaire that included a total of 46 questions: 11 demographic questions, 17 knowledge questions about STDs, 7 attitude questions, and 11 questions about teenagers' sexual risk behaviors (See Appendix B). The instrument incorporated questions from published and unpublished resources such as the Colorado 1999 Youth Risk Behavior Survey, Colorado Youth Survey, and knowledge, attitudes, beliefs and behaviors (KABB) surveys. The survey was initially developed in English. Because of differences between the Mongolian and English languages, translation and back-translation were conducted by the researcher and her Mongolian advisor. A pilot test was conducted with volunteer Mongolian teenagers similar to those in the study sample. Six 8-101h grade students (3 males and 3 females) participated in the pilot test and the researcher interviewed the students afterwards. The purpose of the pilot test was to identify unclear questions and to estimate the amount of time needed to complete the survey. As a result, three questions were changed: one question about a family's approximate income and two questions about STD treatment. For the income question, we modified only the categories. For the treatment questions, because of translation problems we combined two questions into one. After the researcher discussed the needed changes with her advisors, the changes were made on the questionnaire. 26

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Survey Administration The questionnaires were administered on days selected by the researcher in October, 2003, to 342 students during health class or the class work. The self reported questionnaire took 20-25 minutes to complete and was administered in the classroom by the researcher. No identifying information was included on the surveys. The completed surveys were collected by the researcher. Following survey administration, the researcher, a Mongolian physician, provided students with information about STDs and answered their questions for the remainder of the class time. Data Analysis The data were entered into SPSS and EXCEL and analyzed using descriptive statistics. The analysis of variance (ANOVA) test and t-tests were used for comparing the knowledge scores for three groups. The findings were described using appropriate tables and figures. 27

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Human Subjects Considerations The research protocol was reviewed and approved by the Human Subjects Research Committee at the University of Colorado at Denver. Both male and female students participated voluntarily in this study. The purpose of the study, rights of participants, and the survey instructions were explained verbally to students as a group. Students were informed of their option to end their participation at any time. Furthermore, we made every effort to keep the students' answers private by not requesting or using any names or other identifying information on the survey. Individual answers were kept private and were not shared with their parents, teachers, or friends. 28

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CHAPTER4 THE PRESENTATION OF FINDINGS Sexuality Education Programs in Schools Although only schools with sexuality education were selected to participate in this study when the survey asked the participants if they had sexuality education in their schools, only 60.5% of participants reported that they had sexuality education in their schools. Totally, 41.8% students reported that they had been taught about STDs other than AIDS in their schools. Table 4.1 represents the students' overall assessment of sexuality education programs in their schools by grade levels. Table 4.1 The participants' perception of sexuality education in school Have you had sexuality education Have you ever been taught about STDs other in school? than AIDS in school? Yes No Not answer Yes No Not sure Not answer 8th grade 34.4% 60.5% 5.1% 22.7% 51.5% 22.7% 3.1% (41) (72) (6) (27) (61) (27) (4) 9m grade 76.2% 21.8% 2% 52.5% 31.7% 12.8% 3% (77) (22) (2) (53) (32) (13) (3) 101 h grade 72.9% 25.4% 1.7% 51.6% 21.3% 26.2% 0.9% (89) (31) (2) (63) (26) (32) (I) Total 60.5% 36.5% 3% 41.8% 34.8% 21% 2.4% (207) (125) (10) _(_143) (I 19) (72) (8}_ 29

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As would be expected from the health class curriculum (see Appendix C), higher grade levels, 9th and 1oth grades had more students who reported having sexuality education in school (76.2% and 72.9%). Similarly, gth and lOth grade levels had more students who reported being taught about STDs other than AIDS in school (52.5% and 51.6%). Information Resources about STDs other than AIDS The survey asked the participants to note which of nine information resources common among teenagers they used to learn about STDs other than AIDS. The participants also had a chance to add other sources of information. The main sources of information on STDs were television (35%, N=120), friends (30%, N=102), newspapers or magazines (27%, N=92), and teachers or school programs (24%, N=82) (see Figure 4.1 ). Figure 4.1 Information resources about STDs other than AIDS i i I ; teacher or school prog newspaper or magazines I friends I I I television 1 I I i I I : 0% 5% 10% 15% 20% 25% 30% 35% 40% 30

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In addition, a few students reported that they obtained information on STDs from the Internet and public places, such as overhearing conversations on a bus. Also, it is interesting to note that 6 students responded that an adolescent newspaper, "UerkheLove", was their main source of information on STDs. Only 7% of the participants reported that they got some information about STDs from their parents or relatives. When asked about needing additional information, 71.1% responded that they wanted more information about STDs. Ninth grade students were most interested in receiving more information (80.2%) as compared to the 101h grade students (70.5%) and gth grade students (63.9%). Students who wanted additional information listed the following topics they were interested in learning about: How can I prevent STDs? Are there any special methods or drugs? What are common and classic symptoms of STDs? Is it possible for me to get most STDs from touching toilet seats, moist towels, or clothes? Is it possible for me to get an STD the first time I have a sex? Ifl have a problem with STDs, who can help me? Are there any special organizations or hospitals for teenagers? 31

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Teenagers' Knowledge about STDs other than AIDS An overall knowledge score was calculated based on the percentage of correct responses to the 17 knowledge questions. There were 35 points possible. Using the sum of scores from the 17 knowledge questions, the participants were scored as having poor, moderate, or excellent knowledge about STDs other that AIDS (80%100% = excellent; 60%-79% = moderate; 59% or less correct = poor). Overall, the participants' knowledge about STDs other than AIDS was poor. The average knowledge score was 10.29 (SD=5. 73) or 28.6% with scores ranging from zero (0%) to 25 (71%). As shown in Figure 4.2, only 19 students (5.5%) were scored as having moderate knowledge and the rest of the 323 students (94.5%) were scored as having poor knowledge about STDs other than AIDS. Figure 4.2 The participants' average knowledge scores Moderate 6% Excellent 0% 32 Poor 94%

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Table 4.2 represents the students' knowledge scores about STDs other than AIDS by their grade levels and gender. Of the 19 students who were scored as having moderate knowledge, 11 (57.89%) were males and 8 (42.11 %) were females and all were in the 9th and lOth grades except for one male student in the 81h grade. Table 4.2 The participants' knowledge score by grade levels and gender Scores 81 grade 91 h grade 101 h grade Total Male Female Male Female Male Female Average 8.92 7.67 12.15 10.88 12.7 10.82 10.29 score 35-28 0 0 0 0 0 0 0 scores= excellent 27-21 1 0 4 4 6 4 19 scores= moderate 20 or less= 49 73 37 58 31 75 323 poor Total 342 An independent samples t-test showed that the male students' average knowledge score (M = 11.07, SD = 5.81) about STDs other than AIDS was significantly higher than the female students' average knowledge score (M = 9.78, SD = 5.63, p = 0.04). It is interesting that the knowledge scores for students who said they have had sex (M = 11.76, SD = 5.55) were significantly higher (t (333) = 2.39, p = 0.02) than the scores for students who said they have not (M = 9.88, SD = 5.69). A one-way analysis ofvariance (ANOVA) was conducted to evaluate the difference in knowledge scores between students in the three grade levels. A significant difference was found (F (4, 339) = 14.83, p < 0.0001) between the three 33

