Biosocial correlates of adolescent’s knowledge on pubertal changes in rural Bangladesh: A structural equation model

Background The present study aimed to identify factors that are associated with puberty knowledge among school-going rural adolescents in Bangladesh. Methods This cross-sectional study was conducted on 2724 school-going (grades VI-IX) adolescents who were aged between 10–24 years. The adolescents resided only in rural areas of Bangladesh. In this study, relationship between socio-demographic factors and controlling behaviour was assessed considering Bronfenbrenner’s bioecological model. Considering the complex nature of Bronfenbrenner’s bioecological model the structural equation model to explore factors related to the Adolescents’ knowledge of pubertal changes. Results The structural equation model result showed a significant association among gender, education, age, and parental limit setting on daily activities with student’s knowledge on pubertal changes. peer connection, and peer regulation were associated with adolescent knowledge on puberty directly as well as through the mediator variables year of schooling, academic performance and, parental behavioural control. Conclusion Adolescents Age, years of schooling, and teachers concerns are positively associated with adolescents’ knowledge on puberty. Whereas, parents’ and peers’ controlling behaviors are negatively associated with adolescents’ understanding of pubertal changes. Therefore, there is needed an effective plan to raise the attention of parents and teachers on adolescents’ pubertal issues to ensure adolescents’ informed pubertal period.


Introduction
Adolescence is the critical stage when an individual shifts from childhood to adulthood with accelerated hormonal, emotional, social, and physiological changes. The present study aimed to identify factors that are associated with puberty knowledge among school-going rural adolescents in Bangladesh.

Materials and Methods
This cross-sectional study was conducted on 2724 school-going (grades 6-9) adolescents aged 10-18 years who resided only in rural areas of Bangladesh. We applied the structural equation model to explore factors related to the knowledge of pubertal changes among rural adolescents in Bangladesh.

Results
Out of the 2724 adolescents, 51% were male and 49% were female in this analysis. The mean age of the adolescents and their years of schooling was 14.67 and 8.08 , respectively. The structural equation model result showed a significant association among gender ( p <0.001), education ( p <0.001), age ( p <0.001), and parental limit setting ( p <0.001) with student's knowledge on pubertal changes. From the result of the simultaneous equation model, sex, age, years of schooling, Academic performance, teacher concern were significant factors that directly influencing adolescent knowledge on puberty while mother having no education, parental limitsetting, peer connection, and peer regulation were influencing adolescent knowledge on puberty both direct and indirect ways. Conclusion This study provides insights into how school-based sexual health education can be made more effective to increase adolescent's knowledge about pubertal changes in rural Bangladesh.

Background
Adolescence is the critical stage when an individual shifts from childhood to adulthood with accelerated hormonal, emotional, social, and physiological changes. The present study aimed to identify factors that are associated with puberty knowledge among school-going rural adolescents in Bangladesh.

Methods
This cross-sectional study was conducted on 2724 school-going (grades 6-9) adolescents aged 10-18 years who resided only in rural areas of Bangladesh. We applied the structural equation model to explore factors related to the knowledge of pubertal changes among rural adolescents in Bangladesh.

Results
Out of the 2724 adolescents, 51% were male and 49% were female in this analysis. The mean age of the adolescents and their years of schooling was 14.67±1.32 and 8.08±1.02 , respectively. The structural equation model result showed a significant association among gender (p<0.001), education (p<0.001), age (p<0.001), and parental limit setting (p<0.001) with student's knowledge on pubertal changes. From the result of the simultaneous equation model, sex, age, years of schooling, Academic performance, teacher concern were significant factors that directly influencing adolescent knowledge on puberty while mother having no education, parental limit-setting, peer connection, and peer regulation were influencing adolescent knowledge on puberty both direct and indirect ways.

Conclusion
This study provides insights into how school-based sexual health education can be made more effective to increase adolescent's knowledge about pubertal changes in rural Bangladesh.

