Sexual and reproductive health status and health service utilisation of adolescents in four districts in Imprint

Published by: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Registered offi ces Bonn and Eschborn, Germany

Health Sector Support Programme Department of Health Services Teku, Nepal T +977 1 4261404 F +977 1 4261079 E [email protected] I www.giz.de

Authors Edwin van Teijlingen Padam Simkada Dev Raj Acharya

Edited by Eva Schildbach GFA Consulting Group GmbH

Photographs GIZ Archives

Layout by Sigma General Offset Press Sanepa, lalitpur-2, Nepal T : 977 1 5554029

Kathmandu, Nepal August 2012 CONTENTS

ABBREVIATIONS III

1. INTRODUCTION 1 1.1 Rational of the Study 1.2 Aims and Objectives 1.3 Research Questions

2. METHODOLOGY 4 2.1. Study Design 2.2 Study Area and Population 2.3 Sampling Method and Sample Size 2.4 Data Collection 2.5 Data Management and Analysis

3. RESULTS 8 3.1 Demographics of Survey Population 3.2 Knowledge 3.3 Behaviour 3.4 Sexual Intercourse 3.5 Utilisation of and Satisfaction with Health Services 3.6 Records of Sexual Health Service Usage

4. DISCUSSION 18

5. REFERENCES 20 ABBREVIATIONS

AFR Adolescent Fertility Rate ANC Antenatal Care ASRH Adolescent Sexual and Reproductive Health CPR Contraceptive Prevalence Rate DHO District Health Offi ce FHD Family Health Division GIZ Deutsche Gesellschaftfür Internationale Zusammenarbeit (GIZ GmbH) GoN Government of Nepal HMIS Health Management Information System NDHS Nepal Demographic and Health Survey NHRC Nepal Health Research Council RHD Regional Health Directorate SBA Skilled birth attendant I would like to thank Professor Edwin van Teijlingen (Bournemouth University) and Dr. Padam Simkhada (Sheffi eld University) for the supervision and quality assurance of this baseline study conducted by Mr. Dev Raj Acharya. Th is study is the fi rst part of an impact evaluation that documents the eff ectiveness of the National Adolescent Sexual and Reproductive Health Programme led by the Family Health Division.

Special thanks goes to GFA Consulting Group and in particular Ms. Eva Schildbach, Mrs. Pushpa Lata Pandey, Mr. Pushkar Raj Silwal and Mrs. Jamuna Shrestha Bhattarai and my FHD colleague Ms.Mangala Manandhar for their technical guidance.

Th e Nepal Health Research Council by giving their approval made this study possible and I would like to thank them for their constructive feedback during the conceptualization of this study.

Last not but least I would like to mention the enumerators without who this research would have not been possible: Mr. Puran Bikram Adhikari, Mr. Dinesh Gautam, Ms. Mamata Adhikari, Ms. Nirmala Blon, Mr. Janak Maharjan, Ms. Asha Budathoki, Mr. Anjan Adhikari, Mr. Sudarshan Acharya and Mr.Bimal Pandey for the entry of the data.

Dr. Senendra Upreti FHD Director June 2012

Sexual and reproductive health status and health service utilisation 1 of adolescents in four districts in Nepal eld and eld e major e 1 was designed in e research dential services to adolescents; on adolescents ects of the programme adolescent friendly and creating demand adolescent friendly and creating for the services in the communities; basic necessary equipment to provide confi materials; providing health facilities; services health (SRH) to reproductive adolescents (family planning, HIV/STI (sexually transmitted infections)/abortion services). INTRODUCTION

reach the target of 1,000 adolescent-friendly reach services in the public health system. Th in terms of their use of and satisfaction with SRH knowledge health services and improved Th and behaviour. the researcher GFA, close collaboration between in the United and universities in Nepal of Sheffi Kingdom (UK): the University components of national ASRH programme components of national ASRH programme include: • the public health facilities Making • the health facilities with Equipping • on ASRH and health workers Training • adolescent in decision making of Involving • and sexual appropriate Providing of the national ASRH An evaluation GIZ was commissioned by programme to assess Consulting Group) GFA (through the eff Bournemouth University. ese is rst time. rst is es critical interventions, such as epal has 8.8 million young people of epal has 8.8 million young adolescents (aged whom 6.3 million are Survey and Health Demographic e Nepal 10-19), i.e. one-third of the total population 10-19), i.e. one-third people and one-quarterconsists of young is made up of adolescents (WHO 2007). Th means every a large number of young year for the fi people become sexually active Th 2011 (NDHS 2012) suggests a reduction in the adolescent fertility (AFR) and an rate the use of condoms (especially) in improvement use of modern methods people’s and in young the latter of family planning. However, for married adolescents and low remains Th (14.4% and 23.8% respectively). youth why amongst some of the reasons issues are included (GoN) of Nepal the Government and Reproductive Sexual ASRH (Adolescents’ Health Adolescent in its National Health) in 2000. Th Strategy and Development strategy identifi of awareness information campaigns to increase and services. health issues 2007, In reproductive (FHD) published Division Health the Family a guideline on ASRH to support district health the managers to implement the strategy across country. a draft national ASRH programme 2008, In under the leadership of FHD was developed with the support of GIZ and piloted in 26 Surkhet, public health facilities in Bardiya, 2009, Since and Baitadi. Dailekh, FHD has been scaling-up the national ASRH budget and jointly with its own programme to partnerswith xternal development in order N 2 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal environment as a necessary fi environment asanecessary community mobilisationtofosterapositive eff 2004). Overall, thelatterstudyendorsed communication networks (Mathur accurate informationthrough informal unlikely tobeincorporatedintoorreceive health care systemsthanboys have andare institutional structures suchasschoolsand because theyhave lessaccesstoformal discussed infamilies.Girls are more vulnerable reproductive healthare topicsnotopenly education isoff evaluation Th sector (includingnon-governmental providers). reaching young peopleversus usingtheprivate public healthsystemasaneff regarding theoverall approach ofusingthe programming andinternationaldebates Th paramount interest toestablishitseff prevails toscale-upthisprogramme, itisof expenses the FHDlinkedtobudgetary motivation withintheMoHP andspecifi public healthsystemandgiven thatsubstantial time thatAFSsare introduced through the the healthsector. For Nepal, thisisthefi order toaddress theabove problems through as outlinedinthebackground sectionin are scaling-upthenationalASRHprogramme Th women. improving maternalcare foryoung married SRH issues(Acharya about appropriate informationandservices Young peopledonothave adequateaccessto 1.1 RationaloftheStudy isreport isthebaselineofthisimpact eevidencewillfeedbothintonational eGoN andexternaldevelopment partners ectiveness of the participatory process of ectiveness oftheparticipatory ered inschoolsandsex et al. 2009).Littlesex rst stepto ective meansof et al. ectiveness.

