Health-Related Counseling Needs in Adolescent Girls: A Qualitative Study

1. Background

After childhood, a completely different stage of life called “adolescence” begins (1). Adolescence is the most dynamic period in a human being’s development covering nearly all the second decade of life. Puberty, as a newly emerging phenomenon and a crucial stage of an adolescent’s life, is one of the most critical events in this period and is combined with rapid physical, sexual, cognitive, mental, and social changes (2). These changes bring about new needs in adolescents, and meeting those needs will consequently lead to better and faster adaptation (1). Adolescents become anxious and apprehensive because of sudden and rapid changes during puberty. An adolescent who is in a transitional stage from childhood to adulthood confronts various conflicts, which could lead to many physical, mental, and social problems and misbehavior (2).

According to the results of the 2006 national census in Iran, 25.1% of the total population is 11 - 14 years old and girls comprise 50% of this population (3). Adolescents, especially girls, are among the vulnerable groups of the community and their health-related needs are less considered (2). Considering the counseling needs and problems of teenage girls is an investment toward national development (3).

To the best of our knowledge, most of the literature on adolescent health-related issues has been written by adults, and there is a little information from adolescents themselves. So we can deepen our insights into adolescents’ problems and health counseling needs by declaring their own ideas and experiences. We found that there is not such a probing and qualitative approach in Iran, and particularly in Kerman.

2. Objectives

So, with respect to the large population of adolescents in Iran and the need to pay attention to their puberty, especially in girls, this study was designed to investigate adolescent girls’ own ideas about puberty and its problems to plan suitable interventions to help improve their health status.

3. Materials and Methods

This qualitative study was carried out in the southeastern part of Iran, Kerman, from February to June 2013. The inclusion criteria were 13 - 19-year-old girls who had experienced at least 3 menstrual cycles. The subjective sampling method was used. For ethical reasons, all participants were informed of the purpose and method of the study. The researchers assured participants about the confidentiality and anonymity of the study and the participants’ right to withdraw at any time during the study. Informed consent was obtained from participants and their parents. At first, demographic information was gathered, which including age, age at menarche, level of education, and parents’ jobs. The interviews began with semi-structured, in-depth general questions and then moved on to specific questions on various topics, in a location of their choosing (schools, universities, or their homes). Then, participants were asked to describe their opinions about the problems of puberty. Questions included the following:

- What do you know about puberty?

- What problems did you have in puberty?

- What caused these problems? Please explain them in more detail.

All interviews were recorded, transcribed word for word, and analyzed. The duration of interviews averaged 60 - 90 minutes. The content analysis method was simultaneously used to analyze the collected data. Sampling continued until data saturation, and 40 girls were ultimately included.

3.1. Data Credibility

The credibility of the research was examined by following performance to ensure rigor and trustworthiness. At first, primary codes were considered for the participants’ responses. For internal checks and to assess the accuracy of the coding process the interviews, codes, and derived categories were evaluated by research team members. Participants reviewed transcripts. In this step, more interview sessions were conducted to ensure the data’s accuracy; thus, the interviewer’s relationship with the participants improved. For external checks, experts reviewed the transcripts and findings to confirm the results.

3.2. Analysis

Content analysis was used to extract codes, categories, and themes. It was conducted as follows:

- First, all interviews were transcribed word for word.

- After reviewing the interview transcripts, the narratives were identified. After coding was completed, categories were formed.

- This process repeated several times. Finally, meaningful themes emerged.

4. Results

Participants’ numbers by age group were as follows: 13 years old (9), 15 years old (9), 16 years old (10), 17 years old (8), and 19 years old (4). Twenty-eight participants were guidance school students, eight were high school students, and four university students. Age at menarche ranged from 11 to 15 years, with a mean of 13.4 years. The counseling needs of adolescent girls were categorized in 33 codes, 10 groups and 3 main clusters (physical, psychological, and social). The sub-categories of physical problems included personal hygiene, reproductive health, nutrition, exercise and physical activity, and regular sleep. Psychological problems consisted of solitude and depression, shame and embarrassment, and mood swings. Social problems consisted of participating in groups and feeling independent. Each of these categories and sub-categories are presented with quotes from the participants as follows:

A) Physical problems:

1- Personal hygiene: most participants stated that during puberty they felt that they should shower constantly due to their bad body odor and needing to shave.

Quote: “It’s very bad. I should take a shower almost every day because of smelling bad. Indeed I should shave or use some other things. It’s a bad feeling.”

- Nineteen girls showered during their menstruation. The others thought it to be harmful. Unawareness was the root of this inaccurate belief in such girls. Fourteen girls had acquired this belief from their relatives such as their grandmothers.

