Socio-demographic characteristics of study participants

A total of twelve participants were interviewed using an in-depth interview technique. The primary characteristics of the teachers are given below in the table. The participants included four principals, five science teachers, two arts teachers and one mathematics teacher. The mean age of participants was 38.4 years with ± 4.2 years. All the study participants were females (Table 1).

Table 1 Characteristics of the study participantsEmergent themes and subthemes

The interviews revealed several key perceptions and insights about the perception of schoolteachers on the Sexual and Reproductive Health (SRH) of school-going adolescents. Teachers’ perceptions of ASRH were largely consistent across all themes, with minimal variation in their views, indicating a shared recognition of the need for comprehensive ASRH education and support. Four themes and fourteen sub-themes were identified pertaining to adolescent sexual and reproductive health: SRH well-being of adolescents; SRH education in schools; Parental role, Cultural, and Societal influence on ASRH, and Provision of ASRH services. Phrases or sentences of quotes are illustrated from the corresponding codes in each emergent theme and sub-theme (Table 2).

Table 2 Themes, sub-themes, and sample codes showing the perception of schoolteachers on ASRHTheme 1: sexual and reproductive health well-being of adolescent girls

The current theme explores SRH knowledge, attitudes, and practices among school-going adolescent girls, revealing four sub-themes. Teachers reported a lack of SRH awareness and unsatisfactory menstrual hygiene practices among adolescent girls. While most students attended school during menstruation, they remained largely unaware of existing SRH services and were hesitant to share their SRH concerns.

Sub- theme1.1: awareness on sexual and reproductive health

According to teachers, most adolescent girls were unaware of menstruation before its onset, leading to fear and panic when they experienced it. The lack of prior education or guidance on menstruation left them unprepared, making them susceptible to misinformation from peers regarding menstruation, conception, and safe sex.

“Adolescent girls’ still have negligible awareness about menstruation and get panic during the first period, especially among the girls living in rural and tribal areas” (49-year-old T1).

“Girls are misguided by batchmates with possible rumours or judgements. Students need to know which stage is conducive for them to conceive, how to have safe intercourse, and how intercourse leads to a new life. Someone entering the phase of marriage without proper knowledge may lead to many inconveniences.” (40 years old T4).

Sub-theme 1.2: menstrual hygiene management

Teachers reported that while a majority of students used sanitary pads during menstruation, proper disposal remained a significant concern. In addition to adopting unhygienic practices, students restricted activities such as bathing, diet, and exercise during their menstrual cycles. A major challenge for many students identified was the ability to afford sanitary pads. To address these issues, school principals and teachers emphasized the need for smart toilets with incinerators and adequate disposal bins to improve menstrual hygiene management (MHM).

“Adolescent girls do not know how to dispose of used napkins and make the washroom unhygienic. Even some teachers are not aware regarding incinerators and familiarizing them will take time” (53-year-old P4).

“Adolescent girls have conflicting opinions and information on when to take a bath during periods… if it is recommended to take a bath in warm or cold water, how to change sanitary napkin and how often and why there is need to stay hygienic during this phase” (40 years old T4).

“Students do not carry sanitary pads with them, which is of primary concern, and the major reason for this is their low socio-economic background” (55-year-old P3).

Sub-theme 1.3: ASRH health concerns

As per the majority of the teachers, common SRH issues among school-going adolescent girls included menstrual cramps, white discharge, and irregular menstrual cycles. Additionally, students often experience emotional instability and anxiety during menstruation. On a positive note, the majority of adolescent girls attended school during menstruation, with students being granted leave for one or two days when experiencing severe cramps. However, teachers noted that students were often uncertain about whom to approach for support regarding their SRH concerns. Teachers stated that they recommend students consult the doctor for ASRH-related health concerns.

“Most students attend classes during menstruation; it’s just that the ones having stomach pain… they don’t attend schools. So, we tell them to take one day rest and ask them to take leave and come on the next day.” (29 year old T3).