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grades with the lOth grade students having a significantly higher knowledge score (M = 11.54, SD = 5.90), followed by the 9th graders (M = 11.39, SD=5.80), and fimilly the 8th graders (M=8.07, SD=4.79). Additional t-tests indicated that there was a significant difference between the 8th and 9th (t (218) = -4.65, p<0.0001), and between 8th and lOth grade scores (t (239) = -5.01, p<0.0001). However, there was no significant difference between the 9th and lOth grade scores (t (221) = -0.19, p = 0.84). These findings suggest that knowledge about STDs other than AIDS is greater for those students who continue their education beyond 81h grade, and among those who are older or have initiated sexual intercourse. However, the vast majority of these scores still fall in the poor range. The survey asked teenagers to select the names of STDs from a list of 12 disease names, including other disease names, such as cystitis, appendicitis, and hemorrhoids. Of the 334 (97.6%) students who responded to this question, about one third (32.3%) said that they did not know. Nobody identified all 8 STDs. Table 4.3 shows the proportion of students who identified up to 6 STDs correctly. Table 4.3 The number and proportion of students who identified up to 6 STDs 6STDs 5 STDs 4STDs 3 STDs 2 STDs 1 STD correctly correctly correctly correctly correctly correctly 1.5% 5.7% 7.2% 17.7% 18.6% 17.0% (5) (19) (24) (59) (62) (57) 34

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Only 14.4% could identify 4 or more STDs. The three best-known STDs among the respondents were syphilis (59.9%), gonorrhea (44%), and herpes genitals (19.8%). Nobody knew that hepatitis was a sexually transmitted disease. In general, more female respondents (36.5% vs 25.9%) than males said that they did not know any STDs, so, more male students (56.5% vs 51.1 %) than females checked 1-3 correct STDs. The two best-known STDs among both male and female teenagers were syphilis and gonorrhea (see Figure 4.3). Figure 4.3 The best-known STDs by gender I 0 Male IJ Female I 70% 60% 40% 30% 20% I 0% 0% Similar to the findings in other areas of STD knowledge, 91h and 1 01h grade students were better able to correctly identify the names of STDs than were 81 h graders. Nevertheless, there was agreement among all grades that the two best-known STDs were syphilis and gonorrhea. As shown in Figure 4.4, with increasing grade 35

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levels, the proportion of students who identified the two best-known STDs increased dramatically. Figure 4.4 The best-known STDs by grade level I 8th grade D 9th grade 0 I Oth grade I Participants were asked to select which of 1 0 symptoms were common symptoms of STDs. The choices included some symptoms related to other diseases, for example weight loss or weight gain, bleeding hemorrhoids, and nausea and vomiting. Ofthe 334 respondents, 56% reported that they did not know any common symptoms of STDs. Only 2. 7% of the respondents checked all 5 common symptoms of STDs correctly whereas 11.9% checked only one symptom. The proportions of students who reported that they did not know any symptoms of STDs were similar for each gender (55.7% males vs 56.2% females). In general, females were slightly 36

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more knowledgeable with 23.5% knowing three or more symptoms in comparison to only 19% for the males (see Table 4.4) Table 4.4 The students who knew one or more common symptoms by gender Students Students who Students who Students who Students who who knew knew4 lmew3 knew2 knew 1 all5 symptoms symptoms symptoms symptom symptoms Male 3.8% (5) 7.6% (10) 7.6% (10) 9.9% (13) 15.3% (20) Female 1.9% (4) 10.8% (22) 10.8% (22) 10.3% (21) 9.8% (20) Sixty-seven percent, ofthe 81h graders, 48% ofthe 9th graders, and about a half(52%) of the lOth graders reported that they did not know any common symptoms ofSTDs. The 9th and lOth graders were more knowledgeable with 29% and 28.9% respectively knowing three or more symptoms in comparison to only 7.9% for the gth graders (see Table 4.5). Table 4.5 The proportions of students who correctly identified up to 5 common symptoms of STDs by grade level. All5 4 symptoms 3 symptoms 2 symptoms 1 symptom symptoms gtn grade 0.9% (1) 2.6% (3) 4.4% (5) 8.8% (10) 15%(17) 9tn grade 5% (5) 12% (12) 12% (12) 14% (14) 9% (9) lOtn grade 2.5% (3) 14% (17) 12.4% (15) 8.3% (10) 11.6% (14) 37

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The most common symptoms of STDs identified by the respondents were: abnormal discharge from penis or vagina (28. 7% ), painful urination (27 .8% ), appearance of blisters and sores (22.5%), itching or burning in genitals (21.3%), and pelvic pain or pain in lower abdomen (11.4%) In general, a higher proportion of females than males identified common symptoms of STDs. As with other knowledge questions the 91h and 1 01h graders were more likely to know common symptoms of STDs (see Table 4.6). Table 4.6 Proportion of students who identified common symptoms of STDs Conunon symptoms of STDs 8111 9th 10111 Male Female grade grade grade 1. Painful urination .12.4% 39% 33% 29.7% 26.6% (14) (39) (40) (39) (54) 2. Abnormal discharge from penis or 15% 34% 37.2% 28.2% 29% vagina (17) (34) (45) (37) (59) 3. Itching or burning in genitals 8.8% 29% 26.4% 19.8% 22.2% (10) (29) (32) (26) (45) 4. Some blisters and sores appear 11.5% 28% 28.1% 16.8% 26.1% (13) (28) (34) (22) (53) 5. Pelvic pain or pain in lower abdomen 9.7% 16% 9% 9.9% 12.3% (11) (16) (II) (13) (251 The survey asked if it is necessary to seek a health professional's help if a person has an STD. Of the 340 respondents, the vast majority (85.6%) reported that they would need to seek medical professionals' help if they had an STD. A few (6.7%) respondents mistakenly believed that the need to seek medical professionals' help for an STD depended on the STD. Only one eighth grader reported that she would treat an STD herself if infected. There was not any difference between male 38

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and female students or between grade levels for knowledge about the need to seek medical care for STDs. When asked "Can you avoid STDs?" the majority (71.7%), ofthe respondents said that avoiding STDs is possible whereas only 3.9% reported that STDs could not be avoided. Almost a quarter (24.3%) responded they did not know. More males than female students reported that avoiding STDs was possible (81.1% and 65.8% respectively). As would be expected from the lower overall knowledge scores of females, more female students (28.7%) than male students (17.3%) reported that they did not know if STDs could be avoided. The percentage of students who said that avoiding STDs was possible increased with advancing grade levels (60.7% for the 81 h graders, 76.5% for the 91 h graders, and 78.2% for the 101 h graders). Likewise, with advancing grade levels, the percentage of students who responded that they did not know decreased (19.3% for the 101h graders, 23.5% for the 91h graders, and 30.3% for the 81h graders). The survey asked those respondents who thought avoidance was possible to choose which of five possible prevention options they should adopt (see Survey in Appendix B). Participants could select more than one option. Seventy-two percent (N=169) reported that using a condom was a possible prevention option. Over one third (36.8%, N=87) reported they should not have sex and also just over one third (34.7%, N=82) responded that limiting the number of partners was a possible option to avoid STDs. Moreover, 30.5% (N=72) students considered not using drugs as 39

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another option to prevent STDs. Only 3 (1.3%) 81 h grade students mistakenly believed that avoiding kissing is a possible way to prevent STDs. Figure 4.5 shows the students' responses about possible options to avoid STDs. Figure 4.5 Options to prevent STDs A void sex ' Use a condom ,: I : I I I 0 I 0 20 30 40 50 60 70 80 Percentage As mentioned earlier, that only 3 eighth graders reported that avoiding kissing was a possible choice to prevent STDs, so the next table does not include this option. There were major differences between male and female students' choices of prevention options as noted in Table 4. 7. Table 4.7 Students' choices of avoiding STDs by gender Avoid sex Use a Limit# Avoid drugs condom partners Male 24.3% (25) 82.5% (85) 34.9% (36) 28.2% (29) Female 46.6% (62) 63.2% (84) 34.6% (46) 32.2% (43) 40

