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Sexual and Reproductive Health Needs and Service Utilization among Adolescents in Nepal

Nabaraj Adhikari , Shahad Uddin, Krishna Prasad Sapakota, Saraswati Adhikari
American Journal of Public Health Research. 2020, 8(2), 47-53. DOI: 10.12691/ajphr-8-2-2
Received February 11, 2020; Revised March 01, 2020; Accepted April 02, 2020

Abstract

Background: Adolescents can experience various sexual and reproductive health (SRH) challenges. It is crucial to make sure that adolescents use SRH related services and information to protect themselves from any complications such as early and unwanted pregnancy, sexually transmitted infections, HIV and psycho-sexual problems. Objectives: The aim of this study is to explore SRH needs and SRH service utilization by adolescents in Nepal; factors influencing utilization of SRH services; and to provide recommendations for the optimal improvement and use of existing SRH services. Study Method: This is a descriptive study which is based on a review of the literature according to the “WHO framework for understanding adolescent help-seeking behavior and use of social supports”, which was adapted in to this paper. Findings: In Nepal adolescents are concerned about sexual development and reproductive health. However, current health programs are not completely addressing these issues. Limited knowledge, social and cultural associations with SRH services, health staff competencies to address adolescent SRH, and friendliness of health facility staff influence health seeking and SRH service utilization by adolescents in Nepal. Conclusion: Despite all of the efforts from the government and non-governmental sectors, utilization of SRH services by adolescents in Nepal is low because of various factors that are often interrelated. There is a need to further improve the adolescent friendliness of services, promote these (free) services, and to increase use of SRH services in Nepal.

1. Introduction

Adolescence is a transition period from conventional parent-controlled health-seeking behavior to self-determined health-seeking behavior 1, 2. Therefore, it is crucial that adolescents make use of health services during this period to improve their health, adjust risky behaviors, and promote healthy habits. However, health care services are sometimes unable to respond to the unique circumstances and needs of adolescents 3. Sexual and reproductive health is crucial for the wellbeing of adolescents 4. Age-appropriate services targeting adolescents are necessary to meet adolescent SRH service needs. These services must maintain adolescents’ rights to privacy, respect, and informed consent while respecting cultural and religious values 3, 4.

Adolescents in Nepal do not have adequate access to information and services, which is further exacerbated by the limited sex education taught in schools and the hardly open discussion about sex and sexuality in families and society 5. The government of Nepal recognizes that these services should be youth-friendly. Furthermore, the government of Nepal and external partners are scaling up adolescent sexual and reproductive health programs to address these issues. However, little information exists at the national level regarding what Nepalese adolescents perceive as their SRH needs, their service utilization patterns, and factors that act as barriers or facilitate the use of existing services. Correct evidence is crucial to properly plan SRH services for Nepalese adolescents. Amongst the many means to measure their needs, their own reports of health behaviors and lifestyles, as well as utilization of health services are especially valuable. This data allows adolescents to be heard, as opposed to adult professionals making judgments for them. In addition to this, it is very important to explore the apparent sexual reproductive health needs of adolescents for effective provision of SRH services to these young people, and to make them accessible to all.

This paper tries to explore the sexual and reproductive health needs and service utilization of adolescents in Nepal, as well as factors influencing the utilization of those services, and provides recommendations for improvement.

2. Method

2.1. Study Design

This is a descriptive study which is based on the review of literature. The reason for choosing to conduct a literature review is that it helps to access the current ASRH issues of Nepal in detail. In addition, it helps to synthesize the evidence from various studies that focus on SRH issues of adolescents 6.

2.2. Search Strategy

The literature has been searched through PubMed, Google Scholar, and Google search engines, by using different keywords and their combinations, which are further elaborated in Table 1. The VU library database, Science Direct, and Elsevier were also used to search for scientific articles. World Health Organization (WHO), UNICEF, UNFPA, IPPF, and Department of Health Service of Nepal reports were accessed through their respective websites. Similarly, various social science journals were also looked into to find articles related to adolescent SRH issues and perceptions. Reference lists of the selected articles have also been checked for relevant articles.