Introduction
Adolescence is the most complicated and complex period of life with rapid hormonal, emotional, biological, cognitive, and social transformations [1]. To make healthy adults from childhood, it is essential to have correct information about physical and psychological changes they will go through. This critical transition period of life span starts with the onset of puberty [2]. The onset of puberty causes physical and physiological, psychological, social, mental, cognitive, and behavioural changes [3,4]. The physical changes during puberty among girls are breast foliage, rapid height and weight rise, pubic and axillary hair development, and hip widening menstrual onset in girls [5][6][7][8]. Likewise, boys experience changes in tone, increase in shoulder width, night-time ejaculation, penis enlargement, axillary hair growth, boys' facial hair [9]. At the same time, adolescents go through a profound psychological transformation, and they experience a wide change in their self-image, attitude, relationship. Moreover, they also experience a sudden change in the social, academic, and other environmental influences [10]. Those multidimensional changes make them confused, insecure, and self-centred [11,12]. As a result, mental disorders, such as severe depression, anxiety disorders, eating disorders, and substance use disorders, can arise during puberty [13]. More than 50 percent of female adolescents had experienced moderate to severe stress due to changes in puberty [2].
If adolescent can recognize themselves and their body functioning during the adolescence period, they may experience a smooth pubertal period and establish a healthy attitude towards sex, marriage, parenthood, and family. Therefore, they need an explanation about the process of puberty that unfolds for everyone and what changes to expect. The lack of adequate knowledge and confusion about their own physical and/or sexual development (i.e., changes in growth) can expose problems for them [1]. Moreover, misconceptions, taboo and myths about sex, sexuality, reproduction, and contraception also deprived them of obtaining correct knowledge [14]. Thus, the fragile teenagers are getting more fragile along with their distinctive development stage.
Society is responsible for ensuring informed puberty so that adolescents can lead healthy, secure, productive, and enjoyable lives and protect themselves from reproductive health problems. But in the socio-cultural context, parents neglect their duty to pass health information to their children because of either shame or indifference or life obligations.
Ignoring their child's difficulty and discomfort in this process and putting their responsibility to guide their kids on the shoulders of teachers who may also overlook it [15]. In such instances, adolescents have no choice other than to go to their peers, siblings, and mass media. It might tend to inaccurate or insufficient knowledge and misconception of the condition [16]. In reality, these adolescents can create problems for themselves and their parents, putting their physical, emotional, and social well-being at stake [15].
Both the Government of Bangladesh (GOB) and NGOs have undertaken various activities at different times to alleviate the current disparity between the need and comprehension of adequate knowledge and awareness of puberty. Those activities are implemented under the adolescent sexual and reproductive health (ASRH) program initiatives.
There were 32 adolescent sexual and reproductive health awareness-raising and service delivery initiatives introduced in Bangladesh between 2005 and 2015 [17]. To make awareness raising program successful, it is essential to find out the factors that affect adolescent's knowledge of pubertal changes. No specific research has been done so far on how parents and our society hinder adolescent's knowledge of pubertal changes. However, to make the awareness-raising program effective, it is highly demanded to carry out an empirical study about how family and community level factors effects adolescent's knowledge of pubertal changes.
Therefore, in the situation of minimal evidence, this study set out to add empirical evidence effect of socio-demographic factors and controlling behaviour of our society on adolescent's knowledge of pubertal changes.

Conceptual Framework
In this study, the effect of socio-demographic factors and controlling behaviour was assessed considering Bronfenbrenner's bioecological model [10,18]  The survey consisted of two modules of data set named household module and a school module of data sets. Finally, two data modules were merged for analysis. The survey used a three-stage stratified sampling procedure to collect information for school-going students of grade VI to IX. A total of 3000 adolescents aged 10-24 were identified from the selected areas.
In the survey, 3014 adolescents were successfully interviewed in rural areas of Bangladesh, with 1504 adolescents were in the household module and 1509 adolescents were in the school module. After deleting the missing and incomplete cases, there were 2724 cases used for the final analysis.

