COVER STORY (Spotlight Weekly)

Looking For Their Own Space

The youth and adolescents make up nearly one-third the country's population. But there are no specific programs to address their needs and concerns. The government and civil society need to work out a functioning strategy before it is too late

By BHAGIRATH YOGI

"Governments, in collaboration with non-governmental organizations, are urged to meet the special needs of adolescents and to establish appropriate programs to respond to those needs. Such programs should include support mechanisms for the education and counseling of adolescents in the areas of gender relations and equality, violence against adolescents, responsible sexual behavior, responsible family-planning practice, family life, reproductive health, sexually transmitted diseases, HIV infection and AIDS prevention."

- Program of Action, ICPD, 1994

Sanu Gharti (not real name), a resident of Laxmipur VDC in Dang district, delivered two babies, both dead, with the help of a traditional birth attendant at her house in July this year. She had been married only a year ago at the age of 15. She did not consult a physician when she was pregnant and did not know about the complications. Forced to become a mother at a tender age, she is yet to come out of the trauma she recently suffered. She doesn't know what adolescence really means.

Thousands of girls like Sanu become mothers in Nepal even before knowing the meaning of motherhood. According to current estimates, people in the adolescent and youth age group in Nepal constitute about 31 percent of the total population.

Adolescence is a period of transition from childhood to adulthood. These are the formative years when most physical, psychological and behavioral changes take place. These years are also a time of preparation for greater responsibilities, a time of exploration and widening horizons, and a time to ensure healthy all-round development.

There are approximately 1.5 billion young people between the ages of 10 and 24 years worldwide. Of them, four out of five live in developing countries. Young people are defined as people in the age group of 10 to 24 years, which includes pre-teens and teenagers (age 10-19 years) and young adults (20-24 years).

Problems that adolescents in Nepal often encounter include poor nutrition, early marriage, early and unwanted pregnancy, abortion, sexually transmitted diseases (STDs) and HIV/AIDS. Often these issues are compounded by social problems such as illiteracy, school drop-outs, child labor, and sexual abuse including girls trafficking and prostitution.

Though the literacy of youth population has increased over the years, among the male youth, the percentage of those who have never been to school ranges from 17 percent in the age group 15-19 to 24 percent in the age group of 20-24 years. Corresponding figures for females are 50 percent and 67 percent respectively.

Studies say that during the last 40 years, the youth population has increased by 2.03 percent per annum and is expected to increase by 1.88 percent per year in the next 40 years

A 1962 law set the minimum marriage ages of 14 years for females and 18 years for males. A later revision changed the minimum ages to 16 and 18 years respectively, with parental consent. Without parental consent, the minimum ages are now 18 for females and 21 for male. However, age at marriage ranges from a low of 15.1 years to 23 years in the 75 districts of the country.

As per the recommendation of the Population and Development Committee of the Parliament, the government has proposed a bill to raise the age at marriage for girls at 18 and for boys at 21 without the consent of their guardians. But experts say, in Nepal's context the age at marriage for boys has gone up while that for girls is still low, thereby leading to huge spousal age difference. "In order to reduce age difference between spouses and help better fertility planning, the age at marriage for both girls and boys should be fixed at 22 years in Nepal,"says Dr. Ram Hari Aryal, a population expert and joint secretary at the Parliament Secretariat. "At the same time, making girls education compulsory has become urgent to raise the age at marriage of the girls."

Knowledge about sexual maturity and sexual health among adolescents was found to be inadequate in a study conducted last year in two schools in Kathmandu valley. 65 percent of the girls did not know what is happening when experienced the menarche.

Risks to the young females

Studies say childbearing at young age doubles the risk of death by pregnancy-related causes. Hospital-based studies in Nepal have suggested that illnesses such as pregnancy-induced hypertension and anemia were associated with teenage pregnancy. The Nepal Family Health Survey (NFHS, 1996) showed that 32 percent of the girls surveyed had discontinued school after getting married. Early childbearing has had a number of adverse impact upon a girl's physical and mental health.

