INTRODUCTION:

As in many other developing countries, Vietnam is entering a period of rapid economic growth, which has resulted in negative social side effects. These social side effects have raised many challenges for adolescents and youth in Vietnam. Some of these challenges include HIV/AIDS, drug abuse, mental health issues, and limited access to quality health services (UNFPA Vietnam, 2006). In Hanoi, the capital of Vietnam, the population is 6.5 million; nearly 50% of the inhabitants are under 24 years of age, and over 10% are between the ages of 10 and 15 years old (General Office for Population Family Planning, 2006).

Reproductive health is a state of complete physical, mental, and social well-being and implies that people are able to have a satisfying and safe sex life and also the capability and freedom to decide if, when, and how often to do so (World Health Organization a). Promoting young people’s sexual and reproductive health means ensuring their physical and emotional well-being, as well as protecting them from unwanted pregnancy, abortion, sexual transmitted diseases (STDs), HIV/AIDS, reproductive tract infections, maternal mortality, infertility, and all forms of sexual violence (World Health Organization b).

Pregnancy in females eighteen years of age or younger puts both the mother and child at a higher risk of health complications, and the maternal mortality rate is estimated to be two to five times higher in this age group versus women between the ages of 18 and 25 (World Health Organization b). Fourteen percent of unsafe abortions occur among women under the age of 20 years, and in Asia, the rate of unsafe abortions is even higher at 30% (Shah & Åhman, 2004). There are approximately 13 million female teenagers living in developing countries who face an unmet need for family planning. In many Asian countries, more than 30% of married adolescent girls are unable to delay or limit childbearing due to non-use of contraceptives (Gubhaju, 2002).

Poor overall knowledge of fertility, HIV/AIDS, and sexually transmitted infections (STIs) is common among secondary-school students (Jaffer, Afifi, Ajmi & Alouhaishi, 2006). Munthali et al. (2006) conducted a study among adolescents between the ages of 12 to 19 years old in Malawi, and their results demonstrated that while adolescents were informed about the changes happening within their own bodies, they did not have as much information about pubertal changes in the opposite sex. These studies demonstrated that it is imperative that effective educational strategies be implemented to improve adolescent's knowledge regarding reproductive health. In Pakistan, a study conducted by Ali et al. (2006) showed that the lack of knowledge about puberty, and the resultant health behavior, created a need for sexual health education before and during puberty. This type of program would help teenagers to respond more effectively to changes happening during this critical period of time. During this period of physical and emotional development, adolescents will face important decisions at this stage, and they will encounter considerable external pressure through the mass media and from their peers to become sexually active and to adopt behaviors that threaten their health (Dilorio, Kelley & Hockenberry-Eaton, 1999). Reproductive health training should begin earlier and target younger adolescents, because adolescents who experience puberty earlier are more likely to engage in sexual activity. Primary health care providers need to screen and counsel young people regarding puberty, sex, and sexual risk behaviors at younger ages than what is the current standard (Kalmuss, Davidson, Cohall, Laraque & Cassell, 2007). Earlier sexual education will minimize the risk of sexual intercourse among youths, and will also enable the development of healthier sexual behavioral patterns (Cowan, 2002).

Educating adolescents about puberty and reproductive health is a very new topic in Vietnam, just as in many other parts of the world, sexuality is considered a difficult topic to discuss. A recent study reported that over 75% of parents feel overall discomfort in broaching the subject of sexuality with their children (Jerman & Constantine, 2010). In Vietnam, parents think that adolescents are too young to know about sex and will hesitate to accept information that tells them otherwise. Parents and adults rarely talk to adolescents about birth control or sex and mostly just advise them to not have sex before marriage (UNFPA Vietnam, 2006, Hanoi Medical University, 2005). In China, where the culture is considered to be similar, findings from an intervention study concluded that sex education is important, effective and applicable among 6th and 7th grade students, aged 11 and twelve years old (Chen & Ye, 1997).

Every school in Vietnam is required to have a health care unit on school grounds. The nurses within these units have an important role in aiding the wellbeing of students; however whether nurses can play an effective and active role in giving reproductive health information to students is unclear. There is a need to research how teenagers gain information about reproductive health and what information might benefit them. Therefore, the purpose of this study is to investigate the perceptions of puberty and reproductive health in 12 and 13 year old adolescents in Vietnam. The findings in this study may be used to guide school nurses in designing intervention strategies to improve overall sexual health knowledge of students in the area.

