Authors
Abstract
Background: School‑based sex education has the potential to prevent unwanted
pregnancy and to promote positive sexual health at the individual, family and community
level. Objectives: To develop and validate a sexual health questionnaire to measure young
peoples’ sexual health knowledge and understanding (SHQ) in Nepalese secondary
school. Materials and Methods: Secondary school students (n = 259, male = 43.63%,
female = 56.37%) and local experts (n = 9, male = 90%, female = 10%) were participated
in this study. Evaluation processes were; content validity (>0.89), plausibility check (>95),
item‑total correlation (>0.3), factor loading (>0.4), principal component analysis (4 factors
Kaiser’s criterion), Chronbach’s alpha (>0.65), face validity and internal consistency using
test‑retest reliability (P > 0.05). Results: The principal component analysis revealed four factors
to be extracted; sexual health norms and beliefs, source of sexual health information, sexual
health knowledge and understanding, and level of sexual awareness. Kaiser‑Meyer‑Olkin (KMO)
measure of sampling adequacy demonstrated that the patterns of correlations are relatively
compact (>0.80). Chronbach’s alpha for each factors were above the cut‑off point (0.65). Face
validity indicated that the questions were clear to the majority of the respondent. Moreover, there
were no significant differences (P > 0.05) in the responses to the items at two time points at seven
weeks later. Conclusions: The finding suggests that SHQ is a valid and reliable instrument to
be used in schools to measure sexual health knowledge and understanding. Further analysis
such as structured equation modelling (SEM) and confirmatory factor analysis could make the
questionnaire more robust and applicable to the wider school population.
Keywords
1. Health Promotion Agency. Relationships and Sexuality Education
in Schools. Belfast: HPA; 2009.
2. World Health Organisation. The Sexual and Reproductive Health of
Younger Adolescents. Geneva: WHO; 2011.
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in adolescents. Int J Gynaecol Obstet 1998;63 Suppl 1:S157‑60.
4. Singh S, Darroch JE. Adolescent pregnancy and childbearing:
Levels and trends in developed countries. Fam Plann Perspect
2000;32:14‑23.
5. Wight D, Henderson M, Raab G, Abraham C, Buston K, Scott S, et al.
Extent of regretted sexual intercourse among young teenagers in
Scotland: A cross sectional survey. BMJ 2000;320:1243‑4.
6. World Health Organisation. The Second Decade: Improving
Adolescent Health and Development. Geneva: WHO; 1998.
7. Frost JJ, Forrest JD. Understanding the impact of effective
teenage pregnancy prevention programs. Fam Plann Perspect
1995;27:188‑95.
8. Hughes J, McCauley AP. Improving the fit: Adolescents’ needs and
future programs for sexual and reproductive health in developing
countries. Stud Fam Plann 1998;29:233‑45.
9. Oakley A, Fullerton D, Holland J. Behavioural interventions for HIV/
AIDS prevention. AIDS 1995;9:479‑86.
10. NIMH. National Institutes of Mental Health: Methodological
Overview of a Multisite HIV Prevention Trial for Populations at Risk
for HIV/AIDS. London: NIMH; 1997.
11. Pradhan A, Strachan M. Adolescent’s Reproductive Health in Nepal:
Status, Policies, Programs and Issues. Washington, DC: Policy
Project; 2003.
12. Health Development Agency. Teenage Pregnancy: An Overview of
the Research Evidence; 2004. Available from: http://www.nice.org.
uk/niceMedia/documents/teenpreg_evidence_overview.pdf. [Last
accessed on 2011 Nov 14].
13. Acharya DR, Van Teijlingen ER, Simkhada P. Opportunities and
challenges in school‑based sex and sexual health education in
Nepal. Kathmandu Univ Med J (KUMJ) 2009;7:445‑53.
14. Harden A, Brunton G, Fletcher A, Oakley A, Burchett H, Backhans M.
Young People, Pregnancy and Social Exclusion: A Systematic
Synthesis of Research Evidence to Identify Effective, Appropriate
and Promising Approaches for Prevention and Support. London:
Institute of Education; 2006.