rst cally 1.3 ResearchQuestions implementation. (b) Identify waystoimprove theintervention’s (a) Establishtheeff to: specifi decisions by theMoHP (includingFHD).Th and contributetostrategicprogrammatic the evidence-baseforASRHinterventions young peopleinNepal. Th utilisation, satisfactionandhealthoutcomesof the nationalASRHprogramme intermsof Th 1.2 AimsandObjectives Whatare thediff • Whatisthediff • Whatisthediff • eaimistoevaluate theeff communities? andcontrolavailable in theintervention satisfaction by young peopleoftheservices andcontrol communities? intervention by young peoplebetween the services communities? andcontrol in theintervention outcomes between young people c objectives oftheevaluation research are ect of the intervention, and ect oftheintervention,

erence inlevels of erence inutilisationof erences inhealth isstudywillimprove ectiveness of e Sexual and reproductive health status and health service utilisation 3 of adolescents in four districts in Nepal . ects 2 e e eff e . (2000). et al using such routine e limitations of . Outcomes are measured at the same measured are . Outcomes METHODOLOGY

HMIS). Th of interventionsdata sets in the evaluation Kane been outlined by have Nevertheless, this evaluation includes HMIS this evaluation Nevertheless, to determine whether uptake data in order of services among the target is increasing population. identify an intervention this study we In the intervention and which receives group which does not. Th group the control similar and interventioncontrol are group socio- on key characteristics, e.g. size, Th or rurality. demographic features collecting of an intervention tested by are and afterthe interventiondata both before for the control and the results was introduced, compared then and intervention are groups (Fig.1) hence, the questionnaire times for both groups, survey will be conducted thrice among the once during intervention (once before, group and once after the intervention) and twice and after) (before group among the control is design e mixed-method ect of the intervention over 2006). One of the ways to 2006). One et al. before– is based on controlled is evaluation address the question of changes in the uptake address of services study communities is to study in the service routine use data facilities’ Government System, Information Management (Health and above changes in young people’s uptake of people’s changes in young and above sexual health services taking place in already widely used CBA studies are society. Nepalese as in education (behavioural in health as well samples change) settings with representative feasible comparison populations and wherever (Tucker 2.1 Study Design Th mixed- and-after-study (CBA) design using a Th methods approach. compensatory to give strengths applied in order each method to understand the process from researchers of behavioural changes. Many of combining research argued in favour have 1998). Weston 1994, &Tilford methods (Tones would after element we a before-and Without time and not be able to identify change over would not be able to group without a control an possible eff show 4 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal

Midterm Baseline 2012 2011 2013 Final struc Targ Inter Targ inte stru Targ e e • • • • e • • • • e • • • • • • • • r r c v c v t t ( ( et group (17- et group • • • • t group (15-1t group o (15-19yrs t Intervention views 4 districts-18 ured Intervie tured andke iew Health ou Quality of Satisfactio Services u Health ou Quality of Satisfactio Services u Services Health o Quality o Satisfacti o o Figure 1:Evaluation framework o o o o Ris Kn R K u u o o 2 2 u u y R K y g R K t g t t t 9 9 w w o o f f k t t k t t n n i i n n s s lds) comes comes tcomes services wledge 1 years) sk behaviour ilization ilization informant tilization roup sites) nowledge isk behaviour yrs) behaviour n ervices ervices owledge

– structur – – e e d stru Tar inte stru Tar g g g g r c c r c c et (15-19 yrs et group (17- et group • • • • • • • • views tured Intervi tured and ke Matched co group (4 dis Services Health o Quality o Satisfacti Service u Health o Quality o Satisfacti sites) o o o o u u n u u n 2 e 2 u e u t t y R K R K y R K R K t o o f f t o o f f a adolescents) rict-12 tcomes tcomes services trolled services ilization 1 years) w informant tilization nowledge nowledge isk behaviou isk behaviou n n – – – r r r r