2.3. The Conceptual Framework for the Study

The conceptual framework used in this study is adopted from the “WHO framework for understanding adolescent help-seeking behavior and use of social supports”. It is based on evidence in the literature, suggesting that there are various factors which are interrelated and influencing what adolescents perceive as needs, and how this affects the utilization of sexual and reproductive health services (SRH).

The framework shows how adolescents perceive certain problems as their needs, and further identifies various factors that influence their help-seeking behavior. The first part of the framework (Chart 1) shows an individual decision model in a given social context, which includes individual perception for needs and individual factors associated with help-seeking. This is associated with the demand side for need, that means the factors which encourage or motivate adolescents to use services. The later part (Chart 2) includes exogenous factors, social supports, programmer efforts and policy initiatives to promote adolescent help-seeking 7. These are linked to the supply side and show how appropriately adolescents’ needs are addressed.

3. Result

3.1. Perceived Sexual and Reproductive Health Needs of Adolescents in Nepal

Very few studies have been conducted to explore the perceived needs and preferences towards the SRH of adolescents in the context of Nepal. In 2014, a descriptive cross-sectional study was conducted among 388 adolescents aged 15-19 in three government run higher secondary schools. The study asked adolescents whether they ever felt need for SRH; 15% said they felt a need for SRH services. From this 15 %, only 9.2% were able to utilize SRH services. The majority of adolescent girls (60%) felt they needed services for problems related to menstruation. Half of the study participants (51.2%) felt a need for psycho-sexual problems, among them a majority were male. Both girls and boys felt major need for SRH, where masturbation (50.6%), information related to physical change (54.8%), information on intimate relationships (54.8%), or STI counseling (53.3%) 8 were the main issues. In 2015, Magdalena et al. conducted a study among 160 students at four schools in Kathmandu. The study showed that for young people, avoiding pregnancy is much more important than other SRH problems such as protection from STIs 9. This is because, in Nepal, being pregnant before marriage will have a much more negative social consequence than having STIs 9. Furthermore, this can also be associated with a low level of knowledge about SRH issues. For instance, in this study only one-third of 160 students were not aware they can become pregnant by having sexual intercourse only once. The study further shows that some of the students think they can use a condom multiple times 9.

There are various factors that influence how adolescents make the decision to seek sexual and reproductive health services. Adolescent perception to seek SRH services depends on how they perceive the severity of certain problems. A mixed-method (quantitative and ethnographic) study conducted among unmarried adolescent girls aged 14-19 in six districts of Nepal in 2006, shows that adolescents girls do not perceive reproductive health problems as severe 10. For instance, problems related to menstruation and white discharge are considered as normal, they think it is usual for girls and believe it happens because of weakness. This perception is higher among the Tarai region ethnic groups (Tharu and Rajbanshi) compared to the hill region ethnic groups (Gurung and Tamang) 10. These perceptions about the severity of reproductive health problems have a negative influence on service utilization. The quantitative part of this research further verifies the finding that only 7%, 17.2% and 12.2% of the adolescent girls aged 14-15, 16-17, and 18-19 respectively, seek SHR services about their menstrual problems 10. In addition, adolescents’ recognition of SRH needs and service utilization is influenced by their surroundings. A qualitative study conducted in Kathmandu and Chitwan district in 2010 shows adolescents often take suggestions provided by their peers seriously 11.