15. Oakley A, Fullerton D, Holland J, Arnold S, France‑Dawson M,
Kelley P, et al. Sexual health education interventions for young
people: A methodological review. BMJ 1995;310:158‑62.
16. Mellanby AR, Newcombe RG, Rees J, Tripp JH. A comparative
study of peer‑led and adult‑led school sex education. Health Educ
Res 2001;16:481‑92.
17. Ministry of Health. National Adolescent Health and Development
Strategy. Kathmandu: Department of Health Service; 2000.
18. Stone N, Ingham R, Simkhada P. Knowledge of sexual health
issues among unmarried young people in Nepal. Asia Pac Popul J
2003;18:33‑54.
19. Regmi P, Simkhada P, Van Teijlingen ER. Sexual and reproductive
health status among young peoples in Nepal: Opportunities
and barriers for sexual health education and services utilization.
Kathmandu Univ Med J (KUMJ) 2008;6:248‑56.
20. BVTS. Bradford Vocational Training Scheme: Teenage Knowledge
of Contraception and Sexual Health: Questionnaire Study in West
Yorkshire. Bradford: BVTS; 2002.
21. BUPA. Bupa Well‑being Check (Sexual Health). London: BUPA,
Bupa Occupational Health Limited; 2008.
22. Stephenson JM, Strange V, Forrest S, Oakley A, Copas A,
Allen E, et al. Pupil‑led sex education in England (RIPPLE study):
Cluster‑randomised intervention trial. Lancet 2004;364:338‑46.
23. Polit DF, Beck CT, Hungler BP. Essentials of Nursing Research:
Methods, Appraisal and Utilization. 5th ed. Philadelphia: Williams &
Wilkins; 2011.
24. Baker TL. Doing Social Research. 2nd ed. New York: McGraw‑Hill
Inc.; 1994.
25. Corbetta P. Social Research: Theory, Methods and Techniques.
London: Sage; 2003.
26. Mason DJ, Zuercher SL. Pilot studies in clinical nursing research.
J N Y State Nurses Assoc 1995;26:11‑3.
27. Peat J, Mellis C, Williams K. Health Science Research: A Handbook
of Quantitative Methods. London: Sage Publications; 2002.
28. Ahmed N, Flisher AJ, Mathews C, Mukoma W, Jansen S. HIV
education in South African schools: The dilemma and conflicts of
educators. Scand J Public Health 2009;37 Suppl 2:48‑54.
29. John C. Sexual and Reproductive Health of Adolescents; Asking
Young People about Sexual and Reproductive Behaviors; 2012.
Available from: http://www.who.int/reproductivehealth/topics/
adolescence/questionnaire.pdf. [Last accessed on 2012 Feb 18].
30. Komorita SS. Attitude content, intensity, and the neutral point on
a Likert scale. J Soc Psychol 1963;61:327‑34.
31. Garland R. The Mid‑point on a Rating Scale: Is It Desirable? Mark
Bull 1991;2:66‑70. Available from: http://www.marketing‑bulletin.
massey.ac.nz/V2/MB_V2_N3_Garland.pdf. [Last accessed on
2011 Aug 22].
32. Lynn MR. Determination and quantification of content validity. Nurs
Res 1986;35:382‑5.
33. DeVon HA, Block ME, Moyle‑Wright P, Ernst DM, Hayden SJ,
Lazzara DJ, et al. A psychometric toolbox for testing validity and
reliability. J Nurs Scholarsh 2007;39:155‑64.
34. Wildt AR, Mazis MB. Determinants of scale response: Label versus
position. J Mark Res 1978;15:261‑7.
35. Trochim WM. The Research Methods Knowledge Base. Cincinnati:
Atomic Dog; 2001.
36. Nunnally JC, Bernstein IH. Psychometric Theory. New York: Sage
Publications; 1994.
37. Kane M. Current concerns in validity theory. J Educ Meas
2001;38:319‑42.
38. Guadagnoli E, Velicer WF. Relation of sample size to the stability of
component patterns. Psychol Bull 1988;103:265‑75.