METHOD:

Data was collected through unstructured interviews, with the use of an interview guide. A qualitative content analysis was performed utilizing the Krippendorff method (Krippendorff, 2004).

Sample

According to the World Health Organization (World Health Organization c), adolescence is defined as the period between 10 to 19 years old. However, only children at the early stages of adolescence were targeted in this study (Vietnam’s Ministry of Health, Vietnam’s general statistics office, UNICEF & World Health Organization, 2005). This age group was targeted, because at the age of 12 years in Vietnam these children start their first year at secondary school (grade 6). Attendance at secondary school is another marker of development and attaining adulthood.

Participants

One private and one public (government) secondary school in the local area allowed student participation in the study. Sixty students between the ages of 12 and 13 years old from grades 6 and 7 were selected randomly by the principals of each school to participate in the study. The private school had approximately 400 students enrolled, and the public school had approximately 600 students enrolled at the time of the study. All enrolled students had the equal possibility of being selected to take part in the study. An information letter about the study was sent to each adolescent and to his or her parents requesting permission to interview the child. Thirty parents consented to have their adolescent participate in the study. After receiving written informed consent from the parents and the child, private interviews were scheduled at each individual child's school by the head of the schools. Children were interviewed in the order they submitted their consent forms, and alternated between boys and girls to allow equal numbers of each gender to participate.

One interviewer conducted all the interviews in the same language spoken by the interviewed children (Vietnamese), and all text in the interviews was reviewed by a professional English translator. The interviews and the names of the participants were confidential, and all of the participants were unknown to the interviewer prior to interview. The authors used the principle of saturation (Polit & Beck, 2006) to determine when to cease conducting interviews; interviewing ceased when no more new information emerged. Twenty- four children were involved in the study, which consisted of 12 boys and 12 girls. Participation was divided evenly between the schools.

Interview

An interview guideline was developed after three pilot interviews. The interviews began with an open-ended question, “Tell me what you know about puberty and reproductive health?” Whenever the adolescent found it difficult to answer a particular question, the interviewer used other related questions to encourage the adolescent to express themselves. The tape-recorded interviews were conducted in a private room between the main author and each individual child, and lasted an average of 30 to 40 minutes. Each interview was conducted by the main author of the study, and a master student and lecturer in nursing with extensive experience in pediatric nursing. The interviews were conducted in a private room between the main author and the child, and no other individuals were present.

DATA ANALYSIS:

Krippendorff´s (2004) technique of content analysis was used to identify categories that described the children's experiences and ideas concerning sexuality. Content analysis is a research technique used in making valid and replicable interferences from the text to the context of their use. The authors removed all identifying data to keep the interviews confidential, and all texts were read separately several times by both authors to get an overall impression of the text. Meaningful units were identified and condensed, and after several processes for encoding and decoding, subcategories were identified and clustered into categories. The selection of categories included is a change between the text as a whole and its parts.

ETHICAL IMPLICATIONS:

Participation was voluntary after written and signed informed consent, and because the participants were under 18 years of age, an agreement and a signature from the parents was also required. All participants understood they could have left the study whenever they chose to, without facing any questions or legal responsibility. All information about the subjects was kept confidential. The Head of the two participating schools in Hanoi approved this study, and a local ethical review was conducted by the National Pediatric Hospital, Hanoi. After the study design was accepted, the Helsinki declaration was then followed.

FINDINGS:

Sixteen sub-categories were identified and divided into three categories: Experience of puberty, concept of sexual intercourse and risks, and concept of friendship and love. An example of the analysis process is provided in Table 1.

Experiences of puberty

Physical and emotional changes

Boys recognized the outward physical changes that accompanied puberty; they knew that they would experience a growth spurt resulting in becoming taller and physically larger, and they also knew that they would develop armpit and pubic hair. Some boys reported misconceptions about changes that were not outwardly physical. One boy reported that boys also experienced menstruation. “I read it in a newspaper and I knew that girls start menstruation at puberty so I think boys also have menstruations like girls.” Boys were also aware of the possible emotional changes that would occur at the onset of puberty. Some boys had positive expectations based on information that they received from older and more experienced male friends. These boys expressed happiness towards becoming an adolescent so that they could in turn have responsibilities and be more independent. Boys reported that there was a feeling of shame connected to the transition into becoming an adult but also a fear of not being likes other boys their age. One boy felt dissatisfaction in regards to growing up and said, “I do not feel confident…it seems I grow slower than my other friends… my friend is much taller and bigger than I am.”

