marked by profound physical, emotional, and social changes. Among the most critical aspects of this transitional period is reproductive health, encompassing puberty education, awareness of contraception, and the promotion of safe sexual practices. Globally, the need for comprehensive adolescent reproductive health education has been recognized as essential for empowering young people to make informed, responsible decisions about their bodies and relationships. In the context of India, where adolescents constitute nearly one-fifth of the total population, the provision of accurate, age-appropriate sex education is not only a public health priority but a critical investment in the nation's future well-being [1-3].

Despite increasing global emphasis on adolescent health rights,  reproductive  health   education   in  India  continues  to face significant challenges, particularly in rural and semi-urban regions like Himachal Pradesh. Socio-cultural taboos, misconceptions, lack of open communication, and the sensitivity surrounding discussions of sexuality often hinder the delivery of effective sex education in schools. Consequently, adolescents frequently turn to unreliable sources for information, leaving them vulnerable to myths, risky behaviors, unintended pregnancies, and sexually transmitted infections (STIs). Furthermore, the absence of structured puberty education programs leaves many adolescents ill-prepared to navigate the physical and psychological changes associated with   maturation [4-7].              

Government initiatives such as the Adolescent Reproductive and Sexual Health (ARSH) program and the School Health Program under Ayushman Bharat seek to bridge these gaps by promoting adolescent-friendly health services and life skills education. However, the reach, quality, and acceptance of such programs vary considerably across different regions. Understanding students' current knowledge, attitudes, and practices concerning reproductive health is crucial for tailoring interventions that are culturally sensitive, accessible, and effective [4,5].

This study aims to assess the level of awareness regarding adolescent reproductive health among school students in Himachal Pradesh, with a particular focus on knowledge related to puberty changes, contraceptive methods, and safe sexual practices. By identifying knowledge gaps, misconceptions, and barriers to effective education, the research seeks to inform strategies for strengthening school-based sex education programs and promoting safer, healthier transitions from adolescence into adulthood.

Study Design

A descriptive, cross-sectional, online survey was conducted to assess the awareness of adolescent reproductive health, including puberty education, contraception, and safe sexual practices, among school students in Himachal Pradesh.

Study Area and Population

The study targeted school-going adolescents aged 13–19 years, studying in government and private secondary and senior secondary schools across rural and semi-urban regions of Himachal Pradesh. Eligible participants included both male and female students who could comprehend Hindi or English.

Study Duration

Data collection was carried out over a three-month period, from January to March 2025.

Sample Size and Sampling Technique

Assuming a 50% awareness level regarding adolescent reproductive health (due to lack of prior comprehensive regional data), with a 95% confidence interval and a 5% margin of error, the minimum required sample size was calculated to be 384 participants. To account for potential incomplete responses, a final target of 420 completed responses was set.

A convenience sampling method was adopted. The survey link was shared digitally through school management systems, educational WhatsApp groups, school email chains, and social media platforms such as Instagram and Facebook education pages, with prior permissions obtained from school authorities.

Inclusion and Exclusion Criteria

Inclusion Criteria

• Students aged 13–19 years currently enrolled in secondary or senior secondary school

• Residents of Himachal Pradesh

• Ability to read and understand Hindi or English

• Voluntary consent provided electronically by both the student and a parent/guardian (for participants under 18 years)

Exclusion Criteria

• Students unwilling to participate or unable to complete the online questionnaire

• Duplicate responses identified through email or IP tracking

Data Collection Instrument

A structured, bilingual (Hindi and English), pre-validated questionnaire was developed and hosted on Google Forms. The questionnaire consisted of four sections:

• Socio-Demographic Profile: Age, gender, grade level, type of school, parental education, and residence (rural/semi-urban)

• Puberty Education: Knowledge of physical, emotional, and psychological changes during adolescence.