3.2. Sexual and Reproductive Health Services Utilization among Adolescent in Nepal

SRH service utilization in Nepal is poor, and there is a huge disparity in access and resource distributions within 75 districts 8. A mixed-method study conducted among 680 males and 720 females aged 15-24 in Kathmandu valley in 2015, shows that 20% of adolescents visited a health facility or doctor for SRH information and services 12. Among them, two thirds of the young people sought sexual and reproductive health information. The study further shows that the majority of young people’s last visit for SRH services was in a government health facility, followed by the private sector, with pharmacies and non-governmental sectors accounting for 8.5%, 7.5% and 0.6% respectively. However, during focus group discussions when adolescents were asked about where they preferred to visit for SRH services and why, most preferred private health facilities because they think they have greater privacy and confidentiality, and greater safety and quality of services. Furthermore, women are more likely to seek SRH services and information than men.

3.3. Factors Influencing the Utilization of Sexual and Reproductive Services among Adolescents in Nepal

Various individual and exogenous factors, such as personal ability, awareness of needs, accepted gender norms, self-agency, as well as stigma, community values, and health staff ‘s response all have significant influence on the SRH services seeking behavior of adolescents and on their utilization of such services. Among them, the following factors have been identified as being more influential and predominately associated with the utilization of SRH services by adolescents in Nepal.

3.4. Knowledge of Sexual and Reproductive Health and Services

Adolescents’ knowledge about sexual health services has a profound influence on service utilization. An interventional study conducted among 2,970 adolescents in four districts of Nepal shows that half of them are aware that ASRH is available at health facilities in their area 5. Similarly, a small-scale qualitative study conducted in the Arghakhanchi district in 2016 shows that most of the study participants were aware about some components of SRH services such as contraception. However, the majority of them were not aware about abortion services provided by government health facilities 13. This is similar to national data; NDHS 2011 shows that about 60% of adolescents aged 15-19 do not know about the safe abortion services, however, knowledge about HIV, STI’s and contraception is common 14. Another mixed method study conducted among 3,041 adolescents of four districts in 2011, shows that there is a gender difference in the level of knowledge about sexual and reproductive health. For instance, male adolescents have a higher knowledge of HIV and AIDs compared to their female counterparts. On the other hand, female adolescents have the better knowledge about contraception 5. A qualitative study conducted among urban and rural young people in Kathmandu and Chitwan in 2007, shows that younger adolescents lack comprehensive sex education 15. Similarly, P. Regmi et al.2008 reported that because of poor knowledge on sexual and reproductive health, especially in rural areas, young people do not utilize SRH services 11.

3.5. Personal Beliefs about What Constitutes a Need for Help

Most young boys and girls do not realize they need any SRH services because of a lack of information, and appropriate knowledge about SRH issues 27. A focus group discussion by R. Regmi et al. 2007 reports that a 15-year-old girl did not seek any health care when she had pain and lumps in her breast. The girl explained that she thought it was normal and would disappear in a couple of days. Such beliefs and wrong perceptions about the severity of health conditions have negative effects on service utilization 6.

3.6. Local Values about Adult Adolescent Interactions

Sex and sexuality are taboo in Nepal and are not discussed openly in families and communities. Studies show that teachers, family and health care workers are reluctant to discuss sexual and reproductive health with adolescents 8, 16, 17, 18. In relation to this, most adolescents fear sharing their sexual and reproductive health issues with their parents, guardians or elderly people 10. However, some of the studies in urban settings show that some parents, brothers, and sisters provide suggestions about sexual health issues such as relationships or condom use 15. It is seen that adolescents who have positive integration with adults in their surroundings feel more at ease to discuss sexual concerns. Another study shows that young urban girls were able to take their boyfriends to their home because of positive interaction between their parents 15.

3.7. Staff Receptivity and Youth-friendly Health Services

Health care providers’ receptivity towards adolescents’ needs is one of the factors which has an extensive effect on SRH service utilization. Negative behavior of heath care providers includes rudeness, unfriendly behavior, blaming, and sometimes scolding, which deteriorates adolescents’ willingness to seek health services when they are in need 25. Parkhanel K. 2016 reported that most of the adolescents are not treated properly in various health facilities 13. Similarly, a mixed method study conducted among 1,400 young people aged 15-24 in Kathmandu, shows that health care staff behavior was not friendly 5.