The NFHS also revealed that Neo-Natal Mortality Rate is 73 percent more among infants of mothers aged 15-19 years compared to mothers of 20-29 years.

"Early pregnancy and childbearing are associated with less education and lower future income for young mothers,"said Prof. Dr. Ramesh Kant Adhikary of Kanti Children's hospital, in his paper presented at the international seminar on adolescents (Nov. 1-4, 2000) in Mumbai. "Programs that would keep girls in school longer will contribute by delaying marriages. Those adolescents who delay marriage and childbearing beyond the age of 20 years will benefit by completing their growth so that their pregnancy later does not put them and their babies to the risk of nutritional deprivation."

The Nepal Adolescent and Young Adult (NAYA) study, conducted with the support of USAID, has found that poverty was a primary contributing factor to leaving school for boys as well as girls, though marriage was not the motivating force for boys.

"Girls should get married only after age 20. But the majority of girls in Nepal get married before that,"said Dr. Saraswoti Padhe, director, Maternity Hospital, Thapathali. "The main thing is raising the level of education and public awareness. People should be persuaded to give up the sentiment that they can get rid of their responsibility by marrying off their daughters early."

Studies show that 50 percent of girls in Nepal are married before the age of 18. Early childbearing follows early marriage, usually within 18 months. Infant mortality for mothers aged 15 is twice that for mothers aged 25.

Out of more than 200,000 patients who visit TUTH every year, nearly 14,000 (or, 26 percent) are adolescents. Similarly, out of 95,000 patients who visit the Maternity Hospital every year, nearly 20 percent are adolescents. But very few seek counseling or other services.

Given that young people do not tend to use existing reproductive health services, specialized approaches must be established to attract, serve, and retain young clients. From young people's points of view, they face many barriers to service use, including laws and policies that may restrict their access to affordable services and useful information, embarrassment at being seen at clinics, fear that confidentiality will not be honored, and concern that staff members will be hostile and judgmental. Many operational barriers also exist, such as inconvenient operating times, lack of transportation, and high cost of services.

Though there is an ëAdolescent Corner' to provide services to the young adults at the Maternity Hospital, almost no one visits the center, perhaps because of lack of information.

Dr. Rajashree Jha, assistant professor, Department of Obstetrics and Gynaecology, at the TU Teaching Hospital says young people will not access health services unless there are special outlets for them. Clubs or counseling centers should have provisions for disseminating correct information to young people in a friendly environment because they want privacy and confidentiality. "Well-trained young people themselves can be mobilized to disseminate such information. Both school and post-school education has to be provided to this segment of population,"says Dr. Jha.

Giving correct information to the young population has become urgent as they are getting contradictory and often-wrong information from television, newspapers and books. Moreover, because of improving nutritional status, children are growing quite early and fast. "The age of menarche of girls in Nepal has come down by one year from 14 to 15 years three decades ago to 13 years now. This means there is a greater need of providing them with correct information as early as possible, says Dr. Padhe.

Peer Group members at the FPAN/RHI-run Youth Information Center in Dang : Discussing their concerns

Adolescence is a period of life when young people notice changes in their body and mind. They want to experiment with new things and are likely pick up habits like smoking, alcoholism, drug abuse and visiting prostitutes. They find themselves under media and peer pressure to grow fast and behave like adults. They are also likely to suffer from sexual abuse within the house, school or at the workplace.

As busy parents find little time to talk to their growing up children and share their views, they tend to give more and more time to televisions and obscene Internet websites. In such a situation, it is only a matter of time before they pick up the wrong habits. "So family members and parents need to give more time to their children. The counseling should start at home."

ICPD Program of Action

The Program of Action adopted by the International Conference on Population and Development (ICPD) in Cairo in 1994 accepted that existing reproductive health services needs of adolescents as a group have largely ignored the reproductive health. The response of societies to the reproductive health needs of adolescents should be based on information that helps them attain a level of maturity required to make responsible decisions. In particular, information and services should be made available to adolescents that can help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility. This should be combined with the education of young men to respect women's self-determination and to share responsibility with women in matters of sexuality and reproduction. This effort is uniquely important for the health of young women and their children, for women's self- determination and, in many countries, for efforts to slow the momentum of population growth, the document said.

