1.  Introduction 

Nepal is passing through the most crucial phase of its existence. The fragile Nepalese socio economic condition is deteriorating with every increase in the socio-economic casualties in Nepal. Many problems confront us and we are running sort of solutions. The major problems paralyzing us in the social side are the non-awareness on sexual and reproductive health (SRH), lack of quality SRH information and services for the Adolescents and Youths (AYs) followed by the non potent communal action for the prevention of HIV/AIDS to name a few. 

Nepal’s vulnerability to sexual and reproductive health is fueled by poverty, gender inequalities, love level of education and literacy, denial, stigma and discrimination. Though the absolute number of HIV/AIDS cases is still low. There are already “concentrated” epidemics within certain high-risk behavior groups in Nepal. Immediate and vigorous action must be taken now to prevent further spread of HIV among groups at high risk and stop the infection from taking a foothold in the larger population. In Nepal, there are many health problems that compete with in terms of the morbidity and mortality burden they place on the population. But because of the unique clarity with which HIV illuminates societal factors influencing health, it provides an effective entry-point to reveal the deeply rooted societal causes of risk-taking behaviors which, consequently, lead to illness and premature death. 

Adolescence is a life phase in which young people are particularly vulnerable to health risks, especially those related to sexuality and reproduction: HIV/AID, unwanted pregnancy, unsafe abortion, too early marriages and child bearing, sexually transmitted infections, substance abuse, and poor nutrition. Nepal has a high proportion of young people. Adolescents (10-19yrs of age) and youths (15-24 years of age) comprise approximately 22% and 19% of Nepal’s total population. A recent study among unmarried 12-18 yrs old adolescents revealed that 22% of the boys and 9% of the girls indicated having had sex of which 52% and 32% indicated having had sex with more than one partner, while condom use among these sexually active adolescents was 65% for boys and 75% for girls (UNICEF/UNAIDS 2001) 

The status of adolescent in Nepal is poor. They suffer from specific conditions that have more devastating effects such as reproductive health problem, early/unwanted pregnancy, unsafe abortion and STI/HIV/AIDS; psychosocial problems such as substance abuse, delinquency, truancy, sexual abuse, etc. Adolescent Sexual and reproductive health include safe motherhood (prenatal care, safe delivery, and management of problem of pregnancy, postnatal care) access to family planning. Prevention and management of STD includes AIDS, prevention and management of complications of abortion, elimination and harmful practices such as FGC, premature marriage, domestic and sexual violence.  

This module has been prepared specifically for delivery of training for adolescents and youth in Sexual and Reproductive Health Planning. It is aimed at providing a guide for adolescents and youth who have influence on reproductive health of men and women in the community, considering reproductive health from a holistic approach to prevent problems from arising, integrating development into cultural norms and values. This module provides basic explanation on gender to understand the concept of gender and the importance of integrating a gender approach into planning and development spheres. This will assist men, women and families providing positive actions in response to reproductive health problems. The module provides learning objectives, daily themes, session outlines, and handouts. Training sessions take a step approach to learning gender and development from basic understanding of concepts to applying these concepts into reproductive health development and grass root planning frameworks.  

The module will be delivered in a participatory approach so that participants can use the material, or redevelop them to specifically focus on the sexual and reproductive health issues of Nepal. 

2.  Overview 

The research documents retrieved from agencies and libraries has highlighted that despite the high knowledge of issues of sexuality, it has not been followed with the same behavioral change. Condom use and Contraception has increased especially among the school youths. There is still less access of adolescents reproductive health services that are friendly 

There was minimal focus on: 

• Drugs and substance abuse among the youth that impact on their sexual reproductive health
• Life skills
• Adolescent actual participation in planning their programs
• Disabled youth
• Youth in difficult circumstances (conflict areas)
• Adolescent mothers and their children
• Injecting drug user

3.  Facts 

The AIDS epidemic in Nepal seriously threatens the future of the country’s youth. Female adolescents are at high risk of contracting HIV/AIDS because of socio- cultural pressures, including traditional sex behavior, and because of development and behavioral factors, including early initiation of sexual activity in the country. It is estimated 60000 (WHO/UNAIDS 2002) Nepalese are infected with HIV. Among the 2,506 HIV positive cases registered in Nepal, 9% are adolescents 14-19 yrs of age and 54% are young people 20-29 yrs, 27% of the registered HIV positive cases are women/girls, while among the registered HIV positive 14-19 yrs old are adolescents and 64% are girls. 18% of the HIV positive cases are sex workers, while 62% are clients of sex workers and 12% are intravenous drug abusers (NCASC Sep’02). 