For all of the girls that were interviewed, initiation of menstruation was the most commonly mentioned change in the body connected to puberty. Some of the other changes they spoke about were the growth of breasts, pubic and armpit hair, and also growing taller and bigger. The girls experienced an uncertainty regarding these changes and felt worried about becoming an adult, and sometimes wanted to hide these changes, “Only my mother knew about my changes and she just told me that they were normal.” Others felt anxious about their menstrual cycle or felt uneasy when they wore bras, “I do not want to change sanitary napkins at school, somebody can see if there is some blood in my trousers. I feel ashamed if my friends know.” It was uncommon to feel confident about the changes that occurred at the onset of puberty, but there were instances of girls being informed of the changes and feeling comfortable. One girl said that she had been informed by her mother of these changes, “Changes will happen to everybody at puberty. It means that my growth is normal.” Girls were also aware of the emotional changes connected to puberty and like boys, they also felt that this showed that they were transitioning into adults. They also began to develop an interest in boys, and expressed the belief that they needed to try to be more attractive to the boys by being charming and wearing makeup. Developing an interest in the opposite sex was mentioned by both genders when they spoke about the emotional changes associated with puberty.

Consequences of adolescence

A few adolescents expressed that the sign of someone being an adolescent is that a girl would begin menstruation or that a boy would have his first ejaculation. However, when asked about wet dreams, only a minority explained this as “ejaculation when sleeping.” Some boys mistook wet dreams for bed-wetting, and more than half of the boys and all of the girls did not know what a wet dream was. “I was bed-wetting when I was a preschool child then it stopped. Now it comes back but not as often, about every two months, it’s just enough to wet my pants. My mother told me that my kidneys are weak.” This statement may also show that some of the parents also do not know about wet dreams. One girl said that “wet dream means that a girl has eggs.”

Masturbation was only mentioned by the boys, and none of the boys had a clear understanding of the term or what masturbation may involve. Some boys thought that there was an association between masturbation and violation, “Masturbation is something related to violence, a man rapes a woman if she disagrees.” One boy seemed to have had experiences with masturbation, but was unable to attach a name to this action, “Sometime, in the bathroom, I felt uncomfortable, I touched my penis, it became erect, I pulled up and down, it is difficult to express my feelings but it was very interesting, then it was wet”.

When speaking of their hygienic experiences, all the boys were aware that they should perform penis hygiene everyday with soap and water, and knew that they should pull back the foreskin when cleansing the penis. One boy said that his father asked him to do this, but that he felt pain when pulling his foreskin back, and avoided doing this. Girls also believed that they should clean themselves everyday with soap and water, especially during their menstrual cycle. They complained that there was a limited amount of water available for hygiene in school and that because of this they felt uncomfortable on “these days”. One girl said, “At my school, there is no water for hygiene, just toilet paper so because of that I do not want to change my sanitary napkins in school. I tried to drink very little water so that I would not need to go to the toilet.” In both sexes there was a general lack of knowledge regarding genital hygiene in the opposite sex.

Sources of information about puberty

Adolescents explained that they received information on puberty from compulsory health science classes that they attended in 5th grade, the final year of primary school. They believed that these classes did not give them sufficient information on the subject of puberty. Books, television and the internet were mentioned as sources of information for both genders. The interviews showed that girls were able to locate more information compared to the boys. Girls mentioned a book written for teenagers that provided information about adolescence that they had read and also educational television programs aimed towards adolescents. Only one boy mentioned reading a teenage book about puberty, and another boy mentioned that he found information about puberty on the internet. Adolescents said that adults disapproved of young people searching out information from pornographic books. One boy said that, “I wanted to read one of my father's books but he said that I was not old enough.”

The information that the participants received from other adolescents was usually related to bodily changes, and included experiences of ejaculation for boys and menstrual cycles for girls. Boys mentioned that male friends who had already experienced puberty as a source of information, and girls usually mentioned that their mothers and, more rarely, female friends as their sources of information. One girl said, “I have not started menstruating, so therefore if I ask my friends about that, they will say that I was being lewd.” Some boys had difficulties getting information from more experienced or older people, “If I ask my sister, she always annoys me. If I ask my mother, she thinks I am too young to understand. I am not sure if my grandmother can explain it in the right way. I feel ashamed to ask my teacher. I do it by myself, it is the best way.”

