Adolescent's Health Needs in Aran Bidgol city in 2015-16: A Cross-Sectional study


 BackgroundPaying attention to the health of adolescents, especially girls, is one of the Millennium Development Goals and one of the missions of the member countries of the World Health Organization. Considering the importance of the health of this age group and that the first step in designing a comprehensive health plan is to assess the needs of the target group in the community, so this study was conducted to determine the health needs of adolescents in Aran and Bidgol in 2015-16.MethodThis cross-sectional study was performed on 497 students of 12-18 years in Aran and Bidgol in 2015-16. The data collection tool used in this study is the Adolescent Health Needs Questionnaire which is a psychometric instrument in accordance with Iranian culture. Data were analyzed using SPSS software version 16 (IBM, Armonk, NY, USA) with the help of descriptive statistics and Chi-square test.ResultsParticipants in the study were 53.30% girls and 46.70% boys. The mean score of students' health needs in order of priority included nutrition (22.09±3.80), physical activity (10.19±2.90), health education services (64.30±15.90), healthy communication with parents (44.60±7.60), personal hygiene (21.10±2.71), mental health and counseling services (52.50±7.90) and spiritual health (21.90±3.70). ConclusionAccording to the results of this study, it is suggested that educational programs and interventions be designed and implemented in schools in order of priority to address the needs in various areas such as nutrition, physical activity, and healthy communication with parents, personal hygiene and spiritual health.

provide care services to them and leads to the health of adolescents and the promotion of community health [5]. Needs assessment is in fact the cornerstone of health promotion programs. Needs assessment can be considered as a way to identify health needs as well as presentation of suggestions for actions that be able to meet such needs [6]. Explaining adolescents 'health needs begins with exploring health priorities from their own perspective and can be combined with the experiences and perspectives of other aware sources of adolescents' health needs [7].
There has been little research on adolescent health, and what is mostly available is information about measuring awareness and beliefs about the phenomenon of puberty with quantitative perspectives and methods. A study by Mohammadi et al. on Iranian adolescents in 2006 showed that their in-depth knowledge about reproductive and sexual health and sexually transmitted diseases was limited and misconceptions were widely seen about the dangers of unsafe sex and its consequences [8]. A study on [12][13][14][15][16][17][18] year-old Chinese students shows that there is a lack of appropriate information on puberty issues [9]. In a study by Afshari et al., it was found that girls' awareness of puberty, menstruation and fertility is low and the greatest need felt by girls is related to sex and menstruation [10].
Due to the different health needs of adolescents in each region due to its cultural background and social structure and the importance to pay attention to the health needs of adolescents due to the vulnerabilities of this age group and the research gap in this eld, researchers to conduct a study to determine the health needs of adolescents in Aran and Bidgol in the year 2015-16. It is hoped that the present study can take a step towards promotion nowadays health and country's future of the future makers of the country.

Materials And Methods
This cross-sectional study was performed on 947 high school students in Aran and Bidgol in 2015-16.
The sampling method was clustering. First, a list of all 53 high schools in the city was prepared. Then, based on the population covered by them, the number of schools in each area was determined and the schools in each area were selected at random. In the next step, according to the population of students in each school, the number of students that should be selected from each school was determined. Then, the proportion of students in each grade was determined and the students of each class were selected randomly. If each student was eligible to study and wanted to participate in the study, a questionnaire would be completed for them. Considering the number of 6321 students in the high school, the sample size was obtained using Cochran's formula and with 95% con dence, the sample size was 465 people, who nally entered 500 people by predicting possible defects in completing some questionnaires.
The data collection tool consisted of two parts: the rst part included students' demographic information and the second part was the questionnaire of health needs of adolescents in the high school. This section was a psychometric instrument in accordance with Iranian culture, which was designed by Shah Hosseini and her colleagues in 2010 [5]. This questionnaire had 65 items that addressed the health needs of adolescents in the areas of personal hygiene (5 questions), nutrition (6 questions), physical activity (3 questions), mental health and counseling (15 questions), healthy communication with parents (12 questions), school health education (19 questions) and spiritual health (5 questions). Answers were selected based on the Likert scale, 5 points, which were determined after calculating the sum of scores and the difference between the desired and existing needs in each area. Scores of every area was computed in percentage according to following formula. Need priority was done [11].
