SEXUAL AND REPRODUCTIVE HEALTH NEEDS OF MALE ADLOESCENT AND GAP BETWEEN SERVICES AND NEEDS A study in selected

wards of Dakshinkali VDC

A Research Dissertation and Seminar (RDS366) Submitted to the Faculty of Humanities and Social Science Purbanchal University (PU) In Partial Fulfilment of the Academic Requirement for the Degree of Bachelor of Social Work

Submitted by Sangeet Gopal Kayastha Department of Social Work Kadambari Memorial College of Science and Management Kathmandu, Nepal 2011

ACKNOWLEDGEMENT First of all I would like to express my gratitude to the department of social work, Kadambari Memorial College of Science and Management for providing me permission to write dissertation in this title. I would like to acknowledge my family for their continuous support and help directly or indirectly for the completion of this research. I would like to thank Pharping Higher Secondary School for permitting me to interview the students and providing me necessary arrangements. My gratitude also goes to all the respondents who provided their precious time and effort for interview to fill up the questionnaire. I take this opportunity to pay my gratitude to key informants for my research dissertation, Dr .Yadav Gurung for their valuable ideas and suggestions. I cannot go expressing my thanks to the Head, Research and Training, Kadambari Memorial College of Science and Management for her positive guidance and administrative support. It is my pleasure to express my sincere thanks Ms. Subharna Pandey for her constant support and appreciation. The completed dissertation is an immediate out-put of her appreciative guidance.

Sangeet Gopal Kayastha

II

III

LETTER OF RECOMMENDATION

I certify that Mr. Sangeet Gopal Kayastha has written this thesis titled under my supervision, in partial fulfillment of the academic requirement for the degree of Bachelor of Social Work (BSW), Purbanchal University. No part of this thesis has been submitted for any other academic degree in any other university. I recommend this thesis for examination and acceptance.

. Dr. Yadav Gurung Dissertation Supervisor Date: July 1 , 2011

IV

Table of Contents
Table of Contents....................................................................................................... V Abstract...................................................................................................................... X Chapter-I..................................................................................................................... 1 Introduction................................................................................................................ 1 1.1 Theoretical Background.....................................................................................1 1.2 Statement of the Problem:................................................................................3 1.3 Objectives of the Study.....................................................................................5 1.4 Rational of the Study:........................................................................................5 1.5 Research Question:...........................................................................................6 1.6 Conceptual Framework......................................................................................6 1.7 Limitations of the Study:...................................................................................7 Chapter-II....................................................................................................................9 Literature Review.......................................................................................................9 Chapter III................................................................................................................. 15 Research Methodology.............................................................................................15 3.1 Study Site / Description and Rationale for the Selection of the Site................15 3.2 Research Design:.............................................................................................16 3.3 Nature and Source of data..............................................................................16 3.4 Sampling Procedure........................................................................................17 3.4.1 Sample size.................................................................................................. 17 3.4.2 Key informant...............................................................................................17 3.5 Data Collection Technique and tools. .............................................................17 3.6 Pre-test of Tools: ............................................................................................17 3.7 Monitoring and Supervision of Data collection................................................17

3.8 Data Management and Analysis .....................................................................18 3.9 Ethical Consideration.......................................................................................18 CHAPTER IV.............................................................................................................. 19 Sexual and reproductive health gap between service and Need Analysis ...............19 4.1 Demographic Profile of the Respondents........................................................19 4.1 .1 Age of Respondent......................................................................................19 4.1.2 Education Level of Respondent....................................................................20 4.1.3 Engagement in Formal Education.................................................................21 4.2.1 Source of Information Related with SRH.......................................................21 4.2.2 SRH content in School Curriculum................................................................22 4.2.3 Teaching of SRH Education in School...........................................................23 4.2.4 Knowledge about HIV and AIDS....................................................................23 4.2.5 Respondent View on Proper Age of Marriage...............................................25 4.2.6 Knowledge on Contraceptives ...................................................................26 4.2.7 Heard about Emergency Contraceptives ....................................................27 4.2.8 Appropriate Source to Access Condom.........................................................28 4.2.9 Perception on Premarital Sex.......................................................................28 4.2.10 Perception on Masturbation .......................................................................29 4.2.11. Participation in SRH Programme ..............................................................30 4.2.12 Health Seeking Behavior ...........................................................................31 4.2.13 Perception on Health Services ...................................................................31 CHAPTER V...............................................................................................................33 SUMMARY, CONCLUSION AND RECOMMENDATIONS................................................33 5.1 Summary of the Findings.................................................................................34 5.2 Conclusion....................................................................................................... 35 5.2.1 Gap between Services and Needs................................................................35

VI

5.3 Recommendation............................................................................................37 5.3.1 To Health Service Providers..........................................................................37 5.3.2 To Educational Institutions...........................................................................37 5.3.3 To the Government .....................................................................................37 5.4 Social Work Intervention.................................................................................38 B. ASRH service access and utilization.....................................................................42

References Annex I: Key Informant Interview Guideline Annex II: Interview Schedule/Questionnaire

VII

List of Figures
Figure 1 :Age of respondents....................................................................................19 Figure 2 : Education level of respondent..................................................................20 Figure 3 : Sources of information related with SRH..................................................21 Figure 4 : SRH content in school curriculum.............................................................22 Figure 5:Respondent view on proper age of marriage..............................................25 Figure 6:Name of contraceptive ever heard.............................................................26 Figure 7:Preference to take health seeking behaviour.............................................31 Figure 8: Preference to take health seeking behaviour............................................32

List of Table
VIII

Table 1 : Respondents engagement in formal education.........................................21 Table 2: Teaching of SRH education in school..........................................................23 Table 3: Knowledge about HIV & AIDS......................................................................24 Table 4: Heard about emergency contraceptives.....................................................27 Table 5 : Appropriate source to access condom......................................................28 Table 6: Perception on masturbation........................................................................29 Table 7: Participation in Programme related to SRH.................................................30

IX

Abstract
The study is focused on the Sexual and Reproductive health of male adolescent and the gap between services and needs. The objectives of the study was to explore the SRH needs of male adolescent and gap between services and needs of male adolescents. Research methods Non Probability purposive sampling method was applied for selection of the respondent. Universe of the study was school going and out of school male adolescents aged 1519 years at least with the minimum primary education. Adolescence interviewed were from ward number 1, 2, 3& 4 of Dakshinkali VDC in which unit of analysis was individual. The main findings: From the study it was found that the source of information which adolescents prefer to get information on SRHR is orientation program , radio programs , news papers ,clubs and mainly through peers/friends .Besides that the adolescents needs and want youth friendly health facility in available health service centres nearby. The existing health centres in the study area are; Man Mohan Memorial hospital, Dakshinkali sub health post and some private clinics. Responded said that the existing hospital and health post in the study area providing services lack privacy and lack of necessary services like; free condom distribution, therefore, they do not prefer to access the services there. The research shows that, though many adolescents are unaware about the Nepal Governments Legal age at marriage but all of them think that proper age at marriage is after 20 years. The study also showed that school curriculum containing SRH information is insufficient. The teaching method was also not good as there is lack of trained teachers. The majority of the students had the neutral view about premarital sex; they feel that if its safe, its good. There are some misconceptions prevalent about HIV and AIDS, few find the terms same as their curriculum indicates it as HIV/AIDS. Male condom and pills are mostly known contraceptive devices among adolescents whereas only Emergency contraceptive is least popular. The study showed that adolescent in the area has very limited knowledge on HIV and contraceptives. Also it's found that the services are not much appropriate and have to be improved. It also should be youth friendly so that more adolescent can use the services.