Sexual and reproductive health status and health service utilisation 5 of adolescents in four districts in Nepal fteen face- fteen nal evaluation. evaluation. nal has been largely e questionnaire e sampling calculated that 2,970 young database in an electronic e data was entered based on a questionnaire e study is largely nal evaluation. In addition, ten to fi addition, ten to In nal evaluation. evaluation we shall use an opportunistic shall we sample. evaluation we of health facilities of records the study For health facilities government relevant selected all in both intervention areas. and control Th interventionpeople (1,980 from 990 and be surveyed to using were areas) control from in an interview questionnaires structured (if a self- or through illiterate) are the respondents to be completed administrated questionnaire to be were of the respondents (for literate). Half using males and half females. A similar survey, will be carried out in similar questionnaire and in 2013 for a 2012 for a mid-term review fi to-face in-depth interviews will be carried out during mid-term and fi 2.5 Data Management and Analysis Th coded were (SPSS 18.0), and questionnaires 2.4 Data Collection Th supportedqualitative a smaller by study, element. Th ones, such constructed existing validated from and GIZ questionnaires. as the DHS, GFA these newly constructed questionnaires Further people nine young pilot tested with were (male=5, female=4), some at school and area. some out of school outside the research a structured given were Literate respondents (self administrated) to complete questionnaire had an opportunity Respondents themselves. to ask any unclear questions to the researchers. interviewed were face-to- respondents Illiterate questionnaire. face using the same structured facilities we of health the study of records For the relevant designed a short form to capture service use. people’s information on young e ese districts ese nal evaluation evaluation nal ed into ed ces (DHOs). (DHOs). ces rst classifi rst ) with similar characteristics. fi e sample in the strata i.e. by district, school i.e. by strata ed random sample method was e study is carried out in four intervention or comparison sites (VDCs) e control were consists of 15 to 19-year- e baseline sample will be 15 to 19-year-old e mid-term sample groups (called groups and out of school applied to select the study population. Th calculations a simple on sample-size Based each of the random sample was chosen from study qualitative For four districts separately. (in-depth interviews) during the mid-term 2.3 SamplingMethod and Sample Size survey people, the quantitative of young For a stratifi study population was fi Th Banke Dang, (Far-Western), districts; Doti (Central and Dolakha Far-Western) (Mid and Dang districts Doti, the three In Region). implemented are ASRH programmes Banke it in Dolakha and with support GFA/GIZ from Th MoHP/FHD. is implemented by in discussions for research been selected have Directorates Health with FHD, Regional Offi Health (RHDs) and District Th the same districts, to selected from carefully keep intervention communities and control a total of 30 reached We as similar as possible. one including health facilities (HP/SHP/PHC) and one sub-regional hospital (Bheri) zonal districts. in four hospital () Th living in these four old adolescents currently districts (both in intervention area). and control Th living in the four selected adolescents currently as selected key stakeholders / districts, as well Th professionals. (post intervention) people who will be young the intervention (17 to 21-year-old) received as living in those four districts, as well currently selected stakeholders / professionals. 2.2 Study Area and Population Area and 2.2 Study 6 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal Health Research Council(NHRC). Th Ethical clearancewasobtainedfrom theNepal and Excel foreaseofanalysis. usagedatawere enteredservice inbothSPSS confi by numbernotby the nametomaintain dentiality. Sexual andreproductive health e latter cultural values of the participants. cultural values oftheparticipants. Th maintain theiranonymityandconfi verbal and consentfrom theparticipants toobtaininformed emphasized theimportance eresearcher dulyrespected thesocialand dentiality. Sexual and reproductive health status and health service utilisation 7 of adolescents in four districts in Nepal 3 e proportion of e proportion of RESULT the between erence

ed themselves as Muslim, with as Muslim, ed themselves Age of survey participants (baseline survey participants (baseline survey Age of survey Age areas Intervention areas Control 15 years16 years 66717 years 50918 years 32.5% 35519 years 24.8% 361 377 17.3% 159 252 17.6% 39.3% 125 7.8% 26.3% 126 13.0% 80 13.1% 8.3% Half of the respondents were from the upper the upper from were of the respondents Half caste in the intervention a (50.1%), group proportion which was slightly higher in the (57.0%). Th group control in the two populations was 8.5% in the Dalits intervention area. and 9.1% in the control was a diff there However, in districts; the highest proportionof Dalits the study was found in the intervention areas in Dolakha (20.7%) and the lowest of Doti (3.7%). areas control in a majority in both the were Hindus 89.5% intervention areas; and control Th and 93.1% respectively. 0% in Doti(both from varied Buddhists to 26.0% intervention areas) & control intervention Overall in the Dolakha area. 3-4% identifi 9.2% of the where of Banke the exception intervention areas and 11.5% of the control Table 2: Table 2011) *age of 30 respondents is missing (out of 3041), hence *age of 30 respondents table is 3,011. total number in above 160 310 370 150 Control 320 620 740 300 e targets for each Banke, ces in Doti, Intervention Target sample size for questionnaire survey by by survey for questionnaire sample size Target