“ Students, when they have stomach pain or white discharge, don’t know where to go, whom to ask. They just stay at home, they have no clue.” (57-year-old P1)

“……..They are encouraged to visit doctors in case of illness like Urine infection, itching and take proper action.” (59-year-old P2)

Subtheme 1.4: communication on ASRH

The majority of teachers reported that students feel embarrassed and shy when discussing their SRH concerns. In most cases, teachers became aware of students’ SRH issues through parents or peers rather than direct communication. Teachers emphasized the need to eliminate stigma, even among educators, and to encourage open discussions on SRH. While most teachers shared this perspective, one school principal and a teacher noted that students in their school felt comfortable sharing their concerns. However, in some instances, when students sought information on topics like condoms out of curiosity, they were dismissed by both parents and teachers, underscoring the persistent challenges in SRH communication.

“Considering shyness, taboos and myths, school students feel uncomfortable discussing issues about itching, white discharge, and irregular monthly cycles.. I assume that children would be sharing with parents as we have never heard anything from them. At times parents communicate with the teachers regarding similar issues and that’s a relief that at least some children are speaking to their mothers” (34-year-old T7).

“Children share their concerns at times, especially the intimate issues like white discharge,irregular bleeding, abdominal pain etc. and steps are taken by the school administration and teachers to educate both children and their parents (59-year-old P2)

“A student from sixth grade was willing to know the meaning of condoms and was beaten by both teacher and parent. Leaflets are shared with senior students, and this kid got one, which led to his curiosity. Instead of punishment, the matter could have- been handled in a better way by communicating it is not age- age-appropriate for him to know.” (37 year old T5).

Theme 2: SRH education in schools

Teachers identified significant gaps in the existing curriculum on ASRH. Three key sub-themes emerged which include the need to enhance the current curriculum, the discussion of SRH in parent-teacher meetings, and the training of teachers on ASRH.

Subtheme 2.1: enhancing existing ASRH curriculum

Most teachers reported that the existing curriculum lacks essential topics such as puberty, menstrual hygiene management, white discharge, irregular periods, and reproductive tract infections. While certain topics, like the anatomy of the reproductive system, contraception, and HIV/AIDS, are included, they are often covered superficially. However, a few teachers were resistant to including sex education due to societal conservatism. They found it challenging to teach these topics to school students and instead suggested focusing on improving sanitation facilities, such as providing disposal buckets, high-quality sanitary napkins, incinerators etc.

“Topics such as puberty, infections, discharge, burning micturition, phases of reproductive life, special care and hygiene need to be included in the syllabus, and comfortable environment needs to be created for the holistic development of students” (38-year-old T2).

“The current curriculum doesn’t include much about menstrual hygiene, and it is very important for students to know sanitation practices to identify the ideal gap from one period to the next….Central board schools have much broader coverage. Also, textbooks don’t contain any graphics, and adding them would be great for students to relate to and memorize.” (49 year old T1).

“Topics such as safe sex and condom usage would be difficult to teach in school and better to be introduced in colleges; teaching these topics would be a double-edged knife, and most parents won’t agree to teach” (28-year-old T8).

Teachers noted that most adolescent girls begin puberty by the age of nine and emphasized the importance of introducing SRH education in earlier grades. They also suggested that a gender-specific syllabus would be more effective in addressing the unique needs of adolescent girls, rather than skipping teaching sessions on SRH.

“Puberty should be covered by the sixth standard as these days, children are attaining puberty by the age of 10–12…. They feel uncomfortable because of less awareness about changes that happen during puberty.” (53 year old P4).

“Girls need to know where to approach pertaining to SRH, which can be taught in special education sessions. The issue of co-education can be tackled by having gender-specific syllabi” (37-year-old T5).

Apart from SRH, teachers noted that while life skills education (LSE) has been part of the curriculum for a long time, its effective implementation remains a concern. They observed that adolescent girls encounter various challenges daily, such as being pressured to accept favours from unknown persons. Teachers felt that the emphasis often shifts toward merely completing the syllabus rather than genuinely imparting essential life skills to help students navigate real-life situations.

“Everyone is in a race to complete the syllabus, and only asking them to read, memorize, and score well is of limited use if we do not educate them on handling real-life scenarios. Self-defence training is the need of the hour. There is a lot of reluctance in girls to raise their voices for themselves” (49-year-old T1).

“Scenarios like blackmail, good touch, and bad touch keep happening to girls. If children are made conscious enough by getting guidance and instruction through schools, they will be able to handle real-life scenarios” (38-year-old T2).