ABBREVIATIONS AIDS ASRH CBS CPRT ECP FPAN GTZ HIV HMG HeRT ICPD ICRW INGO IEC MDGs MoHP NDHS NGO STI/Ds SHP SRH UNICEF UNESCO WHO VDC YFHS - Acquired Immune deficiency Syndrome - Adolescent Sexual and Reproductive Health - Central Bureau of Statistics - Centre for population research and training - Emergency Contraceptive Pills - Family Planning Association of Nepal - German Technical Cooperation - Human Immunodeficiency Virus - His Majestys Government -Health Research and Training Centre - International Convention on Population and Development - International Center for Research on Women -International Non Governmental Organisation - Information Education and Communication -Millennium Development Goals - Ministry of Health & Population - Nepal Demographic Health Survey -Non Governmental Organisation - Sexually Transmitted Infections/ Diseases - Health Post - Sexual and Reproductive Health - United Nations Children's Fund - United Nations Educational, Scientific and Cultural Organization -World Health Organization -Village Development Committee -Youth Friendly Health Services

XI

Chapter-I Introduction
1.1 Theoretical Background Health is one of the essential issues to deal, in any social and development sector. Reproductive health within the health is more crucial especially in developing countries. In the human growth and development, adolescent is an important phase in terms of physical, mental as well as social development. According to World Health Organisation (WHO) and United Nation, the age group of 10-19 are categorized as Adolescent. Adolescence can be divided into early, middle and late periods, which are respectively 10-14, 15-17 and 18-19 years age group.1 In Nepal, adolescent population is approximately 5.4 million as per 2001 census. This population is nearly one fourth (23.6%) of the total population of the country.2 According to CBS 2001, 10.97% of adolescent people are married and 80.62% of them are literate. The adolescent population is estimated to reach 6 million by the year 2011 and to almost 7 million in 2021. 3 The International Conference on Population and Development (ICPD) held in Cairo in 1994 was a milestone in the history of population and development that focused on young peoples sexual and reproductive health issues including promoting safer and responsible sexual and reproductive behaviour.4 The Government of Nepal is committed to implement ICPD program of action which integrates young peoples sexual and reproductive health. This is a considerable challenge because Nepals population is characterized by a large number of young in age.
1

Adolescent Health and Development in Nepal status, issues, programmes and challenges, 2005 Pg 2 Ibid, Pg 4 Cited in, Ram Hari Aryal and Upendra Prasad Adhikari, Adolescents and Youth in Nepal, pg 10

Regmi, P., Simkhada, P., & Van Teijlingen, E.R., Sexual and reproductive health status among young people in Nepal: opportunities and barriers for sexual health education and services utilization, 2008, pg 249

Studies suggest that sex and reproduction remain taboo subjects within families throughout Asia, in such conditions Nepal presents an important setting for addressing youth reproductive health needs. Adolescents in Nepal often face severe poverty, limited access to education and health services, and restrictive cultural and sexual norms. 5Young people access to proper information and services is related to their sexual and reproductive health. Early marriage leading to early pregnancy is one of the main factors that increase the Maternal Mortality Rate (MMR) and IMR (Infant Mortality Rate). Sex and sexuality education provided in schools and families in Nepal has not been effective enough either. In context of developing country such as Nepal, although there had been some achievements in the sexual and reproductive health of female and also the services had been increased but for male there are limited numbers of services. Because of lack of information many male having the problems do not get proper services which led to various problems on their life. Governmental and nongovernmental organizations working in SRH service sector had much focused in the health of women but not much in the needs and services to male. National Adolescent Health & Development Strategy Nepal 2000 was made with the goal of the National Adolescent Health and Development Strategy is to improve the health and socio -economic status of adolescents. The strategy was made in objective with increasing and improving the SRH information & services for the adolescent. It was also focused to provide opportunities to build skills of adolescents, service providers and educators. Besides that it was focused to increase accessibility and utilization of adolescents' health and counselling services for adolescents and o create safe and supportive environments for adolescents in order to improve their legal, social and economic status.6 To implement the National Adolescent Health & Development Strategy, Family Health Division (FHD) under the Ministry of Health (MoH) ASRH implementation guide has been developed in 2007.

Ibid National Adolescent Health & Development Strategy Nepal ,Family Health Division , Ministry of Health, 2000 ,

1.2 Statement of the Problem: Adolescent population usually has limited knowledge on their Sexual and Reproductive Health (SRH). Young people rely on different sources of information for SRH queries and problems. These may include friends, parents, media, schools, college, brother/sister, etc. As sex and sexuality are not issues discussed openly in Nepalese society, the information provided may be insufficient or misleading. A proper medium to deliver sex and sexuality education to young people has to be identified and provision of the age appropriate information is to be carried out. Education about responsible sexual behaviour and specific, clear information about the consequences of sexual intercourse is frequently not offered at homes, schools, or in other community settings. In context of Nepal , although proper education had some how been provided in the schools of the urban areas but many youths in the schools of rural area had not got proper education related with Sexual and Reproductive health. Sexual and reproductive health is a topic of shyness that most people even cannot talk about it easily. Although Government had provided the SRH education as a part of Health Education but there is not proper complete knowledge in it that are necessary for adolescent. Young people today are growing up in a culture in which peers, television and motion pictures, music, and magazines often transmit either covert or overt messages that unmarried sexual relationships are common, accepted, and at times expected, behaviours.7 Lack of knowledge among the peer and flow of that knowledge may led to much problems. Adolescent stepping to the college study after their School Leaving Certificate (S.L.C), are generally not desired to be viewed as a children and they feel mature enough to decide for their sexual behaviour. In this type of condition they are more prone to involve in risk behaviour like premarital sexual activities. Findings from studies which have investigated premarital sexual behaviour among high school and college students have found rates of activity to vary from 11 per cent among students in Pokhara to 14 per cent among Kathmandu students and 16 per cent among students1 in Palpa District. 8

Cited in opcit 4 pg. 250

Stone, N. Ingham , R. and Simkhada, P. Knowledge of sexual health issues among unmarried young people in Nepal, 2003, pp. 34

The knowledge and use of Emergency Contraceptives (EC) that can prevent unintended pregnancy is very less in Nepal. Only 7.3% males and 6.7% females had knowledge on EC among the adolescent. Furthermore, adolescent unsafe sexual activities can bring them at the risk of Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS) and sexually transmitted diseases (STDs). These problems create physical, mental as well as emotional stress on adolescent which may hamper for their development and thus the development of the nation. The sexual reproductive needs and services of male are not addressed much. Also although there are services but due to lack of information is there. Adolescent is the age where the physical and mental changes take place in them.

In year 2000, Adolescent Health and Development Strategy were launched. The strategy was focused to address the needs of adolescent and youth using a multi-sector approach. The goal was made Strategy is to improve the health and socio-economic status of adolescents by increasing the services and information to adolescent and to increase skills of the service providers and educators of the country. The decentralization and implantation of the programs with the help of all NGOs, Ingos, Youth group, Village Development Committees, District Development Committees, Municipalities and Metropolitan cities was targeted. Adolescent Friendly Services (AFS) was introduced to increase quality SRH services to the adolescent through present outlets which will cover will cover the services in the health care continuum of promotive, preventive, curative and rehabilitative health services. The ASRH implementation guide intends to facilitate district health managers (District Health Officers, District Public Health Officers) in implementing the Adolescent Health and Development Strategy at district and community health care settings, educational institutions, NGOs and civil society organizations. This guide is only a framework for implementing programs to improve young people's sexual and reproductive health in Nepal and is intended to use innovatively and constructively in districts and the communities. ASRH Implementation Guide is expected to encourage young people's participation, intra and inter- sectoral partnership, gender equity and equality, youth friendly services and linkages to other strategies and programs

at every stage of implementation. 9 Though the guide is friendly in terms of provision of access to information and service on ASRH, it has not been properly implemented. Young people and specially adolescents do not seem to have proper utilized the existing health centres due to issues like; lack of privacy, lack of trained human resource, infrastructural structure, etc.

1.3 Objectives of the Study General Objectives: To explore the SRH needs of male adolescent and gap between services and needs of male adolescents. 1.3.2 .Specific Objectives: 1.
2.

To find out the Sexual Reproductive Health Needs of Male adolescents (15-19) of To find out the services available in the area related with SRH. To find out the Gap between Services and Needs. To find out the knowledge and attitude about SRH among male adolescents of Dakshinkali

Dakshinkali VDC. 3. 4.

VDC.

1.4 Rational of the Study: Adolescent sexual and reproductive health in Nepal is a critical issue. There are very limited researches done on the issues related to male reproductive health in Nepal. As researchers target group in this research were male adolescents between the ages of 15-19 years, the group is rarely brought into the research focusing on their SRHR. There is a dearth of studies on male adolescents SRHR. Adolescent have their different need and may seek different services for solving problems and getting information related to their SRH. The need changes according to the time. The present need of the adolescent is to be identified with the proper source of information, the services available and the gap between services and needs. The main service providers in Nepal related with the SRH of male are the local health post and government hospital, some private NGOs and
9

, Implementation guide on Adolescents sexual and reproductive health, for district health manager , Family Heatlh Division ,MoHP, 2007

clinics. Many studies have shown that there is insufficient information about provided to adolescent on SRH in schools, family and society in general. Social taboos in society against issues of sex and sexuality do not allow family to teach their children and lack of trained teachers hinders proper information channelizing with students. Interventions from few non-governmental sectors for additional awareness sessions inside and outside schools are also limited. The researcher feels that the semi urban area is more vulnerable as there would be ongoing process of urbanization and the influence of media is high. Trend of premarital sex is increasing in Kathmandu valley. The study will find out the needs of male adolescents is the Dakshinkali VDC, the services available and the gap between services and needs. It will also find out the perception and knowledge of adolescent regarding the HIV, Premarital Sex and the age of marriage. The findings will help to find gaps between the services and needs and make contribute in future government and non government activities.

