School-Based Adolescent Reproductive Health Education in Afghanistan and other Muslim-majority Settings: A Systematic Review and Key Informant Interview Study of Knowledge, Attitudes and Barriers

Abstract

Importance: Poor access to, and knowledge of, reproductive health care in resource-limited, Muslim-majority settings is a significant barrier to economic development and women’s advancement. Objective: To explore (1) the state of young women’s knowledge of female sexual health; and (2) how best to increase women’s knowledge of their sexual health in Muslim-majority settings. Methods: Systematic Review: Systematic Search of EMBASE and MEDLINE for all articles published in English from January 1st 2002 to December 31st, 2016 that (1) surveyed adolescent women on knowledge and attitudes related to sexual and reproductive health in a Muslim-majority setting, or (2) presented an educational intervention for sexual and reproductive health for adolescent women in a Muslim-majority setting. Studies targeting adolescent or youth females in Muslim-majority settings were included. Studies targeting males, other age groups, non-Muslim majority environments, or specific populations such as postpartum women were excluded. Key Informant Interviews: Eleven semi-structured interviews were conducted with experts in women’s reproductive health in a Muslim-majority setting including public health officials, NGO leaders, medical providers, and health educators. Interviews covered topics including public knowledge and attitudes about reproductive health, school-based health education, and public initiatives to improve reproductive health knowledge. Informants were professionally fluent in English. Results: Systematic Review: Twenty-five studies surveyed adolescent females on sexual and reproductive health knowledge in Muslim-majority environments. Knowledge level was low across all surveyed topics, including understanding of reproductive anatomy, mechanism of pregnancy, and of sexually transmitted infections. In aggregate, 69.9% of students knew fecundity begins at menarche, but only 40% knew pregnancy could result from a single sexual encounter. Schools were rarely students’ primary source of accurate information. Nine studies reported on reproductive health interventions for adolescent girls in Muslim-majority environments. Seven successful interventions oriented around peer educators that could interact with students without the presence of an adult. Three unsuccessful programs aimed to deliver sexual health knowledge through adult teachers. Key Informant Interviews: Ten out of 11 experts felt sexual and reproductive health should be taught in schools in Muslim-majority settings. Experts differed widely in their opinions about which topics should be taught and the year in school to begin teaching. Four emergent themes summarized key issues associated with and barriers to school-based reproductive health education in Muslim-majority settings: quality of educators, cultural sensitivity, community buy-in, and bureaucratic barriers. Conclusions: Sexual and reproductive health knowledge among adolescent girls in Muslim-majority settings is low. Successful interventions to improve knowledge have utilized peer educators, whereas programs mediated by adult teachers alone have seen less success. Key informants feel schools are an under-utilized resource, and program success requires well-trained, highly motivated teachers delivering culturally-sensitive health information to youth with the support of communities.