The program of action, endorsed by more than 150 countries including Nepal, said countries must ensure that the programs and attitudes of health-care providers do not restrict the access of adolescents to appropriate services and the information they need, including on sexually transmitted diseases and sexual abuse. These services must safeguard the rights of adolescents to privacy, confidentiality, respect and informed consent, respect for cultural values and religious beliefs.

New efforts have emerged that bring services to locations where young people are learning, working and socializing. Telephone hotlines, mass media and other communication approaches help provide information, motivation and referral to service delivery points.

Viewing adolescents as a specific group with their own needs is a relatively recent practice, especially in the developing world. Young, unmarried people in the past were not expected to need reproductive health (RH) services. If young women were married, they received the same services as older women, except that nobody assumed the young women needed pregnancy prevention. Most developing-country societies expected women to bear children soon after marriage.

Significant social changes worldwide have prompted program planners and managers to consider specialized services for people in the adolescent or young-adult age group. Some of these changes relate to broadened opportunities for women, who are now staying in school longer and entering the workforce in larger numbers. The age of marriage is rising in most countries. Combined with the decreasing age of menarche, those years create a longer time period when young women are single and are capable of becoming pregnant. Sexual activity during this nonmarital time has increased, fostered by other social changes such as urbanization and mass communications, thereby creating a new level of need for RH care.

Another impetus for placing a priority emphasis on the RH of this group is the alarming increase of sexually transmitted diseases (STDs), including HIV. Young people are contracting STDs out of proportion to their numbers. In particular, young women represent the fastest-growing cases of new HIV infection. Nearly 45 percent of all new HIV infections, that is some 2-4 million people per year globally, are among 15-24 age group. Similarly, one in every 20 young people are found to have contracted sexually transmitted infection (STI).

Adolescent behavior, including experimentation and risk-taking, makes young people more vulnerable to pregnancy and STDs. Young people want to try new things, including sexual activities, often feeling invulnerable to negative consequences. Other psychosocial reasons, especially for female adolescents, place them at higher risk: wanting to please, having difficulty in refusing advances, and needing to provide sexual favors to meet various needs. Finally, there is emerging evidence that indicate that sexual abuse is a major issue for adolescents worldwide, with effects on the sexual and reproductive health of young adults.

For adolescents, concerns about sexuality and RH are new in their lives. In fact, the major defining biological aspect of adolescence is the process of attaining sexual and reproductive maturity. Given most societies' reluctance to approach the subject forthrightly, it is not surprising that young people view these new feelings and needs with some trepidationóand are suspicious of where to find answers.

Adolescents face fears, concerns, and lack of understanding about their own needs. Thus asking for or seeking guidance and services is very difficult, and they tend to avoid seeking needed care. Any program hoping to serve young people must factor in these multiple psychological and physical realities. The program must design services that can attract young people, while assuring them that they will be well treated and have their needs met, says a publication by Focus on Young Adults, a US-based agency.

Given the rapid changes that adolescents experience, a need exists for education and counseling services, especially related to development and maturation, boy-girl relationships, decision making about sex, gender issues, sexual abuse and exploitation, sexual and contraceptive negotiation, adoption of contraceptive methods, and pregnancy options should pregnancy occur.

Partnering with existing agencies that serve youth is a way to reach a significant number of young people already organized into programs and activities. In Africa, the 29-country Africa Region Boy Scout Association implemented a family life education project (though not offering services). The program, however, proved to be more challenging than anticipated and fell short of objectives and anticipated expansion activities. An apparently more successful model implemented by International Planned Parenthood Federation (IPPF) in six countries, Youth for Youth, worked through a variety of nongovernmental organizations (NGOs) that reached young people in urban slums, in prisons, in schools, and in the military, as well as those already parenting.

Even the corporate sector could be roped in to address the needs of youths. For example, in India the Tata Iron and Steel Company, through its Center for Family Initiatives (CFI), is helping young people become informed on sexual and reproductive health matters. It targets adolescents aged 14-18, single or newly married, living in nearby residential and slum areas, as well as those whose parents work in the company.

