Knowledge and attitude regarding pubertal changes among adolescents of Eastern

Adolescence is one of the most charming and convoluted period in life span which brings childhood to adulthood. It is a period of biological, cognitive, and social transition of high magnitude and rapidity and is also associated with the onset or exacerbation of several health-related problems. A descriptive cross-sectional study was carried out in three different schools in Jhapa districts, Nepal in which 146 adolescents were included through a random sampling method. A structured questionnaire was used to collect data regarding attitudes toward Pubertal Changes which was analyzed and interpreted using SPSS version 16. The study along with the sociodemographic profile also enumerated the results of 37% strongly agreeing that pubertal changes are normal and more than half agreed that sex education is essential. Half of the participants agreed adolescents suffer from anxiety during this period and 59.6% agreed that adolescents should not be ashamed of the changes. The study revealed that 60.3% of the respondents had a favorable attitude and 39.7% had a moderately favorable attitude toward pubertal changes. Although a majority of the students had a good attitude, it can be further improved by conducting classes, and programs about menstruation, and pubertal changes, and encouraging the involvement of students in it. Parents, as well as students, can also be educated about pubertal changes through teachings and awareness programs in communities to increase positive attitudes.


Introduction
Adolescence is one of the most charming and convoluted periods in the life span which brings childhood to adulthood [1]. It is a period of biological, cognitive, and social transition of high magnitude and rapidity and is also associated with the onset or exacerbation of several health-related problems [2]. Adolescence consists of the period between puberty and adulthood. Puberty is a normal part of life and indicates the time in life when a boy or girl becomes sexually mature. It is a process that usually happens between ages 10 and 14 for girls and ages 12 and 16 for boys. Girls and boys experience different hormonal changes in their bodies during puberty. Hormonal changes lead to the onset of puberty characterized by rapid physical growth and development of secondary sexual characteristics [1,3].
The changes during puberty are not only physical, but also, physiological, psychological, social, emotional, cognitive, and behavioral [4]. Physiological changes include breast budding, rapid increase in height and weight, growth of pubic and axillary hair, widening of the hip, and the onset of menstruation in girls. Similarly, for boys, change in voice, increase in the width of the shoulders, nighttime ejaculation, enlargement of the penis, growth of axillary hair, and facial hair is seen [5]. Psychological changes in adolescents are uncertain in their emotional state and social changes include searching for identity and seeking for independence [6].
United Nations estimates more than 1.2 billion adolescents worldwide from the age group 10-19 years which indicates that roughly one in every six persons is an adolescent [7]. About 21% (6 million) of Nepal's 29.91 million population are adolescents aged 10-19 years [8]. India has the largest population of adolescents in the world being home to 253 million individuals aged 10-19 years [9]. Research from the past suggests due to rapid physical changes coupled with an inability to adapt can cause sudden changes in behavior and reactions toward other people and the environment. Physical and psychological changes during puberty contribute adolescents to suffering from anxiety, depression, substance use disorders, etc. Various studies done to assess awareness and attitude on pubertal changes among adolescents have shown average awareness and many adolescents in the study had unfavorable attitudes towards pubertal changes [10]. This shows that there is a need for attitude-promoting awareness programs regarding pubertal changes to help them prevent stress, anxiety, frustration, and depression associated with it.
To grow and develop in good health, adolescents need information, including age-appropriate comprehensive sexuality education; opportunities to develop life skills; health services that are acceptable, equitable, appropriate, and effective; and safe and supportive environments [7]. They also need opportunities to meaningfully participate in the design and delivery of interventions to improve and maintain their health. Expanding such opportunities is key to responding to adolescents' specific needs and rights. There are very few studies being conducted to assess the attitude of pubertal changes in Nepal and till time there is no recorded research in eastern Nepal on this subject. So, this study was designed to assess the attitude towards Pubertal changes among adolescents of Eastern Nepal. The findings of this study will provide baseline data on attitudes toward pubertal changes in adolescents and other related variables and also can suggest the regulatory bodies to organize and implement formal and informal programs regarding pubertal changes.

Material and methods
A descriptive cross-sectional study design was conducted on three different schools from eastern Nepal. The study was conducted among adolescents of age group (10)(11)(12)(13)(14)(15)(16) year studying in 6-10 grade. Students of grades 6-10 who were available at the time of data collection and willing to participate were included. The tools of data collection were structured questionnaires according to the objective of the study. The tool was divided into two parts: PART 1: Sociodemographic questionnaire and Part II: Attitude towards pubertal changes. These questionnaires were developed by reviewing related works of literature thoroughly and were validated before conducting the study. The sample size was calculated using the relation: n = (z)2 p ( 1 -p ) / d2 where n = sample size; z = level of confidence according to the standard normal distribution; p = estimated proportion of the population that presents the characteristic and d = tolerated margin of error [11,12]. The study was conducted only after approval from the Institutional Review Committee of Nagarik College of Health Science. (IRC/78-79/026) Formal permission was also taken from schools where the study was to be conducted. Confidentiality was maintained by securing all the information provided by the respondents and ensuring that the information of respondents was not disclosed to anyone outside the research team. The anonymity of the respondents was maintained by using code numbering in the questionnaire and not including identifier data like names that would link responses to specific individuals. The collected data were collected, coded, classified, and tabulated. The data was entered in SPSS v16 for analysis. The data analysis was done using descriptive statistics in terms of mean, percentage, frequency, and standard deviation. Out of 146 respondents, 51% were female and 49% were male with the mean age of respondents being 14 years. The majority followed the Hindu religion and were from a nuclear family. Regarding the source of information on every prospect, 67.8% of the respondents gathered information from social media as given in table 1.