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Although the top choice for each gender was to use a condom for avoiding STDs the male students' percentage was higher (82.5% males vs. 63.2% females). More female students (46.6% vs.24.3%) reported that they would choose to avoid sex and avoid drugs (32.2% vs.28.2%) for preventing STDs. Table 4.8 Students' choices of prevention methods for STDs by grade level Avoid sex Use a Limit# Avoid drugs condom partners 8tn grade 36.7% (25) 61.7% (42) 29.4% (20) 33.8% (23) 9tn grade 36% (27) 73.3% (55) 45.3% (34) 22.6% (17) 101n grade 37.6% (35) 77.4% (72) 30.1% (28) 34.4% (32) As shown in Table 4.8 the proportion of students who responded that using a condom was a possible way to prevent STDs increased with advancing grade levels. There was not any differences between grade levels for the proportion of students who responded that abstinence was a possible way to prevent STDs. Interestingly, more 9th grade respondents as compared to 8th and 91h grade respondents indicated that limiting the number of sexual partners is something you should do to avoid STDs. However, the proportion of students who chose avoiding drugs for preventing STDs was the lowest for the 9th graders (22.6%). There are a lot of misconceptions among teenagers about STDs other than AIDS. For instance, some teenagers mistakenly believe that they can not get an STD the first time they have sex, they can not get more than one STD at the same time, 41

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and that taking birth control pills is an effective way to avoid STDs (Buckingham & Derby, 1997, p. 16). In order to reveal any misconception among the participants the survey asked several questions. Table 4.9 summarizes the students' answers these questions. 42

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Table 4.9 Misconceptions about STDs Questions Yes No I do not % responding know 1. It is possible that if 47.2% 5.8% 47% you are a virgin, you can (153) (19) (152) get an STD the first time you have sex? (94.7%) 2. It is possible that you 21.1% 11.9% 67% can get more than one (69) (39) (219) STD at the same time? (95.6%) 3. Taking birth control 13.9% 35.6% 50.5% pills is an effective way (44) (113) (160) to avoid STDs. (92.7%) 4. Washing after 16.6% 28.8% 54.6% intercourse is an (53) (92) (175) effective way to avoid STDs. (93.6%) 5. Some STDs do not 12.1% 18.8% 69.1% have any symptoms. (38) (59) (217) (91.8%) 6. You can get STDs 27% 25.5% 47.5% from touching toilet (86) (81) (151) seats, moist towels, or clothes. (92.9%) 7. You can tell by 2.8% 71% 26.2% looking at and talking to (9) (228) (84) a person if they have an STD. (93.8%) Note: More females reported that they d1d not know .I. -More males answered correctly. Conclusion ..... .... The proportion of students who reported that they did not know was almost split equally for each grade level. .... Interestingly, the proportion of students who answered correctly was the highest for the 8th graders. + With advancing grade levels, the proportion of students who answered correctly increased. + -Higher graders were more likely to answer correctly. There was not any differences between gender for the proportions of students who got right answer. Overall, the participants' knowledge of misconceptions about STDs other than AIDS was poor. Male participants and students from higher graders were more knowledgeable than females and the 81 h graders. Yet, the percentages that did not 43

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know the correct information (those who answered "I do not know" or incorrectly) ranged from 52.8% to 87.9%. Attitudes and Beliefs The survey included 7 questions to identify the teenagers' attitudes and beliefs about STDs other than AIDS: 3 statement agreement questions, 1 worry question, and 1 intimate helper question. Initially, responses were measured on a 5 point Likert scale. For analysis, responses were collapsed from 5 to 3 categories: "I agree", "I disagree", and "I'm neutral or undecided." Table 4.10 Summary of 3 statement agreement questions Statement I agree I I'm Did not Results disagree neutral answer 1. STDs are 71.9% 5.3% 19.3% 3.5% -With increasing grade levels, a big (246) (18) (66) (12) the students were more likely problem to be concerned about STDs among and less likely to be neutral. teenagers. -More males agreed (78.7% vs. 71.9%). 2. Do not 60.5% 14.9% 21.7% 2.9% More 81 and 1 01 graders have sex (207) (51) (74) (10) agreed. until you With advancing grade levels, are the students were less likely married. to be neutral. More females agreed (71.1% vs. 48.4%). 3. Do not 77.2% 4.1% 14.6% 4.1% The 9tn and 1om graders were have sex (264) (14) (50) (14) more likely to agree and less until you likely to be neutral. know a -More females agreed (85.7% person very vs. 72%). well. 44

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To assess perceptions of personal risk all participants, not only those who were sexually active, were asked how often they worried about getting an STD. Of the 342 participants, 327 students (95.6%) answered this question. 60.9%, ofthe respondents reported that they did not know if they would get an STD. Another 25.4% worried a lot. Only 2.7% reported that they never worried. Table 4.11 The students' worry about getting an STD # of students Percent Generally, I worry a lot. 83 25.4 I worry when I have sex. 15 4.6 I worry when I have unprotected sex. 21 6.4 I never worry. 9 2.7 I do not know. 199 60.9 Total 327 100.0 As shown in Table 4.12, with advancing grade levels, the proportion of students who worried a lot increased. Likewise, with increasing grade levels, the proportion of students who reported that they did not know decreased. In addition, the 91h and 1 01 h graders were more likely to worry when they had unprotected sex. 45

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Table 4.12 The students' worry about getting an STD by grade level How much do you worry that you might get an STD? Total Generally, I worry I worry I never I do not I worry a when I have when I have worry lrnow lot sex unprotected sex 8tn 23.2% 4.5% (5) 2.6% (3) 3.6% (4) 66.1% 112 grade (26) (74) 9th 24.5% 4.1% (4) 9.2% (9) 2%(2) 60.2% 98 grade (24) (59) lOth 28.2% 5.1% (6) 7.7% (9) 2.5% (3) 56.5% 117 grade (33) (66) Total 83 15 21 9 199 327 According to the below table, the following findings were drawn: More males (33.9%) than females (20%) generally worried a lot about getting an STD. More female students reported that they did not know (71.5% vs.44.1 %). Table 4.13 The students' worry about getting an STD by gender Gender Total Female Male Generally, I worry a lot 20% (40) 33.9% (43) 83 I worry_ when I have a sex 3% (6) 7.1% (9) 15 I worry when I have an 3.5% (7) 11% (14) 21 unprotected sex I never worry 2% (4) 3.9% (5) 9 I do not lrnow 71.5% (143) 44.1% (56) 199 Total 200 127 327 Participants were asked who they would go to first if they thought they had an STD. They could choose from a list of potential intimate helpers9 or add their own 9 !-Parents, 2-Relatives, including brothers and sisters, 3-Friends, 4-Teachers, 5-Medical doctors and other professionals of public clinics, 6-Medical doctors and other professionals of private clinics, and 7-Pharmacists 46

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intimate helper. Nobody named any other intimate helpers. The 320 students who responded said that they would seek help for an STD from: medical doctors and other professionals of public clinics (29.4%), parents (29%), friends or peers (21.8%), and medical doctors and other professionals of private clinics (16.2%). As shown in Table 4.14 the students' intimate helpers by gender. Table 4.14 The students' intimate helpers by gender For female students For male students 1. Parents-33% I. Medical doctors of public clinics-32.5% 2. Medical doctors of public clinics -2. Friends-23.8% 27.3% 3. Parents-23% 3. Friends20.6% 4. Medical doctors of private clinics-15% 4. Medical doctors of private clinics 17% According to the above table, the female teenagers reported that they trusted the most in their parents and medical doctors and other professionals of private clinics. In comparison, the male students responded that they trusted the most in medical doctors and other professionals of public clinics and in their friends. 47