Most problems faced by adolescents in Nepal are behavior related. As a result adolescents face many sexual and reproductive health problems that affect their health and development. They include STD’s and HIV/AIDS, early pregnancy, early marriage and childbirth, maternal mortality, and high infant mortality rate. They are also affected by many social problems that lower their quality of life. These are poverty, drug, alcohol abuse, and dropout of education and sexual harassment of female adolescent. To make matters worse they have little knowledge on the risk of unprotected sexual acts – thus unwanted pregnancies; STI and HIV/AIDS are the more obvious and unavoidable consequences. 

Many programs have tried to reach the youth both in rural and urban areas. Strategies used to improve adolescent health included behavioral change., service delivery and the government initiatives. However the coverage is still limited. Some of the districts have not been reached. The programs reach less than half of Nepal’s districts. That means few adolescents are currently reached. Most projects/programs on adolescents reviewed have targeted few districts. Others are based in urban areas and the deep rural areas where majority of adolescents who need the services are left out. 

Health care services are still inadequate. Health centers and hospitals have a lot to be desired. They’re inadequate health supplied such as drugs for STD’s, condoms and contraceptives. Stock outs have been common phenomena in many health centers where adolescents go for treatment. Accessibility of services in terms of affordability is one disincentive for uptake of service. In health facilities, adolescent may not access the services due to financial constraints. IEC materials on RH for adolescents have not been adequate in terms of quantity, quality and types/choices. 

 

4.  Objectives 

1. To enhance awareness on sexual and reproductive health (SRH) and the availability of quality SRH information and services for AYs
2. To improve awareness and assertiveness on gender based violence (GBV) and girls trafficking among female AYs and increase community action to reduce GBV
3. To increase community action for the prevention of HIV/AIDS
4. To enhance capacity of RHI partner NGOs / CB0s to manage and sustain SRH services and information for AYs and activities promoting HIV/AIDS prevention and reduction in GBV and girls trafficking.

5.  Obstacles 

 

There are many risk factors that put Nepal in danger of experiencing a widespread epidemic if immediate and vigorous action is not taken: 

Adolescent Sexuality

The sexual behavior of adolescents has led to increasing rates of STDs, AIDS, pregnancy, abortion, and high rates of maternal and child mortality among youths in Nepal. In Nepal the initiation of sexual activity starts as early as 15-17 years of age with a mean of 16 years. Most adolescent’s sexual activity is unprotected resulting to pregnancy and unsafe abortions. Lack of access to cash and employment opportunities for females resulted in risky sex. For both sexes, it means difficulty accessing condoms and contraceptives, as well as curative health services at local clinics. Adolescent behavior related to HIV/AIDS was affected by multiple factors including economics, gender dynamics and social perceptions. 

Early marriages and pregnancies

Nearly half of 15-19 yrs old adolescent girls and fifth of adolescent boys of the same age group are married (1991 census), and a fourth of the married adolescent girls are either pregnant or already mother of their first child (NFHS, 1996). A large proportion of the adolescents are malnourished, which increases the risk of difficult child birth (NFHS 1996, NMNSS 1998). Children born to adolescent mothers have a higher risk of death. (NFHS 1996). Rates of adolescent pregnancies and childbearing vary inversely with their level of education.  

Males enter into first union at a much later age than females. Early marriages expose adolescent girls to risks of too early pregnancies that results in complications during delivery and eventual poor health. They are at higher risk of obstetric complications since their pelvises are not yet well developed, leading to obstructed and other complications such as prolonged labor, stillbirth, postpartum hemorrhage and maternal distress.  