Subtheme 2.2: discussing SRH in parent-teacher meetings (PTMs)

Parent-teacher meetings are held to discuss the holistic development of the students in the schools. However, teachers reported that during these meetings the primary focus is usually on students’ academic performance, with SRH topics often being overlooked. They believe it is crucial to address SRH issues during these meetings, as it would provide a valuable platform for discussing SRH concerns and resolve various issues faced by adolescent girls.

“Certain programs need to be conducted to educate parents and students on SRH. Few issues can be addressed straight away if a meeting is arranged between children and mothers to facilitate a platform for friendly discussion….Such kinds of meetings could not be taken even on a monthly basis” (55-year-old P3).

“Though there are monthly parent-teacher meetings, most part of the discussion is on studies.” (28-year-old T8)

Sub-theme 2.3: teacher training on ASRH

Awareness of SRH among teachers was primarily limited to those teaching life sciences. A significant gap identified was the lack of specialized training for teachers on ASRH. While some teachers acknowledged the availability of online training courses provided by the education department, they believed that receiving training directly from medical professionals through collaborative efforts would significantly enhance their ability to address ASRH issues effectively.

“Reproductive health awareness should not only be imparted to biology teachers but as a common subject to all teachers.” (34-year-old T7)

“Teacher training is equally important and would be more impactful when provided by doctors. The clearer teachers are in concepts, the easier it would be to teach and also diagnose the students.” (31-year-old T6).

Theme 3: parental role, cultural, and societal influence on ASRH

Under this theme, five sub-themes emerged: the vital role of mothers, parent-adolescent communication, myths and taboos, community norms and practices, and the impact of digital media on ASRH. Teachers highlighted the critical importance of parental involvement, particularly that of mothers, in raising awareness about SRH. However, societal taboos and conservative attitudes posed significant barriers, often preventing open discussions and guidance on the SRH needs of adolescent girls.

Subtheme 3.1: the vital role of mother’s in ASRH

Life science subject teachers emphasized the significant role of mothers in creating an impact on ASRH, provided they receive adequate training. However, they observed that most mothers of adolescent girls do not teach their daughters about menarche, dietary practices during menstruation, menstrual hygiene, and even topics like safe sex. To address this major issue teachers recommended conducting ASRH awareness programs to the mothers during PTM, which they believed would greatly benefit adolescent girls.

“Learning starts from home. Usually, mothers are the ones imparting related knowledge mainly about menstrual cycles, and when mothers are not well aware of this, the right information is not passed to children.” (40 years old T4).

“Mother and the child need to be taught regarding reproductive health in separate program. This will facilitate mother to be a trusted source for adolescent girls” (37-year-old T5).

Subtheme 3.2: parent-adolescent communication

As noted earlier, the majority of students come from low socio-economic backgrounds, and teachers reported that parents often have low literacy levels. Teachers felt that these factors contributed to limited awareness of ASRH, acting as a barrier to open communication between parents and their children. However, few teachers stated that parents with high literacy levels have adequate knowledge and communicate with their daughters. In such cases, teachers often learn about students’ SRH-related health concerns through these informed parents.

“ Even parents feel immense shy.. to talk about these matters with their children if parents are not well educated on this..” (59-year-old P2)

“Those families who are well educated have good. Knowledge, but most are not educated. During PTM we educate the guardian, which in turn can make children feel at safe hand while dealing with real-life scenarios.” (57 year old P1).

Subtheme 3.3: myths, taboos, and ways to tackle them

Teachers reported that myths and taboos surrounding ASRH persist, particularly among economically disadvantaged families. A few teachers emphasized the need for educating parents, suggesting that ancestral beliefs should be evaluated for their scientific validity before being passed on to students. They also noted that these myths often cause stress among students. To address this, teachers recommended implementing appropriate measures, such as organizing special interactive sessions that include parents, to debunk myths and provide students with accurate SRH information.

“Parents are sceptical about using sanitary napkins, apprehending the side effects due to chemicals therein rather than preferring cotton cloth as a healthier option.”(29-year-old T3).

“Menstrual hygiene and sex education are still considered taboo topics in India, mainly among backward societies. Since the myths have existed for years, it would take a significant length of time to tackle; however, conducting regular campaigns involving parents and teachers would help in busting myths.” (29 year old T3).