nal actual number of survey participants Area/ districtArea/ Target e fi e Doti Banke Dang Dolakha TOTAL 1,980 990 Sample size calculations suggested we needed calculations suggested we size Sample 2000 2970 adolescents with approximately living in the intervention and 1000 in areas 1). Th sites (Table the control 3.1 Demographics of Survey 3.1 Demographics of Survey Population calculated with the help from district were Offi Health Public District and Dolakha. Dang was 3,041. In the intervention males was 3,041. In areas, 49.5% of the total sample and represented up 49.2%. they made areas in the control the intervention both areas In and control of sub-group made up the largest 15-year-olds the smallest. the population and 19-year-olds and intervention that the control 2 shows Table fairly similar in age communities are composition, although the population of the to be slightly older intervention appeared areas than in there with fewer 15- and 16-year-olds 2). ones (Table the control Th Table 1: Table district 8 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal group group; 619(63.9%)inthecontrol intervention mobile phone:1,066(51.5%)inthe A majorityofadolescentshadnopersonal 36.4%). 29.4%;controlin agriculture (intervention= 60.0%; control 52.5%),followed by working (intervention= most likelytobehousewives fathers inbothgroups, andmotherswere Agriculture wasthemainoccupationof 39.2%andcontrol groups 38.6%. intervention contrast, mother’s illiteracywashighinboth control=45.3%). In(intervention=42.9%; education fathers hadcompletedsecondary and control area. Asizeable minorityof educationbothintheintervention primary (65.5%) offathershadcompletedatleast had leftschoolby Grade 6.About two-thirds Between oneinfi =44.2%;control =45%). (intervention wereparticipants currently atschool (99.2%). Just lessthanhalfofallsurvey (98.4%)andcontrol areasintervention wasliterateinboththe participants Th 113 (64.9%)were female. people inthisstudy61(35.1%)were maleand (about6%).Of allmarriedyoung intervention were married(n=174)inbothcontrol and called themselves Muslim. Very adolescents few the control group. More men than womenhad asin access wasfairlysimilarinthe intervention 3.7%). Th to have suchaccess(overall male8.6%;female access athomewaslow, menwere twiceaslikely as inthecontrol group. While overall internet imbalance wasfairlysimilarintheintervention than females(11.0%versus 7.8%);thisgender to report havingalaptoporPCinthehouse Overall maleswereintervention. more likely computer, internetaccessoramotorbikeinthe (57.3%) hadone.Most didnothave alaptop/ but more thanhalfofallmalerespondents of allfemalerespondents hadamobilephone, a mobilephone,lessthanonethird (32.0%) e overwhelming majority of survey eoverwhelming majorityofsurvey . Overall, fewer womenthanmenhad egenderimbalance inhomeinternet ve tooneinfouradolescents no genderdiff information fromschool teachersandthere was from books.Overall 46.1%received ‘some’ (44.2%) reported getting‘some’ information books; more males (50.6%)thanfemales andbodilychangesfromschool puberty (47.4%) received ‘some’ informationon Additionally, nearlyhalfofallrespondents information from peers/friends. females (41.0%)hadreceived ‘a lot’ ofsuch getting information,more males(51.7%)than However, inreply tothesamequestionabout women (51.1%)thanamongthemen(41.8%) friends and/orpeers;more soamongtheyoung received ‘some’ ofsuchinformationfrom However, justlessthanhalf1408(46.5%) (55.4%)ofthefemales. and proportion (50.8%) andslightlylargernumber(n=851) bodily changesfrom theirparents; 760males received and someinformationaboutpuberty Just over halfofadolescents (53.2%)had their friendshadtakendrugs. andcontrol group thought the intervention about11%inboth do nottakenarcotic drugs, (around 98%)adolescentsresponded thatthey 844 (87.5%)inthecontrol group. Nearly all group and 1708 (82.6%)intheintervention responded thattheynever drinkalcohol: sometime. Ahighpercentage ofadolescent of fi that theyhadnever smoked,andfourout In termsoflifestyles, more than90%responded 55.7%). 60.5%;control and/or television(intervention= control=77.7%) home (intervention=83.9%; at home(over 80%)andmanyhadradioat respondents from bothgroups hadelectricity third (36.1%)ofthefemales.Amajorityall having apedalbikeandonlyjustover one- with more thanhalfofthemales(52.4%) Th control=44.5%).bicycle (intervention=44.0%; ofadolescentshada A fairlylargeproportion a motorcycle (male7.5%versus female6.1%) ere wasaconsiderablegenderdiff ve respondents visiteddohori /clubs erence. Nearly alladolescents erence . Sexual and reproductive health status and health service utilisation 9 of adolescents in four districts in Nepal In a question In . was a gender ere males and between erences ea, or bedbug bite; 5. a person can get AIDS by ea, or bedbug fl correctly in questionnaire). Young Young in questionnaire). correctly 1 Knowledge questions: 1. condom can be used more than once; 2. 27/1,538). In total 2535 respondents claimed total 2535 respondents 27/1,538). In males to use condoms, more they knew how than females did claim to know ‘if used properly condom can protect against against condom can protect ‘if used properly majority HIV transmission?’ an overwhelming the intervention in of adolescents agreed (91.7%) and in the control group=1897 (88.0%). Th group=850 imbalance with 95.0% of the males agreeing 86.2% of the females. and ‘only’ that generally less than 3 shows Table people had a of all young one-third of HIV and AIDS knowledge comprehensive knowledge all seven (i.e. they answered questions if used properly condoms can protect against HIV transmission; 3. a person looks strong & healthy can have HIV; 4. a person can get AIDS through mosquito, sharing food with a person who has AIDS; 6. a person can get AIDS by touching with a person who has AIDS; 7. condom use reduces the chance of getting AIDS. 1 females in view of the correct answers to the answers females in view of the correct questions. seven people in Banke scored lowest, whilst Dang had whilst Dang lowest, scored people in Banke people who the highest proportion of young Table questions. knew to these seven the answer the diff 4 shows ets/brochures and ets/brochures Figure 2: Sources of information on SRH (Baseline survey 2011) survey (Baseline on SRH of information 2: Sources Figure not among those who reported erence 3.2 Knowledge of contraceptives; all had heard Nearly intervention (96.3%). (97.4%)/ control group likely than more were respondents Female of any men to say that they had not heard but note that the numbers are contraceptives, very small (males 10 out of 1,498 & females receiving such information through the such information through receiving media. electronic of survey one-third approximately For participants friends/peers and school books for adolescents and SRH information provided that each of the responded about two-thirds no information on such provided following issues: (a) telephone hotline; (b) internet; and leaders (longest blue lines in Figure (c) religious to most participants telephone 2). According hotlines, the internet, leafl of not a common source were older relatives and HIV/AIDS. information on STIs (92.9%) also reported that television/cinema/ (92.9%) also reported some information on puberty radio provided was no gender and bodily changes and there diff 10 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal claiming tohave hadsexandlessthan onein (28.8%)oftheyoung men than onequarter Th group saidthattheyhadsexualintercourse. eight (128/968whichis13.2%) inthecontrol group andaboutonein in theintervention Only oneinfi slightly more (85.6%) inthecontrol group. group and intercourse; 78%intheintervention Th 3.3 Behaviour control=47.2%). followed by gonorrhea(intervention=49.9%; control=65.3%) (intervention=70.2%; (STIs), ofthese,syphiliswasbestknown heard aboutsexuallytransmittedinfections ofadolescentshad A largeproportion Notes: * T=True, F=False; **thosewhoanswered correctly outofallmenorwomenrespectively. Table 4: Table 3: * Proportion ofrespondents whocorrectly answer all7HIV-related questions ere existsahugegender diff emajorityofadolescentshadnosexual odmuerdcstecac fgtigAD T 12(78)10 7.% 2263(74.8%) 1101(71.8%) 1162(77.8%) Condom usereduces thechanceofgettingAIDS(T) 1940(64.0%) AIDS (F) 956(62.2%) Person cangetAIDSby touchingwithapersonwhohas has AIDS(F) 984(65.8%) Person cangetAIDSby sharingfoodwithapersonwho bite (F) 135/493(27.4%) Person cangetAIDSthrough mosquito,fl 340/1111(30.6%) Person 236/887(26.6%) looksstrong &healthycanhave HIV(T) 130/479(27.1%) transmission (T) If usedproperly condoms canprotect 36/135(26.7%) againstHIV 120/352 (34.1%) False*) 69/298(23.2%) Condom canbeusedmore thanonce(correct answer = 34/163(20.9%) 99/358(27.7%) 220/759(29.0%) 167/589(28.4%) 96/316(30.4%) Dolakha Dang Banke Doti ititIntervention group District Comprehensive knowledge ofseven HIV-related questions Correct answers toseven HIVquestionsby gender(inintervention orcontrol group is) ve (427/2067whichis20.7%) usinMl* eaeTotal Female Male** Question N (%)* erence withmore ea, orbedbug Control group group andthecontrol group (52%),thenext for themajority(59.3%)of theintervention forsexualintercourse; thiswasthecase partner Someone’s girlfriendor boyfriend wasthe major control=75.8%). (intervention=65.1%; intercourse attheageof16oryounger reported thattheyhad hadtheirfi Of thosewhohadsex,themajority (41.7% versus 24.0%). know’ inanswer tothisquestionthanmalesdid nearly doubleasmanyfemalesstated‘Idon’t their friendshadsex.It isinteresting that and only8.3%oftheyoung womenthinking men (50.0%)thinkingtheirfriendshadsex larger genderdiff 30.9%; control 24.9%).Againthere isaneven their friendshave already hadsex(intervention more young peoplethoughtthat themajorityof ten oftheyoung women(8.1%).Interestingly, 31(91)11 8.% 2646(87.5%) 1315(85.9%) 2444(81.0%) 1331 (89.1%) 1225(80.0%) 1878(62.3%) 1219 (81.9%) 859(56.1%) 1019 (68.7%) 2747(90.5%) 1325(86.2%) 2447(80.6%) 1422 (95.0%) 1160(75.6%) 1287 (85.8%) N (%)* erence withhalfoftheyoung District Total N (%)* rst sexual Sexual and reproductive health status and health service utilisation