1.5 Research Question: The targeted respondents for the research will be Male adolescent aged 15-19 years studying in schools and colleges and school/college dropouts within selected ward of Dakshinkali VDC. Some of the research questions are; 1. What are SRH needs of male adolescents? 2. What are the SRH services provided to male adolescents? 3. What are the sources of SRH information and services which is the most effective one? 4. What are the knowledge and perception on SRH among male adolescents?

5. What is the level of knowledge on Contraceptives? 6. How do the adolescent people perceive the need of SRH education? 7. In which way SRH education in schools provided to young people properly?

1.6 Conceptual Framework

6

Frame Work on gaps between SRH needs and services

Sexual Reproductive Health of male Adolescent

SRH NEEDS -information about physical and mental changes -Information and access to contraceptives -Awareness about STIs, including HIV & AIDS

SRH SERVICES -School curriculum on SRH -Equipped Health service center (Private and public) -Youth Friendly Health services -Counseling -Trainings and orientation

Gap between Services and Needs Inadequate privacy Inadequate of proper timing Inadequate of Counselling services No proper easy access to Contraceptives Inadequate of young friendly service provider Lack of trained teachers and comprehensive school curriculum on SRH

Lack of SRH needs affects over all health Effects in development of individual & effects 1.7 Limitations of thedevelopment Study: national

The sample size of the study was 35, limited inside Dakshinkali VDC of Kathmandu district, so the findings cannot be used to generalize for the whole country. The study covered different components surrounding ASRH including attitude and behaviour on premarital sex, knowledge about contraceptives, view of marriage was limited so, detail finding on particular issue was not gathered.

There were limitations of time and resources.

Chapter-II Literature Review

Nearly half of all people in this globe are under the age of 25. Some 1.2 billion people are between the ages of 10 and 19, of which, 87 percent live in developing countries. 10 Adolescents constitute nearly a quarter of Nepals population (23%), and half of them are male adolescent. As per the 2001Census as published in the District Profile of Nepal 2007/2008, 32.4% of the total population in the study area is between 10 24 years old. Broken down into the specific sub-groups, 13.5% are between 10 and 14 years old (early adolescents), 10.4 % are between 15 and 19 years old (late adolescents).
11

Adolescent had been taken as the period after

the childhood where an individual develops physical, social and emotional changes that is essential and exists as foundation for their adult life time. Various changes make the adolescent fall into various behaviours including the sexual relationships without thinking about its consequences. A study done among the adolescent in selected school of Kathmandu in 2008, the source of information on SRH, most of the respondents had more than one source. The most common source was friends mentioned by 80% of the respondents. Similarly, media (radio, television, newspaper, books, internet) by 66%, parents/guardian by 36%, educational institutions (schools, colleges, teachers) by 32%, brother/sister/cousin by 20% and others (helpline services, youth clubs, hide problems, self treatment) by 16%, similarly the desired source of information, most common answer from the respondents was media (radio, television, newspaper, books and internet) said by 44%, then friends by 30%, educational institutions by 26%, family by 24%, youth centres/clubs by 18% and orientations from experts by 8% . In same study done among 50 adolescent it was found that discussing about the sex with their friends were 38% (79% males, 21% females) of the total respondents whereas, 32% (50% males, 50% females) discusses sometimes and 30% (15% males, 85% females) never discuss about sex with their friends. Only
10

Karki, K., Advocacy paper on access to SRH information education and services to adolescent and to youth and role of GO/NGOs in meeting their SRH needs in Nepal ,SOLID Nepal, 2005
11

National Census 2001, Central Bureau of Statistics, Government of Nepal

9

6% (0% males 6% females) discuss about sex in their family quite often whereas 40% (60% males and 40% females) discuss sometimes and 54% (48% males, 52% females) never discuss about sex in their family.12 As a signatory to the 1994, International Conference on Population and Development Programme of Action (ICPD-POA), Government of Nepal is committed in providing a package of reproductive health services to its population, including adolescent and youth friendly services (AYFS). This is a considerable challenge because Nepals population is characterized by a young age structure. 13 In 2003, the committee of the Convention on rights of Children (CRC) issued a General Comment in which special health and development needs and rights of adolescent and young people were recognized14 Similarly, to address adolescent health and development issues, a comprehensive "National Adolescent Health and Development Strategy" was developed and adopted by Ministry of Health (MoH) in 2000 with the support of World Health Organization. The main objectives of the strategy are 1) To increase the availability and access to information about adolescents' health and development, and provide opportunities to build skills of adolescents, service providers and educators, 2) To increase accessibility and utilization of adolescents health and counselling services for adolescents and 3) To create safe and supportive environments for adolescents in order to improve their legal, social and economic status. It recognizes the importance of NonGovernmental Organizations (NGOs) and the private sector in supplementing and complementing government efforts to provide accessible and appropriate services to adolescents. NGOs and community based organizations work with the government to create a safe and supportive environment for ARH and to sensitize parents, teachers and social workers/leaders on needs and issues related to ARH through Information Education and Communication (IEC) and interpersonal communication15.
12

Kayastha. S , Perception of Premarital Sex among Adolescent in Selected Schools of Kathmandu Valley , 2008

13

Silwal,P.R . , Sexual and reproductive health of young people in Nepal , A literature review of existing research and data (2009), GTZ & Health Sector Support Programme Department of Health Services, Kathmandu 2010.
14

WHO fact sheet N345 august 2010 , WHO

15

Adolescent Health and Development in Nepal status, issues, programmes and challenges., HMG, 2005, Pg. 42

10

A study done in five district of Nepal, it was found that 92.2 % of the young people had heard about HIV and AIDS and 76.6 % had heard about STI.
16

Adolescents and young people are

poorly informed about sexuality, reproductive health and the consequences of unprotected sex or drug use. In a 2004 survey in China, 80 percent of high school students said they had never participated in a course, or in extra curricular activities related to HIV prevention.17 A survey among adolescents conducted in 2001 revealed that although a vast majority (92 percent) of teenagers had heard about HIV/AIDS, a significant proportion (23 percent) had misconceptions about HIV transmission17. Similarly, a knowledge, attitude, and practice survey conducted in 2004 reveals that although an overwhelming majority (92 percent) of teenagers had heard about HIV/AIDS, only 74 percent of them knew that they should use condoms to protect themselves from HIV and only 69 percent said they should not have sex with commercial sex workers18. A baseline survey conducted in 2009 showed almost 90 percent of the adolescents and young people (15-24 years) had heard about HIV/AIDS. 80 percent of them were aware about its signs, symptoms, and modes of transmission and but less than 70 percent about its preventive measures. Three quarter of the respondents (75.6 percent) knew that someone looking healthy can have HIV and may infect another person with the virus and almost two third of them (63.66 percent) showed their willingness to test their blood for HIV. Although, there is high level of awareness about HIV/AIDS among adolescents in Nepal, this awareness has not necessarily translated into safe sexual behaviour. In a study done in 2009, it was found that only one-third (33.3 percent) of the adolescents and youths who have had sexual intercourse in the past had used a condom19.

16

Baseline Study - Young peoples sexual and reproductive health status in 5 districts of Nepal , HSSP , MoHP ,GTZ 2009
17

Adolescence Education news letter Newsletter for policy makers, programme managers and practitioners, UNESCO Asia and Pacific Regional Bureau for Education Vol. 9 No. 1 June 2006
18

Mathur S, Mehta M, and Malhotra A. Youth reproductive health in Nepal : is participation the answer? , 2004

19

HeRT Centre. A Baseline survey on MPRC Initiatives-Improving SRHR for young women in selected districts of Nepal, Health Research and Training (HeRT) Centre, Family Planning Association of Nepal, 2009