39. MacCallum RC, Widaman KF, Zhang S, Sehee H. Sample size in
factor analysis. Psychol Methods 1999;4:84‑99.
40. Kaiser H. An index of factorial simplicity. Psychometrika
1974;39:31‑6.
41. Cortina JM. What is coefficient alpha? An examination of theory
and applications. J Appl Psychol 1993;78:98‑104.
42. Haladyna T. Developing and Validating Multiple‑Choice Test Items.
New Jersey: Lawrence Erlbaum; 1999.
43. Linn R, Gronlund N. Measurement and Teaching in Assessment.
New Jersey: Prentice Hall; 2000.
44. Considine J, Botti M, Thomas S. Design, format, validity and
reliability of multiple choice questions for use in nursing research
and education. Collegian 2005;12:19‑24.
45. Siegel S. Non‑parametric Statistics for the Behavioral Sciences.
New York: McGraw‑Hill; 1956.
46. Field A. Discovering Statistics Using SPSS. London: Sage; 2005.
47. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the
validity of self‑reported health‑risk behavior among adolescents:
Evidence from the scientific literature. J Adolesc Health
2003;33:436‑57.
48. Alexander CS, Somerfield MR, Ensminger ME, Johnson KE, Kim YJ.
Consistency of adolescents’ self‑reports of sexual behavior in a
longitudinal study. J Youth Adolesc 1993;22:455‑71.
49. Winters KC, Stinchfield RD, Henly GA, Schwartz RH. Validity of
adolescent self‑report of alcohol and other drug involvement. Int J
Addict 1990;25:1379‑95.
50. Kröz M, Feder G, von Laue H, Zerm R, Reif M, Girke M, et al.
Validation of a questionnaire measuring the regulation of autonomic
function. BMC Complement Altern Med 2008;8:26.
51. Fenton KA, Johnson AM, McManus S, Erens B. Measuring sexual
behavior: Methodological challenges in survey research. Sex
Transm Infect 2001;77:84‑92.52. Blake SM, Sharp ES, Temoshok L, James R. Methodological
considerations in developing measures of HIV risk‑relevant behaviors
and attitudes: An empirical illustration. Psychol Health 1992;6:265‑80.
53. Coates RA, Soskolne CL, Calzavara L, Read SE, Fanning MM,
Shepherd FA, et al. The reliability of sexual histories in AIDS‑related
research: Evaluation of an interview‑administered questionnaire.
Can J Public Health 1986;77:343‑8.
54. Parsian N, Dunning T. Developing and validating a questionnaire
to measure spirituality: A psychometric process. Glob J Health Sci
2009;1:2‑11.
55. Ashcroft DM, Morecroft C, Parker D, Noyce PR. Safety culture
assessment in community pharmacy: Development, face validity,
and feasibility of the Manchester Patient Safety Assessment
Framework. Qual Saf Health Care 2005;14:417‑21.
in Schools. Belfast: HPA; 2009.
2. World Health Organisation. The Sexual and Reproductive Health of
Younger Adolescents. Geneva: WHO; 2011.
3. Saito MI. Sex education in school: Preventing unwanted pregnancy
in adolescents. Int J Gynaecol Obstet 1998;63 Suppl 1:S157‑60.
4. Singh S, Darroch JE. Adolescent pregnancy and childbearing:
Levels and trends in developed countries. Fam Plann Perspect
2000;32:14‑23.
5. Wight D, Henderson M, Raab G, Abraham C, Buston K, Scott S, et al.
Extent of regretted sexual intercourse among young teenagers in
Scotland: A cross sectional survey. BMJ 2000;320:1243‑4.
6. World Health Organisation. The Second Decade: Improving
Adolescent Health and Development. Geneva: WHO; 1998.
7. Frost JJ, Forrest JD. Understanding the impact of effective
teenage pregnancy prevention programs. Fam Plann Perspect
1995;27:188‑95.
8. Hughes J, McCauley AP. Improving the fit: Adolescents’ needs and
future programs for sexual and reproductive health in developing
countries. Stud Fam Plann 1998;29:233‑45.