11 of adolescents in four districts in Nepal cult far the e condom was by of adolescents fty percent during their last intercourse than those who had than those who last intercourse during their 61.3% respectively. 68.1% versus left school, in the age use during last intercourse Condom (73.0%) and in Doti 15-19 was highest group (61.3%). in Dang lowest (n=113) of looked at the sub-sample We (aged 15-19) in all married women young (61.9%) combined. Close to two-thirds areas method which used a modern contraceptive using condoms. As the meant for the majority it is diffi number (n=113) is low overall it appeared comparisons, but to make reliable least were married women in Banke that young likely to use modern methods of contraception 35.9% versus most likely, and those in Dolakha 91.3% respectively. of participantsA large percentage was currently method to delay not using any contraceptive (intervention= pregnancy 85.0%; or avoid 87.6%). Th control= method of contraception in both most preferred the intervention (91.9%) and the control group a very preference by low one (92.1%), followed 4%. for oral pills of only approximately the major were health facilities Government in both of emergency contraceptives source the intervention group (69.8%) and control medical shops private by (71.1%), followed (25%). A small proportion of all respondents emergency contraception, (9.3%) had acquired male (65%) and of those were two thirds among total users of emergency contraceptives, those who had unmarried. Of 85% were girls were used emergency contraceptives, those that had likely to be married. Of more males were used emergency contraceptives emergency acquired slightly less likely to have health facilities government from contraceptives 76.4%). than females (67.1% versus Less than fi devices they that contraceptive responded health facility the government from received (intervention=46.8%; always available were rst e ese erence erence rst partner most was partnerrst sexual was most likely was very ere little diff key partner was someone’s wife/husband with wife/husband key partner was someone’s the intervention21.6% in 31.7% and group it is very However, group. in the control important at the gender segregation to look men their fi for young here; whilst only 8.9% of the their husband (77.5%), to be their fi their ‘wife’ men reported young likely their girlfriend (69.4%), but for young (69.4%), but for young likely their girlfriend women their fi sexual partner. A large proportion, i.e. 271/419 (64.7%) in the intervention and 87/123 (70.7%) in group they had used that replied group the control Th a condom the last time they had sex. to those who had already proportions relate Asked why they had had sexual intercourse. not used a condom, 30.7% of the intervention replied group and 41.0% of the control group Th that they had had trust partner. in their next largest category not using a condom for (intervention available was none was that there one in 15.4%). About 18.7%; control group were that ‘they eight adolescents responded sexual and also that ‘it reduces of it’ not aware participants said that they more Far pleasure’. than to avoid pregnancy used condoms to avoid used than 99% of the females More STI/HIV. and 71.3% of pregnancy condoms to avoid males used condoms More the males did so. than females (5.0%), (23.3%) STIs to prevent likely to use condoms more also males were HV/AIDS (30.0%) than females to prevent the main were / local clinics (2.5%). Pharmacies got their condoms people young places where in both the intervention (54.3%) and control to (47.2%), and many also preferred group (intervention=44.5%; there get condoms from control=38.2%). equally women were men and young Young likely to say that they had used a condom the 65.3% last time they had sex, 64.7% versus Th respectively. adolescents. married and unmarried between slightly less still at school were Respondents a condom that they had used likely to report 12 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal were married,representing 1.2%inboththe of thosewhosaidthatthey had notsex,29 28.8% versus 8.1%respectively. Interestingly, intercourse thanyoung women in thesurvey, likely toreport thattheyhadsexual diff percentage ofschoolcategoriessignifi still atschool.Chi-square test revealed thatthe likely tohave hadsexualintercourse thanthose Respondents whohadleftschoolwere more 3.4 SexualIntercourse correct answer thangirls. harmful, withmanbeingmore likelytogive the correctly statedthatmasturbationwasnot On thetopic ofmasturbation,only28.3% half ofthecontrol group (48.8%). group (56.2%)andjustlessthan intervention before marriage’; namelyjustover halfofthe loses hisselfrespect anddignityifhehassex more likelytosay‘no’ tothestatement‘a boy control=69.2%). In contrast,respondents were 72.9%; has sexbefore marriage(intervention= believed thatagirllosesherself-respect ifshe say ‘no’.A signifi sex shouldrespect therightofothersto the statementthatpeoplewhowanttohave Nearly tenpercent inbothgroups rejected control=48.9%). (intervention=45.4%; pregnant whenshehassexduringmenstruation that awomanhasgreater chancetoget A substantialminorityofrespondents stated males (78.5%)did. female respondents (85.1%)reported thisthan 79.8%andcontrol 86.2%),more(intervention: the onetheywere usingfrom ahealthworker other methodsoffamilyplanningto had not(yet) received anyinformationabout control=24.6%). Th the healthfacility(intervention=25.1%; not getcontraceptives oftheirchoicefrom respondents replied thatyoung peopledid control=40.4%). About of aquarter ered (p<0.05). Young menwere farmore cant numberofadolescent emajorityofrespondents cantly intercourse. less likelytoreport thattheyhadsexual related; henceyounger respondents were by mostotherstudies,havinghadsexisage- andcontrol group.intervention Asconfi waiting area. Th Communication) materialsdisplayed inthe have theyIEC(Information, Education and control=62.8%), nor (intervention=42.8%; often theydonothave afunctionaltoilet control=59.3%), privacy (intervention=54.6%; included: healthfacilitiescannotmaintain addition, otherreasons fornotbeingfriendly control=76.9%). In(intervention=63.8%; there isnoseparateroom foradolescents that thehealthfacilitywasnotfriendlyas However, themajorityofthemthought control=89.9%). facility (intervention=90.2%; walk lessthananhourtoreach thehealth A signifi respectively. to young women,38.7%versus 30.0% for obtainingreproductive compared services, been tothenearest government healthfacility Male were participants more likelytohave ever (33.9%) andinthecontrol group (35.1%). group similar between thoseintheintervention higher at35.4%.Th for thosewhohadleftschoolitwasslightly was33.8%and still atschooltheproportion for obtainingreproductive forthose services, been tothenearest government healthfacility who hadleftschoolaboutone-third hadever In boththegroups stillatschoolandthose with HealthServices 3.5 UtilisationofandSatisfaction control=34.3%). Ahigh numberofadolescents health care providers (intervention=30.5%; discussing theirsexualhealth problems with stillfeltuncomfortable of theparticipants and thecontrol group (45.7%). About athird waiting areas (71.1%) between theintervention regarding IECmaterialsbeingdisplayed in cant numberofrespondents hadto ere wasalargediff e proportion was also very wasalsovery eproportion erence rmed Sexual and reproductive health status and health service utilisation