11

Young people, 15 to 24 years old accounted for 40% of all new HIV infected among adult in 2008. Everyday 2500 more young people get infected and globally 5.7 million young people living with HIV/AIDS. Currently 30 % young men and 19% young women have comprehensive and correct knowledge they need to protect from HIV virus.20 A study conducted in 1999 showed that one in every four adolescents claimed to be sexually experienced. First sexual intercourse usually occurred at ages before adolescents finished schooling a mean of 16.4 years for boys and 16.0 for girls. Males often had premarital sex while female adolescents rarely engaged in sex before or outside marriage. 21 20 % of the teenagers say right to be involved in premarital sexual activities .Study done among the 50 adolescent in Kathmandu Valley showed that 38 % of the respondent are positive about premarital sex in which 79% were male and only 21% were female. A comprehensive study conducted among adolescents in Bangladesh reported that only 13 to 14 percent of them were aware of syphilis and gonorrhoea. About one-half of the adolescents could not correctly identify a single STI symptom and more than one-half of the adolescents could not correctly identify a mode of STI transmission. Although social customs usually discourage premarital or extra-marital sexual relationships, the scant evidence from small-scale, in-depth qualitative studies indicate that such relationships are more frequent than commonly believed. These groups are especially vulnerable to unwanted pregnancy and disease, including STIs and HIV infection, and the stigma and discrimination associated with either condition.22 According to WHO, 1 in 20 teenagers worldwide in acquires an STD each year. A survey in a Peruvian town found that 23 % of secondary school males had an STD (Koontz & Conly, 1994). Cceres et al. (1997) found that 18% of subjects surveyed had experienced symptoms or had been diagnosed with an STD, with respondents of lower socio-economic status showing higher
20

WHO fact sheet N345 august 2010 Cited in Opcit 3

21

22

Barkat, A. & Ahmed, N. , Human Poverty and Deprivation in Bangladesh: Lack of Substantive Freedom and Eradication Possibilities. Presented at a Workshop, organized by DLB, Engelskirchen, Germany: September 1, 2001.

12

rates. In a study of the sexual practices of street youth in Brazil, one fifth of the respondents said they had contracted an STD and that half of their friends had one previously (Raffaelli, et al, 1993). Furthermore, at least 6 million people infected with HIV are under the age of 25 and it is likely that most of the one million cases of AIDS worldwide contracted the disease during their teen years.23 In the base line study done among 1924 young people between 10-24 ,80.5% had heard about contraception, in which (88.3%) male had heard and (72.6%) of female respondents had heard . Condom was most commonly known contraceptive which was (90.4%). The second commonly known was pills (61.6%) followed by Depo-Provera injections (58.8%), copper-T (44.7%), Norplant (35.8%) and Minilap (26.4%). Using the percentage of young people who ever reported having had sex as a denominator, the contraceptive use rate is 38.6%. Of those reporting having had sex in the past 12 months, 47.7% reported using a condom. 3.1% of the male and 8.3% of the female respondents reported having undergone a permanent family planning method. 68.5 had heard about abortion and 33.9% knew that it was legal in Nepal24

Talking about sex or contraceptive use is generally considered taboo. Given that there are more opportunities to discuss sexual issues among the younger generation in Western societies, it is not surprising to learn that 80-90%ofsexually active adolescents in more developed countries use contraception, while Contraceptive prevalence rates among Young people in the developing world are far lower.25 Despite the universal awareness about contraceptive options, there is large gap between the level of knowledge and the actual practices of using contraceptive devices among adolescents in Nepal. In a study conducted by Valley Research Group in 1999 among adolescents aged 15-19 years and mostly unmarried (78 percent) reveals that about 94 percent of the adolescents heard of
23

Rebecka Lundgren , Research protocols to study sexual and reproductive health of male adolescent and young adults in Latin America , Division of Health Promotion and Protection Family Health and Population Program January 2000
24

Cited in Opcit 19

25

Adolescence Education news letter Newsletter for policy makers, programme managers and practitioners, UNESCO Asia and Pacific Regional Bureau for Education Vol. 9 No. 1 June 2006

13

female sterilization. Male adolescents were very familiar with condoms (96.8 percent), male sterilization (94.3 percent), and female sterilization (93.5 percent). Almost all of them (94.9 percent) expressed their willingness to use family planning methods in the future but only eight percent of the adolescents used at least one modern method of contraception.26 In Nepal, emergency contraception is increasingly promoted for the past few years as an alternative way to prevent unwanted pregnancies. Mainly national and local level NGOs are promoting or providing emergency contraception. However, very few of the adolescents know about it. The study undertaken by HeRT Center in 2009 in two districts of Nepal reveals that 12 percent of the adolescents interviewed had heard about the emergency contraceptive and about seven percent of those who have had sexual intercourse reported to have used it. There was a common misperception among the adolescents and youths that contraceptive devices, particularly emergency contraception, are only for married couple27 Study showed that only 10% of adolescent have heard of EC. Only 40 % of them said the correct time up to which it can be taken after unsafe sex whereas majority i.e. 60% dont know or either answered incorrectly28 Emergency contraceptives (EC) can be both hormonal and non hormonal that can be used to reduce risk of becoming pregnant after unsafe sex. Emergency contraceptives pills (ECPs) are oral pills that women can take within 72 hours or more after unprotected intercourse. It is sometime named morning-after pills. Similarly, Copper-T can be used as non hormonal EC. Making Emergency contraceptives available to adolescent can prevent unintended pregnancy. 7.3% males and 6.7% females have knowledge on EC.29 Some other barriers are lack of awareness, barriers to use family planning clinics, embarrassment, legal and social restriction etc. Providers lack of awareness and knowledge and awareness of the correct use of ECPs is another additional barrier. Access to essential health services is lacking in the Asia-Pacific region. For example, the coverage of voluntary counselling and testing (VCT) services was less than 0.1 Percent of the
26

Reproductive health awareness, attitudes, and behaviour of adolescents in Nepal. Valley Research Group, 1999 Cited in Opcit 19 Kayastha.S , Perception of Premarital Sex among Adolescent in Selected Schools of Kathmandu Valley , 2008

27

28

29

Baseline survey report on sexual and reproductive health knowledge, attitude behaviour and practice among adolescent, youth and adult people in FPAN operational area, FPAN , 2005

14

population (aged15-49) in the region30. Of the total respondents, 13.3% had stated that they had visited a health centre in the past year 13.0% of all male and 13.6% of all female respectively). Of these, 7.4% were fully satisfied, 0.1% was satisfied and 12.5% were not satisfied with the services provided. The health facility assessment conducted at 26 health facilities in the 5 district show that while many reproductive health services are available, separate and special provisions for young people do not yet exist and basic requirements for AYFS are not yet in place.31 There are various challenges of for SRH of men. Some main challenges are Mainly, there is no clear definition of mens reproductive health services. Also there is not clear sense of mens need and/or desire for reproductive health services. In context of developing nation there is lack of funding and lack of staff dedicated to the mens reproductive health program. There is also the lack of support for the mens reproductive health program by facility administrators or health officials. IEC materials are mainly focused on the women rather than men and also there is lack of marketing of available mens reproductive health services.

Chapter III Research Methodology

3.1 Study Site / Description and Rationale for the Selection of the Site The selected site for the study was Dakshinkali VDC which lies in southern part of Kathmandu district. Although being in Kathmandu District and also just being around 20 Km from main city, it is least developed in terms of health, education, employment, etc. Dakshinkali itself is a Semi
30

Cited in Opcit 20 Cited in Opcit 16

31

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Urban Area. Due to influence of modernization and urbanization, communication and technology is playing important role in lives of people in this area that includes media as well. This has also made impact on the adolescence SRH behaviour and way they perceive their health condition. At the present context, youths are in between traditional belief and modern viewpoint. Being the semi urban area there is low access to health facilities related with SRH. Thus finding the need and the services available related with SRH can help to find the gaps and steps to fulfil the gaps. 3.2 Research Design: The research is descriptive Cross Sectional. The study provides information related to the present SRH of adolescent in details and also explore the needs of male adolescence in terms of the services they get form health centre and also education. The data which are collected is both qualitative as well as Quantitative. The study also inform about the knowledge of adolescents on contraceptives, HIV, premarital sex, myths of masturbation. 3.3 Nature and Source of data This study used both primary and secondary types of data. The nature of data was both qualitative and quantitative. Primary data was used mostly to meet the objectives of the study. The secondary data was used in order to support the primary information and to develop the valid conclusion.

3.3.1. Primary Data: Interview through scheduled questionnaire was done among the respondent, Key Informant Interviews from teachers of schools and health worker at government health service centre. 3.3.2 Secondary Data: - Referred literature: read journals, books, reports, magazines, browsed internet. 3.3.3 Nature of data: - The data collected are both qualitative and quantitative.