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Figure 4.6 Intimate helpers by grade level I 8th grade D 9th grade D 1Oth grade I 35 +----30 25 20 15 10 5 0 Public clinics Parents Peers Private clinics With increasing grade levels, the proportion of students who trusted medical doctors and other professionals of private clinics increased. In contrast, the percentage of students who trusted their parents decreased from 34.6% in gth grade to 25.2% in 1oth grade. In addition, the 91h graders placed greatest trust in medical doctors and other professionals of public clinics (31.6%) whereas the 101 h graders placed their greatest trust in friends (23.5%) compared to other two grade levels. Teenagers' Sexual Risk Behaviors In this survey, the participants' sexual risk behaviors were considered as two overlapping but separate entities: behaviors over their lifetime and current behaviors within the past three months. 48

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Sexual Intercourse Ofthe 342 participants, 18.7% (64) responded that they had experienced sexual intercourse during their lifetime (sexually active). Of these 64 students, 65.6% (42) were males and 34.4% (22) were females. Sexual intercourse appeared to increase with age as indicated in Figure 4. 7. Also, for all grades, the male students were more sexually active than the female students. Figure 4. 7 Gender and grade level of sexually active participants I D Male II Female I !!l 20 c:: 0 15 a "' ...... 0 ... 10 (I) -a ;:I 5 c:: II) 0 8th grade 9th grade lOth grade Participants were asked about having had sexual intercourse during the past 3 months. Of the 51 sexually active students who responded, 43.1% (22) reported not having had sexual intercourse during the past three months. Of the 19 sexually active female respondents, 42.1% (8) responded that they did not have sexual intercourse during the past three months whereas this number was slightly higher (43. 75%, 49

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N=I4) for the 32 male respondents. To compare grade levels, the number of students who had not had sexual intercourse during the past three months was the highest for the tenth graders (63.6%, N=I4) and the lowest for the ninth graders (9.09%, N=2). Age at First Sex The age for first sexual intercourse ranged from I1 or younger to 16 for the male students and 11 or younger to I8 or older for the female students. The mean age for first having sex for the male students was 14.9 years (SD=1.12) and for the female students it was slightly older at 15.3 years (SD=l.78). Number of Sexual Partners Teenagers who we surveyed were asked how many sexual partners they have had during their life. Ofthe 63 sexually active participants who responded, almost half 46.03% (29) reported having had sex with only one person. Another 17.46% (11) of the students reported having sex with two different partners. Therefore, most students (63.49%, N=40) have had between I or 2 partners in their lifetime. An additional 36.51% ofthe students have had 3 or more partners. The mean number of partners for female students was 2 and for male students this number was slightly higher (2.5). As would be expected, the survey showed with increasing grade levels, that the mean number of partners increased: for the gth graders 1.82; for the 91 h graders 2.3; and for the I 01 h graders 2. 7 respectively. 50

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Participants were asked how many sexual partners they had during the past three months. Of the 51 sexually active students who responded, 56.9% (29) students reported having sexual intercourse during the past three months. Sixty-five point five percent (19) students reported having had sex with only one person during the past three months. Another 17.2% (5) students reported having had sex with two different partners. The remaining 17.3% (5) reported having had sex with more than two different partners. In addition, 52.6% ofthe female students and 43.75% of the male students had 1 or 2 partners during the past three months. Furthermore, 50% of the sexually active eighth graders, 76.9% of the ninth graders, and 30.8% of the tenth graders have had between 1 and 2 partners during the past three months. Alcohol Use Before Sex In accordance with the laws governing alcoholic consumption in Mongolia, it is prohibited to use alcoholic beverages if a person is under 18 years old (State Great Khural, 2001, 7.3.2 provision). Ofthe 64 students who reported having had sexual intercourse, 95.3% (61) of the participants responded to the question about drinking alcohol before sexual intercourse. As shown in Figure 4.8 9.8% (6) students usually, 34.4% (21) students sometimes, and 55.8% (34) students never drank alcohol before sexual intercourse. Nobody reported always drinking alcohol before sexual intercourse. 51

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Figure 4.8 Sexually active students' alcohol use Usually 10% Some times 34% Forty-two point nine percent (21) of the sexually active female respondents responded that they drank alcohol usually or sometimes before sexual intercourse as compared to 45% ( 40) for the sexually active male respondents. In addition, onefifth (20%) of the 15 eighth grade respondents, half(50%) ofthe 18 ninth grade respondents, and just over half(53.6%) ofthe 28 tenth grade respondents reported that they usually or sometimes drank alcohol before sexual intercourse. In other words, with increasing grade levels, the number of students who drank alcohol before sexual intercourse increased. The teenagers were asked about their alcohol use when they had sexual intercourse the last time. Of the 64 students who had sexual intercourse, 90.6% (58) responded to this question. Ofthese 58 students, 24.1% (14) reported that they drank alcohol before they had sexual intercourse the last time. Twenty-one percent (4) of the 19 female respondents and 25.6% (10) of the 39 male respondents reported 52

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drinking alcohol before they had sexual intercourse the last time. Thirteen point three percent (2) ofthe 15 eighth graders, 29.4% (5) ofthe 17 ninth graders, and 26.9% (7) of the 26 tenth graders reported that they drank alcohol before they had sexual intercourse the last time. Drug Use Before Sex Of the 64 students who reported having had sexual intercourse, 93.7% ( 60) responded to the question about using drugs prior to sexual intercourse. As shown in Figure 4.9, of these students, 8.3% (5) usually, 23.3% (14) sometimes, and 68.4% ( 41) never used drugs before sexual intercourse. Figure 4.9 Sexually active students' drug use Usually 8% Some times 23% Fewer female respondents (23.8%, N=21) than the male respondents (38%, N=39) reported that they usually or sometimes used drugs before sexual intercourse. Moreover, 14.3% (2) ofthe 14 eighth grade respondents, 33.3% (6) ofthe 18 ninth 53

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grade respondents, and 39.3% (11) ofthe 28 tenth grade respondents respectively reported usually or sometimes using drugs before sexual intercourse. Therefore, the survey showed with increasing grade levels, the number of students who used drugs before sexual intercourse increased dramatically (see Figure 4.1 0). Figure 4.10 Drug use by grade levels 45 40 35 Q.l 30 00 25 E Q.l 20 0 .... Q.l IJ.. 15 .) / / /. l 't .) 10 5 0 8th grade 9th grade lOth grade When we asked about the teenagers' drug use before they had sexual intercourse the last time, of the 64 students who have had sexual intercourse, 92.2% (59) responded to this question. Of these 59 students, the majority of students (86.4%, N=51) reported that they did not use drugs before they had sexual intercourse the last time. 54

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Condom Use Although abstinence is the best and most foolproof method of protecting oneself against contracting an STD, consistent condom use is the most effective and simplest way to prevent STDs for those having sexual intercourse. Of the 64 students who reported having had sexual intercourse, 89% (57) answered this question about condom use. As shown in Figure 4.11, of the 18 female respondents, 72.2% (13) reported using a condom "always" or "usually" whereas this number was slightly higher (87.2%) for the 39 male respondents. Similarly, to combine answers always and usually the ninth graders (70.6%) were the most likely to use a condom, followed by the eighth graders (50%) and then the tenth graders (46.2%). Figure 4.11 Sexually active participants' condom use times 28% Usually 18% 55