Concept of sexual intercourse and risks

Knowledge about sexual intercourse and the risks

Adolescents believed that sexual intercourse was a way of satisfying mental and physical needs between one male and one female, or between two persons of the same sex.

The adolescents stated that safe sex meant having sexual intercourse after getting married. They knew that the risks of unsafe sex were unplanned pregnancies or STDs, and mentioned that using a condom when having sexual intercourse could prevent these risks. When talking about STDs, HIV/AIDS were mentioned by almost all of the boys and girls, but only one boy mentioned that STDs also included syphilis, gonorrhea, and hepatitis B. Some interviewees said that HIV/AIDS were named differently for different periods of one disease, while others claimed that they were different diseases.

The opinion with both genders was that “adolescents should not have sexual intercourse.” Some of the reasons mentioned were, “the growth of the body is incomplete, if the girl becomes pregnant, it will be very dangerous for adolescents,” or “if a girl has an abortion in adolescence, she might not be able to have a child later in life.” Adolescents were aware that by having sexual intercourse girls would become women of ill repute and that the girl’s hymen would break. They also believed that virgin hood was a sign of a pure soul, and that it was directly connected to the morality of girls. A minority of the interviewed girls mentioned that the existence of the membrane is evidence of virgin hood and that the membrane is torn during sexual intercourse or could be torn in an accident.

Adolescents seemed to know about the effects of condom usage, but not everyone knew what a condom looked like or how to use one. One boy said, “My friend showed me a condom on the riverside when we were back from the school; I felt it was strange-looking. Do all of them look like that?” Some of them also believed that using a condom could prevent the tearing of the membrane, or that the reason for the tearing is that the membrane had an infection. In some cases, both sexes recognized that their friends’ understanding of these issues were also limited. A few respondents posed questions to the interviewer without hesitating, “Does a girl get pregnant when she kisses a boy?” one boy asked. One girl expressed her concern, “In my class, some adolescents are together and call each other husband and wife, it is just funny, but only until someone gets pregnant.” Another individual stated, “I have some difficult problems that I just want to discuss with my close friends, but just like me, they did not know.”

Sources of information on sexual intercourse and the risks

As previously mentioned, adolescents had found information on sexual intercourse and the risks from teenagers’ books; the same books where they found information about puberty. They pointed out that the information about the positive effects of condom usage was well advertised in the media, and almost all of the adolescents were familiar with the television slogan, “Using condom to prevent HIV and unplanned pregnancy.” Other adolescents revealed that they received information about the risks of sexual intercourse or sexual abuse through newspapers or magazines. One girl said, “I read in a magazine, that a father and his daughter had had sexual intercourse. I felt scared.” Acquiring illegal books and films (pornography) were also mentioned as a source of information. One boy said that he had already read an illegal book related to sexual intercourse, which one of his male friends had lent to him. Another boy said that he had watched a sexual film with a female friend, and another girl said that she had watched a pornographic film with some male and female friends, “That day, my friend's parents were out and he called me and some other friends, six boys and three girls, and we went to his house and watched. His father had concealed a videotape very carefully, but he found it.” All of the adolescents involved were hesitant to talk about it and expressed the need to keep this event a secret, since they were afraid that their parents or others would find out that they had watched the film.

Concept of friendship and love

All adolescents recognized that friendship was an emotional link between two people or a group of people. Sharing hobbies, interests, and supporting each other to improve and achieve things together were commonly mentioned as aspects of friendship. Some said that close friends could share their feelings, secrets, happiness and sadness with each other. One girl offered a proverb as an attempt to explain friendship, "Shared joy is a doubled joy; shared sorrow is half a sorrow." Friendships between two opposite sex peers could exist at school according to the interviewed adolescents and some expressed the opinion that it was not necessary to avoid this friendship, because a good friendship with someone of the opposite sex would diversify their psychological life and make it more meaningful. Adolescents were also aware that these types of friendships should not turn into a love relationship at this age. All of the participants believed that love at this age could potentially have negative effects, and mentioned that one of these negative effects could be a lack of concentration on school work.

“They always think about their partner, which leaves them with very little time to study,” one boy said. They also mentioned the decline of moral standards of some of their peers. One girl stated about a pair of her classmates, “There is a couple in my class, they fell in love. When school finished, they embrace each other right here, in my class … it was too bad.” Another girl gave an example of the couple from class, “They are always together, the boy even stood in front of the class and came to the girl’s house and said that he loves her… it was too much.”