“Myths around menstruation need to be eradicated especially in rural and tribal areas by introducing various SRH initiatives with teachers, students and stakeholders as participants.” (38-year-old T2).

Sub-theme 3.4: community norms and practices

Teachers highlighted that prevailing myths and taboos in society lead to restrictive practices, such as preventing adolescent girls from attending exams during menstruation. Additionally, these deeply rooted beliefs contribute to early marriages among adolescent girls. However, teachers emphasized that girls have the potential to contribute to the betterment of society and should not lose opportunities due to these challenges. Instead, they should be empowered to challenge societal norms and advocate for change.

“We also see many families following some blind beliefs and restricting students from visiting schools, taking exams, praying and not speaking to boys. Students are afraid and bound to these practices” (49-year-old T1).

“Many students are getting married after schooling; adolescent girls and teachers need to be trained in contraception, sexual hygiene, and safe sex practices to increase the awareness.”(59 year old P2).

Sub-theme 3.5: impact of digital media on ASRH

With advancing technology, teachers perceived that digital media could have both positive and negative impacts on ASRH. Unlike earlier times, most students today have access to smartphones and are exposed to a wide range of ASRH-related information. Teachers believed that disseminating ASRH information through schools with an established curriculum would be more effective than students seeking ASRH-related information from diverse social media sources.

“Most students today have access to the internet. This access has been offering both opportunities and challenges in the dissemination of accurate SRH information….Even students are curious, and instead of students finding the details from YouTube, it would be great if we teach them.” (40 years old T4).

“This generation is more exposed to visual learning through WhatsApp and Instagram videos. It has become very difficult to keep away from social media influence, and their negative effects are also a matter of concern.” (37-year-old T5).

Teachers noted that movies play a significant role in raising awareness and debunking myths in communities. The release of the film Pad Man in India was particularly acknowledged for fostering openness around menstrual hygiene. However, they emphasized the need for regular awareness campaigns utilizing media platforms to effectively improve ASRH education and outreach.

“The release of movies has enabled an atmosphere of openness, and people are more comfortable discussing reproductive health-related issues.” (55-year-old P3)

“SRH Awareness episodes at regular intervals through traditional media such as television, radio, and newsletters from the government side would reach larger populations and could be a solution to tackle the resistance.” (29 year old T3).

Theme 4: provision of ASRH services

The current theme explores the provision of ASRH services by various stakeholders, such as services by the Health Department, and Non—Governmental Organizations. Two sub-themes emerged from this theme.

Subtheme 4.1: services by the department of health

As noted in earlier themes, students were not able to afford sanitary pads due to their low socio-economic status. In response, teachers appreciated government initiatives like the distribution of free sanitary pads to adolescent girls under the menstrual hygiene scheme, which had a positive impact by reducing school absenteeism due to menstruation.

“Students from economically backward sections were not able to afford napkins previously. Free distribution by the government made it accessible and affordable.”(55-year-old P3).

Apart from the provision of free sanitary pads, a lack of awareness was noted among school teachers, parents, and students regarding adolescent-friendly health clinics (AFHCs) established at primary healthcare centres. To better address ASRH-related health concerns, teachers emphasized the need for regular school visits by doctors to address the ASRH needs of adolescent girls.

“I don’t know about AFHCs; if such clinics are there to address adolescents’ health, then all the stakeholders’ parents and teachers need to know.” (34-year-old T7)

“Doctor’s visits to schools would ease the children, and students can share their issues expecting solutions from them.” (31-year-old T6)

Subtheme 4.2: NGO’s services

Teachers reported that, in the absence of a comprehensive ASRH curriculum in schools, NGOs played a crucial role in bridging this gap. Various NGOs regularly conducted school visits to raise SRH awareness by teaching the topics which are not covered in the school curriculum. Despite the lack of an established system for doctor’s visits, NGOs provided essential ASRH education, trained teachers, distributed sanitary pads, and facilitated interactive sessions to teach practical life skills.

“Some of the topics, such as safe sex RTI/STIs, are not present in the school curriculum, but there are some NGOs who come and teach. They also distribute sanitary pads and teach about the harmful effects of child marriage. But doctors don’t come and teach.” (57 year old P1).

“NGOs show videos to impart sex education. This went on for 2–3 days, and that definitely made a significant impact in terms of spreading awareness.” (31-year-old T6)