9. Oakley A, Fullerton D, Holland J. Behavioural interventions for HIV/
AIDS prevention. AIDS 1995;9:479‑86.
10. NIMH. National Institutes of Mental Health: Methodological
Overview of a Multisite HIV Prevention Trial for Populations at Risk
for HIV/AIDS. London: NIMH; 1997.
11. Pradhan A, Strachan M. Adolescent’s Reproductive Health in Nepal:
Status, Policies, Programs and Issues. Washington, DC: Policy
Project; 2003.
12. Health Development Agency. Teenage Pregnancy: An Overview of
the Research Evidence; 2004. Available from: http://www.nice.org.
uk/niceMedia/documents/teenpreg_evidence_overview.pdf. [Last
accessed on 2011 Nov 14].
13. Acharya DR, Van Teijlingen ER, Simkhada P. Opportunities and
challenges in school‑based sex and sexual health education in
Nepal. Kathmandu Univ Med J (KUMJ) 2009;7:445‑53.
14. Harden A, Brunton G, Fletcher A, Oakley A, Burchett H, Backhans M.
Young People, Pregnancy and Social Exclusion: A Systematic
Synthesis of Research Evidence to Identify Effective, Appropriate
and Promising Approaches for Prevention and Support. London:
Institute of Education; 2006.
15. Oakley A, Fullerton D, Holland J, Arnold S, France‑Dawson M,
Kelley P, et al. Sexual health education interventions for young
people: A methodological review. BMJ 1995;310:158‑62.
16. Mellanby AR, Newcombe RG, Rees J, Tripp JH. A comparative
study of peer‑led and adult‑led school sex education. Health Educ
Res 2001;16:481‑92.
17. Ministry of Health. National Adolescent Health and Development
Strategy. Kathmandu: Department of Health Service; 2000.
18. Stone N, Ingham R, Simkhada P. Knowledge of sexual health
issues among unmarried young people in Nepal. Asia Pac Popul J
2003;18:33‑54.
19. Regmi P, Simkhada P, Van Teijlingen ER. Sexual and reproductive
health status among young peoples in Nepal: Opportunities
and barriers for sexual health education and services utilization.
Kathmandu Univ Med J (KUMJ) 2008;6:248‑56.
20. BVTS. Bradford Vocational Training Scheme: Teenage Knowledge
of Contraception and Sexual Health: Questionnaire Study in West
Yorkshire. Bradford: BVTS; 2002.
21. BUPA. Bupa Well‑being Check (Sexual Health). London: BUPA,
Bupa Occupational Health Limited; 2008.
22. Stephenson JM, Strange V, Forrest S, Oakley A, Copas A,
Allen E, et al. Pupil‑led sex education in England (RIPPLE study):
Cluster‑randomised intervention trial. Lancet 2004;364:338‑46.
23. Polit DF, Beck CT, Hungler BP. Essentials of Nursing Research:
Methods, Appraisal and Utilization. 5th ed. Philadelphia: Williams &
Wilkins; 2011.
24. Baker TL. Doing Social Research. 2nd ed. New York: McGraw‑Hill
Inc.; 1994.
25. Corbetta P. Social Research: Theory, Methods and Techniques.
London: Sage; 2003.
26. Mason DJ, Zuercher SL. Pilot studies in clinical nursing research.
J N Y State Nurses Assoc 1995;26:11‑3.
27. Peat J, Mellis C, Williams K. Health Science Research: A Handbook
of Quantitative Methods. London: Sage Publications; 2002.
28. Ahmed N, Flisher AJ, Mathews C, Mukoma W, Jansen S. HIV
education in South African schools: The dilemma and conflicts of
educators. Scand J Public Health 2009;37 Suppl 2:48‑54.
29. John C. Sexual and Reproductive Health of Adolescents; Asking
Young People about Sexual and Reproductive Behaviors; 2012.
Available from: http://www.who.int/reproductivehealth/topics/
adolescence/questionnaire.pdf. [Last accessed on 2012 Feb 18].
30. Komorita SS. Attitude content, intensity, and the neutral point on
a Likert scale. J Soc Psychol 1963;61:327‑34.