“Health workers like nurses or other staff do not treat clients well. For example; if a girl goes there to abort her pregnancy then the nurses will start criticizing her which is bad practice and this adversely affects the client’s psychological wellbeing”. —Unmarried male, aged 24 years 12.

In Nepal, many adolescents perceive that sexual health education and services are not sufficient or youth-friendly 12. For instance, especially in rural areas, condoms are not easily available and young people are always in fear about other people knowing when they buy condoms. Although young urban people have easier access to condoms, they still fear other people’s reaction, and this prevents them from buying and using condoms 24. Though there are private clinics which provide SRH services, most adolescents depend on government facilities because of costs associated with private services. Opening hours of the government run health facilities coincide with school opening hours. Government health facilities are labeled as adolescent-friendly, however, opening hours for hospitals are from 10 am to 2 pm, and 10 am to 3 pm for health posts, which are inconvenient for adolescents 24. Training of health staff about adolescent needs and communication skills, have a positive influence on service utilization. Midterm evaluation study of National ASRH, shows that the majority of adolescents were satisfied with the way health staff responded to their needs, and health staff also felt this training helped them change their attitude towards adolescents’ needs 24.

3.8. Gender Inequality

Though gender inequality is not explicitly mentioned as an exogenous factor in the conceptual model, it has a considerable influence on adolescent SRH service utilization. Various studies show that young boys get more freedom in many aspects of their life, which also includes access to health care 12, 13, 15. In 2015, a qualitative study conducted by UNICEF in 12 districts exploring the current utilization of AFHS, shows that girls often face restrictions to leaving home, which hinders SRH service utilization 19. The statement presented below further explains the gender difference.

“Family members scold if a girl goes out of house without parental consent but they don’t care if it’s a boy in the family, he can go anywhere he wants.”-FGD with parents, Kaski 19

However, studies also report that in urban areas young males and females are treated much more equally than in rural areas 15, 20, 21, 22.

4. Discussion

The literature review shows that adolescents are concerned about the mental, emotional, and behavioral aspects of their sexual development. However, current health programs are not completely addressing these issues. There are various factors which have a profound effect on the limited utilization of SRH services by adolescents in Nepal. Some small-scale studies show that adolescents do not prioritize their SRH. The reason behind this is a low level of knowledge among adolescents, which makes them think it is less important. Social and cultural factors such as gender inequality, as well as the unwillingness of parents and teachers to talk about these issues, are often a hinderance for seeking SRH services. In addition, health staff competencies to address SRH also influences help seeking and service utilization among adolescents. The government of Nepal has developed policies and strategies which aim to promote SRH for adolescents, but these need to be better implemented, as intended by the respective policies. Some current Nepalese SRH programs have good initiatives, such as involvement of young people, peer education, and inclusion of comprehensive sex education in the school’s curriculum. These programs could be expanded.

In Nepal, most adolescents depend on government health facilities for SRH services. However, study findings show that they prefer to go to private health facilities because of issues related to privacy and confidentiality. Findings also show that adolescents would prefer government health facilities if they are made friendlier. The reason behind this is that the government health facilities provide the majority of adolescent SRH services free of cost. Global experience shows that training of health workers to address young peoples’ issues is necessary to make services acceptable and accessible to young people. In addition, programs which focus on schools and peer groups are crucial for demand generation 23, 24. The training of health care staff on adolescent sexual health could have a positive effect on SRH service utilization, however, the limited number of trained health staff often makes it difficult to provide effective and high-quality services 25. Studies show that Nepalese adolescents trust their peer groups about their sexual and reproductive issues and seek support and suggestions from them. However, government run national adolescent SRH programs do not have any components which involve adolescents in the development and implementation of the programs. Therefore, the government of Nepal can learn from experiences and practices of FPAN, IPAS, UNFPA and other organizations’ practices of involving adolescents in SRH programming. Their experiences show that involving young people helps to develop trust and acceptance of programs and services 22, 26.