Score of every area in percentage = Sum of achieved scores * 100/ (Maximum Score-Minimum Score) Due to the approval of the questionnaire in Sari and possible cultural differences, the content validity was used to con rm the validity, so that after obtaining the opinions of 15 faculty members of Kashan University of Medical Sciences and experts with knowledge and experience in the eld of adolescent health, its validity was con rmed. Also, to determine the reliability of this questionnaire, the bisection method was used, so that rst the questionnaire was completed for 40 students, then questionnaires were randomly divided into two parts and the correlation coe cient was obtained between two sections (r=0.73). Data were analyzed by SPSS16 software (SPSS Inc., Chicago, IL, USA) and using descriptive and comparative statistics.

Results
53.30% (265 people) of the study participants were female students and the rest were male (46.70%). The age range of the subjects was 12-18 years and their mean age was 15.08±1.59 years. The present study showed that 51.50% (256 people) of the adolescents were in the rst year of high school and the others were in the second year of high school. The 77.1% of the students lived in the city and the rest in the village. The education of the 65.8% of mothers and 61.2% of fathers was below the diploma level. The average scores of adolescents are given in the eld of health needs in different areas in Table 1. Based on the difference between the scores obtained and the percentage of scores obtained, the health needs of the adolescents were prioritized, which is shown in Table 2. The mean of scores obtained in the items of each area are given separately in Table 3.
In terms of personal hygiene needs, the lowest score is related to the items "I sleep at least 8 hours a day" and "I brush my teeth every night", in the eld of nutrition, the items are "Free food is given at school" and "My food looks decorated", in the area of physical activity, the items "I have restrictions for outdoor sports (cycling, walking, ....)" and "I have access to healthy sports facilities", in the eld of mental health, the items "My counselor blames and ridicules me" and "If I go to the counselor, others will misjudge me" "They discriminate" and "My family tells my secrets to others", in the eld of health education services, the items "Special education are provided for adolescents under domestic violence" and in the eld of spiritual health, the items "Religious matters are told to me with reason" and "I am presented with a beautiful manifestation of religion" and "adolescents needed more in these areas".
Chi-square test showed that the status of personal hygiene needs of adolescents by gender was signi cantly different (P = 0.030); so that the personal health needs of male students were signi cantly higher than female students (19.00% vs. 12.50%). The status of personal hygiene needs of adolescents according to location showed a signi cant difference (P = 0.003), So that the personal hygiene needs of adolescents living in rural areas were signi cantly higher than students living in urban areas (24.60 vs. 12.80%). Based on the results of the study, the status of students 'personal hygiene needs did not show a statistically signi cant difference in other related factors (age, level of education and parents' occupation) (p>0.05).
The results of this study showed that the nutritional needs of 48.90% students were moderate and only 5% of the adolescents in the study reported high nutritional needs and 46.10% of them had lower nutritional needs. The results of chi-square test showed that the nutritional needs of adolescents had a statistically signi cant difference (p =0.005) according to their place of residence, so that the nutritional needs of adolescents living in rural areas were signi cantly higher than adolescents living in cities (7.90% vs. 4.20%). The nutritional needs of students did not show a statistically signi cant difference in other related factors (age, gender, educational level, education and parents' occupation) (p>0.05).
48.10% of the students had assessed their needs in the eld of physical activity as moderate and only 33.60% of them stated that their needs in the eld of physical activity are low. There was a statistically signi cant difference (P <0.001) in the status of physical activity needs in the adolescents at different ages, the need for physical activity of students aged 12 to 14 years was signi cantly higher than the ages of 15 to 18 years (44.60% vs. 32.40%). There was a statistically signi cant difference (P = 0.003) in the physical activity needs related to location, the need for physical activity of students living in rural areas was signi cantly higher than students living in urban areas (27.20% vs. 15.70%). Based on the results of the study, the status of meeting the physical activity needs of students in other related factors (gender, place of residence, education and occupation of parents) did not show a statistically signi cant difference (p>0.05).