Limited access to Adolescent/ Youth Friendly Services

Limited access to adolescent/ Youth friendly services and information is another problem affecting adolescents in the bid to have protected sex or postpone sex. Most services in the country are generally offered to all people but adolescents are not accessing the services due to lack of confidentiality and rudeness among service providers, rumors about contraception use and ignorance about the existence of these services.  

Violence against Adolescents

Violence occurring against adolescents in Nepalese society includes all forms of violence, including domestic violence, sexual slavery, prostitution, cross border trafficking of women, incest, and rape. Circumstances leading to sexual abuse included: poverty or economic dependency, indecent dressing, staying with the people of opposite sex in closed places, children left by themselves and those left with other people such as houseboys. 

Girl trafficking

Nepal runs the risk of an increased epidemic due to an active sex trade and high rates of girl trafficking to India for sex work. Estimated 5000-7000 Nepalese girls are trafficked to India annually. Key factors responsible for the high rates of girl trafficking are poverty, lack of economic opportunities for the family and the low status of girl child. The total number of Nepalese girls below 18 yrs of age working as commercial sex worker( CSW) in India is estimated at 60000( ABC/Nepal, 1994). Moreover, out of 25000 estimated female sex workers in Nepal, 5000 are adolescents under the age of sixteen years.( UNICEF 1998) 

Unsafe Abortion

Unsafe abortion is a major problem in Nepal contributing to about 539 deaths per 100,000 live births of which one fifth were adolescent girls (MMM Study, DoHS, 1998). Due to adolescent’s low perception of the risks of unprotected sex, studies have shown that adolescents are at higher risk of complications of unsafe abortion. However, of all deaths that occurred among girls in the 15-19 yrs age group, more than one fourth (27.8%) was due to suicide. Findings of the maternal mortality study indicate that 5.4% of maternal deaths were due to abortion, but this proportion has been estimated to be considerable higher among the adolescent’s maternal deaths. One in five women visiting government facilities for abortion related complications are adolescents (CREOHA 1998). 

High rates of maternal mortality and morbidity have been associated with high rates of induced abortion, increased school dropout, violence and expulsion from home. While knowledge about family planning is high (97%), only 12% of married adolescent girls (15-19Yrs) and 23% of married young women 20-24 yrs of are currently using FP method. Unmet need of FP has been estimated at 36% and 33% for married girls 15-19 and 20-24 yrs of age respectively. Similarly adolescents receive limited care from health workers during pregnancy, childbirth and postpartum. Of the women below 20 yrs of age with a live birth, 60% had received antenatal care at lease once during their pregnancy, while only 18% received skilled care during delivery and less than 10% received postnatal care for themselves and their newborns (DoHS 2001) 

Substance Abuse

Though rarely investigated, substance abuse is not uncommon in Nepal. It is rising in Nepal. It is common among street children and urban city secondary schools. The most commonly used is Marijuana (Cannabis Sativa). There appears to be a close relationship between drug abuse, violence and HIV/AIDS. Habituation and drug addiction is a problem that has multiple devastating impacts on the youth, their health and social structure drug abuse, violence and reckless sexual behavior have a close relationship with consequences of unwanted pregnancies STDs and HIV/AIDS. 

Street Children/Adolescents

Due to civil strife, family disintegration and AIDS epidemic, some children have taken street as a source of livelihood. Street children and adolescents survive through manual labor, carrying loads for business people, stealing; pick pocketing, while girls get involved in sex for survival. Defilement is common among these children. They have suffered a number of diseases such as STDs/ HIV, cough and skin rash. A number of them have become pregnant and many of them have abandoned their children. 