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Participants were asked if they or their partners used a condom when they had sexual intercourse the last time. Of the 64 students who have had sexual intercourse, 93.75% (60) students responded to this question. Ofthese 60 students, just over half (53.3%, N=32) reported that neither they or their partners used a condom. The remaining 46.7% (28) reported that they or their partners had used a condom when they had sexual intercourse the last time. More males (51%) reported condom use when they had sexual intercourse the last time than females (3 8.1% ). The proportion of students who said they or their partners used a condom the last time was the highest for the ninth graders (50%), followed by the tenth graders (46.4%) and then the eighth graders (42.8%). 56

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CHAPTERS DISCUSSION AND CONCLUSION Discussion This study of 342 eighth, ninth, and tenth grade students selected from three urban schools in the capital city, Ulaanbaatar, Mongolia described their sexual risk behaviors, measured their knowledge, and identified their attitudes about STDs other than AIDS. The study revealed several important findings. The participants' knowledge about STDs other than AIDS was poor. Knowledge about STDs other than AIDS is greater for males, those students who continue their education beyond 81 h grade, and among those who are older or have initiated sexual intercourse. The participants from all grades showed insufficient knowledge about STDs other than AIDS in general. For example, 32.3% of the respondents said that they did know any names of STDs. The majority did not know that some STDs do not have any symptoms, they were uncertain whether they could get more than one STD at the same time, and believed that washing after intercourse is an effective way to avoid STDs. Over half of the participants (56%) did not know any common symptoms ofSTDs. Only 4 students (1.2%) !mew that chlamydia was an STD and 57

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nobody recognized hepatitis as an STD. These findings suggest that a successful school-based sexuality education program (health class curriculum) in Mongolia has to have more information about STDs, in general, and about chlamydia and hepatitis specifically. This is especially important for two reasons. First, because liver cancer caused by hepatitis B virus is the first leading cancer in Mongolia. Second, because in most cases chlamydia infection will not have any symptoms. In other words, it is a kind of silent infection in up to 20% of infected men and up to 80% of infected women (Daugirdas, 1991, p. 18). Consequently, special costly tests must be performed to diagnose chlamydia. Due to limited financial resources in Mongolia, early screening and diagnostic levels are low, so most people do not know about this disease. However, knowing about chlamydia and hepatitis B might help teenagers prevent these potentially serious diseases. Finding insufficient knowledge about STDs in this study population was not surprising or unexpected because sexuality education is a relatively new program in Mongolia and teenagers do not have enough accurate sources of information about STDs. This was shown in a 1999 study conducted by the Adolescent Reproductive Health Project that assessed the participants' knowledge about reproductive health. Eighty-five percent, of the participants got less than 30% of the questions correct. The study indicated that the participants knew little about STDs and how to prevent them (Adolescent Reproductive Health Project, 2002 p. 50). In addition, the UNFPA and the MOHSW conducted another study called "Adolescent 58

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Reproductive Health Knowledge, Attitudes, and Practice" in which only 30%, of the participants reported that they lrnew some symptoms of STDs. (MOHSW & UNFPA, 1996, p. 33). Furthermore, another study completed in 2002 showed that the vast majority (63.3%) of participating students did not lrnow whether or not all STDs have some symptoms (National Statistical Office ofMongolia, 2002, p. 40). This current study showed that although the teenagers who participated know that abstinence is the best and most foolproof method of protecting oneself against contracting an STD, the vast majority (71.6%) of respondents said using a condom was a possible prevention option whereas only 36.8% reported they should not have sex. The participants agreed that STDs are a big problem among teenagers. The vast majority of participants (71.9%) believed that STDs are a big problem among Mongolian teenagers. The study showed that with advancing grade levels, the number of students who thought STDs are a problem for teenagers increased. The participants had "traditional" beliefs about sexual relationships that could encourage teenagers to be abstinent from casual sexual relationships. The majority (60.5%) believed it was best not to have sex before marriage. Most participants (77 .2%) also believed that they should not have sex until they know a person very well. The study indicated that with increasing grade levels, the number of students who had these "traditional" beliefs increased. 59

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Some participants engaged in sexual behaviors that put them at high risks for STDs. In this study, 18.7% (64), ofthe participants were sexually active. Older students and males were more likely to report being sexually active. These findings are corroborated by other studies of youth in Mongolia (Adolescent Reproductive Health Project, 2002, MOHSW & UNFP A, 1996, & National Statistical Office of Mongolia, 2002). This study showed that the mean age for first having sex was 14.9 years for the male students and 15.3 years for the female students. Compared to a 1996 study, the average age at first sex for the students in this study was relatively younger. The average ages for first having sex in the 1996 study were 16.76 years for the male students and 17.22 years for the female students (MOHSW & UNFPA, 1996, p. 18). It is difficult to explain why these averages might be so different. Maybe, the relatively younger age for first having sex is related to specific population characteristics in this study. By chance, all three selected schools were on the outskirts of the city where families with lower education level and lower incomes tend to live. However, the 1996 study shows a demographic picture similar to this study. It is unlikely that the average age of first sexual intercourse would have declined so dramatically in six years. It would be important to further investigate this discrepancy. 60

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Our study found that 36.5%, of the sexp.ally active participants reported having had 3 or more partners. With advancing_grade levels, the mean number of sexual partners increased. No data from other studies were available for comparison. Although the law prohibits alcohol use by minors under 18 years of age, alcohol use is high among Mongolian teenagers. A 1998 Assessment on Alcoholism in Mongolia found that 51.2% ofthe entire population regularly drank alcohol and were involved in various law violations. Seventy-one percent of adolescents under age 20 and 54.7% under 16 tried to use alcohol during their life (not regularly). Reasons for high rates of alcohol use include growing unemployment and poverty, the widening gap between the rich and the poor, and declining standards ofliving among the population in general (WHO, 2003, p. 17). The Adolescents' Needs Assessment (2000) survey found that the average starting age for drinking alcohol among respondents was 17.6 years for both urban and rural areas. However, urban adolescents drank twice as much alcohol as rural adolescents (WHO, 2003, p. 17). In this study, 44.2% reported that they usually or sometimes drank alcohol before sexual intercourse. According to a 2002 study, conducted by the National Statistical Office, 44.2%, ofthe participants (about 3600 41h to 101h graders and 400 young people not in school from both rural and urban areas) reported that they used alcohol, but this study did not explore a relationship between sexual intercourse and alcohol use (National Statistical Office of Mongolia, 2002, p. 28). In addition, another study conducted by the Adolescent Reproductive Health Project (Adolescent Reproductive Health 61

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Project, 2002, p. 34) indicated that with ages, alcohol use and sexual intercourse increased. According to the most recent data from WHO, 2.2-2.3% of adolescents use drugs of some kind, including pain-relieving drugs. The younger ones mostly sniff petrol, polish or glue, and 10.1% of 17-20 year olds have tried drugs. There is little information about injectable drugs, but there is no evidence that they are a problem among adolescents (WHO, 2003, p. 17) A 2002 study found that 0.5% of the participants (about 3600 4th to 1oth graders and 400 young people not in school from both rural and urban areas) reported using opium and 2.3% said they used pain relievers. Another 5.9% reported that they inhaled polish, glue, or perfume (National Statistical Office of Mongolia, 2002, p. 29-30). However, in the current study, 31.6% of those who were sexually active reported that they usually or sometimes used drugs before sexual intercourse. This number is surprisingly high and unexpected, in light of the small number of students who report using drugs in other studies. Nevertheless, for other studies, not only sexually active participants but also not sexually active participants reported about their drug use. For the current study, it was possible that the participants thought that tobacco and alcohol were drugs. Maybe, we should have said "illegal drugs" in the question to make it more clear. The number of students who used drugs before sexual intercourse increased dramatically with advancing grade levels. Unfortunately, in our survey, we only 62