Government policy

The World Health Organization (WHO) defines Reproductive Health (RH) as a state of complete physical, mental and social well-being in all matters relating to the reproductive system and its functions and processes. Adolescent Reproductive Health (ARH) is considered one of the vital components of reproductive health.

Adolescent specific health services were virtually non-existent in Nepal before the ICPD in 1994. In 1991, HMG/Nepal initiated a HIV/AIDS control program in order to address this concern. The Ninth Five Year Plan and the Second Long Term Health Plan (1997-2001) has emphasized developing special programs for both population management and reproductive health. The National Reproductive Health Strategy developed in 1998 identified ARH as a critical component of the integrated RH package and thus an important indicator of the nation's overall health status. The draft National Adolescent Health and Development Strategy aims at increasing availability and accessibility of appropriate adolescents-friendly RH information and health services, among others. The strategy has identified providing safe and supportive environment, providing information and skills and providing health services and counseling as major interventions to attain its objective.

Strategies apart, of course, what counts are implementation. "At the implementation level, we will be focusing on family, community and adolescent themselves and work in a decentralized way,"said Dr. Laxmi Raj Pathak, director, Family Health Division at the Department of Health Services, who is also the chairman of RH Coordination Committee at the Ministry of Health. "We will work with local bodies, and other government, non-government, INGOs and youth groups to achieve our goals."

According to Dr. Pathak, the National Strategy will work as guidelines and everybody will be free to do whatever they like based on these guidelines. "To provide effective health services to this age group is a great challenge as neither the family, nor community or health professionals have the expertise on how to deal with them. So, there should be collaboration between all the parties concerned and NGOs should take a lead,"said Dr. Pathak. "We are also promoting a concept that the community should take the ownership for proving health services at the community level. The role of the government will then be that of the facilitator only."

The Ministry of Population and Environment (MOPE) has also set up a separate unit called ëAdolescent and Youth Section' early this year to deal with the issue. "We will be focusing on coordinating with different ministries, NGOs and donor agencies on the issue and will also be formulating policy, program and strategies as necessary,"said Upendra Adhikary, chief of the Adolescent and Youth Section at the MOPE.

Some NGOs like Family Planning Association of Nepal (FPAN) have already started such initiatives. They have their own youth committee which devises programs like peer education, counseling and other services offered by the FPAN outlets.

Disseminating the message to more than seven million people, 40 percent of whom are illiterate, is not easy. So, FPAN has started outreach clinics in different parts of the country and set up peer education groups encouraging them to discuss their RH problems and delivering them services, as and when necessary. "We are already running five youth information centers in the Kathmandu valley and plan to add two more next year,"said Rupak K. Rajopadhyay, senior branch manager at the FPAN's valley branch. "There is very good response from both the youths and local community. But we haven't been able to meet their expectations due mainly to resource constraints."

The challenges are manifold. Lack of laws related to abortion and socially unacceptable practices like unmarried pregnancy and making family planning commodities available to young and unmarried people puts health providers at an awkward situation. As such girls tend to turn to quacks, the risks of maternal mortality become quite high. "The concerns and needs of the adolescents and youths often go beyond reproductive health,"says Dr. Shyam Thapa, senior scientist with the Family Health International (FHI). "How to address these concerns and needs in a holistic manner? That remains a big challenge, but it is not exclusive to Nepal by any means."(See: Interview)

Perhaps the most important element is political commitment. "Problems are well identified in Nepal. What is lacking is commitment,"says Dr. Aryal. A bill to amend some civil code is awaiting discussion at the Parliament for the last one year. As the bill has some controversial clauses such as women's property rights and legalizing abortion, it is likely that the bill will be delayed further. "There is a need to mobilize lawmakers as they have contacts both at the grassroots and the government and develop national consensus on an urgent issue like adolescents' reproductive health,"says Dr. Aryal.