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3.4 Sampling Procedure Non Probability purposive sampling method was applied for selection of the respondent. Universe of the study was school going and out of school male adolescents aged 15-19 years at least with the minimum secondary education. Adolescence interviewed were from ward number 1, 2, 3& 4 of Dakshinkali VDC in which unit of analysis was individual. The help was taken from the teachers of schools & form youths of the area to find out the respondents. 3.4.1 Sample size Total 40 samples are taken and among it 5 refused to continue the interview once their consent was asked. The 35 Sample Size is equal to the 15 % of the adolescent living in the selected wards of Dakshinkali VDC. 3.4.2 Key informant Key informants from whom information were collection included; health worker (CMA) from HP and a doctor from a Hospital. 3.5 Data Collection Technique and tools. The method of data collection with respondents was collected using structured interview schedule. An introduction on the research topic and the issue of Sexual and Reproductive Health of young people was provided to individuals adolescent for volunteering participation if they are interested. Pre inform and consent of the respondents was taken. Questionnaire contained both close ended and open ended questions.Key informant interview was taken using checklist. Semi structured interviews were also taken with key informants including a doctor of the Manmohan Hospital and health worker who works in the Dakshinkali VDC.

3.6 Pre-test of Tools: The study area was finalized with consultation with thesis guide. The questionnaire and checklist for key informant interview and interview with adolescents were finalized. For the pre-test of the schedule interview/questionnaire 5 Male adolescent from Bhaktapur district were interviewed using the tool and finally schedule interview was finalized. 3.7 Monitoring and Supervision of Data collection Field visit was made by thesis guide during the data collection by the researcher. Necessary suggestions were given to improve data after collection and were adapted as per the necessity.

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3.8 Data Management and Analysis Collected data were edited first giving the unique code number to each questionnaire. The data was kept in separate locked cabinet. After code was given to all questions, data were entered in SPSS Ver 16 in password protected computer .Data cleaning process were carried and analysis was done. Then analysed data copied in excel 2007. Each analysis was made in different sheet for interpretation. 3.9 Ethical Consideration Privacy and Confidentiality of the respondent was maintained. Interview was taken in the separate place where others could not hear the answers of the respondent. Respondents personal dignity was respected and belief of the respondent was not harm. Coding of the data was done so that the information given by the respondent will be confidential. Information taken from the respondent was only used for statistical purpose.

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CHAPTER IV Sexual and reproductive health gap between service and Need Analysis
4.1 Demographic Profile of the Respondents The profile of the respondents based on age, grade, & engagement in formal education system is presented in the following sub- sections. 4.1 .1 Age of Respondent The study was targeted for adolescent boys within the age group of 15-19 years of age. Different percent of adolescents within this age group is as shown in the figure 1 below.
Figure 1 :Age of respondents

Source: Field Survey, 2011

The target population of the study is adolescent group between the age group of 15-19 years of age. Most of the respondents were 17 & 18 years old i.e. 25.7%, then 20% were of 19 years & 16 years old, 8.6% were of 15 years old.

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4.1.2 Education Level of Respondent The study was targeted for adolescent boys within the age group of 15-19 years of age. Education is considered as an indicator of development. It is consider as a lamp of intelligence of human life. It plays significant role in personal development and decision making of an individual highest level of educational by adolescents within this age group is as shown in the figure 2 below.
Figure 2 : Education level of respondent

Source: Field Survey, 2011 Among the total respondent 17.1 % of the respondent had already left formal education and 82.9 % of the respondent are current engaged in formal education system. Among all respondent, 14.3 % of the respondent had received education up to grade 8, 25.7 % of the population received education between grade 9-10, 45.7 % of the population received education between 11-12 & 14.3 % of the population received above grade 12. The figure showed that more than 85.70 percent of the responded had already taken the SRH education which are given in grade 8 and are expected to have proper basic knowledge on SRH.

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4.1.3 Engagement in Formal Education Formal education refers to the currently engagement in any school or colleges . It helps to know their educational status .The current in formal education is been given in the Table 1 below
Table 1 : Respondents engagement in formal education

S.N 1. 2.

Participation in SRH Programmes Yes No Total

Number 29 6 35

Percentage 829 17.1 100

Source: Field Survey, 2011 Among the 35 adolescent, 82.9 %of them are currently engaged in reading formal education from school and college where as 17.1 % of them were not involved in formal education system. 3 of the respondent left the school at between 6-8 class and 3 left their studies between grades 910. As per the respondents, the reasons for them to left study was because of poor performance in the school and because they were not interested to study. 4.2.1 Source of Information Related with SRH The source of SRH information is helpful in identifying the quality of information acquired by adolescents.The present source of respondents for SRH knowledge is shown by figure .3 below
Figure 3 : Sources of information related with SRH

Source: Field Survey, 2011

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The chart given shows the popularity of different sources. The most common present source of SRH information for adolescent is TV mentioned by 85.7% of the respondents, Educational institution (schools, colleges, teachers) by 68.6%, magazine by 68.7%, friends by 65.7 % , news paper by 57.1 % , health center ( hospital & health post ) by 22.9 % , community programs and training by 22.9 % other sources ( Films , internet ) by 20 % and cousins and family by 5.7%. From the data it can be analysis that majority of the respondent get the information form TV, magazine, friends, school and newspaper. It shows that the influence of the media mainly the foreign channels have high impact on the adolescent for delivering information and knowledge on in issues related with SRH. . From the data it can also be analysis that family and cousins have very less influence on adolescent to deliver message related with SRH. It also showed that although SRH is very important part in human health but it still exists as a taboo in the society. 4.2.2 SRH content in School Curriculum Sexual Reproductive Health Curriculum refers to the chapters included in secondary heath education book .It helps to identify the curriculum is sufficient or not in the view of student. Its shown in figure 4 below.
Figure 4 : SRH content in school curriculum

Source: Field Survey, 2011 Among the total respondent , 22.85 % of the respondent said that the education curriculum and information about the Sexual Reproductive Health is Sufficient for the Adolescent, 40% f the

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respondent said that as per the modernization the curriculum content is not sufficient where as 37.15 % do not have any knowledge or want to say something . From the data given from the respondent it can be analysis that majority of the respondent have the feeling that the present curriculum being taught in schools are not sufficient. Respondent also said that the curriculum was old and many of the SRH problems faced by the adolescent are not even addressed it the curriculum. The respondents say that HIV & AIDS are still taught as same in school. They also say that the curriculum is mostly focused on girls. Although physical changes had been made but the psychological changes and problems are not mentioned. The responded focused reproductive health should be included the curriculum. It can also be analysis majority that the responded do not have proper information related with minimum education on SRH which one should get. 4.2.3 Teaching of SRH Education in School Teaching of SRH education refers to the view of the respondent, weather they feel the teaching of those chapters is done in proper way or not. It is shown in Table 2 below.
Table 2: Teaching of SRH education in school

S.N 1. 2. 3

Participation in SRH Programmes Yes No Don't Know Total

Number 17 6 12 35

Percentage 48.56 17.15 34.28 100

Source: Field Survey, 2011 Also 48.57 % of the respondent said their teacher teach well about the SRH where as 17.15% of the respondent said that the teacher dont teach well as needed and 34.28 % of respondent didnt gave any response. From the data it can be analysis that although 48.57 percent of the respondent believes that the teaching on SRH issue in the school was good but 17.15 percent still feels that the teacher did not teach well. Teachers ask them to read themselves, skip the chapters & teacher even shy was the major reasons which the respondent gave. The data showed that, there is lack of proper skill among the teachers to teach the SRH education in more effective way.

4.2.4 Knowledge about HIV and AIDS

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The knowledge about HIV & AIDS of the respondents is shown by Table 3 below
Table 3: Knowledge about HIV & AIDS

S.N 1. 2. 3

Participation in SRH Programmes Yes No Don't Know Total

Number 21 13 1 35

Percentage 60 37.1 2.9 100

Source: Field Survey, 2011

100% of the respondent had listened about the HIV and AIDS. 60 % of the responded said that HIV & AIDS are different and know well about it. 37 .1% of the Respondent believes that HIV & AIDS both are same where as 2.9 % of the population didnt had any idea about it. It can be figured out from the above data that, although HIV and AIDS are being taught in school and also through different sources but 37.1 percent of the respondent still thinks that HIV and AIDS are same. Also 2.9 percent do not have idea weather HIV and AIDS are same or different. The respondent who said HIV and AIDS are same said they got this information from the course book where it is still written HIV/AIDS. It can also be figured out that , although respondent are living in Kathmandu district which have high facility of information and technology but also there knowledge is very low regarding HIV and AIDS. The delivery of the information seems poor.