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asked about using drugs before sexual intercourse, so we are unable to tell about drug use in general. It is important to note that all those youth who reported using drugs before sex also said they used alcohol sometimes or usually before sex. Further research is needed on teenagers' drug use in general, especially teenagers' knowledge about drugs, what kinds of drugs are available for them, accesses to drugs, and the factors that influence teenagers' drug use. Research on American teens indicates that youths who participate in one risk behavior often participate in multiple risky behaviors (DiClemente, Havsen, & Ponton, 1996, p. 3). More research is needed to see if risk behavior clustering is evident among Mongolian teenagers also. Although Mongolian teenagers have relatively unrestricted access to condoms (free from family doctors and school doctors, free in adolescent clinics, and they can buy one at a time from pharmacies), teens report inconsistent and infrequent condom use. In the current study, just over one-third (36.8%) of sexually active students reported that they always used a condom. Fifty-three percent reported that they or their partners did not use a condom when they had sexual intercourse the last time. A similar finding was found in a 1999 study. One-third ofthe sexually active participants said that they did not use a condom when they had sexual intercourse the last time because they never thought about the risk of getting an STD (Adolescent Reproductive Health Project, 2002, p. 49). 63

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The participants want more information about STDs other than AIDS. The vast majority (71.1%) of participants wanted more information about STDs. This finding is corroborated by several previous studies (Adolescent Reproductive Health Project, 2002, p. 48 & MOHSW & UNFPA, 1996, p. 37). It is very important to note that compared to the 9th and lOth graders (80.2% and 70.5%), fewer 8th graders (63.9%) reported that they wanted more information about STDs other than AIDS. Maybe, this is related to their lack of knowledge, so they do not know what information they need. The most frequently reported sources of information on STDs other than AIDS are friends and media (television, newspapers, and/or magazines). According to two previous studies (Adolescent Reproductive Health Project, 2002, p. 48 & MOHSW & UNFPA, 1996, p. 38), these sources ofinformation on sexuality and reproductive health are common among the Mongolian teenagers. Thus, this finding suggests that television programming and printed materials may be used to positively influence teenagers' knowledge, attitudes, and their sexual behaviors. In addition, only 7% of the participants reported that they got some information about STDs from their parents and relatives. However, when participants were asked who they would go to first ifthey thought they had an STD, 29% chose parents as potential intimate helper (parents were selected as the second most likely potential intimate helper among the participants). The above two percentages (7% and 29%) 64

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are relatively low, but there is a hope that the number of teenagers who want to discuss with their parents sexuality topics, such as STDs will increase further. Also, our study found that teenagers would seek help for an STD from medical doctors and other professionals at public and private clinics, as well as from parents and peers. However, the percentages are relatively low (less than 30%) for each category. These findings are similar to those in previous studies that found that teenagers intended to seek help for reproductive health problems from medical doctors (34.9%), peers (33.3%), and mothers (27.9%) (MOHSW & UNFPA, 1996, p. 21 ). With increasing grade levels, the proportion of students who trusted medical doctors and other professionals of private clinics increased. In contrast, the percentage of students who trusted their parents decreased. Developmentally, this makes sense because as teens, they want to become more independent and they are concerned about their privacy. Students in higher graders preferred private clinics perhaps because private clinics do not require personal information. Today, many teenagers and their parents do not feel comfortable discussing sexuality because for long time discussing sexuality was a taboo in Mongolia. However, our study showed that parents would be the second intimate helper for teenagers to seek help for an STD. Consequently, it seems advisable to put greater investment into providing parents with accurate information about sexuality and STDs since they never had sexuality education in their schools. Parents may be able to make a valuable 65

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contribution through talking with their teens about sexuality, but only if. they know as much or more about sexuality as their teenagers. Furthermore, the findings from our study suggest that training peer educators might be a good way for teenagers to get accurate information about STDs. The STD education part of the health class curriculum in schools is unsatisfactory. Although only schools with sexuality education were selected to participate in this study only 60.5% of the participants reported that they had sexuality education in their schools. According to the health class curriculum, all grades should not have learned something about STDs other than AIDS in the previous school year (see Appendix C); however, 22.7% of the gth graders, a half of the 91 h graders, and 41.8% of the 1 01h graders respectively reported that they had been taught about STDs already. The study revealed that students in higher grades reported having sexuality education in their schools and having been taught about STDs other than AIDS more often than those in 81h grade which would be expected. Similar findings were found in a 1999 study conducted by the UNFPA, the MOHSW, the MOSTEC, and other international organizations; 50% of the participants attending schools that provided sexuality education did not report having any sexuality education in their schools (Adolescent Reproductive Health Project, 2002, p. 9). 66

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Limitations Limitations existed in this study that could bias the results. First, the study was conducted at the beginning of the 2003-2004 school year. Ifthe study were conducted at the end of school year, the findings would be different. Students from all grades would have more knowledge about STDs other than AIDS at the end of school year. For example, the knowledge demonstrator by the 9th grade students in this study actually reflected what they learned in gth grade or before. This would be similar for all 3 grades. On the other hand, it is difficult to understand because another factor is that only outstanding students continue their education beyond gth grade. Thus, in order to assess real knowledge, the sample should have included other youth who did not continue their studies beyond gth grade. Because of limited time and financial difficulties, this study did not include this population. Second, although sample size was large in this study the subjects were selected from only the 12 schools that offered the health class in the first semester. Also, by chance, all three selected schools were on the outskirts of the city where families with lower educational level and lower incomes tend to live. Thus, the results ofthe study can not be generalized to all Mongolian 81h, 91h, and 101h grades teenagers. 67

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Third, this study included only students who were in school. Further research is needed on out-of-school students who did not study beyond 81 h grade. Fourth, due to the sensitive nature of the survey, some students may have answered some questions in a socially desirable manner. The investigator tried to minimize these threats to internal validity by promising to maintain respondent confidentiality, by collecting no identifying information, by having surveys completed without any teachers in the classroom, and by giving students extra paper to hide their answers. Fifth, although the survey format was necessary for assessing knowledge, attitudes, and behaviors from a large sample, the closed-answer-format did not allow for the collection of additional explanatory information from students. Thus, teenagers' knowledge and attitudes about STDs other than AIDS and their sexual behaviors may not have been fully addressed or investigated. Finally, there is no standard test to assess teenagers' knowledge about STDs other than AIDS, so the responses ofthese teens can not be compared to the response of other groups of teens. Conclusion Mongolia is a landlocked country in northeast Asia and has the total population of 2.4 million. Twentyfive percent are adolescents aged 10 to 19. Mongolia was a part ofthe socialist system. By the late 1980s the socialist system 68

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collapsed and Mongolia has been experiencing changes in its political, economic, social, and cultural structures. One of the changes has been a dramatic increase in sexual activity among adolescents, which has led to increased numbers of STDs in this population. Since sexuality education is new in Mongolia, very little information is available about teenagers' sexuality, especially teenagers' sexual behaviors and their knowledge and attitudes about STDs other than AIDS. Thus, it was important to address this issue, especially looking at those students who continue their education beyond gth grade and those who do not. Because different sexuality education curriculums are offered in gth, gth, and lOth grades and only lOth grade students learn about STDs in school. This study included 342 eighth, ninth, and tenth grade students selected from three urban schools in the capital city, Ulaanbaatar, Mongolia. The study described their sexual risk behaviors, measured their knowledge, and identified their attitudes about STDs other than AIDS. This study indicated that overall, the participants' knowledge about STDs other than AIDS was poor and students who were in higher graders or had more sexuality education in schools were more knowledgeable. The vast majority of participants believed that STDs are a big problem in their community. Moreover, the majority had "traditional" beliefs about having sexual relationships believing they should wait until marriage and knowing a person very well to have sex. The study showed that with increasing grade levels, the number of students who were 69