• Contraception and Safe Practices: Awareness of contraceptive methods, STI prevention, myths and facts about sexual health

• Sources of Information and Barriers: Students' primary sources of information and perceived obstacles in accessing accurate reproductive health knowledge

The questionnaire was pilot-tested among 30 adolescents (excluded from final analysis) for clarity, cultural appropriateness, and technical functionality. Revisions were made based on pilot feedback.

Data Collection Procedure

An introductory page on the Google Form explained the study objectives, assured confidentiality, and sought electronic informed consent from participants and, where necessary, their parents/guardians. Participation was voluntary and anonymous, with no personally identifiable information collected. Only one response per device was allowed through Google Forms settings to avoid duplication. Students were encouraged to complete the form independently in a private and distraction-free setting.

Scoring and Categorization

Each correct response received 1 point, while incorrect or "Don't Know" responses received 0 points.

The cumulative knowledge scores were categorized into four groups:

•      Very Good Awareness: ≥80% correct answers

•      Good Awareness: 60%–79% correct answers

•      Fair Awareness: 40%–59% correct answers

•      Poor Awareness: <40% correct answers

Sub-domain scores were separately computed for puberty education, contraception knowledge, and safe practices understanding.

Data Analysis

The collected responses were exported from Google Forms into Microsoft Excel and analyzed using IBM SPSS Statistics Version 26.0. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize demographic data and awareness levels. 

Ethical Considerations

Participation was voluntary, and electronic informed consent was obtained from students before participation. Confidentiality and anonymity were strictly maintained throughout the study, and students were assured that their participation or responses would not influence their academic status.

The socio-demographic profile of the 420 participating students  revealed  a  balanced  representation  across age (39.3%), followed by 16–17 years (33.8%), and 18–19 years (26.9%). Gender distribution showed a slightly higher proportion of female students (56.0%) compared to males (44.0%). Regarding educational levels, the largest group comprised students from classes 10–11 (45.2%), followed by classes 8–9 (31.4%) and class 12 (23.3%). In terms of school type, 60.7% of respondents were enrolled in government schools, while 39.3% attended private institutions. The majority of participants (61.9%) resided in rural areas, with 38.1% from semi-urban regions, reflecting a predominantly rural student population in Himachal Pradesh.

Table 1: socio-demographic characteristics of participants

The survey findings showed an overall encouraging awareness of adolescent reproductive health concepts among the students. A large proportion (81.0%) correctly identified hormonal development as the primary change during puberty, and 77.6% acknowledged emotional mood swings as a natural aspect of puberty. Knowledge about contraception was moderate, with 70.2% understanding its role in preventing pregnancy and 79.0% recognizing that condom use reduces STI transmission. Awareness that menstruation is a normal sign of reproductive health was high (82.6%), and 74.8% recognized that puberty onset varies among individuals. Knowledge gaps were noted in areas such as the safety of hormonal contraceptives (61.2%) and HPV vaccination (58.6%). Importantly, 83.3% were aware that unprotected sex increases STI risk, and 84.5% agreed that sex education should be part of the school curriculum. Peer pressure was recognized as influencing risky behaviors by 78.6% of students, while 83.6% correctly identified trained educators as the ideal providers of sex education. Nonetheless, misconceptions persisted regarding condom use and puberty myths, highlighting the need for targeted education interventions.

Table 2: awareness and knowledge of adolescent reproductive health and sex education among participants

Based on the cumulative knowledge scores, 46.9% of students demonstrated a "Good" level of awareness (60–79% correct responses), while 27.6% achieved "Very Good" awareness (≥80% correct responses), suggesting that nearly three-quarters of participants possessed satisfactory knowledge regarding adolescent reproductive health. However, 19.3% were categorized as having "Fair" knowledge (40–59%), and 6.2% had "Poor" awareness (<40%), indicating that a notable proportion of students remain at risk of misinformation and inadequate understanding. These findings emphasize the necessity for enhanced, consistent, and culturally sensitive reproductive health education in schools across rural and semi-urban areas of Himachal Pradesh.
 