So, what could be the key to success? "Put young people at the center of programming, address their multiple health problems simultaneously, combine interventions in the areas of health, education etc., build on and link existing interventions and respect cultural diversity,"said Dr. Paul FA Van Look, a senior official with WHO, at the Mumbai conference last month. "Adolescene is a phase rahter than a fixed age group."

So, dealing with youth and adolescents need extra sensitivity, be it within the family, school or an outreach clinic. In the modern times, youths have their own ambitions and aspirations. The society needs to learn about their perceptions and provide them their due space. Sooner the better.

"Adolescents Are A Heterogeneous Group; Naturally, Their Needs Are Varied."

— Dr. Shyam Thapa

Dr. Shyam Thapa (PhD, Brown University, USA) is a Senior Scientist with Family Health International (FHI), a US-based research organization. He is currently chief of FHI's research and technical services office of population and reproductive health in Kathmandu. One of FHI's new areas of ongoing research, funded by the United States Agency for International Development, focuses on adolescents and youths in Nepal. Bhagirath Yogi interviewed Dr. Thapa on this topic.

Could you briefly describe who adolescents are and why the term adolescence is sometimes confusing?

Generally speaking, persons in the 10-19 age group are referred to as adolescents. However, adolescence is a phase of life rather than a particular age. It is the second decade in a person's life when important changes occur in different dimensions of life—physical, biological, mental and emotional. These changes may occur at different paces in different sociocultural settings and for different individuals. The sequence and manner of these changes can be different for males and females. Furthermore, some of these changes due to adolescence can be perceived and handled differently in different cultures. That is why it is difficult to pinpoint an age at which adolescence begins or ends. For practical purposes, adolescence can be defined as a developmental period during which a person is "no longer a child, but not yet an adult." This definition allows for culture-specific variations to be recognized for both policy and program development.

Why should Nepal invest in adolescents and young adults?

Let me point out three main reasons. First, adolescents and youths together represent a significant segment of the country's total population. This population subgroup—ages 10 through 24—in Nepal is currently estimated to be 7.1 million, that is, 31% of the total population. Due to the phenomenon known as "population momentum," the number of adolescents will continue to grow. It is estimated to increase to 12.6 million by 2030 before beginning to decline. Second, behaviors formed during adolescence or young adulthood are known to have profound implications for the rest of the person's natural life. For example, smoking or drinking habit initiated during this period is several times more likely to lead to chronic conditions or result in worse scenarios (such as chain smoking or alcoholism) than habits picked up during later stages in life. Conversely, good habits or positive behaviors formed during adolescence and young adulthood can be expected to have salubrious effect on a person's psychosexual and psychosocial health during adulthood. Third, and finally, adolescents and youths of today are the parents and responsible citizens of tomorrow and the most important resource for community- or nation-building. For these and other reasons, Nepal cannot afford to not invest adequately and deliberately in the health and other areas of life of its adolescent and youth population.

You have carried out a comprehensive analysis of schooling, marriage, work and childbearing among the adolescent and youth population of Nepal. How would you summarize the findings of that study?

The study was based largely on further analysis of a 1996 national survey in Nepal. Let me summarize the findings in a simple capsule form: low school enrollment, early marriage, early entry into work and early entry into childbearing are the defining characteristics of many adolescents and youths in Nepal. These characteristics, operating in circular rather than linear ways, together constitute a socioeconomic challenge that warrants expeditious response and innovative strategies. If the youths and adolescents present challenges, they also bear huge potentials that need to be carefully cultivated and fully realized. The government, the private sector and the international community each have very important roles to play in meeting the challenges and harnessing the potentials inherent in the adolescents and youths of Nepal.

FHI has an ongoing study on adolescents and young adults in Nepal. Could you shed light on it?

The objective of the ongoing survey—i.e., Nepal Adolescent and Young Adult (NAYA) Survey—is to collect information relevant to the reproductive and sexual health needs of representative adolescents and young adults, ages 14 through 22, for use in the development of appropriate policies, programs and strategies. The Survey aims at interviewing close to 9,000 respondents in five urban areas and eight rural districts. In terms of scope and representative-ness, the Survey will provide first-ever baseline information relating to parental, familial, health and non-health aspects of life among adolescents and young adults in Nepal. Prior to the Survey, we also conducted a qualitative study with adolescents and youths in several communities in Nepal.