Ethical Consideration
All participants of this study were informed before data collection about the purpose of the study. Verbal consent was taken from the headmasters of all secondary schools and students before data collection. Participant anonymity and confidentiality of data were ensured, and then participants were provided with information about the nature and purpose of the study, the procedure, and the right to withdraw their data from the study. The study protocol was taken from the Jagannath University, Bangladesh institutional ethical committee (JEC) (Under the project number 37.20.0000.004.033.020.2016.7725).

Outcome Variable
The outcome variable was knowledge of pubertal changes. To assess adolescent's knowledge regarding pubertal changes, students asked about the physical, mental, and behavioural changes during puberty. The number of changes they can correctly identify, which is described on the national curriculum, is marked as the score of their knowledge regarding the pubertal changes.
The maximum and minimum scores of knowledges on pubertal changes could be 18 and 1, respectively.

Socio-demographic determinants
Independent variables were year of schooling, age, sex (male and female), religion (Islam and others), Father's education (no education, primary, secondary and higher) and Mother's education (no education, primary, secondary and higher).

Contextual Factors
These contextual factors were measured by utilizing the method from Amoateng and Kalule-Sabiti [19].

Community Disorganization (CD).
The mean score of five questions related to how often they are disrupted in the community is used to assess the community's disorganization.
The questions are-"How often do you see the litter or trash on the sidewalks and streets?", "How often do you see graffiti on building walls?", "How often you do you see alcoholics or drug sales?", "How often you become afraid or worried when you are walking through the empty place?", "How frequently burglary happened?". The responses range from 1 to 3. 1 stands for "Often", 2 for "Sometimes" and 3 for "Never".

Community Psychological control (CPC). The average response of three five-point
Likert scale questions is used as community psychological control. The problems are related to is your neighbours always watch what you are doing, interfere with what you are doing, and is noisy.

Peer Connection (PeC). The average values of three questions on when and how
respondents communicate the friend via 'phone conversation' 'go over to one another residences' and 'go together for a movie/skating/shopping/sports event' is evaluated as connection with friends. The answers are coded as 'never', 'once a month', 'once per week', and 'many times a week or every day'.

Peer Psychological control (PePC).
Psychological control of peers is quantified by the mean score of the answers to three questions on how often their peers disagree with you, how often they make you feel that your ideas are not as good as theirs,' humiliate or bug you' and 'drag you down.' The answers are coded as:' hardly ever,' once every month,' once per week,' a couple of times in a week ', and "every day.

Peer regulation (PeR). Friend's regulation focuses on friends' influence in complying
with laws and regulations. It is measured as the mean of two questions about how often the friend "supports you do whatever is correct" and "motivates you to abide by the rules. 'Never', 'once a month', 'once a week', 'a few times a week and every day' are the replies.
Teacher's concern (TC). The teacher's concern demonstrates teachers' supportive, friendly relationship with students that supports student's academic well-being. To measure teacher concern, four questions asked about teachers' willingness to assist them with schoolwork and solve personal problems. The average of responses is used as a measure of teacher's concern.

Student's Academic Performance (SAP). Academic success is assessed on an ordinary
scale by a single question:' In general, how well are you doing in school? The replies are: 1 'way above average', 2 'a little above average', 3 'average', 4 'at just below average' and 5 'far below average'.

Statistical Analysis
Simple descriptive analysis and multivariate statistical analysis were performed in this study.
The socio-demographic characteristics were presented by frequency and percentage distribution. At the same time, median with maximum and minimum value was used to describe the general information of contextual factors. The generalized structural equation model was also used to test the hypothetical causal path in which individual level, family level and community level variables affect adolescent's knowledge on pubertal changes. There was no latent variable included in the model. All the analysis was conducted using the software R version 3.6.0. A Simultaneous equation model was fitted using "lavaan" package [20].

