A cross-sectional questionnaire based survey was conducted over period of six months from August 2018 to February 2019. For an education based survey, with a population of 20,000, using a confidence interval of 99% with 10% margin of error, a sample size of 166 would be required. To allow for possible dropouts and missing data, a sample size of 200 was selected. The population may be representative of educated Indian youth belonging to middle and high socioeconomic groups. Institutional Ethical Committee clearance was obtained before the initiation of the study. (IEC:333/2018). Participation was voluntary and digital informed consent was obtained from all the study subjects after administering participant’s information sheet.

Inclusion and exclusion criteria: Current students (with an email address registered with the university) enrolled in any undergraduate or post-graduate studies of age between 17-26 were included in the study. ‘The mail list for recipients was obtained from the University student centre. Simple random sampling’ technique was used to select participants. Ex-students and students not yet enrolled were excluded from the study.

The questionnaire was partially based on previous literature [9,10] with major modifications to simplify the questionnaire. The domains insight and attitude were scored based on the level of response, with scores 10, 5 and 0 for good, fair and poor level of knowledge, respectively. The questionnaire was designed and consultations were sought with a group of five physicians with expertise in the field of gynaecology and public health and tested for content validity. To ensure that the questionnaire was easily comprehendible, we applied the questionnaire to 50 student volunteers prior to the study. During the pilot study, modifications were made to improve the face validity. The students were observed completing the forms online and interviews were conducted to ensure the questionnaire was easily understood. The questionnaires were repeated two weeks later to see the test-retest variation in the sample of population, the mean scores were not statistically significant from zero. Internal consistency was measured by Cronbach’s alpha, which measured at 0.61, 0.7 and 0.72 for domains insight, attitude and preference respectively.

The study required the research participants or the subjects to fill the questionnaire that contains 10 questions along with basic demographic data. Each of the 10 questions were specific and precise, directed towards five main domains: ‘insight’, ‘attitude’, ‘preference’, ‘reason’ and ‘suggestion’. Insight was defined as the capacity to gain understanding of reproductive health and Attitude was defined as the individual’s approach towards reproductive health care. Preference was based on categorical responses of web vs non-web sources of information [11]. This study is not a Knowledge Attitude and Practice (KAP) study and only attempts to look at the overall prevalence of student’s positive insight and attitude, the study was not aimed at analysing practices and barriers of sexual health.

The questionnaire consisted of ten questions, three belonging to the domain of insight, three in attitude, two in preference and one each for reason and suggestion. The questions for reason and suggestion listed the possible answers as options and with an extra space for other opinions. The open ended question for opinions was not part of the analysis. All the domain related questions were closed ended. Such a simplified questionnaire ensured 100% response rate and no missing values. The participants were the students who were approached after their classes in university campus. The questionnaire was administered online after obtaining a digital informed consent. After the data collection, an educational PowerPoint presentation was shared regarding sexual health awareness. Misconceptions of the participants on sexual and reproductive health issues were addressed and their doubts were cleared. After the completion of the study, the results were mailed to all the participants individually on the mail id’s that were registered.

The data collected was entered into SPSS 20 software. Each domain was analysed and descriptive statistics were calculated. Demographics of the students such as age and gender were considered as independent variable for subgroup analyses. Descriptive statistics were used to calculate frequencies and the mean scores were compared using student’s t-test.

The domain of insight had three questions with three degrees of response. The responses were given scores of 10, 5 and 0 based upon the degree of insight. Similarly, the domain ‘attitude’ had three questions and responses were given scores accordingly. The domain Preferences had no scoring and was analysed according to the categorical response. Factors and suggestions were analysed in terms of individual response.

The questionnaire that was administered in attached as [Annexure-1]. Out of 200 participants, 101 (50.5%) were males and 99 (49.5%) were females. Mean age of male was 21±2.89 and female was 20±2.79. The participants were grouped into: a) less than 21 years age- 154 (77%), and more than 21 years age- 46 (23%); b) Science students-130 (65%) and Non-science students- 70 (35%); c) Sexually active-99 (49.5%) and Sexually Non-active-101 (50.5%).

Questions 1, 2, 3 were used to assess insight. Mean scores obtained by the respondents in question no. 1 was 6.66±3.53, with 46.5% students responding positively regarding the importance of contraception.

Mean scores obtained by the respondents in question no. 2 was 7.63±3.71 with 67.5% having insight on the matters of unwanted pregnancy. Question 3 focussed on insight into the matters of sexually transmitted diseases, students attained a mean score of 8.38±2.73 while 71.5% of students had adequate awareness of its importance.

Insight was found to be better in individuals >21 years. of age. Females showed better knowledge than males. Education was also found to be significant factor as students of science courses were found to have better insight than non-science students [Table/Fig-1]. There was no statistically significant difference in results between sexually active and sexually inactive students.

Questions 4, 5 and 6 were directed at attitude. Attitude here is depictive of students’ approach to the idea of sexual and reproductive health as a social topic and their perception of health care.