31. Garland R. The Mid‑point on a Rating Scale: Is It Desirable? Mark
Bull 1991;2:66‑70. Available from: http://www.marketing‑bulletin.
massey.ac.nz/V2/MB_V2_N3_Garland.pdf. [Last accessed on
2011 Aug 22].
32. Lynn MR. Determination and quantification of content validity. Nurs
Res 1986;35:382‑5.
33. DeVon HA, Block ME, Moyle‑Wright P, Ernst DM, Hayden SJ,
Lazzara DJ, et al. A psychometric toolbox for testing validity and
reliability. J Nurs Scholarsh 2007;39:155‑64.
34. Wildt AR, Mazis MB. Determinants of scale response: Label versus
position. J Mark Res 1978;15:261‑7.
35. Trochim WM. The Research Methods Knowledge Base. Cincinnati:
Atomic Dog; 2001.
36. Nunnally JC, Bernstein IH. Psychometric Theory. New York: Sage
Publications; 1994.
37. Kane M. Current concerns in validity theory. J Educ Meas
2001;38:319‑42.
38. Guadagnoli E, Velicer WF. Relation of sample size to the stability of
component patterns. Psychol Bull 1988;103:265‑75.
39. MacCallum RC, Widaman KF, Zhang S, Sehee H. Sample size in
factor analysis. Psychol Methods 1999;4:84‑99.
40. Kaiser H. An index of factorial simplicity. Psychometrika
1974;39:31‑6.
41. Cortina JM. What is coefficient alpha? An examination of theory
and applications. J Appl Psychol 1993;78:98‑104.
42. Haladyna T. Developing and Validating Multiple‑Choice Test Items.
New Jersey: Lawrence Erlbaum; 1999.
43. Linn R, Gronlund N. Measurement and Teaching in Assessment.
New Jersey: Prentice Hall; 2000.
44. Considine J, Botti M, Thomas S. Design, format, validity and
reliability of multiple choice questions for use in nursing research
and education. Collegian 2005;12:19‑24.
45. Siegel S. Non‑parametric Statistics for the Behavioral Sciences.
New York: McGraw‑Hill; 1956.
46. Field A. Discovering Statistics Using SPSS. London: Sage; 2005.
47. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the
validity of self‑reported health‑risk behavior among adolescents:
Evidence from the scientific literature. J Adolesc Health
2003;33:436‑57.
48. Alexander CS, Somerfield MR, Ensminger ME, Johnson KE, Kim YJ.
Consistency of adolescents’ self‑reports of sexual behavior in a
longitudinal study. J Youth Adolesc 1993;22:455‑71.
49. Winters KC, Stinchfield RD, Henly GA, Schwartz RH. Validity of
adolescent self‑report of alcohol and other drug involvement. Int J
Addict 1990;25:1379‑95.
50. Kröz M, Feder G, von Laue H, Zerm R, Reif M, Girke M, et al.
Validation of a questionnaire measuring the regulation of autonomic
function. BMC Complement Altern Med 2008;8:26.
51. Fenton KA, Johnson AM, McManus S, Erens B. Measuring sexual
behavior: Methodological challenges in survey research. Sex
Transm Infect 2001;77:84‑92.52. Blake SM, Sharp ES, Temoshok L, James R. Methodological
considerations in developing measures of HIV risk‑relevant behaviors
and attitudes: An empirical illustration. Psychol Health 1992;6:265‑80.
53. Coates RA, Soskolne CL, Calzavara L, Read SE, Fanning MM,
Shepherd FA, et al. The reliability of sexual histories in AIDS‑related
research: Evaluation of an interview‑administered questionnaire.
Can J Public Health 1986;77:343‑8.
54. Parsian N, Dunning T. Developing and validating a questionnaire
to measure spirituality: A psychometric process. Glob J Health Sci
2009;1:2‑11.
55. Ashcroft DM, Morecroft C, Parker D, Noyce PR. Safety culture
assessment in community pharmacy: Development, face validity,
and feasibility of the Manchester Patient Safety Assessment
Framework. Qual Saf Health Care 2005;14:417‑21.
)