- Most adolescent participants knew about facial pimples during puberty; however, they did not know how to treat them and tended to use rapidly acting medication.

Quote: “I asked my friends about acne treatment and I searched the internet. I bought some vegetable soap.”

2- Reproduction and its health: twenty-seven participants had enough information about menstruation, dysmenorrhea, and hygiene issues in this period. They mentioned using sanitary pads or clean cloths, a method of washing their genitalia, using warm towel or hot water bottles for dysmenorrhea, and avoiding foods that cause bloating during menstruation. These girls had obtained such information from their mothers, sisters, friends, or the internet.

Quote: “It’s painful. I use hot water bottles and my mother makes me home remedies.”

Thirteen participants had very little information about contraceptive devices. Nearly all participants had no information about sexually transmitted diseases and their prevention methods.

Quote: “What on earth is sexual disease?! Do you mean a disease specific to the female or male sex?”

Most of the participants were too shy and embarrassed to talk too much about sexual relationships or pregnancy.

- Only half of them knew about vaginal discharge, and the remaining girls did not have any information about vaginal infection, its symptoms, and complications. Most participants had negative feelings about menstruation and perceived it as something bad and disgusting.

Quote: “I don’t like menstruation. I’m not comfortable with it…at parties, on travel, even at school.”

3- Nutrition: we found a strong preference for fast foods, such as sandwiches and pizza, among the participants. Nine girls stated that their appetite had increased and that they ate more food, especially sweets, compared with the past. Considering that adolescents need more calcium, 16 girls stated that they did not like yogurt and milk because they experienced abdominal pain and sleepiness.

Fifteen girls consumed an adequate daily amount of vegetables (mostly in the form of salads) and fruits. The most frequent in-between meals that they ate were samosas, piroshkis, and potato chips. One of the girls said, “Cheese sandwiches are for children, not us!”

4- Exercise and physical activity: Three girls were interested in skating and skated in the park at least once a week. One girl was a member of her school’s volleyball team. In addition, two girls swam during the summer. Six participants stated that they only walked from home to school and considered that physical activity. The remaining participants used the school bus to go to school.

Quote: “We don’t have enough time to exercise and play sports.”

Quote: “Although it is advised to have physical activity, I think we are young and we will have time in future for it. I prefer to play on the computer.”

5- Regular sleep: twenty-eight participants mentioned that they had an average of less than 8 hours of sleep per night that was sometimes as little as 4 hours; this was usually attributed to studying, watching television, or working with the computer. Five girls said they compensated for the lost sleep in the afternoons.

Quote: “I can’t sleep easily. Maybe because of my late sleeping, during the day I am drowsy and tired.”

Quote: “Nowadays technology does not allow us to have enough rest. We enjoy new modern technology and it doesn’t matter that we have less sleep. I believe we will get used to it.”

B) Psychological problems:

1- Solitude: most participants said they preferred to be alone and thought solitude and withdrawal to be more comfortable. They did not like socializing, especially when their parents insisted on it and often perceived it as excruciating.

Quote: “Most of my hobbies at home involve studying, chatting, and watching TV. So I prefer to be alone in my room, but at school and parties, I go with my friends.”

2- Feeling ashamed and embarrassed: Eighteen girls mentioned that they were ashamed of their appearance and constantly wanted to look better. Their physical changes did not make them feel good; therefore, they did not like to be in a crowd, even if it was their family. They were especially embarrassed in the presence of their fathers and brothers.

Quote: “My face is full of pimples and freckles. I can’t wear tight clothes. I have become taller and my clothes become too short quickly. I hate myself and I am ashamed in front of others.”

3- Mood swings: sixteen girls had become irritable, and even the smallest thing would irritate them.

Quotes: “Sometimes I’m really fresh, while other times I can’t stand anybody. I become agitated and angry quickly and lose my temper.”

“I am constantly fighting with my older brother and we criticize each other.”

C) Social problems:

1- Participating in groups: most girls stated that they liked to socialize with their peers and dress and act like their friends. In fact, a group of friends consists of people with common interests.

Quote: My parents don’t let me choose my clothes. They criticize how I dress.”

We found that adolescents are faithful to their peer groups and are sensitive toward other people criticizing their group.

Quote: ”My mother criticizes one of my friends and says I should not see her; she’s a bad person. But you can’t judge people by their appearance.”

2- Independence: five girls regretted that they could not work in addition to studying and that they were financially dependent on their parents. They wanted their parents to have faith in them and give them some responsibilities in the family.

Sixteen participants felt that their home and family was not a safe place to be hopeful and eager to maintain and strengthen family ties and create a family in the future.