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4.2.5 Respondent View on Proper Age of Marriage Right age at marriage refers to the respondent views about the proper age when an individual should marry. Its shown in fighte5 below.
Figure 5:Respondent view on proper age of marriage

Source: Field Survey, 2011

Among the total respondent, 8.6% of the population said that right age at marriage for boys should be between 20-21, 11.4 % said between 22-23, 60 % said 24-25, 11.4% said between 2528 &8.6% said between 29-30. Similarly, Among the total respondent, 28.6% of the population said that proper age of marriage of girls is 20 years , 8.6% said 21 , 28.6 % said 22 , 8.6% said 23 & 25.7% said 25 years. From the data, it can be analysis that 100 percent of the respondent has the knowledge that its is not good to marry before 20 years for both boys and girls and its good to maintain gap between boys and girls. Most of the respondent said that its not good to marry before 20 years because it may cause to various problems such as miscarriage, misunderstanding between husband and wife

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and also will hamper study. It also shows that the adolescent in the area are aware about the child marriage, underage marriage and consequences. Most of the responded also gave answer that , the best age of marriage for girls should be between 20-25 years because it will be hard to marry for girls if they cross more than 25 years. But only 11.42 percent of the respondent has knowledge of legal age of marriage.

4.2.6 Knowledge on Contraceptives Nepali society perceives that family planning is the issue of concern, only for the adult or married people. Knowledge on contraceptives among unmarried adolescents helps in the controll of unwanted pregnancy among them. Level of knowledge on contraceptives among respondents was found universal but at various level as shown in figure 6 below
Figure 6:Name of contraceptive ever heard

Source: Field Survey, 2011

This was a multiple answer question in which of the respondents named hormonal methods pills were 88.6 %, norplant 48.6% , dipo provera 85.7% ,than 100% named male condom, 48.6 % named Permanent family planning methods (vasectomy, minilap, laproscopy), non-hormonal

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method (copper-T) by 62.9 %, femidom (female condom) was mentioned by 57.1% whereas the least known contraceptive was natural method and calender method mentioned by only8.6 %. From the above data it can be figured out that 100 percent of the respondent have knowledge about Condom which can prevent pregnancy but most of them had hardly seen or touched condom by them self . For the data it can be analysis that, although the adolescent had knowledge from book and other source about contraceptives but its still not sufficient. shows the knowledge is very poor among the adolescent. 4.2.7 Heard about Emergency Contraceptives EC can prevent unintended pregnancy among adolescents if they have unsafe sex. The knowledge level on EC is found minimum as shown by table 4
Table 4: Heard about emergency contraceptives

Except male condom, femidom, pills

copper- t and depo, majority of the adolescent had not heard about other contraceptives. Which

S.N 1. 2.

Heard of Emergency Contraceptive Yes No Total

Number 8 27 35

Percentage 22.9 77.1 100

Source: Field Survey, 2011 Only, 22.9% of the total respondents have heard of Emergency contraceptives Among them no one has ever seen it. The source which they had heard is only from TV media and from the trainings. From the data it can be analysis that 77.1 percent of respondent had not even heard about the emergency contraceptives. it showed that the information about new contraceptives are very low among the adolescent .The respondent were very close to capital and have lot of influence but also had not proper information about Emergency Contraceptive pills. The respondent never heard about EC from the nepali media which showed that the information which our local media and organisations give related with SRH is still not enough still till present.

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4.2.8 Appropriate Source to Access Condom Appropriate source to access condom refers to the source where respondent feels easier to get or buy condom. The sources are shown below in Table 5.
Table 5 : Appropriate source to access condom

S.N 1. 2. 3 4 5

Appropriate Source to Access Condom General Shop Pharmacy Health Post Hospital Friend

Number 14 7 7 5 2

Percentage 40 20 20 14.3 5.7

Source: Field Survey, 2011 Among the total respondent , 40% of respondent said they can get from general shops, 20 % said health post, 20 % said pharmacy and 14.3 % said hospitals 5.7% of the respondent said they can get or ask condom with their friends when they will need. The respondent said that there are many general shops where they can find the condom. Also they feel easy because, many shops have youth owner from which they feel easy to ask condom in compare to the staffs of hospital, pharmacy and health post where most of the staffs and workers are senior in age. For the data it can be analysis that, the government and organisations should also focus on the medial shops and general shops for promotion of contraceptives, mainly the condom. The provision of youth counsellors and service providers are also the needs of the male adolescent so there should be provision in main health centres. 4.2.9 Perception on Premarital Sex Premarital sex refers to the physical relationship between two individuals with each other before marriage .The views of the respondents gave variety of answers for their view related with premarital sex It is presented as in the Table 6 below.

S.N

Perception on Premaritial Sex

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Number

Percentage

1. 2. 3.

Good Bad Don't Know Total

6 11 18 35

17.1 31.4 51.4 100

Source: Field Survey, 2011 Young people have following various perceptions related with premarital sex. Respondents gave their own opinion in this open ended question. In this multiple answer question, 17.1% respondent said premarital sex is good because it's normal and also allowed in the modern society. 31.4% of the respondent said that premarital sex is bad because of various reasons that our culture and society dont accept it. Remaining 51.4 % of the respondents have no idea about the premarital sex. From the above data, it can be figured out that, majority of the respondent have either neutral view or the negative view about pre marital sex. The social taboo and traditional believe had the deep effect in the youths. 4.2.10 Perception on Masturbation When the respondents were asked about their perception on masturbation, their views are presented in the table 7 below.
Table 6: Perception on masturbation

Views about Masterbation Yes No Don't Know Total Source: Field Survey, 2011

S.N 1. 2. 3

Number 12 1 22 35

Percentage 34.3 2.9 62.9 100

Young people have various views related with the masturbation. Respondents gave their own opinion in this open ended question. In this multiple answer question, 34.3% of respondent said masturbation is normal and good and safe too, 2.9% of the respondent said masturbation is bad

29

as it may cause infertility and remaining 62.9 % of the respondent had neutral view about the masturbation. From the data it can be analysis that 2.9 percent of the respondent still thinks masturbation is bad and can cause various problems such as infertility. Besides that 62.9 percent of the respondent who had the no view about the masturbation also have various reasons for it. Most of them do not have any idea about the harms or advantages and some do not want to answer. This also showed that proper knowledge of masturbation among the adolescent is low because lack of proper information and education.

4.2.11. Participation in SRH Programme The attendance of respondents in any program from any GO, NGOs or other institute that provides information related with Sexual and reproductive health is shown in Table 8 below:
Table 7: Participation in Programme related to SRH

S.N 1. 2.

Participation in SRH Programmes Yes No Total

Number 4 31 35

Percentage 11.4 88.6 100

Source: Field Survey, 2011 The data shows that young people in the semi urban Dakshinkali VDC had very less opportunity related with the training and orientation related with SRH. Among the total respondent 11.4% had attended the orientation program and 88.6% of the respondent had not yet attended any program yet. From the data it can be analysis that, although living in Kathmandu district and only 20 km far form the main city, but the opportunity for getting training and orientation related with SRH is very less. The respondent who had not got any orientation have many myths related with SRH and the information which they get from modern technology such as movie and internet had made the adolescent more confuse about SRH.

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4.2.12 Health Seeking Behavior The multiple choices are there for the youths in the Semi Urban area that they can choose to take services. The preference of the respondent to health related centres are shown in figure 7 below:

Figure 7:Preference to take health seeking behaviour

Source: Field Survey, 2011 In the multiple choice question , 34.3% of the respondent said that they prefer to go health post , 22.9% hospital of the respondent preferred to go hospitals, 45.7% of the respondent preferred to go private clinic and 14.3% of the respondent preferred to go individuals health personnel. From the data it can be analysis that, the most preferred place where the respondent wants to go for any health related services including SRH service is private clinic. The reasons were such as more privacy in compare with other places and also because of multiple choices. The reasons also were that the hospital and health post staffs do not behave well as much as the private clinic.

4.2.13 Perception on Health Services The following figure 8 shows the views of the respondent about the service centre (hospital and Health post) appropriate for the youths or not:

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Figure 8: Preference to take health seeking behaviour

Source: Field Survey, 2011 The main two service centre available in the area which are hospital and health post, 31.4% of the respondent said that the service centres were appropriate for them in terms of raising their query and problems related with SRH, 68.6% of the respondent said that the service centre are not much appropriate because of the timing , privacy and other reasons. Majority said that they feel the privacy will not be maintained because there are not separate room for the SRH services in service centre. Some of the adolescent also said that the service centre is very much to the home and the staffs know them. The time factor was also raised by majority of the respondent, as per which they say the opening and closing time of the general service in hospital and health post are same as the tine of their school and college. Besides that they also focused on there are no youth councillors to whom they will feel ways to share their problem and also condom distribution was not proper and not kept in separate corner. It can be analysis that, the opening and closing time of health post is not appropriate for the adolescent to take SRH services .Besides that there should be the separate room for counselling and SRH services should be there in health centres. Provision of youth counsellor or peer approach should be made to flourish the SRH information among adolescent.