Both the boys and girls brought up the fact that love may bring serious consequences, and a majority thought that pregnancy was one of the most serious consequences, “If someone thinks that love is the act of showing devotion to the partner, the girl can get pregnant,” one girl said. Some expressed their understanding that if they did get pregnant during adolescence they would not be prepared to take care of a child, “We are too young to have a baby, we do not have enough experience to take care of the baby, and we would have to drop out of school.” Some interviewees expressed critical views on adolescent pregnancy, and one girl mentioned that jealousy was one of the consequences, and that other problems may occur if the partner had other sexual encounters, or started spreading rumors. Some talked about their experiences and explained that they had learned from them, “It was terrible, I know a girl in one school, she got pregnant when she was in ninth grade.” Another interviewee shared an example that she had read about in the newspaper, “One 24 year old boy fell in love with a 14 year old girl but the girl’s parents did not like it. The boy killed the girl and burned her house down.”

DISCUSSION:

Sexuality remains a sensitive topic in Vietnam. Only half of the parents and adolescents invited to the study agreed to participate, therefore collecting reliable information on this topic required a method of interviewing that would ensure that the interviewees felt sufficiently comfortable discussing this sensitive subject.

The interviews were performed in a conversational format to encourage the participants to speak freely. A qualitative method using unstructured interviews was chosen in order to get an exact description of adolescent perceptions (Kvale, 1983). Some additional guiding questions, which created a clearly focused problem orientation for the study, became necessary throughout the interviews.

The results showed that adolescents already had experienced puberty at the time of the interviews that they were aware of these changes, and that they had knowledge about sexual health issues, but there were many misunderstandings in their awareness regarding some of these issues. The interviewees also expressed that they were experiencing mixed emotions regarding these changes, which initially made them feel hesitant to respond to the researcher’s questions. Studies (Brown, Jejeebho, Shah &

Yount, 2001; Francisco, Dixon-Mueller & D'Arcangues, 2007) showed that many adolescents lack basic information about sex and reproduction. The (Munthali, Moore, Konyani & Zakeyo, 2006) study suggested that if adolescents had received more information about their bodies, they would have been in a better position to acquire the resources to take care of their overall sexual health.

The present study also found that knowledge regarding adolescent personal hygiene was not complete, and that there was also a lack of knowledge concerning appropriate hygiene for the opposite sex. This lack of knowledge may be attributed to this information not being taught in sexual education classes at school. Adolescents’ knowledge may come from their own experiences from what they do every day; we have not found any other studies that show similar findings. Findings from this study revealed that at this age, most adolescents felt a lack of self-confidence when coping with physical and emotional changes, which in turn caused them to not seek out adequate information regarding their sexual health (Baldo et al., 1993). Adolescents also expressed that parents, healthcare workers, and educators were frequently unwilling or unable to provide complete, accurate, and age-appropriate reproductive health information to adolescents. Creating a comfortable environment for adolescents and improving adult communication to discuss sexual issues with adolescents is imperative in Vietnam today. It still remains a challenge to create a comfortable environment for the adolescents to access this information. Grunseit, Kippax, Aggleton, Baldo & Slutkin (1997) found that adolescents sought more information from adults and qualified sources than from their friends, and that their expectations of receiving reproductive health information from their parents had risen greatly. The provision of a single lesson on the physical changes of puberty is not sufficient to establish an adequate understanding of the subject. It is very important that schools take a formal role in adolescent sexual education, because contact with health professionals in health clinics is uncommon, and parents of adolescents may also have misconceptions about the changes during this time. In addition, one study suggested that sexual education is a particularly challenging issue to address and therefore should be included at the upper elementary school level. This period of time is when most of the students have not yet become sexually active, and could benefit from this information (Landry, Singh &Darroch, 2000).

As discussed earlier, media was one of the most common sources used by adolescents to obtain sexual health information. Munthali et al., (2006) found that the media was the most popular source of information for adolescents in Vietnam. In present studies, there is evidence that media outlets are more frequently used by girls rather than boys. The reason can be explained that at this stage in development, girls tend to be more cliquish than boys, and have a greater need for close friendships where they can exchange resources of information Hockenberry & Wilson, 2009). Looking at the topic from another angle, it may reflect the fact that these informational resources may be more available to girls than boys in Vietnam. These studies show that it is essential to develop sources of information that can be obtained by both genders.