Table 3: knowledge score classification

This study provides valuable insights into the current level of awareness regarding adolescent reproductive health and sex education among school-going adolescents in Himachal Pradesh. Given that adolescence is a transformative phase involving crucial biological, emotional, and psychosocial changes, ensuring access to accurate reproductive health information is indispensable for fostering responsible and healthy transitions into adulthood. The findings of this survey underscore encouraging trends in knowledge among adolescents, while simultaneously highlighting significant gaps that necessitate urgent attention.

The socio-demographic profile of participants revealed a fairly balanced distribution across early and late adolescence, with a slightly higher proportion of female students. Most respondents were enrolled in government schools and resided in rural areas, reflecting the broader educational and demographic landscape of the region. This demographic representation is particularly important, as rural adolescents often face compounded challenges—such as limited access to adolescent-friendly health services, entrenched socio-cultural taboos, and misinformation about sexual health—that urban adolescents might be better equipped to navigate.

Awareness regarding physical and emotional changes during puberty was relatively high among participants, with over 80% recognizing hormonal development as a primary change and mood swings as a common experience. This suggests that basic puberty education has permeated adolescent knowledge to some extent. However, the persistent feeling of shyness when discussing puberty topics (reported by 71.9% of students) highlights the deep-rooted discomfort and cultural reticence surrounding open conversations about reproductive health. Such discomfort can lead adolescents to seek information from unreliable or potentially harmful sources.

Knowledge regarding contraception and STI prevention was moderate but leaves room for concern. While 79.0% understood that condom use reduces STI transmission and 83.3% acknowledged the risks associated with unprotected sex, misconceptions persisted about hormonal contraceptives and STI prevention methods. Notably, only 61.2% correctly identified that hormonal contraceptives are safe under medical guidance, and only 64.3% knew that condoms are not the sole method of STI prevention. This partial understanding could lead to inconsistent or incorrect use of contraceptive methods, thereby increasing vulnerability to unintended pregnancies and infections.

Furthermore, the awareness regarding HPV vaccination, which is critical in preventing cervical cancer, was notably low (58.6%), underscoring a major gap in preventive health knowledge among adolescents. Given the increasing burden of HPV-related cancers and the government's efforts to introduce HPV vaccination programs, greater emphasis on vaccine education within school-based curricula is urgently needed.

Encouragingly, there was overwhelming support for formal sex education within schools (84.5%), and a large proportion of students (83.6%) believed that trained educators, rather than peers or untrained adults, should deliver such education. These findings advocate strongly for structured, age-appropriate, and scientifically accurate sex education programs that are institutionalized within the school system, particularly in rural and semi-urban areas. The positive perception toward school-based interventions also signals an opportunity to address and dismantle the stigma associated with reproductive health discussions.

Knowledge score classification further illuminated the state of adolescent awareness: while 74.5% of participants demonstrated either "Good" or "Very Good" knowledge, about 25.5% fell into the "Fair" or "Poor" categories. This vulnerable subgroup is at heightened risk of misinformation, poor decision-making, and adverse reproductive health outcomes. It is critical that educational interventions are not only widespread but also inclusive, ensuring that the most at-risk adolescents—especially those in rural schools—are effectively reached.

Despite the overall positive trends observed, the study has certain limitations. Being an online survey, it may have disproportionately favored students with better digital access, possibly underrepresenting adolescents from more remote or economically disadvantaged backgrounds. Additionally, the self-reported nature of the survey responses may be influenced by social desirability bias, leading students to provide answers they believe are correct rather than reflecting their true knowledge or beliefs.

In conclusion, while there is growing awareness of reproductive health among adolescents in Himachal Pradesh, substantial gaps remain—particularly regarding contraceptive methods, HPV prevention, and overcoming the stigma around reproductive health discussions. The findings call for urgent, systematic, and culturally sensitive strengthening of adolescent reproductive health education through schools, involving teachers, health professionals, and community leaders. A multi-pronged approach emphasizing scientific accuracy, emotional support, and inclusivity will be key to empowering adolescents to make informed choices, safeguard their health, and contribute to a more informed and healthier generation.

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