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For the data it can be analysis that, even the health post and hospital situated in Kathmandu valley are not appropriate, so how bad can be the situation of the health centre of rural part of country.

CHAPTER V SUMMARY, CONCLUSION AND RECOMMENDATIONS

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5.1 Summary of the Findings This study was carried out in selected wards of Dakshinkali VDC, Kathmandu using qualitative and quantitative research methodology. On the basis of all the findings from the previous Chapter number IV, result and discussion, the study has summarized the major findings in followings. The most common present source of SRH information for adolescent is TV mentioned by 85.7% of the respondents, Educational institution (schools, colleges, teachers) by 68.6%, magazine by 68.7%, friends by 65.7 % , news paper by 57.1 % , health centre ( hospital & health post ) by 22.9 % , community programs and training by 22.9 % other sources ( Films , internet ) by 20 % and cousins and family by 5.7%. In my view, besides TV other sources of information should also be focused to raise awareness and to deliver proper information. The peer approach of delivering information should be focused properly. 40% of the respondent said that the SRH content in school curriculum is not sufficient and is old. The respondent that TV and radio programs are giving much information related with SRH but the knowledge in books are limited. The respondent also gave focus on the book in which HIV/AIDS is written instead of HIV & AIDS So the modification and new content should be added in the curriculum. They also said that psychological changes are very less mentioned in books. 17.15% of the respondent said that the teacher doesnt teach well as needed & also skip chapters related with SRH. They found that many important contents such as menstruation was skip by teachers. 34.28 % of respondent didnt have any idea weather teacher is teaching well or not. It shows that there is lack of skills in teachers to teach SRH contents to adolescent. So proper trainings to teachers should be given to teachers so that correct information could be delivered to adolescent. 37.1% of the respondent believes that HIV & AIDS are same and have no difference, where as 2.9% of the respondent do not have proper idea about it. It shows that the old curriculum containing word HIV/AIDS as well as improper information given to students is the cause of it. Thus proper information should be given to them through orientation, proper IEC materials etc.

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Only, 22.9% of the total respondents have heard of Emergency contraceptives (EC). It shows that the new means of contraceptives are not much familier among the adloescent. Thus the proper information should be provided to them using the easier and convinent mentod. 40% of respondent said they can get condom from general shops, 20 % said health post, 20 % said pharmacy and 14.3 % said hospitals 5.7% of the respondent said they can get or ask condom with their friends when they will need. Thus government and organisation working in the sector of SRH should also use general shop as a place from where the information related with SRH can be given. Only 11.4% had attended the orientation program and related with SRH , thus the numbers of trainings should be done in the area to raise awareness and deliver information to adolescent 68.6% of the respondent said that, the two main service centre (i.e. Hospital and Health post) available in the area are not appropriate because of various reasons such as opening timings, contraceptives available, lack of youth friendly environment, lack of confidentiality, etc. Thus the service centres should be made as youth friendly and proper services should be provided.

5.2 Conclusion 5.2.1 Gap between Services and Needs Adolescent are sensitive age groups who are going through various mental, physical and social changes .As being sexual and reproductive health an important part of any individual, services, knowledge and information should be given to make them sexually responsible and safe. The SRH need of Adolescent today, is the services and information related with SRH. Due to lack of the proper source of information they are taking information through movies and other modern means of communication. Those modern means of communication are not only giving the correct information but various Myths and negative information are also being transferred to adolescent. Media and result of globalization has lead to this kind of their involvement in high risk behaviors. Myths and wrong information related with HIV, masturbation & premarital sex is still there in high numbers of adolescent. Therefore proper sexual health education is to be provided to suggest them for the safe sexual behavior and shoving the problem. Needs of proper SRH related services are there for the adolescent. There are only few places where their problem and quarry could be solved and because of lack of proper information of it
35

they are not being able to utilize the service. Various causes such as lack of privacy, timings, available of skill person etc are the main barriers. Therefore increase in the quality of the health center and youth friendly clinic should be made. The establishment of clubs and forums should be done for adolescent where they can share information and knowledge related with the issue. The SRH education given in secondary schools are old and had not added more content .It is not enough to guide them towards safe sexual behavior and to make them able to take informed decisions. There exists various sources of SRH information but the validity and quality of information is to be taken care of, as the information delivered may be incorrect or may be perceived it in a different way which can have negative impacts in their attitude and behaviors. Most of the sources are made by the adult without discussing with the adolescent, thus the source used also should be according to the convenience and comfort of the adolescents and it should also honor confidentiality. The teaching methodology should be proper and effective by trained people with age appropriate content. The education given must be gender sensitive as the findings clearly show that the perception of male adolescent and female adolescent differs widely. The proper information about SRH of all gender should be given so that they can understand nicely. Basically, services given should be adolescent friendly. The variations among the gender are to be taken care while planning for the programs by non-governmental organizations. As peers are seen being used mostly for SRH information, peer education can be one of the best approach to reach young people. Similarly, media can be highly useful for awareness programs. There are still taboos in society during talks related with Sexual Reproductive health, thus Parents and teachers being direct educators of adolescents regarding their sexuality, sensitization program for teachers and parents should be implemented so as to provide supportive environment to adolescent. As the research is focused on the male adolescent students of school and college level and school dropouts, from the data analysis and even the desire of the sample population, an improvement in curriculum on sexual and reproductive health can be develop to educate the adolescent. This will

36

help them to provide knowledge on safe and responsible sexual behaviors as a reference for informed choice and proper decision. Also the proper health facility can be done reducing the gap between services and needs.

5.3 Recommendation 5.3.1 To Health Service Providers There are some SRH services in the service centres for the adolescents but because of various causes such as lack of publicity of services , lack of information about the services the number of adolescents; especially male adolescents are very low. The youth friendly health services should be focused with maintaining the privacy during the visit. The available of contraceptives such as condom should be kept in place where peoples can get easily whenever needed. More than that, the information about the services should be given to adolescents by going to schools, colleges and through community program. 5.3.2 To Educational Institutions There is curriculum content related with SRH is secondary education, but it is found that many teachers dont feel easy to teach because it is still as a taboo in the society. Thus the educational institute should only appoint the teacher having proper knowledge and skill. Besides that, as the curriculum is a bit old, so with the help of well trained person, there should be proper orientation given to teachers as well as students related with SRH. 5.3.3 To the Government Government had brought plenty of plans to improve the SRH of adolescents in Nepal, but there had been lack in the implementation phase. ASRH implementation guide was brought few years back but still there had not been proper implementation of it. Besides that, the of lack of proper training the teachers and health workers could not be much youth friendly. It had not only affected the service and education part but directly had affected the health of the male adolescents. The government have to published more reading materials related with male SRH. Thus the government should provide proper training to health workers and staffs related with youth friendly approach. And also publish the book and other reading materials to male regarding their SRH .

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5.4 Social Work Intervention Good and healthy life of an individual is the basic need of an individual. Sexual and Reproductive health of an individual should be healthy so that he/she can enjoy a good and healthy life. As being a member and part of the society a social worker should involve in health sector by helping the service providers The social worker should also participate on the different programs related with the sexual reproductive health and should share their learned knowledge for improvement of services. The social worker should be able find the loop holes in delivering those services. Raising awareness through various means such as training and using various modern and traditional materials should be done. Social worker are the activist of the society for the well being of the society and Help people by involving in advocating for the rights of people. Social workers are the activist of the society so they should participate in community activities and help the community people as a facilitator and trainer. Social worker can make new positive change and removing bad trends in the society in each and every social issue. Social worker play important role in the development and promotion of sexual and reproductive health services. They are the one who can make the progressive change in the society. They can play different role like an advocate, academician, researcher, policy maker and more in the community for the progressing the current situation health system.

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References
Adhikari, U.P., & Aryal, R.H. Adolescents and Youth in Nepal. Retrived 2nd Nov, 2008 from http://www.cbs.gov.np Barkat, A. & Ahmed, N (2001 Sep 1) ,Human Poverty and Deprivation in Bangladesh: Lack of Substantive Freedom and Eradication Possibilities. Presented at a Workshop, organized by DLB, Engelskirchen, Germany: Family Planning Association of Nepal .( 2005). Baseline survey report on sexual and reproductive health knowledge, attitude behaviour and practice among adolescent, youth and adult people in FPAN operational area.