A study finding shows that adolescent girls do not perceive reproductive health as serious, which is rather interesting. However, this study finding might not be applicable to all Nepalese adolescent girls as it includes only four ethic groups from the Tarai and Hill region. This is of less importance partly because adolescents have limited knowledge of sexual and reproductive health. In some studies, it is shown that adolescents have limited knowledge of SRH services that are available. It is also important to note that social and cultural taboos, or shame associated with sexual health, are often a hinderance to access SRH information because there are limited programs which address the social and cultural issues. In addition, these customs and values are deeply rooted and entrenched in Nepalese society, and would be difficult to transform from the effort of any one program, and needs a multi-sectorial approach and collaborations. Global experience shows that a school based SRH education is one of the best strategies to inform adolescents about SRH services and information. However, in Nepal teachers are unable to teach sexual education effectively in class. This may be caused by the fact that they feel reluctant, and may be shy because of social norms and values. The rare discussion about SRH with parents’ further limits adolescent accessibility to these services.

In Nepal, social norms and cultural values related to sex and sexuality, such as linking sexual terminologies with something bad, dirty and immoral, often hinders adolescents to discuss and seek SRH information and services. Unacceptability of premarital sex hinders use of contraceptives among Nepalese adolescents. However, the study of Niranjan S.et, al. conducted in Pokhara, shows a high rate of contraceptive use among adolescents, which is somewhat opposite to other studies without any explanation 27. All SRH programs focus on adolescents in school, thus this group may have better knowledge about contraception than Nepalese adolescents in general. Furthermore, existing gender inequality, such as restriction on mobility and decision-making power, exacerbate adolescent girls’ use of SRH services, especially among unmarried adolescent girls. Furthermore, economic restraints among adolescents’ act as barriers for SRH service utilization.

The global evidence on how to integrate SRH services in school settings would be an important aspect to explore in the Nepalese context 23, 27. Kiran B. et al. 2015 shows that students are seven times more likely to use SRH services if they are school based 8. However, the study does not mention which services, and nor how they were provided to adolescents. It is also important to highlight that Nepal is making some positive efforts such as inclusion of various SRH topics in the school curriculum, liberalization and provision of free abortion and contraceptive services, and initiation of adolescent friendly health services to promote SRH. This can serve as a good example for other neighboring countries in South Asia.

There is limited information about adolescents’ perception to seek SRH services and their needs, which should be explored in depth in the Nepalese context. In addition, it is important to explore how SRH services can be made more effective outside health facilities, such as in schools, involving adolescents as agents of change, and reducing financial barriers. Other issues, such as the formation of formal support networks, which includes youth clubs and peer groups, needs to be explored more.

The major limitation of this paper is that most of the studies in Nepal are focused on the age group 15-19 or 15-24, which makes it difficult to make a concrete conclusion about adolescents aged between 10 and 15. Exclusion of this age group might be a result of social norms and values, where it is considered inappropriate to talk or ask about SRH issues. Also, many papers were small scaled studies, so there are limited nationwide data on adolescent SRH needs and utilization patterns. Furthermore, the limited research on out of school adolescents makes it difficult to generalize findings in a broader context. This paper has adopted a systematic review process, which means it has predetermined inclusion and exclusion criteria, that includes studies conducted among young people, studies conducted in Nepal, and papers published in English, etcetera. This analysis does not include the view points from research that has been published in the Nepalese language journals. This paper presents data from both qualitative and quantitative studies, which have helped explore the factors in a comprehensive manner.

5. Conclusion

Utilization of SRH services by adolescents is low in Nepal, variation can be seen according to gender and urban or rural residence. Furthermore, it is seen that adolescents actively outreach for services and information related to bodily changes, intimate relationships and psycho-sexual problems. However, the current SRH services are not responsive to their needs and are more inclined towards provision of reproductive health services. In the Nepalese context, adolescents’ individual factors - predominantly knowledge related to sexual health, knowledge about services and earlier experiences with health facilities, have profound influence on SRH service utilization. Social and cultural norms about SRH issues also reduce health seeking and service utilization. On the other hand, provision of adolescent-friendly services, free services, and the positive legal environment, help increase use of SRH services in Nepal.