Orphans

As more countries in Asia move from HIV to an AIDS epidemic with corresponding rise in deaths, the number of orphans is rising and will continue to rise steeply. Care of orphaned children in Nepal usually falls to the extended family irrespective of whether the extended family can cope or not. Currently, in most cases, the extended family can no longer afford to absorb this additional burden as they find themselves battling to survive with the current economic hardships that everyone else in the villages faces. Orphans not accommodated into the extended family and looking after themselves and their siblings, children shuttled between relatives all face stigma. Many have to make crucial life decisions without the guidance or support from parents or elders. Poor parenting and socialization, and fragmented schooling affect these children. Further more, even those absorbed, by relatives or members of the community frequently abuse them especially orphaned girls, while others have been turned into child slaves leading to low self-esteem and self-efficacy. The orphan hood situation has been worsened by the death of both parents thus leaving complete total orphans in the family- the child headed households. 

A child living alone in child headed houses is not a new phenomenon though it has become more pronounced in the recent past. Such refers to children between the age of 13-17 years heading families or households. A study revealed that adolescent girls in such households have suffered defilement, or have engaged themselves in early sexual activities for basis necessities at home. 

Why adolescents have persistently practiced unsafe sex and involved in sex at an early age 

The review wanted to find out despite the interventions why adolescents still have early and unprotected/unsafe sex. Data revealed that a number of adolescents are still practicing unsafe sex due to a number of factors. A study revealed that circumstances of first sex by adolescents were varied. They included: to show love to lover, to know how it feels, forced into sex, to be like friends. 

Pressure of early sex

Girls are particularly vulnerable to pressures for early sex. The phenomena of “ sugar daddies” are still prevalent. Older men are persistently enticing young girls into sex for favors/gifts/money. This problem has been exacerbated by the AIDS epidemic where more men are seeking adolescent girls in an attempt to avoid contact with HIV. 

Financial needs

Rampant poverty among adolescents makes it difficult for them to afford some basic needs and also buying condoms in order to avoid having unprotected sex. Poverty is one of the leading problems particularly among the girls. Some of these girls who get involved in sex at an early age are because some lack financial support from their parents and guardians. Parents might not satisfy their daughter’s financial need, which forces their daughters to go out and expose themselves to risks of unprotected sex.  

Cultural issues affecting adolescent in Nepal

Adolescents are being exploited due to the culture of silence in Nepal. They lack a voice in the family and community affairs, and assertiveness when confronted with adults who may entice them into sex has made them more vulnerable. Most of the social mechanisms operate in the principle of cutting off girls’ options and opportunities right from birth. 

Lack of guidance from parents 

Parents are seemed not to be guiding their children with the necessary information while growing up. The breakdown of child-parent communication seemed to be seriously affecting the behaviors and morals of the young people. Lack of parental guidance is one of the possible causes for early marriages and the associated problems of having no career and bearing many children that young people could not afford to look after. The socio- cultural orientation is not favorable to enable parent’s talk to their children on sexual issues yet young people their parents are backward to advise them. 

Peer Pressure 

Peer pressure is a significant force making youth engage in early and unprotected sex. Adolescent engages in unprotected sex because their friends are doing it. Peer pressure motivates many adolescents to initiate sexual activity. Dropping out of school early, force girls to have sex at an early age and hence early pregnancies and marriages. 

6.  Interventions 

A number of stakeholders that include government, international donor agencies, local NGOs and CBOs have come up to work towards the plight of adolescent SRH. Currently interventions include policy developments, behavioral change activities, services delivery and attempts to build AYsRH program management capacity. 

There is need for a coordinating body that brings together stakeholders: Ministers, agencies, NGOs involved in AYsRH to develop more effective intervention strategies to meet adolescent/youths needs in a cost effective and efficient way, to avoid duplication of resources and functions. 

 

7. Policy development and implementation 

• Minimum age for sexual consent has been put to 18 yrs, below that age is regarded as defilement.
• The government has enacted policies to reinforce young people’s health and development.
• Child rights statute developed and disseminated country wide for protection of children including adolescents.
• National population policy put in place.
• National RH service delivery policy guideline.  
• MOH minimum sexual and reproductive health package.

MOH initiatives at the District Level 

One of the roles of the Ministry of Health (MOH) then the capacity of District Health Management team to develop district plans. To this effect a planning guide for reproductive health program should be formulated to assist various planners and implementers at national and district levels to identify and prioritize community and reproductive health service needs. Districts are to plan, implement, and monitor selected interventions to address the identified RH needs in the planning period. The districts have to mobilize and allocate appropriate resources to those cost-effective interventions geared at reduction of maternal prenatal mortality, morbidity, promotion of adolescent and family health. 