Government of Nepal, Nepal Census, (Census, 2001), Central Bureau of Statistics His Majesty's Government Ministry of Health and Population Dept. of Health Services Family Health Division. A country profile 2005: Adolescent Health and Development in Nepal status, issues, programmes and challenges. His Majesty's Government Ministry of Health and Population Dept. of Health Services Family Health Division. National Adolescent Health & Development Strategy Nepal 2000 Health Research and Training (HeRT) Center & Family Planning Association of Nepal. (2009). A Baseline survey on MPRC Initiatives-Improving SRHR for young women in selected districts of Nepal Ingham, R., Simkhada, P. & Stone, N. (2003) Knowledge of sexual health issue among unmarried young people in Nepal, Asia-Pacific Population Journal, 18(2), 33-54 Karki, K., (2005), Advocacy paper on access to SRH information education and services to adolescent and to youth and role of GO/NGOs in meeting their SRH needs in Nepal.

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Kayastha.S (2008), Perception of Premarital Sex among Adolescent in Selected Schools of Kathmandu Valley Lundgren ,R. (2000 January), Research protocols to study sexual and reproductive health of male adolescent and young adults in Latin America , Division of Health Promotion and Protection Family Health and Population Program

Malhotra, A., Mathur, S., & Mehta, M. (2004).Youth Reproductive health in Nepal: Is participation the answer?: International Center for Research on Women, Engender Health. Nepal Government Ministry of Health and Population Dept. of Health. ( 2007), Implementation guide on Adolescents sexual and reproductive health, for district health manager

Nepal Government MoHP ,GTZ , HSSP. (2009) , Baseline Study - Young peoples sexual and reproductive health status in 5 districts of Nepal . Nepalese adolescents lack proper knowledge on sex. (2058, Chaitra 07). The Kathmandu Post.

Regmi, P., Simkhada, P., & Van Teijlingen, E.R. (2008). Sexual and reproductive health status among young people in Nepal: opportunities and barriers for sexual health education and services utilization. Kathmandu University Medical Journal.6(2), Issue 22, 248-256. Silwal , P, R .(2010), Sexual and reproductive health of young people in Nepal , A literature review of existing research and data (2009), GTZ & Health Sector Support Programme Department of Health Services, Kathmandu

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Valley Research Group.(1999) Reproductive health awareness, attitudes, and behavior of adolescents in Nepal.

UNESCO (2006 June) Adolescence Education news letter Newsletter for policy makers, programme managers and practitioners, UNESCO Asia and Pacific Regional Bureau for Education Vol. 9 No. 1

World Health Organisation. (2001). Sexual relations among young people in developing countries. Retrieved October, 2008 from http:/www2.alliance-hpsr.org

World Health Organisation (2010) ,WHO fact sheet N345 august 2010 ,

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Annex I: Key Informant Interview Guideline District Kathmandu VDC- Dakshinkali

Name of the health facility.. Facilitator: . Date: Time: Location:

Key Informant: Health worker / Doctor / Nurse Introduction Namaste! My name is Sangeet Gopal Kayastha. I am student of Bachelor of Social work. I am here to collect baseline information on Adolescents Friendly services related to Sexual and Reproductive Health Needs & services in your area. The information provided would help me to find the services available in the area. With your kind consent, I would like to commence the discussion. Please feel free to take part in the discussion and ask if you have any questions. A. General health and ASRH problems 1. To your best knowledge, what is the general health situation of the adolescent in this VDC ? 2. In your best experience, what type of ASRH problems do male adolescent and youth face in this ward ? B. ASRH service access and utilization 1. What are the services on ASRH being provided by your hospital / health post? -What kind of ASRH services (preventive vs. curative)? 2. What are the contraceptives freely available in this health center? - Where are they placed or to whom it should be asked to get it C . 1 .In your opinion, what are the things to be considered for the better access and utilization of ASRH services in your community, so that the services are easily access and available?

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Probe the things in terms of physical infrastructure, trained health workers, quality care, quality medicine etc. Who should be involved in providing ASRH services such as GOs, INGOs, NGOs

2. What are the average numbers of male adolescent coming to take SRH services in your health post/hospital ? 3. If less numbers of adolescent are coming that what may be the reasons?

4. What the ratio is of married and not married male adolescent coming here?

5. Do you have a counseling facility for the peoples searching for those services?

6. Do you have separate place or room for counseling and checkup?

C. Trainings & information 1. Had you heard about Youth friendly health services?

2. Had any one of the health service provider is being trained for youth friendly health services?

Closing down the discussion Now we are at the end of discussion, now you have about 2 minute time if you have any suggestions for better access and utilization of quality ASRH services in your community? a). .. b). ..

Thank you

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Annex II:
Interview Schedule/Questionnaire

SEXUAL AND REPRODUCTIVE HEALTH NEEDS OF MALE ADOLOSENCE (15-19 Years) & THE GAP BETWEEN SERVICES AND NEEDS in selected wards of Dakshinkali VDC

Identification 1. 2. 3. 4. District Name of VDC Ward No Respondent ID No Kathmandu Dakshinkali VDC 1 2 3 4

5. 6. 7.

Respondents name Interviewers name Date of Interview

Section 1: General Information

8. Sex of the respondent Male

9.

Date of birth of Respondent in BS Date of Birth of respondent in AD

10.

What is your age?

Age in complete years

11.

Caste / ethnicity?

Bramhin Chhetri

1 2

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Newar Aadiwasi/Janajati Dalit/Marganilized Others

3 4 5 6

12.

What has been your highest level of educational attainment?

Illiterate Literate with no formal education. 15th.. 68th....... 9 -10th...... 11 12th. Above 12

1 2 3 4 5 6 7

13. 14.

Are you currently studying? What is your current marital status? What was your age at marriage?

Yes Married

No

Unmarried Your Wife

15.

SECTION 2 : Source of information

After certain age mainly during adolescent period young people have various physical, mental and changes. Such as sexual feeling, wet dreams, masturbation relationships etc. & get information on these topics. 16 From where do you get information on these topics? TV Radio Tick

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School News Paper Magazines Health post Hospital Community programs Parents & Cousins Others (mention) 19. Are there contents on puberty, sexual and reproductive health &relationships in your school curriculum? Do/Did your teachers teach you these topics? YES NO If yes 20 , If no Skip to 23 Yes No Dont Know 22 Do u feel that information which you got is Sufficient Not Sufficient Dont Know

20

Section 3: Knowledge

2 3 .

Have you heard about Sexually transmitted infection (STI)?

YES NO

If yes continue, If no skip 25

2 4 .

What are they , name some

HIV & AIDS Syphilis

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Gonorrhoea Warts Others 2 5 . Have you heard about HIV & AIDS? Yes No If yes continue, If no skip to 29 2 6 . 2 7 . Is HIV & AIDS same? Elaborate YES / No ( ) How can it be transmitted or not transmitted? Sexual intercourse Oral sex Anal sex Blood transfusion Using same towel Others 2 8 . 2 9 . How one can save him/herself for HIV transmission? In your opinion what is the appropriate age of the marriage for girl and boy? Why ? Do you know what family planning (Contraceptives) is/are? Name which you remember GirlBoy

3 0 .

Yes No

If yes continue , if no skip to 33

3 1 .

Condom Femidom Withdrawal..

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Injectables (Depo) . Pills .. Copper-T/IUD Norplant Sponge/vaginal tablet .. Emergency Contraception Calendar /Periodic Abstinence.. Others. 3 2 . Do you know places or persons from where you can obtain a condom? Where can u find them in your area? Is it avaiable easily? Had you seen some of them? 3 3 . Shop (General) .. Pharmacy/Medical shop . Govt Hospital... Private Hospital..... Friends others Good Bad . Neutral .. multiple answers multiple answers

What do you think premarital sex? In your view? Please say why?

3 4 . 3 5 .

Do you know what masturbation is?

Yes No

Your view about masturbation:

normal abnormal

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neutral 3 6 . If masturbation is abnormal, why?

37.

Had you ever went to health centre for services related with SRH (pain, asking some questions related it, etc)?

Yes .. No .

38.

If Yes. For what?

39.

Did you felt easy to ask question and treatment with the health person related with this issue?

40.a b

Do you think the Hp/Hospital have all facility related with SRH? Will you feel easy ?

Yes No

Yes No

41. 42.

If yes Why/If no why? Why not went to take services related with SRH No problem yet Dont know where I get service Feel shy Others

43.

Are service enters are appropriate place? (time,

Yes

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location) 44. 45. If no Please mention Do you feel service providers are friendly/will treat friendly if you visit for taking service or making query related with SRH? Are you involved or know any institution / clubs where you can get that SRH service? Have you been exposed to any programs which provided information on reproductive and sexual health issues?

No

46.

No Yes (where) . Yes No.

47.a

47.b 48.

If yes by whom? What do you want more in Health Service Centres in this area? (Give some suggestions?) Suggestions to others related with SRH information and services. (school,community,governmen t,N/Gos etc)

49.

Thank You

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