Based on the research findings, it is suggested that the government, parents and community members, should work towards making adolescent-friendly families and communities where they can easily access SRH services and information.

Conflict of Interest

There is not any conflict of interest.

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Published with license by Science and Education Publishing, Copyright © 2020 Nabaraj Adhikari, Shahad Uddin, Krishna Prasad Sapakota and Saraswati Adhikari

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Normal Style
Nabaraj Adhikari, Shahad Uddin, Krishna Prasad Sapakota, Saraswati Adhikari. Sexual and Reproductive Health Needs and Service Utilization among Adolescents in Nepal. American Journal of Public Health Research. Vol. 8, No. 2, 2020, pp 47-53. http://pubs.sciepub.com/ajphr/8/2/2
MLA Style
Adhikari, Nabaraj, et al. "Sexual and Reproductive Health Needs and Service Utilization among Adolescents in Nepal." American Journal of Public Health Research 8.2 (2020): 47-53.
APA Style
Adhikari, N. , Uddin, S. , Sapakota, K. P. , & Adhikari, S. (2020). Sexual and Reproductive Health Needs and Service Utilization among Adolescents in Nepal. American Journal of Public Health Research, 8(2), 47-53.
Chicago Style
Adhikari, Nabaraj, Shahad Uddin, Krishna Prasad Sapakota, and Saraswati Adhikari. "Sexual and Reproductive Health Needs and Service Utilization among Adolescents in Nepal." American Journal of Public Health Research 8, no. 2 (2020): 47-53.
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  • Table 2. Summary table; Factors influencing the utilization of sexual and reproductive services among adolescents in Nepal
[1]  Lerner, R. M., Boyd, M. J. and Du, D. (2010). Adolescent Development. In The Corsini Encyclopedia of Psychology (eds I. B. Weiner and W. E. Craighead).
In article      View Article
 
[2]  National Research Council, Institute of Medicine. Growing Up Global: The Changing Transitions to Adulthood in Developing Countries. Lloyd CB, editor. Washington, DC: The National Academies Press; 2005. 720 p.
In article      
 
[3]  Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, Ezeh AC, et al. Adolescence: a foundation for future health. Lancet (London, England). 2012; 379(9826):1630-40.
In article      View Article
 
[4]  World Health Organization. (‎2003)‎. Adolescent friendly health services: an agenda for change. Geneva: World Health Organization. http://www.who.int/iris/handle/10665/67923.
In article      
 
[5]  Teijlingen Ev, Simkada P, Acharya DR. Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal. Kathmandu Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ, Health Sector Support Programme Department of Health Services, 2012
In article      
 
[6]  Cowell JM. The advantage of literature reviews for evidence-based practice. The Journal of school nursing : the official publication of the National Association of School Nurses. 2015; 31(1): 5.
In article      View Article  PubMed
 
[7]  Barker G. Adolescents, social support and help-seeking behaviour ; An international literature review and programme consultation with recommendations for action. Geneva , Switzerland: World Health Organization (WHO), 2007.
In article      
 
[8]  Bam K, Haseen F, BC RK, Newman MS, Chaudhary AH, Thapa R, et al. Perceived Sexual and Reproductive Health Needs and Service Utilization among Higher Secondary School Students in Urban Nepal. American Journal of Public Health Research. 2015; 3(2): 36-45.
In article      
 
[9]  Tamang L, Raynes-Greenow C, McGeechan K, Black KI. Knowledge, experience, and utilisation of sexual and reproductive health services amongst Nepalese youth living in the Kathmandu Valley. Sexual & reproductive healthcare: official journal of the Swedish Association of Midwives. 2017; 11: 25-30.
In article      View Article  PubMed
 
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