The study’s findings also showed that both genders did not effectively discuss sexual issues with others. It became evident that boys mostly discussed these issues with uninformed friends. For example, the boys often relied on friends, sexually explicit magazines, films or internet websites rather than on parents, teachers and other legitimate sources (Francisco, Dixon-Mueller, & D’Arcangues). It has become evident that sexual education programs are more effective before young people of both genders become sexually active (Baldo et al., 1993). It is also necessary to consider the fact that if an adolescent discusses sexual issues with his or her parent rather than with friends, he or she is less likely to initiate sexual intercourse and is more likely to have conservative values (Dilorio, Kelley & Hockenberry-Eaton, 1999). This highlights the importance of fostering good communication and comfort between parents and adolescents about sexual issues (Dilorio et al., 1999).

It is natural that there is emotional attraction between boys and girls at this age, and this study shows that these 12 to 13 year old adolescents are already thinking about these issues. Most importantly, adults need to understand and be able to handle their respective adolescent's emotions in a positive way.

CONCLUSION:

Adolescents’ perception of puberty and reproductive health are still insufficient in Vietnam. Between the ages of 12 and 13 years old, adolescents need more information to be able to protect themselves against STDs, and also to be able to prevent pregnancy. Parents, teachers, school nurses, and related authorities need to play an important role in educating adolescents and encouraging them to make the right decisions, thereby helping them to cope with the special challenges of becoming an adult.

IMPLICATIONS AND FURTHER RESEARCH:

The 5th grade Health Science's book, which is recommended to be used for sexual education by the Vietnamese Ministry of Education and Training needs to be developed. The classes should include the physical and emotional changes connected to puberty as well as their consequences and potential risks. This information should be comprehensive so that adolescents can benefit from it when they are making decisions related to sexual health.

The information from mass media should be diversified so that it is useful for both genders. This informational source should focus on concise answers to queries related to sexual health, as well as helping adolescents to understand the potential risks in relation to sex. Adults should also be involved in helping adolescents find suitable and useful information. They need to enhance their own knowledge and communication skills to create a comfortable environment where information about sexual health can take place as well as preparing children for the challenges of adult society. Within the scope of the health sector, it is urgent for school nurses to implement strategies to improve the knowledge of the students regarding reproductive health by designing and providing appropriate information and education.

REFERENCES

Ali, T. S., All, P. A., Waheed, H., & Memon, A. A. (2006). Understanding of puberty and related health problems among female adolescents in Karachi, Pakistan. J Pak Med Assoc, 56(2), 68-72.

Baldo, M., Aggleton, P., & Slutkin, G. (1993). Does sex education lead to earlier or increased sexual activity in youth? Paper presented at the International Conference on AIDS. Retrieved from http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102206744.html

Brown, A. D., Jejeebho, S. J., Shah, I., & Yount, K. M. (2001). Sexual relations among young people in developing countries: evidence from WHO case studies. Switzerland: Department of Reproductive Health and Research - World Health Organization.

Chen, J., & Ye, G. (1997). Sex education in 6th and 7th grade girls. Zhonghua Yi Xue Za Zhi, 77(1), 11-14.

Cowan, F. M. (2002). Adolescent reproductive health interventions. Sex Transm Infect 78(5), 315-318.

Dilorio, C., Kelley, M., & Hockenberry-Eaton, M. (1999). Communication About Sexual Issues: Mothers, Fathers, and Friends. Journal of Adolescent Health, 24(3), 181-189.

Francisco, A., Dixon-Mueller, R., & D'Arcangues, C. (2007). Research issues in sexual and reproductive health for low and middle income countries. Geneva: Global Forum for Health Research WHO.

General Office for Population Family Planning. (2006). Popuplation structure based on age and gender. from http://www.gopfp.gov.vn/web/khach/tailieuTK

Grunseit, A., Kippax, S., Aggleton, P., Baldo, M., & Slutkin, G. (1997). Sexuality education and young people´s sexual behaviour: a review of studies. Journal of Adolescent Research, 12(4), 421-453.

Gubhaju, B. B. (2002). Adolescent Reproductive Health in Asia. Paper presented at the The 2002 IUSSP Regional Population Conference : South-East Asia’s Population in a Changing Asian Context.

Hanoi Medical University. (2005). Gender & HIV risk for Vietnamese adolescents. Paper presented at the Overview of five-year project.

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th Edition ed.). Missouri: Mosby Elsevier.