Respondents Maturation History
The mean age for menarche and realization of secondary sexual characteristics of females was 12 years. Similarly, the mean age for the realization of secondary sexual characteristics of males was 12 years as given in table 2.  Similarly, 48.6% agreed primary and secondary characteristics develop during puberty. More than half (52.1) of respondents strongly agreed that pubertal changes occur earlier in females whereas 56.8% agreed that behavioral problem is seen during puberty as given in table 3.

Attitude towards Pubertal Changes
While 37% strongly agreed that pubertal changes are normal. More than half agreed that sex education is essential. 59.6% of respondents agreed menstruation is normal and 58.2% agreed that it is appropriate to talk about it. Similarly, 42.5% agreed on open discussion related to pubertal changes. Half of them agreed adolescents suffer from anxiety during this period. While 59.6% agreed that adolescents should not be ashamed of the changes. Meanwhile (67.1%) disagreed that changes during puberty are more than physical ag given in table 4. Changes during puberty are also psychological, social, and emotional.

Support System Regarding Pubertal Changes
Here, 63.7% agreed that it is appropriate to talk about pubertal changes to parents. While 56.2% agreed that educated parents provide information about pubertal changes whereas 67.1% agreed that peer influence helps deal with pubertal changes. However, 37% disagreed that schools should provide education, program related to pubertal changes as given in table 5. Half of the respondents agreed that elders should prove information regarding pubertal changes. Almost onefourth strongly disagreed that sociological factors also affect the coping mechanism.

Level of Attitude
Here, the level of attitude towards pubertal changes among adolescents is shown below. 60.3% of the respondents had favorable attitudes and 39.7% had moderately favorable attitudes toward pubertal changes as given in table 6. Mean± SD 67± 1.8

Discussion
The sociodemographic characteristics in the study represented the gross knowledge of the social prospectus where the respondents are living. The result characterized that the majority population was Hindu and came from a nuclear family.
The result also suggested that the majority of adolescents, (67.8%) gathered information from social media. Research has indicated both advantages and detriments of social media to the health of an adolescent. Besides several risks, healthy social media use can provide increased opportunities for collaboration, communication, self-esteem enhancement, health promotion, and access to vital health information [13]. So regulation of what an adolescent is perceiving from social media is now important for their self-wellbeing. Adolescents must be aware and educated about pubertal changes and empowering them to talk comfortably about such changes by more direct methods might be helpful to perceive knowledge so they don't have to rely on social media for the information.
The mean age for menarche and realization of secondary sexual characteristics of male and female respondents in this study was 12 years. More than half strongly agreed that puberty means the period during which adolescents reached sexual maturity. More than half agreed that sex education is essential. 59.6% of respondents agreed menstruation is normal and 58.2% agreed that it is appropriate to talk about it. A study conducted in the Indo -Bangladesh border of Darjeeling district, West Bengal, India to assess the knowledge regarding pubertal changes showed that out of 138 students, only 28.6% knew growth of pubic hair and 54.3% student faced difficulties related to the adolescent period [14]. However, in this study, the respondents were found to be knowledgeable on this aspect.
In this study, 63.7% agreed that it is appropriate to talk about pubertal changes to parents. 60.3% of the respondents had favorable attitudes and 39.7% had moderately favorable attitudes toward pubertal changes. 60.3 % of adolescents have shown favorable and 39.7 % of the adolescent have shown moderately favorable attitudes towards the pubertal changes which suggested a relatively better perception of adolescence. Similarly, a study conducted in Dhulikhel, Nepal also showed that 56.4% of respondents had positive attitudes toward pubertal changes [15]. A study conducted in Iran in 2019 has shown that the participants had a similar result of respondents having a good attitude towards the pubertal changes [16].
However, in a similar study conducted among adolescents in Bharatpur, Chitwan, 89% had an unfavorable attitude toward pubertal changes [5]. In another study, adolescents showed that 52% had a negative attitude toward it [11]. A descriptive study of the Ambala district showed a majority of pre-adolescent girls and boys (75%) had below-average knowledge regarding pubertal changes. The finding of the study revealed that pre-adolescent girls and boy's knowledge and attitude regarding pubertal changes were not adequate and favorable respectively [17]. This study suggested the regulatory to conduct an awareness regarding the changes and attitudes in adolescents via different means. Several studies conclude that there is a moderate level of knowledge and attitude towards pubertal changes and continuous training in secondary school is necessary to improve the knowledge and attitude [18]. A Quasi-experimental study was done to assess the effectiveness of a structured teaching program on knowledge and attitude regarding pubertal changes also showed that if the knowledge increased the attitude also improved [19].
Thus, educating adolescents via different means might help increase their knowledge regarding the changes in puberty and make them aware of the adventures and risks of the period. Studies have shown that there are still many misconceptions and misbeliefs regarding issues related to sexuality and adolescence, which should be tackled carefully by imparting formal puberty and sex education at the proper age.

Conclusion
The study concluded that the majority of the adolescents had favorable attitudes toward pubertal changes. Educated parents and relations with elders helped to develop a positive attitude towards pubertal changes. The majority disagreed that changes during puberty are more than physical and strongly disagreed that sociological factors also affect the coping mechanism. The result of this study can be used as baseline data for future researchers. It is recommended that large-scale research can be conducted including different grades, schools, and states in the country so that the findings can be generalized. Attitudes regarding pubertal changes can be improved by teachers through teaching, conducting programs, and encouraging student's involvement in it. Parents as well as students can also be educated about pubertal changes through teachings and awareness programs in communities to increase positive attitudes.