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concerned about STDs and had "traditional" beliefs about having sexual relationships increased. A minority of participants (mostly students in higher grades) engaged in sexual behaviors that put them at high risks for STDs, such as having 3 or more sexual partners, using alcohol and drugs before sexual intercourse, and not using a condom regularly. All grades (8th, gth, and 1 01h) are an important period for sexuality education because teenagers become increasingly sexually active at these ages. Thus, they all have high risks for STDs. This study suggests that adolescents' acquired knowledge about STDs other than AIDS from sexuality education and other sources is unsatisfactory. Thus, it is necessary to look the health class curriculums for all grades (8th, gt\ and lOth) and perhaps, make revisions. As a result of these changes, perhaps, increasing the amount learned about STDs in 8th grade before 40% of Mongolian teenagers complete their education. The findings will be very helpful for other sources of information, for example what kinds of information should be covered about STDs other than AIDS in TV programs and printed materials for teenagers. Also, the findings might be important to school teachers because they have a clue about what their teenagers really know about STDs. Finally, as a result of these, we can prevent teenagers from STDs and decrease the number of STDs in this population. More research is needed on the full range ofteenagers' risk behaviors and how those might be changing. Also, it would be important to study the 70

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implementation of the sexuality education presented in the health class to understand what teachers are teaching exactly for each grade level about STDs and why all students do not recall learning about STDs in school. 71

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Appendix A-Human Subjects Research Committee at the University of Colorado at Denver Approval University of Colorado at Denver HUMAN SUBJECT RESEARCH COMMITTEE University of Colorado at Denver Campus Box 129, P.O. Box 173364 Denver, CO 80217-3364 DATE: TO: FROM: SUBJECT: MEMORANDUM July 28, 2003 Erdenechimeg Sereeter, MD Deborah Kellogg, HSRC Chair Human Subjects Research Protocol #988 Adolescent STDs Knowledge, Attitudes, and Behaviors Your protocol, with changes, has been approved as non-exempt. This approval is good for up to one year from this date. Your responsibilities as a researcher include: If you make changes to your research protoco 1 or design you should contact the HSRC. You are responsible for maintaining all documentation of consent. Unless specified differently in your protocol, all data and consents should be maintained for three years. If you should encounter adverse human subjects' issues, please contact us immediately. If your research continues beyond one year from the above date, contact the HSRC for an extension. The HSRC may audit your documents at any time. Good Luck with your research. 72

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Appendix B Survey Questionnaire Adolescent STD Knowledge, Attitudes, and Behaviors A survey of Mongolian adolescents' sexual risk behaviors and their knowledge and attitudes about sexually transmitted diseases (STDs) other than AIDS Thank you for agreeing to participate in this survey. This survey is about what you know and think about sexually transmitted diseases (STDs) other than AIDS. You will also be asked few questions about things you do that affect your health. In order for this survey to be helpful, it is important that you answer each question as thoughtfully and honestly as possible Do NOT write your name on this survey. The answers you give will be kept private and used only for this study. The information you give will be used to develop better sexuality education programs for young people like you. Completing the survey is voluntary. Your answers will not affect your grades and will be not reported to your parents. If you are not comfortable answering a question, just leave it blank. Be sure to read the instructions below before you begin to answer. Thank you very much for your help . i Instructions l.This is not a test, therefore, there is no penalty if you answer a question incorrectly. Consequently, please answer each question the best you can. 2. For some questions, you have several options and for some questions you do not. When you answer the questions, please read the notes. 3. Please use this kind of mark ( Male). Let's begin t/1e survey. The questions that ask about your background will only be used to describe tile types of students answering this survey. The information will not be used to identify you or your answers. 73

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1. Are you: o Female o Male 2. How old are you? o 14 years old or younger o 15 years old o 16 years old o 1 7 years old o 18 years old o 19 years old or older 3. What grade are you in currently? o 8th grade o 9th grade o 10th grade 4. If you are an gth grade student, are you planning to continue to 9th grade? o Yes o No o I do not know. 5. What were your grades like last year? o Mostly As o MostlyBs o MostlyCs o MostlyDs o Mostly Fs 6. What is the highest level of schooling your father completed? o Less than high school o Completed high school o Completed college o Completed university o I do not know. 74

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7. What is the highest level of schooling your mother completed? o Less than high school o Completed high school o Completed college o Completed university o I do not know. 8. What is your family's approximate monthly income? (by togrogs=it is the Mongolian banknote) o Up to 30,000 0 30,001-50,000 0 50,001-70,000 0 70,001-100,000 o 100,001 or more 9. Have you had sexuality education in school? o Yes o No 10. Have you ever been taught about sexually transmitted diseases (STDs) other than AIDS in school? o Yes o No o Not sure 75

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11. Where do you get information about STDs? (Check one option on each line) Sources Always Usually Sometimes Never 1. Radio 2. Television 3. Newspapers, magazines 4. Posters 5. Medical doctors and other medical professionals 6. Religious organizations 7. Teachers and school programs 8. Friends 9. Parents and relatives 10. Other sources please list ............. For the following questions JUST DO YOUR BEST. If you are uncertain, you also have the option of answering "I do not know". REMEMBER YOU HA VB TO THINK ABOUT ONLY OTHER STDs NOT AIDS. 12. Which of the following are the names of sexually transmitted diseases (STDs)? (You may check several options) o Pubic lice (crabs) o Cystitis o Candida (yeast) o Trichomoniasis o Syphilis o Appendicitis o Hemorrhoids o Chlamydia o Genital warts o Gonorrhea o Hepatitis o Herpes genitals o I do not know 76

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13. Which of the following are common symptoms of STDs? (You may check several options) o Painful urination o Weight loss or gain weight o Abnormal discharge from penis or vagina o Itching or burning in genitals o Bleeding hemorrhoids o Some blisters and sores appear o Frequent urination o Nausea and vomiting o Pelvic pain or pain in lower abdomen o Fever o I do not know. 14. Which of the following are common tests for revealing STDs? (You may check several options) o The blood test o X-ray o Swab tests o Urinary test o Microscope tests o I do not know. 15. What causes STDs? (You may check several options) o Bacteria o Viruses o Pubic lice (crabs) o All of the above. o I do not know. 77

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16. Do you need a doctor to treat when you get an STD? o Yes, I need medical professionals' help to treat an STD. o No, I can treat an STD myself. o Depends on the STD. o I do not know. (If you chose "No", you can skip question # 17). 17. If you believe that you need medical professionals' help to treat an STD, what are they going to do for you? o They can diagnose that I get an infection or not o They do some treatment that can only reduce symptoms o They do some treatment that can rid all infection off o I do not know 18. Can you avoid STDs? (If you chose "Yes", please answer question # 19 also, otherwise skip to question # 20) o Yes, I'm 100% sure I can. o Yes, I usually can. o No, it is not possible. o I do not know. 19. If you believe that you can avoid STDs, what should you do? (Here you may check several options) o A void kissing o Do not have sex. o Use a condom. o Do not have many partners. o Do not use drugs. o I do not know. The next 9 questions are YES or NO. If the statement is correct, put the mark (X) in the "Yes" box. If tile statement is not correct, put the mark (X) in the "No" box. You also have the option of answering "I do not know." 78