Quote: “I want to have a say in issues that are related to me and decide for myself…like what extracurricular lessons to take and at what time…. I want to choose my job in the future, not my family.”

5. Discussion

The viewpoints of adolescent girls in this study were very important in finding and assessing their counseling needs in puberty. Most of the participants had limited information about puberty changes. These changes may cause stress and confusion for them (4). A study in Oman showed that only half of 1,675 guidance school girls were aware of the bodily and sexual changes involved in puberty (5). A study in Tanzania also showed that adolescent girls had little information about menstruation, hygiene during this period, sexually transmitted diseases, and sexual hygiene (4). A study in the United States showed that those who had had been educated previously about pubertal changes coped with them better (6).

It seems that girls are not sufficiently comfortable to talk with their mothers about puberty problems. Studies have shown that embarrassment and a distant relationship between the mothers and daughters was a setback for talking about sexual issues, sexual relationships, contraceptive devices, and sexually transmitted diseases (7). Sexual issues, pregnancy, and contraceptives are shameful topics for adolescent girls to talk about, but the number of adolescents having sex during this developmental period is increasing (8). Sexual relationships are taboo in Islam, but this should not be a reason to fail to provide sex and STD education. Iranian cultural and religious backgrounds prevents open conversations about these issues, but religious beliefs play an important role in reducing high-risk sexual behaviors in Iranian adolescents (7).

Low physical activity accompanied by unsuitable nutrition and inadequate sleep creates an unhealthy lifestyle for adolescents. In a study done in Colombia, researchers found that only 19% of adolescents engaged in regular physical activity. Moreover, 50% of the adolescents stated that they played computer games or watched films and television more than three hours per day (9). Other researchers have found that adolescents’ duration of sleep was shorter than the adequate amount, which is dependent on factors such as watching television in the bedroom, receiving education from parents in this regard, etc. (10).

The tendency to eat fast food and the reduced use of dairy products by adolescents lead to worries about resulting problems in the future, such as osteoporosis and obesity. Mousa showed that nutritional problems in adolescents were caused when they compared themselves with their classmates and were discontent with their appearance, which in turn led to hyperphagia and, in most cases, hypophagia and strict and unsuitable diets (11).

In this study, most participants preferred to be alone and thought solitude and withdrawal to be more comfortable. Another study showed that the tendency to be alone is due to poor self-acceptance and self-confidence (12). However, one study in Italia found that if choosing solitude is related to social refusal, it is a risk for adolescents, but sometimes necessary for improving their psychological well-being. And this situation can be distinguished by adolescents themselves (13). Therefore, parents should be careful with adjustment difficulties in their teenagers because the tendency toward solitude is associated with anxiety, depression, and emotion dysregulation (14).

Almost half of the participants were ashamed of their appearance and physical changes that did not make them feel good about themselves. Sexual cause embarrassment in most cultures as well (11). Researchers found that physical appearance and psychological changes in teenage girls caused anxiety and shame (12). An awareness of physiologic changes can help adolescents and somehow prevent embarrassment. They need to know about normal changes. The best time for counseling and education is before the onset of menarche (10).

Irritability, nervousness, and anger are also important problems among adolescents. They cannot tolerate when others, especially their families, want to control them. Studies indicated that some of the hormones that increase during puberty may be associated with aggression, depression, irritability, nervousness, and anger in this period (15).

One of the most important counseling needs of adolescents is finding friends. The need for belonging attracts adolescents to peer groups. A study done in the United States showed that high-risk behavior in adolescents often took place when they were with peers rather than alone (16). Parents should encourage their adolescent children to have social gatherings at their own houses so they can meet their children’s friends (12).

Researchers have shown that adolescents were unhappy about restrictions created by their parents and their parents’ supervision of their relationship with friends, finding it disrespectful (17). Adolescents experience significant physical changes and therefore think that they know everything, and emotions and excitement overshadow their reason. They live in their fantasies and are highly interested in socializing with their peers to be able to accept familial and social responsibilities. According to Robbins and Bryan study, a positive attitude toward the future reduces the adolescents’ tendency to use drugs and alcohol and engage in high-risk sexual behavior (18). A tendency toward independence in adolescence is another cause for discord between parents and children.

5.1. Conclusions

Adolescence is an important period in which puberty takes place. Therefore, identifying the changes in this period and understanding adolescents’ counseling needs would greatly help them in successfully navigating this period of life. Adolescent girls in this study had little knowledge about puberty and the physiological changes of this period. Moreover, their parents did not know how to relate with them and meet their specific needs. Therefore, we suggest designing an educational and counseling program for adolescent girls and their parents.