8.  Proposed Priority Areas 

1. The Ministry of Health in its efforts to strengthen sexual and reproductive health for adolescents in the country had proposed priority areas that include:

• To organize a district local council sensitization on adolescent health policy
• To conduct a district adolescent health needs assessment
• To sensitize other district leaders on adolescent health needs and how they can be addressed

2. Capacity Building and Training

• To train service providers for adolescent/youth friendly SRH services provision.
• To train peer educators on communication and counseling skills

3. Institutional Framework 

• To set up adolescent/youth reproductive health clubs for mobilization both in and out of school adolescents for life skills and other positive reproductive health behaviors

4.  Information Education and Communication 

• To develop and distribute relevant IEC materials to all RH services delivery points

5.  Adolescent/ Youth SRH Service Delivery

• To establish Adolescent/ Youth friendly SRH services at all delivery points
• To initiate community based recreation activities for adolescents/youths
• To explore avenues of setting up income generating activities for adolescents/youths

6 Monitoring and Evaluation 

• To initiate a process of involving adolescents/youths in planning for their health
• To establish at regular basis the indicators for adolescent/youth health as provided for in the SRH minimum package

9.  Behavioral Change and Services Delivery Interventions 

Various organizations have come up to intervene through behavioral change and service delivery strategies for adolescents. Below an analysis is made of the specific approaches they are using, activities they are engaged in, the constraints, lessons learnt and future plans. 

• Attract adolescents/youths into existing health care facilities
• Provide adolescent/youth friendly RH services in an integrated fashion
• Monitor behavior change in RH service providers
• Track RH service utilization by adolescents/youths
• Emphasize HIV/AIDS as a development issue with continued high-level leadership. The epidemic cannot be tackled through medical/clinical interventions alone. HIV/AIDS prevention and control requires a multicultural approach, involving sectors other than health
• Resource mobilization for scaled up targeted responses to vulnerable groups
• Scale up the advocacy measures and actions for behavioral change activities and health promotion interventions for high-risk behaviors of youths, mobile populations and sex workers.
• Promote condom use in casual and commercial sex
• Strengthen behavioral surveillance to enhance understanding of the extent and nature of STD’s/ HIV, sexual behaviors, and health care seeking behaviors related to STDs/HIV.
• Encourage openness to address risk behaviors and to protect vulnerable populations. Denial and stigma of HIV and groups that are at high risk only hamper prevention efforts
• Care and support for people living with AIDS including widely available voluntary counseling, testing facilities and provisions for preventing mother to child transmission
• Service providers need to be trained for Adolescent/youths friendly service. The training should not only emphasis RH but also other pertinent issues of adolescence such as relationships, hygiene, peer pressure etc
• Adolescent friendly environment should be created to attract adolescents more especially females.
• There is need for programs to address the hard to reach adolescents and get female adolescents back to school once they drop out due to pregnancy
• Sustainability question is important even when the project is being designed. The district, community and beneficiaries if they were involved at the inception period would feel the ownership and may suggest ways of sustaining the program
• HIV/AIDS interventions for adolescents should not only end at giving knowledge; rather attempts should be made to address other psychosocial issues that greatly influence behavior
• There is need for a strategy where NGOs could start fund raising and resurging for funds for their activities given constraints of limited funds experienced
• The environment adolescent live in some times is not supportive. The negative parental, religious, community attitude towards unmarried adolescents seeking RH services is also a barrier to access the services by adolescents.

There has been minimal focus on the following areas affecting AYsSRH :

Adolescents in especially difficult circumstances such as the internally displaced, refugees and adolescents in child headed households.

Teenage adolescent mothers have almost left out in most of the adolescent RH interventions, yet they need to be empowered with adequate information and support.

The emerging trend of drug and substance abuse especially among adolescent boys needs to be thoroughly investigated. The implications of drug and substance on adolescent health need to be ascertained

There has been minimal adolescent participation/involvement in planning for interventions most programs involved adolescents as clients.