13 of adolescents in four districts in Nepal e er ed ed with ed ose ed with ed erence was erence ed) with ed) er than their ed whilst 75.3% older between erence e gender diff ed had answered ‘not ‘not answered ed had both the is was the case in ed (or very satisfi er. satisfi ed as not ed’ or ‘I don’t know’ on the questionnaire. on the questionnaire. know’ or ‘I don’t ed’ than those 17 ed with service provision a total of 30 e data collected from Overall a large proportion of young people proportion a large of young Overall satisfi (71.6%) was Th health servicesthe sexual provided. classifi satisfi high likely to report more were men Young the services of satisfaction with levels on off women. Th than young area control in the greater not enormous, but 66.3%) than in the female (male 70.3% versus female intervention versus (male 74.1% area men and (young levels 72.2%). Satisfaction (56.3%) in Doti lowest women combined) were (80.6%). Interestingly, and highest in Dolakha young was the only district where Dolakha likely to be satisfi more women were the sexual health services on off male counterparts. Th and the interventioncontrol group. Analysing satisfaction with services age gave by the intervention In districts a less clear picture. slightly were and younger those aged 16 years satisfi that they were less likely to report aged 17 and older (72.6%) than respondents younger group (74.0%), whilst in the control being likely to report more were respondents satisfi Th and 64.4% respectively. 70.0% and older, diff percentage greatest was found in the respondents and younger only 55.6% of those were group control Banke satisfi aged 17 and older were satisfi of those aged 16 and under were the services on off Th in both the health facilities government insights give intervention areas and control sexual and reproductive in the available health services adolescents. and the uptake by sexual absolute numbers of 5 reports Table 3.6 Records of sexual and reproductive health service utilisation e near to their ered for immunisation (men erence the by the SRH servicesed with provided ed (intervention=16.3%; control=22.1%). e proportion of men and women who men e view was fairly similar between area (intervention=46.9%; area control=51.1%). had local health facilities and schools Neither organised periodic checkups for adolescents (intervention=71.8%; control=70.8%). main purpose to visit a government health main purpose to visit a government facility was to get counselling for SRH and (intervention=46.8%;ASRH problems immunisation by followed control=33.7%), (intervention=18.8%; 22.1%). control= Th for counselling serviceswent for SRH was 43.8%), whilst there similar (42.3% versus diff was great half replied 6.7% and women 37.0%).About was no life skills-based health that there off education programme said they had had wasted trips to health centres to health centres had had wasted trips said they as the health care home return and had to they got in the facility when not were providers (intervention=41.0%; there control=49.6%). was a majority of the respondents Nevertheless, satisfi health facility (intervention=61.3%; control= not who were a group by 55.8%), followed satisfi proportions of participants in both Similar the intervention group (85.2%) and control the health facility (84.2%) would recommend and they prefer to their friends and relatives, problems for HIV/AIDS/STI to go there (intervention=72.7%; control=69.8%). for the help with sexual abuse/ However, assault, they would go to the police station (intervention= control=79.7%). 74.9%; knew that the half of the respondents About ASRH services in the health available are (intervention=50.2%;facilities of their area men knew slightly more control=49.9%), the this (52.3%) than women (47.9%).At these same time, the majority thought that not adolescent friendly health facilities were (intervention=60.7%; control=69.5%). Th and women, as 37.0% of men thought friendly and young-people facilities were Th 35.9% of the women thought so. 14 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal Table 5: henceitcannotbe orsafeabortion, delivery off instance, thehealthfacilitiesassessedwere not caution. In thecontrol group ofDolakha for between the twogroups shouldbedonewith andcontrol groups, comparisons intervention utilisationinthe were assessedforservice Asdiff service. about thenumberofpeopleusingspecifi usagebutnot to getinformationaboutservice amalgamated from thehealth facilitiesallows us In otherwords, thewaydatais services. of thepopulationincatchmentareas using notpeoplenorthe percentagerelevant services Th (HMIS). by thehealthinformationmanagementsystem age group disaggregation currently followed adolescents undertheageof20.Th useby peopleoverhealth service 20years and *Interv. =InterventionANC =antenatalcare =tetanustoxoidTT SBA=skilled attendantatbirth SBA Delivery delivery Institutional Safe Abortion users TT Four ANC First ANC User) (Current Implant User) (Current Depo User) Age (Current OCP Service enumbersrepresent contactswiththe ering services withregardering services toinstitutional erent typesofhealthfacilities Health Use Services oneyear (Shrawan 2068BS) 2067-Ashad 2+ 4 56026 827 12 8 0 0 78 62 27 23 0 2 3 3 134 2 112 6 11 0 2065 0 851 10 97 63 0 10 0 4 767 2256 0 48 210 64 45 214 318 181 70 151 23 0 4596 0 0 0 1296 205 120 127 377 654 101 4759 0 922 0 0 338 0 471 101 16 109 164 3 725 0 29 3 0 243 93 80 489 29 978 0 92 0 1210 1073 5915 220 105 323 177 43 85 20+ 65 254 363 19 0 1904 110 0 < 20 185 10 8 438 20+ 1231 123 5066 1735 119 < 20 359 11 232 230 284 20+ 1334 3 116 6563 25 140 < 20 106 15 58 20+ 1407 0 319 4283 < 20 0 526 38 20+ 721 161 231 6524 < 20 93 20+ 4 42 376 3121 < 20 51 20+ 3254 495 0 < 20 152 20+ 760 29 < 20 20+ < 20 nev oto nev oto nev oto nev Control Interv. Control Interv. Control Interv. Control Interv* oah ak agDoti Dang Banke Dolakha isthe c Table 6. facilities includeintheassessmentisgiven in and withinthecontrol group. Alistofallhealth uptakewithintheintervention trend inservice same healthfacilitiesshouldprovide dataonthe is given here, asthefuture assessmentsatthe denominator isnotgiven. Th used cannotbedirectly compared either, asthe above andbelow 20foreachtypeofservice issue ofaccess.Similarly, thefi butratherthatthere isan use theseservices, included thatthepeopleinthisgroup donot • Th Implants –where available –experiencea • Some generalimpressions from thedataare: BoththeBanke andDang intervention • low uptakeby under20year olds maternity care inthosedistrictsandsites presence oflargerhealthfacilitiesoff deliveries attendedby SBAsowing tothe group have relatively highnumbersof all fourANCvisits visits (ANC)ishigherthanthenumberof enumberofrecorded fi