What was the purpose of the qualitative study you just referred to?

The qualitative study was carried out with the primary purpose of helping in the development of the NAYA Survey and fine-tuning of the survey instrument. The study included 72 focus-group discussion (FGD) sessions, which were conducted in various parts of Nepal, with over 550 adolescents and youths of ages 14-22 as participants. However, since the study proved to be such a rich source of information about the reproductive health needs of the Nepalese youths in general that its findings are being prepared separately to complement the Survey findings.

What would it take to make the healthcare services adolescent- and youth-friendly?

It is important to bear in mind that healthcare services were conventionally structured to cater to child and adult health needs, thereby skipping the focus on the special needs of the adolescents. The first question is, therefore, how to add efficient and effective adolescent services to the existing healthcare system, such that the services properly relate to the transition states from childhood to adolescence to adulthood. Once this prerequisite is met, several components would need to be in place to make the services friendly to adolescents and youths. These components should include supportive policies, community involvement, healthcare facility and professionals that respect the need for privacy and confidentiality, and healthcare providers who are cognizant of and sensitive to the needs of this particular population.

How do you view the recent developments in this area in Nepal?

In the public (i.e., government) sector, the National Population Committee, which is chaired by the Prime Minister, has recognized the challenge that adolescents and youths represent and endorsed the need to pay special attention to the needs of that particular segment of the Nepalese population. Accordingly, the Ninth Development Plan stated unequivocally that the Government encourages and supports special programs in population and reproductive health focusing on adolescents and young adults. The Ministry of Population and Development then formed a taskforce to identify the needs and gaps in services to the youth population. Concomitantly, the Ministry of Health has developed strategies specific to adolescents as part of its overall reproductive health strategy. These are important and welcome developments in the public sector.

On its part, the private sector has pioneered innovative pilot projects, involving activities ranging from sensitization, awareness creation and counseling to service delivery, mainly in reproductive health. Most of these activities, however, have been small-scale and somewhat disjointed. Furthermore, very little is known about the effectiveness of the various activities or projects. We need to better know what worked and what didn't, before the projects can be scaled up and expanded to wider areas.

Overall, I consider the initiatives—both in the public and the private sector—very important and commendable. The country now needs to move to the next level, where the effective projects are identified and scaled up and expanded and, at the same time, new and promising projects developed and implemented in a more systematic and coordinated way. The good news is that there is a rich body of experience available to draw on in the region and elsewhere. Nepal should take advantage of this and not lag behind in adapting relevant, appropriate models and strategies to its specific needs.

What do you think could be some of the potential challenges or barriers to achieving more in this area?

The momentum that exists at this time can be lost due to the lack of sustained financial resources. Therefore, the resources already available need to be utilized in the most efficient and effective manner. At the same time, resources for new initiatives or for expansion of effective projects would need to be found.

At the implementation level, some groups can be expected to fear that providing knowledge about reproductive health and making related services (for example, contraception) available might lead to increased promiscuity and loss of parental control. I think the "comfort level" is still quite low among the Nepalese public in the area of sexuality. Perhaps there isn't a great deal of disagreement on the need to provide some sex education to adolescents, but public opinion will vary widely on related issues: What is the appropriate age for sex education? What should the curriculum include? Who should provide instructional services? How to reach the out-of-school adolescents?

It is also important to recognize that there is no silver bullet nor any one-size-fits-all approach available for addressing the needs of the adolescents and youths. Adolescents are a heterogeneous group; naturally, their needs are varied. This poses a challenge as regards the scope or type of services. Furthermore, not all adolescents and youths are equally needy or vulnerable. Although the majority of them may be in good health and will likely remain so, they will need services . On the other hand, those in poor physical or psychological health will need more substantial services and support. These are two distinct types of service needs. Finally, the concerns and needs of the adolescents and youths often go beyond reproductive health. How to address these concerns and needs in a holistic manner? That remains a big challenge, but it is not exclusive to Nepal by any means.