Resource mobilization and management is important.

Success of programs e.g. school based may depend on the commitment of other stakeholders at the district, community and school. Sustainability of project may depend on the commitment of the district, communities and beneficiaries.

 

Examples of the mail skill areas necessary include  

Self-awareness skills- Knowledge of what adolescents can or cannot do as individuals, e.g., self-esteem and self-confidence, assertiveness (ability to respond confidently to any situation); and coping skills (for self control and dealing with emotions, stress, etc.).

Interpersonal skills- to facilitate development of healthy relationships with the people around. There include positive ones such as friendship formation, adjustment to society and empathy; as well as negative ones, e.g., resisting unhealthy pressures, negotiating one’s way through difficult life situations, and advocating for change in the most effective manner. Effective communication as well as conflict management and resolution are vital interpersonal skills.

Skills in creative and critical thinking: So as to face the challenges of life; decision-making on the appropriate course of action and problems solving (how to deal with specific problem situations).

Access to Health Services 

Access to preventive and curative services including contraceptives and treatment of sexually transmitted diseases are important in ensuring reproductive health of youths. Access to RHS is the extent to which youth can obtain appropriate reproductive health services at a leave of effort and cost that is both acceptable to and within the means of a large majority of youth in a given population. Access could be in terms of geographical access that includes convenient hours and location, and wide range of necessary services. Economic access involved affordability in terms of cost of the services. Psychosocial access is the perception of privacy e.g. perception that male,. Female, married or unmarried are welcome with confidentiality. Administrative access involves trained staffs who have respect for young people, adequate time for interactions, and youth involvement in design and continuing feedback. 

Contraceptive knowledge, access and use 

The belief that contraceptives are unsafe discourages some intending users. Barriers to practice safer sex practices including contraception were that parents do not wish their children to be exposed to contraception especially condom use. They argued that this would encourage adolescents into more sexual practices. However, adolescents expressed need for contraception 

School health education program 

A school health education program in primary schools to prevent AIDS emphasize improved access to information, improved peer interaction, and improved quality of performance of the existing school health education system will make some impact 

Media

The study found that if messages appear in different media simultaneously (music, television, radio, movies, newspapers, and posters) the campaigns become even more effective 

 

10.  Strategies that should be adopted while implementing the AYsRH 

• A program for attracting adolescents to health facilities, and stimulating their interest to use available RH services will be achieved through the provision of recreational activities at the health units. Educational video shows on RH issues; group and individual counseling; targeted rose-plays and case study; and question/answer sessions.
• A program for training health workers in the provision of youth friendly reproductive health services.
• A program for integrating adolescent reproductive health services within existing health services. This will be achieved by creating adolescent friendly environment, which provides free and unrestricted access to RH care, particularly during the afternoons when most service providers are relatively free.
• Ensuring RH service quality through sustained support supervision and monitoring of service providers by a trained and experienced supervision team. During the process critical service utilization date will be gathered in order to provide feed back thus enhancing project performance
• Sensitize health workers on the needs of adolescents and the need to have friendlier attitude towards adolescents seeking RH services. Establish separate RH services for adolescents. This could be done by having clinics for adolescents on separate days or at separate hours of the day
• Sensitize community members especially the opinion leaders about the needs of adolescents with the view to removing stigma on some of the adolescent reproductive health issues. Parents, as key players in the upbringing children, should be empowered to deal with RH problems among adolescents.
• Prevention efforts should be targeted towards the younger adolescents/youths through the parents on the Speak out Teen show.

11. Conclusion

There are no services in a number of districts specifically designed for adolescents due to inestimable obstacles, augmented by some negative characteristics of our Nation. However, various service providers in the district both government and private had a component for adolescent health services in their programs. Providers of adolescent services in the communities included drug shops, teachers, health workers, and community resource people among others. But the irony is that adolescents rarely utilize government health facilities because of inaccessibility due to distance, poor reception by health workers, lack of drugs at the health unites, and lack of financial support leading the otherwise good plans into total disarray.