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Questions : )) :';\-<>ii( Yes' \c.I do 20. It is possible that if you are a virgin, you can get an STD the first time you have sex. 21. It is possible that you can get more than one SID at the same time. 22. Syphilis is usually checked for by a blood test. 23. Taking birth control pills is an effective way to avoid STDs. 24. Washing after intercourse is an effective way to avoid STDs. 25. Some SIDs usually will go away on their own. 26. Some STDs do not have any symptoms. 27. You can get most STDs from touching toilet seats, moist towels, or clothes. 28. You can tell by looking at and talking to a person if they have an STD. For the following questions, there are no right or wrong answers. Please give your opinion. Let's answer these questions. 29. STDs are big problems among teenagers. o I strongly agree (100%). o I agree. o I'm undecided or neutral. o I disagree. o I strongly disagree (100%). 79

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30. What is your opinion about the statement "Do not have sex until you are married. o I strongly agree (100%). o I agree. o I'm undecided or neutral. o I disagree. o I strongly disagree (100%). 31. What is your opinion about the statement "Do not have sex until you know a person very weD." o I strongly agree (1 00% ). o I agree. o I'm undecided or neutral. o I disagree. o I strongly disagree (100%). 32. How much do you worry that you might get an STD? o Generally, I worry a lot. o I worry when I have sex. o I worry when I have unprotected sex. o I never worry. o I do not know. 33. If you thought you had an STD, who would you go to first? (Please choose only one answer) o Parents o Relatives (for example, brothers and sisters) o Friends o Teachers o Medical doctors and other professionals of public clinics o Medical doctors and professionals of private clinics o Phannacists o Others please name .. .................................... 80

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34. Do you need more information about STDs? (lfyou answered "Yes", please answer question# 35) o Yes o No 0 35. What information would be helpful to you? (Please write your answer) ........................................................................................................ Please answer the following questions as honestly as possible. Remember, the answers you give are anonymous, will be kept private and will be used only for this study. 36. Have you ever had sexual intercourse? o Yes o No 37. How old were you when you had sexual intercourse for the first time? o 11 years old or younger o 12 years old o 13 years old o 14 years old o 15 years old o 16 years old o 17 years old o 18 years old or older o I have never had sexual intercourse. 81

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38. During your life, with bow many people have you had sexual intercourse? o 1 person o 2 people o 3 people o 4 people o 5 people o 6 or more people o I have never had sexual intercourse. 39. During the past 3 months, with bow many people have you bad sexual intercourse? o 1 person o 2 people o 3 people o 4 people o 5 people o 6 or more people o I have never had sexual intercourse. 40. How often do you drink alcohol before you have a sexual intercourse? o Always o Usually o Sometimes o Never o I have never had sexual intercourse. 41. Did you drink alcohol before you had sexual intercourse the last time? o Yes o No o I have never had sexual intercourse. 42. How often do you use drugs before you have a sexual intercourse? 82

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o Always o Usually o Sometimes o Never o I have never had sexual intercourse. 43. Did you use drugs before you had sexual intercourse the last time? o Yes o No o I have never had sexual intercourse. 44. When you have a sexual intercourse how often do you use a condom? o Always o Usually o Sometimes o Never o I have never had sexual intercourse. 45. The last time you had sexual intercourse, did you or your partner use a condom? o Yes o No o I have never had sexual intercourse. 46. If you unexpectly meet a nice guy or girl at a party, would you agree to have sex with that person? (You check several options) o Yes, if we were attracted to each other. o Maybe ifl had been drinking alcohol or using drugs. o I would never agree. o I do not know. Thank you for your participation. 83

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Appendix C Compulsory Sexual Health Education Topics in The Formal School Curriculum in Mongolia Grade (age) Topic Content 1 (7-8) No topics 2 (8-9) No topics 3 (9-10) Human development Anatomy and physiology Society and culture Gender roles 4 (10-11) Human development Physical and emotional changes in puberty Menstruation Wet dreams Relationships Feelings 5 (11-12) Hwnan development Self-esteem Relationships Friendships Personal skills Peer pressure and decision-making 6 (12-13) Personal skills Communication: Basics Assertive communication Values Society and culture Society and messages about sexuality 84

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Grade (age) Topic Content 7 (13-14) Sexual health Rape Date rape Relationships Love Personal skills Communication and consent Managing stress Society and culture Diversity 8 (14-15) Human development Anatomy and physiology Conception and pregnancy Sexual behavior Abstinence Sexual health Condoms Contraception and other methods Testicular and breast-self-examination 9 (15-16) Human development Sexual identity and orientation Sexual behavior Sexual relationships and behavior Sexual health Risk assessment Safer sex and alcohol Personal skills Communication about safer sex and condoms use Refusal skills 10 (16-17) Human development Prenatal care and childbirth Sexual behavior Sexuality through the lifecycle Sexual health STDs and HIV/AIDS consequences STD prevention Relationships Marriage commitments and raising children Personal skills Goal setting 85

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Appendix D Glossary of Acronyms AIDS ................................................. Acquired Immunodeficiency Syndrome ANOVA ................................................................... Analysis of Variance HIV ........................................................... Human Immunodeficiency Virus IIPV ..................................................................... Human Papilloma Virus MOHSW .............................................. Ministry ofHealth and Social Welfare MOSTEC ....................... Ministry of Science, Technology, Education, and Culture MSCI. ................................................... Margaret Sanger Center International NGO .......................................................... Non-Governmental Organization NRCFID ................................. National Research Center for Infectious Diseases NSOM ................................................ National Statistical Office ofMongolia STD .............................................................. Sexually Transmitted Disease UNFP A ....................................... United Nations Fund for Population Activities USA ................................................................... United States of America WHO ............................................................... World Health Organization 86

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Appendix E-Glossary of Mongolian Words Aimag .................. . ....... A geographical subdivision, a province state of Mongolia Tugrug ................................................................ The Mongolian banknote Uerkhelove ............................................. The newspaper name for adolescents Zorgaa ............................................................................... .. Number six 87

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REFERENCES Adolescent Reproductive Health Project. (2002) Reproductive health, sexuality: Knowledge, attitudes, and behaviors, 1999. Ulaanbaatar, Mongolia: ARHP, UNFP A, MOSTEC, MOHSW, & MSCI. Adolescent Reproductive Sexual Health. (n.d.). Adolescent reproductive health and sexuality in Mongolia. Accessed March 2003, from http://www.unescobkk.ondips/arh-web/news/newsfiles/arshmon.cfm. Alan Guttmacher Institute. (n.d.). Facts in brief-Teen sex and pregnancy. Accessed March 2004, from http://w\'\-w.agi-usa.org/pubs/fb teen sex.html. Asia & Pacific Regional Bureau for Education UNESCO Bangkok & United Nations Population Fund. (n.d.). Case studies: Mongolia. Accessed June 2003, from http://www.unescobkk.org/ips/arh-web/demographics/mongolia.cfm. Brown, E. J., Simpson, E. M. (2000). Comprehensive STD/HIV prevention education targeting adolescents: Review of an ethical dilemma and proposed ethical framework. Nursing Ethics, 7 (4), 339-349. Buckingham, R. W., & Derby, M.P. (1997) .I'm pregnant, Now what do I do?. NewYork: Prometheus Books. Colorado youth survey. (1998). Colorado Department ofHuman Services Alcohol & Drug Abuse Division. Daugirdas. J. (1991). Sexually transmitted diseases. Illinois: MedText, Inc. DiClemente, R. J., Havsen, W. B., & Ponton, L. E. (1996). Handbook of adolescent health risk behavior. New York: Plenum Press. Do you understand your teenager boy or girl? 2003) The Newspaper of Reproductive Health, 14, 2. 88

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