Only 19.40% of students stated that their mental health and counseling needs are low and the majority of them (80.60%) reported their counseling needs as moderate and high. Based on the results of the study, the status of students 'mental health and counseling needs in related factors (age, sex, place of residence, education and parents' occupation) did not show a statistically signi cant difference (p> 0.05).
The need of the majority (84.10%) of students for healthy communication with parents was moderate and high, and only in 15.90% of them, the needs for healthy communication with parents were low. There was a statistically signi cant difference (P <0.001) in students' need for healthy communication with parents according to gender. The need for healthy communication with parents in female adolescents was signi cantly higher than male adolescents (38.50% vs. 22%). Based on the results of the study, the status of healthy communication needs with parents in other related factors (age, educational level, place of residence, education and occupation of parents) did not show a statistically signi cant difference (p> 0.05).
The needs of the majority (75.20%) of the students in the eld of health education services at school were moderate and high and only in 34.80% of them the need for health education services at school was low. There was a statistically signi cant difference (P <0.001) in the needs of health education services in school by gender. The need for health education services in schools in female adolescents was signi cantly higher than male adolescents (18.50% vs. 9.10%). The status of health education needs in school did not show a statistically signi cant difference in other related factors (age, educational level, place of residence, education and occupation of parents) (p> 0.05).
The needs of the majority (80.10%) of students in the eld of spiritual health were low and 19.90% of students stated that their needs in the eld of spiritual health are moderate and high. The situation of adolescents' needs for spiritual health was statistically signi cant (P = 0.01) based on age; so that the need for spiritual health in adolescents over 16 years of age was signi cantly higher than adolescents of other ages. The status of spiritual health needs in school did not show a statistically signi cant difference in terms of other related factors (gender, educational level, place of residence, education and occupation of parents) (p> 0.05).

Discussion
According to the results of this study, the necessity of adolescents' needs in different areas in terms of priority was as follows: nutrition, physical activity, health education in schools, healthy communication with parents, personal hygiene, mental health and counseling services and spiritual health. Although the results of the study indicated that the students felt less need in the eld of personal hygiene, but in most areas they reported a high need. Moeini et al. (2013) also achieved the following 6 areas to promote health-related behaviors in high school students: physical activity, health responsibility, self-ful llment of nutritional behaviors, social support and stress management [12]. Shah Hosseini and colleagues about the health needs of girls reported importance of the role of the family in health needs and raised the need for emotional support of the family, the need for responsible and informed parents and the need for freedom under family supervision [13].
In accordance with the results of this study, communication between parents and children [14], healthrelated educational needs [5], personal hygiene, sleep and rest [15], spiritual health [16] are some important issues need to be followed up in adolescents. Therefore, it is suggested that comprehensive planning be prepared according to the diverse needs of student adolescents.
According to the results of this study, meeting the needs of students in the eld of personal hygiene in the item "adequate sleep" was not desirable. In the study of Nejat et al., adequate sleep and rest were among the physical needs of adolescents [15]. Adequate sleep in adolescents can affect various aspects of their growth and development. There are many factors that can disrupt normal sleep in them, including age, gender, personal characteristics, nutrition, anxiety, exercise, stress, environment, etc. [17]. It is necessary to make more effective planning to improve the lifestyle of families.
In this study, it was found that the needs related to personal health were better and more met in girls than boys and adolescents living in rural and deprived areas had more unmet needs in this area [16,19]. In the family than boys at younger ages and adolescence, it is suggested that more attention be paid to the implementation of effective interventions in boys' schools and rural areas.
According to the results of the study, the nutritional needs of the majority of students were moderate to low. Breakfast, meat and legumes, dairy products and fruits and vegetables were more common among teenagers, and students needed free school meals and decorated food. In the study of Jalalinia et al., it was found that the adolescents were aware of the importance of nutrition but did not do well in choosing the appropriate diet [18]. The presence of students from morning to afternoon in school, which includes at least two meals, is a great opportunity that principals and o cials improve students' nutritional needs; because assimilation with peers affects the health behaviors of adolescents [19]. There are more unmet nutritional needs in rural areas, and it is necessary to pay more attention to schools in deprived and rural areas.