edatain Table 5 gures between rst antenatalcare ering Sexual and reproductive health status and health service utilisation

15 of adolescents in four districts in Nepal Operational research- List of HFs by Intervention (I) and Control (C) (I) and Control Intervention by List of HFs research- Operational District Facilities Health Category Overview of health facilities included in the assessment facilities included of health Overview DolkhaDolkhaDolkhaDolkhaDolkhaDolkhaDolkhaDolkha Chhetrapa HPBanke HP Sundrawati Banke Katakuti SHPBanke Boch HPBanke Hosp.District Jiri Banke Charikot PHCBanke HP Dolkha Banke HP Namdu Banke HPDang Udharapur SHPDang Naubasta C SHPDang Binauna C Dang HP Phatteypur Dang HP Sonpur C Dang Kamdi SHP I Dang ZH Bheri I Doti SHP Baijapur I Doti HP I Doti Lalmatiya SHP I Doti HP C Doti HP C Doti Lamhi PHC C Doti Hosp Rapti Sub-Regional I SHP Nagar Pawan I SHP Kalena I SHP Berchhaina HP Sanagaun I I C SHP Banlek C SHP Chhatiwan PHC Nagar Saraswoti I C HP Mudvara I I I C C C I I I I Table 6: Table 16 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal T control and intervention areas.control Interestingly, andintervention diff knowledge factorsshowed muchgreater gender As expected,various behaviouraland lower inBanke. control group ofDoti, Dang andDolakha, but condom useishigherinyoung peopleinthe last intercourse, we seethat Table 6shows that behavioural aspect,forexamplecondomuseat one control district(Dang). If we considera (Dolakha 27.7%versus 26.7%) andhigherin districts,nearly similarinone two intervention comprehensive knowledge ofHIVishigherin this pointsee Table 3above. Table 3shows that in behaviournorknowledge. To illustrate Also thediff characteristics tomakereasonable comparisons. i.e. theareas are similarenoughintheirkey However, thesediff would expectinacommunity-basedsurvey. Table 6: DISCUSSION 4 oah 5/6 (97) 1/9 (37)67/95(70.5%) 136/222(61.3%) 101/151(66.9%) 54/74(73.0%) 14/19 (73.7%) 40/54 (74.1%) 15/27 (55.6%) 18/23 (78.3%) 53/76 (69.7%) 96/168(57.1%) 86/124(69.4%) 36/51(70.6%) Dolakha Dang Intervention group Banke Doti District erences thanthosewhichexistedbetween areas and the intervention areas,areas asone andtheintervention here are diff Condomuseamong15to19-year-olds duringlastintercourse erences are notsystematic,neither erences between thecontrol erences are notenormous, N (%) just over halfoftheadolescentshadamobile hadinternetaccessathomeand participants Since lessthantenpercent ofallstudy Education 2003). as muchelsewhere (Sub-Committee onPeer information onsexualissues,butperhapsnot Fig. 2illustratesthatpeerswere asource of are sensitive oraculturaltaboo. Interestingly, of informationfrom theirpeersonissuesthat Youth, 1997). Young peoplegetagreat deal their friendsare sexuallyactive (Advocates for who are sexuallyactive perceived thatmostof (Eggermont, 2005).For example,young people sexual intercourse thanitisthecaseinreality people inNepal thinkthattheirpeershave had at young peopleacross theworldmore young As foundinmanysexualhealthstudiesaimed more likelytoreport itwastheirhusband. had beentheirgirlfriendwhilstwomenare far intercourse menreported thattheirfi among respondents who hadexperiencedsexual Control group N (%) District Total N (%) rst partner Sexual and reproductive health status and health service utilisation