Question 4 reflects the attitude of students to sexual health at a community level. Mean scores obtained by the respondents in question no. 4 was 8.1±3.06 with 69% respondents showing fairly good attitude. Question 5 and 6 reflect on students’ perception towards health care and their trust in doctors. About 77.5% respondents believe health care professionals to have better knowledge than internet whereas with mean score of 4.78±2.41 about 76.5% of respondents believe that information on web can be reliable sometimes if not always.

On comparing, the attitude between different demographics, it was significantly better in individuals above 21 years of age and was better in females as compared to males [Table/Fig-1].

Questions 7 and 8 were used to reveal the source of students’ first-hand information in reality, irrespective of their insight and attitude. Preferences were found to vary among participants of different age, gender and education. Presence of active sexual practices were also found to influence the choice of first-hand information. More than half (54.5%) of <21 years of age participants preferred internet over healthcare as first choice. Similarly, males (39%), Science students (50.5%), and sexually inactive (39.5%), had internet as first preference in seeking sexual or reproductive health related advice. The data obtained is depicted in [Table/Fig-2,3], respectively.

Participants were asked why they think people of their age group prefer to go to internet first before going to a health professional for sexual or reproductive health related issues. About 59% of respondents believe that privacy issues and the fact that confidentiality of their problem as well as their identity is maintained which is violated if they visit a consultant, 30% find it more convenient whereas remaining 11% find it time saving to refer on internet rather consulting a physician in person.

Last question was an open ended question where participants could choose multiple answers and give other suggestions. Many of them (32%) believed maintaining a good doctor patient relationship can ensure more visits to a health professional. They suggested that the physicians should be sensitive towards their complaints and hear them without forming an opinion about them. Another suggestion that was given, though was out of context to sexual/ reproductive health but was a significant factor. The amount of time spent in waiting room in OPD’s make them turn to a quick consult online.

This study investigated insight, attitude, preferences and barriers to receive professional help regarding reproductive health in educated Indian youth. In India, only 15% of young men and women have been reported to receive sex education and thus have a greater risk of approaching unethical and unreliable resources which makes them vulnerable to unsafe sex and unhealthy sexual practices [12].

As in this India, insight was also found to be less in <21 years. age participants and the ones in Non-science courses. This suggests the need to introduce sex education in university curriculum for students of all the degree courses to promote sexual health.

Attitude of <21 years was poor as compared to >21 years participant. This can also be explained on the basis of lack of knowledge as one’s behaviour is guided by what they perceive [13]. Attitude was also found to be better in females. However, recent female health programs that are running in India might be the reason for females to be more aware and attentive for their reproductive health.

The participants were also interviewed about their preferences. About 71.5% of participants who were <21 years prefer to go to internet rather than seeking help from professionals. This data was consistent with other studies as they also reported only approx 36% of young people seeking sexual and reproductive health services [14]. In a cross-sectional study, young people were found to be more involved in seeking informal health care specifically for sexual health related issues. Similar to the present study, it also stated that females seek formal health care for sexual and reproductive issues more frequently than male. The author explained that natural preoccupancy of females to menstruation and contraception issues, tend to be the cause of their frequent visits. Whereas culture of self reliance in males is the reason for them to seek informal health care [15].

On asking about the factors that influence them to search information online, 59% responded privacy to be an issue, 30% participant’s concern was convenience whereas remaining 11% find it to be time saving. Some previous studies also found same barriers [15,16]. As for majority of participants, privacy was the main concern, thus there is a need to sensitise health care professionals and make them comfortable with the sexual health matters so that the young girls and boys are not embarrassed while visiting them for consult.

Health of young people could be improved by providing accessible, acceptable and affordable sexual and reproductive health services, as also highlighted by The World Health Organisation (WHO) and the International Conference on Population and Development (ICPD) [17].

India has introduced reproductive programs through Reproductive and Child Health (RCH). The adolescent reproductive health is addressed by Adolescent Reproductive And Sexual Health (ARSH) program by ministry of health and family welfare [18]. Birth rate in the age group of 15-19 years is still 31.5% with an increasing trend of first pregnancy despite great efforts and focus on adolescence reproductive and sexual health [19]. This could be explained by the uneven approach of program and also to the fact the younger generation relies on internet for sexual advice which is not 100% accurate as seen in the present study. The adolescent clinics are mainly incorporated with primary health centres and access to it is not prevalent among urban youth [20].

The health care seeking behaviour of educated Indian youth was only considered, whereas uneducated or less educated sections were not involved. The health care, in general, is neglected by theses demographic groups, thus it is important to assess their behaviour too. So future studies can be done conducted involving diverse demographic groups to get a deeper insight on the subject. Another source of error could be due to participants not being truthful about their responses.

Informal Health care seeking behaviour is prevalent among the students, younger students and Non-science students are more likely to seek web-based sources than formal health care. Attitude was fairly good when it came to sexual health at community level.

The detailed analyses of behaviour of educated youth suggested that though they are more aware of the topics that were once forbidden or stigmatised, but the real concern is how accurate or relevant their knowledge is?. Also, the health care setting needs to be friendly, non-judgemental and confidential so that students can approach them in confidence rather than compromising their health by relying on information which is irrelevant and can adversely affect their wellbeing. There is also a need to introduce the sexual and Reproductive education at school level as well as a part of college curriculum.