Contextual Factors
Descriptive statistics of contextual factors (  Teacher's concern 4.00 1 5.00

Generalized structural Equation Model of Knowledge on Pubertal Changes
The

***EOS = Year of Schooling; ME = Mother's Education; FE = Father's Education
There  At the family level, the mother's education and parental limit-setting directly affected However, peer regulation (β = 0.134, p< 0.05) and teacher's concern (0.069, p< 0.05) produces positive impact on adolescent's knowledge on pubertal changes.

Discussion
The present study showed that adolescents' knowledge of pubertal changes is influenced significantly by various individual level, family level, and community-level factors. Sex, age, year of schooling, and academic performance were the individual level of factors that displayed a significant effect on adolescent's knowledge of pubertal changes. This current study revealed knowledge of pubertal changes positively influenced by age and years of schooling. A similar type of positive impact of age and year of schooling is also founded by Uddin and Choudhury [21]. An increase in the year of schooling increases knowledge more than the increase in age.
An interesting finding of our analysis showed that female adolescents had more knowledge than the male. In a previous study on young people of Bangladesh illustrate that male adolescent had poor knowledge than the female [22]. Separate studies from India on schoolgoing adolescents [23] and Portugal on college students [24] demonstrated that female adolescents had significantly higher knowledge than males. At the same time, religion plays an important role in the knowledge of pubertal changes. Muslim students had lower pubertal change knowledge than students of other religions. A previous study found that Hindu students had 1.76 times more likely to have better communication with mothers regarding SRH [5].
Among family-level factors, Mother's education shows a positive impact on adolescent's pubertal knowledge. These findings are also consistent with the study of Uddin and Choudhury [21] on adolescent girls in rural areas in Bangladesh and another study in India [5]. This is because daughters also have a trustworthy relationship with mother as a primary source of SRH information [5]. Though mothers are uncomfortable discussing SRH-related problems in our social structure, but educated mothers do not hesitate to talk about SRH issues [25]. While parents imposing limits on adolescents directly and indirectly reduce adolescents' pubertal knowledge. This finding depicts our country's tradition, where parents think that pubertal changes are a natural human development phenomenon that should need to remain secret [26]. However, parental behavioural control showed an indirect positive effect on adolescent's knowledge on pubertal changes. This indicates that parents by imposing restrictions on adolescents' behaviour increase their knowledge of pubertal changes through the mediating variable of year of schooling and academic performance.
Peers and community are two important social components that have a great impact on adolescent functioning. This study found that both peer connection reduces adolescents' pubertal knowledge. Despite being a major source of pubertal and reproductive health knowledge, peer connection reduces adolescent's pubertal knowledge. This contradiction supports the previous finding of Das and Roy that peer almost always supplies incomplete and fantasy-oriented sexual and reproductive knowledge [16]. This may be the reason why peer Among other school-level factors, students' academic performance negative impact on adolescent's knowledge on puberty. On the other hand, the teacher's concern demonstrates an overall positive impact on adolescent's pubertal knowledge. Though teacher concern's direct effect is positive, the indirect effect of teacher's concern is negative. This evidence coincided with other separate previous studies and observed that when teachers exhibit care towards students, it motivates them to learn and eliminate and correct disruptive behaviour [27,28].

Conclusion and Recommendations
In summary, we conclude that intervention, sex, years of schooling, age, parental limit-setting, peer concern, and peer regulation were the significant determinants on adolescent's knowledge of pubertal changes. The intervention that is provided sufficiently increased adolescent's knowledge on puberty. Based on this study it can be said that the content on Adolescent sexual and reproductive health of class 6 to 10 curricula, will enhance adolescent's knowledge significantly if intervention is provided. Therefore, based on the information that is obtained in this study it is recommended that intervention need to apply all over Bangladesh to make school-based sexual and reproductive health effects as well as to ensure adolescents safe and healthy sexual and reproductive health.