17 of adolescents in four districts in Nepal serviceerent/better is would look like, this what they value a notion that people is ere High satisfaction levels are commonly reported commonly reported are satisfaction levels High services. for a range of health the globe across Th envisage what really and cannot (receive) have a diff of ‘what to as the phenomenon often referred 1984; van & Macintyre (Porter is must be best’ et al. 2003). Teijlingen ed 2012). et al. A large proportion of young people was satisfi people A large proportion of young phone (see above) - while only one-third of of one-third - while only above) phone (see is little scope had one - there women young mobile phone and through for high coverage cell phone interventions in as used elsewhere suggested in a recent countries as low-income (Denno systematic review with the reproductive health services provided. services health provided. with the reproductive 18 Sexual and reproductive health status and health service utilisation of adolescents in four districts in Nepal issue/22/248-256.pdf utilisation, among young peopleinNepal: andbarriersforsexualhealtheducation andservice opportunities Regmi, P., Simkhada, P., van Teijlingen E.R.(2008)Sexual andreproductive health status responses toantenatalcare provision. Porter M,Macintyre S.(1984) What is,mustbebest:aresearch ordeferential noteonconservative DoHS, Kathmandu. New ERA,ORC Macro Int’l. (2006)Nepal Demographic Health Survey, Family Health Division, EngenderHealth. the Answer? Washington, DC:International CenterforResearch on Women (ICRW) and Mathur, S.,Mehta, M.,Malhotra, A.(2004). Youth Reproductive Health inNepal: Is Participation andlimitations, opportunities health promotion interventions: Kane, R., Wellings, K,Free, C.& Goodrich, J.(2000)Uses ofroutine datasetsintheevaluation of and Reproductive Health ASystematic Services: Review Denno, D.M, Chandra-Mouli, V., Osman, D.(2012)Reaching Youth With Out-of-Facility HIV Factors. Advocates for Youth. (1997)Factsheet onAdolescent Sexual Behavior: II.Socio-psychological address: www.reproductive-health-journal.com/content/pdf/1742-4755-7-15.pdf viewing. viewing. Eggermont S.(2005) Young adolescents’ perceptions ofpeersexualbehaviours:therole oftelevision 28. Mixed Methods Research: How To and Why Not? Driscoll DL,Appiah YA, Salib P, Rupert DJ.(2007)Merging Qualitative andQuantitative Data in in decision-makingforhealthcare: AdemographicstudyinNepal. D.R.,Bell,Acharya, J.S.,Simkhada, P., van Teijlingen E.,Regmi, P.R. (2010) Women’s autonomy 453 web address: http://kumj.com.np/ftp/issue/28/445-453.pdf based sexandsexualhealtheducationinNepal. D.R.,vanAcharya, Teijlingen E.R REFERENCES 5 Child: Care, Health &Development, Kathmandu University Medical Journal . , Simkhada P. andchallengesinschool- (2009)Opportunities Social Science&Medicine 31 : 459-468 Kathmandu University Medical Journal 6 (2): 248-256.http://kumj.com.np/ftp/ Ecological &Environmental Anthropology. Journal ofAdolescent Health 19: Health Education 1197-1200. Reproductive Health , 100 (onlinefi : 33-41. 7 9 (4): 445- (15).web 3: rst). 19- Sexual and reproductive health status and health service utilisation

19 of adolescents in four districts in Nepal : ce 7 Issue Issue

Critical Critical

Sociological UN edn). London: nd (2 : 75-82. 30 RCM MidwivesJournal Social Research Update Update Social Research Adolescent Health and Health Adolescent Birth Birth Culture, Health & Sexuality & Sexuality Health Culture, (4): 295-296. www.wemjournal. (4): 295-296. ciency and Equity ciency and Equity Evaluating Health Promotion. Health Evaluating 17 ectiveness, Effi ectiveness, Peer Education: Training of Trainers Manual Manual Trainers of Training Education: Peer family methods in research e range of qualitative e importance of pilot studies, Journal of Family Planning & Reproductive Health Care Health & Reproductive Planning of Family Journal Health Promotion Evaluation: Recommendations to policy-makers, Recommendations Evaluation: Promotion Health ) Nepal Adolescents health: fact sheet. Adolescents ) Nepal (2006) Health Demonstration Projects: Issues in evaluating a in evaluating Issues Projects: Demonstration (2006) Health Health Education, Eff Education, Health et al. ornes. Online journal, web address: www.socresonline.org.uk/12/2/van_teijlingen. address: journal, web Online ) ce for Europe). Web address: http://www.who.dk/document/e60706.pdf http://www.who.dk/document/e60706.pdf address: Web ce for Europe). (2 (3): 175-189. 12 Wilderness & Environmental Medical Journal, Journal, Medical & Environmental Wilderness E., Reid, J., Shucksmith, J. Harris, F., Philip, K., Imamura, M., Tucker, J., Penney, J., Penney, Tucker, M., K., Imamura, Philip, F., J. Harris, J., Shucksmith, E., Reid, 16 , (1): 45-58. (3): 171-73. Development (AHD) Unit, Department of Family and Community Health, WHO Regional Offi WHO Regional Health, and Community Department of Family (AHD) Unit, Development Asia. for South-East Chapman & Hall E. Teijlingen J., van Tucker, sexual health, people’s young community-based health intervention to improve programme Health, Public Th Cheltenham: Stanley (1998) Organization Health World (Copenhagen: Evaluation Promotion on Health Group Working WHO European of the Report Offi WHO Regional (2007 Organization Health World Weston, R. (1998) Intertextuality: the current historical context of health promotion, cancer historical context of health promotion, the current R. (1998) Intertextuality: Weston, R. (eds.), Weston, Scott, D. & In: and evaluation, prevention org/wmsonline/?request=get-document&issn=1080-6032&volume=017&issue=04&page=0295#R ef sexual health knowledge, (2010) Sexual P. Regmi, E., Teijlingen van P., Bhatta, P., Simkhada, in Nepal. guides male trekking and condom use among relationships 12 (2003) Education on Peer Sub-Committee and Central in Europe and Protection Development Health Peoples Young on Group Interagency at: http://cfsc.trunky.net/_uploads/Publications/160.peer_education_ on theweb Asia. Available training_of_trainers.pdf (2001) Th V. E., Hundley, van, Teijlingen Simkhada, P., Bhatta, P., van Teijlingen E.(2006)Importanceof piloting a questionnaire on sexual a questionnaire piloting E.(2006)Importanceof Teijlingen van P., Bhatta, P., Simkhada, health research, 35, (Edited by N. Gilbert), Guildford: University of Surrey. Web address: http://www.soc.surrey. address: Web of Surrey. University Guildford: N. Gilbert), by 35, (Edited ac.uk/sru/SRU35.html A. (2003) Maternity Fitzmaurice, W., A-M, Graham. Rennie, V., E., Hundley, van, Teijlingen „What is, must still be best“, satisfaction studies and their limitations: Teijlingen van, E.R., Forrest, K. (2004) Th K. E.R., Forrest, van, Teijlingen health care, planning and reproductive 30 in midwifery E.R., Cheyne, H.L. (2004) Ethics research, van, Teijlingen 208-10. van Teijlingen sexual health, people talking about as a key emotion in young G. (2007) Embarrassment Online, Research html S. (1994) Tilford, K., Tones,

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