According to the results of the study, inadequate activity and low mobility were more common in adolescents living in rural areas. Adolescents in this study stated that they need to remove restrictions on sports such as cycling, walking, etc. outside the home. Given that sedentary behaviors and low levels of physical activity (watching TV and computer) can affect obesity and subsequent problems in adulthood [20], and the need that adolescents felt, centers can be equipped for riding and exercise for girls and boys to increase their level of physical activity in order to modi cation weight and prevent further complications.
According to the results of this study, the majority of adolescent students had many unmet counseling and mental health needs. According to them, programs and the provided trainings should have group counseling, and the appropriate and non-judgment approach of the counselor. Various studies have emphasized the existence of counseling needs of adolescents such as counseling for puberty problems, appropriate educational methods and appropriate educational content [5,21,22]. The results of the study of Mirzaei et al. indicated that adolescents in the eld of various physical, psychological, educational and social problems during puberty need counseling and educational services. They have suggested that hours of the week be devoted to counseling students by experts in the school [23]. The study of Sepehr Manesh et al. showed that about 10% of high school adolescents in Kashan were suspected of mental disorder and therefore considered it necessary to activate school counseling centers [24]. It is suggested that this category be one of the rst priorities of planning and care in adolescents and given that physical and mental health problems are usually affected by each other, provide services related to these two areas together and referrals and feedback. In addition, according to the request of adolescents is necessary that counselors receive the necessary training on the basics of communication with trust and con dentiality.
The majority of adolescents in this study believed that their parents needed to pay more effective attention to adolescents. They believed that their parents were not good con dant for their secrets and did not treat their children fairly. They did not consult with their parents and needed their parents to devote more hours to them. As stated in other studies, there were signi cant differences between the views of adolescents and parents regarding communication problems in the areas of independence, sexual maturity, personality, mental health assurance and identity acquisition [14]. A study has shown that 38% of adolescents have a stressful relationship with their parents [25]. It is suggested that o cials pay more attention to the implementation of educational programs, counseling, and intervention for the parent and the family relationship. In addition, although some studies have pointed to the weaker relationship between boys and parents than girls [14], but in this study, girls mentioned more unmet needs than boys and wanted to communicate more effectively with parents, so perhaps cultural considerations in region has led to such a difference, so it is recommended to conduct speci c studies in this area and design programs based on the needs of girls.
The results of this study showed that the educational needs of adolescents in school are not adequately met and the majority of them recommended education in the areas of mental disorders, sexual health, adverse effects of friendship with heterosexuals, puberty health, personal hygiene and the internet. The rate of high-risk behaviors of students, especially in the areas of unintentional injuries, smoking, sex, inactivity and poor nutrition has been signi cant [26]. The need for appropriate educational content in the elds of reproductive health, life skills and prevention of high-risk behaviors along with appropriate educational methods, improving media performance and social media participation to educate adolescents and families has been emphasized in another study [5]. The results of the present study also showed that the educational needs of girls were underestimated. This result con rms the study of Ali Moradi et al. who examined the challenges of girls 'health education during puberty and identi ed many problems in the eld of girls' lack of knowledge [22].
According to the results of this study, the needs of students in the eld of spiritual health have been met to a large extent, and some of them stated that it is necessary for religious issues to be explained to them with reason and a beautiful manifestation of religion to be provided. Shah Hosseini et al. found that concepts such as reliance on God, the need to do homework as inner peace, the need for God as a refuge, and the recourse to imams in adolescent girls were important [27]. Fabricator [28] also found that religiosity plays a mediating role in times of stress and alters the relationship between stressors and mental health. Zeighami et al. [16] in their study stated that the promotion of hopeful resources such as strengthening the spiritual dimension and hope therapy seems necessary in adolescents to improve their mental health.

Conclusion
Based on the results of this study, it was found that adolescents in all areas of nutrition, school health education, physical activity, mental health and counseling, personal hygiene, healthy communication with parents and spiritual health have many unmet needs. It is necessary to design and perform comprehensive schedule with cooperation for all bene ciaries including teenagers, teachers and parents. With regards to the cultural context of each society and socio-economic conditions, the needs are different and also change over time, it is appropriate to design research programs in o ces and related organizations to be updated in regular intervals and teenagers' needs are applied in programs.   Specialists and psychologists are invited to the school.