Jaffer, Y. A., Afifi, M., Ajmi, F. A. l., & Alouhaishi, K. (2006). Knowledge, attitudes and practices of secondary-school pupils in Oman: II. Reproductive health East Mediterr Health Journal, 12(1), 50-60.

Jerman, P., & Constantine, N. A. (2010). Demographic and Psychological Predictors of Parent-Adolescent Communication About Sex: A Representative Statewide Analysis. J Youth Adolesc, 39(10), 1164-1174.

Kalmuss, D., Davidson, A., Cohall, A., Laraque, D., & Cassell, C. (2007). Preventing sexual risk behaviors and pregnancy among teenagers: linking research and programs. Perspect Sex Reprod Health, 35(2), 87-93.

Krippendorff, K. (2004). Content analysis: An introduction to its methodology. London: Sage.

Kvale, S. (1983). The qualitative research review. Journal of Phenomenological Pychology, 14, 171-196.

Landry, D. J., Singh, S., & Darroch, J. E. (2000). Sexuality Education in Fifth and Sixth Grades in U.S. Public Schools, 1999. Family Planning Perspectives, 32(5), 1-13.

Ministry of Education and Training. (2007). Regulation on health care operations in primary, secondary and high school

Munthali, A. C., Moore, A. M., Konyani, S., & Zakeyo, B. (2006). Qualitative Evidence of Adolescents’ Sexual and Reproductive Health Experiences in Selected Districts of Malawi. .

Polit, E. P., & Beck, C. T. (2006). Essentials of nursing research (6th ed.). Phiadelphia: Lippincott, Williams & Wilkins.

Shah, I., & Åhman, E. (2004). Age Patterns of Unsafe Abortion in Developing Country Regions. Reproductive Health Matters, 12(24, Supplement 1), 9-17.

UNFPA Vietnam. (2003). Manual on organizing "Extra- curriculum activities on adolescent reproductive health education" for schools. Hanoi: Ministry of Education and Training.

UNFPA Vietnam. (2006). Advocacy strategy for adolescent sexual and reproductive health for RHIYA program in Vietnam 2005-2006.

Vietnam’s Ministry of Health, Vietnam’s general statistics office, UNICEF, & World Health Organization. (2005). Savy-Survey and assessment of Vietnamese Youth.

World Health Organization a. Reproductive health. Health topic, from http://www.wpro.who.int/health_topics/reproductive_health/

World Health Organization b. Reproductive health - Adolescent sexual and reproductive health. Health topic Retrieved 2009 June 25, from http://www.wpro.who.int/health_topics/reproductive_health/general_info.htm

World Health Organization c. Adolescent Health and Development. Child and Adolescent Health topic Retrieved 2009 May 25, from http://www.searo.who.int/en/Section13/Section1245_4980.htm

Received on 25.05.2012 Modified on 20.09.2012

Asian J. Nur. Edu. and Research 2(4): Oct-Dec. 2012; Page 228-235

Meaning units	Condensation	Code	Sub-category	Category
I do not want to change sanitary napkins at school. I will feel ashamed if my friends know	Feel ashamed when changing sanitary napkins at school	Feel ashamed about changes	Emotional changes in female, according to female	Experiences of puberty
I am really excited when my father bought a bicycle for me on my birthday. He said that I can ride to school without him when I start grade 6 this year	Feel excited to go to school without the father	Feel more independent	Emotional changes in male, according to male	Experiences of puberty
I usually hear on the television that using condoms can prevent HIV and unplanned pregnancy	Hearing from the television that condoms can be used to prevent HIV and unplanned pregnancy	Information on the effects of condom usage	Sources of information about sexual intercourse	Concept of sexual inter-course
I have some difficult problems that I just want to discuss with my close friends, but just like me, they do not know	Peers also do not know about the issue	Limited understanding about sexual intercourse	Knowledge of sexual intercourse and the risks	Concept of sexual inter-course
I have a close friend, we are not in love, but we really understand each other, she helps me a lot with my studies	Heterosexual friendship is helpful with studying	Heterosexual friendship is good	Concept of heterosexual friendship	Concept of friendship and love
There is a couple in my class, they fell in love. When school finished, they embraced each other right here, in my class …it was too bad, it goes beyond the allowed boundaries in the school	Felt bad when a couple embraced each other in class	Exceeding the limit of friendship is bad	Fine line between love and friendship	Concept of friendship and love