National Resource Centre for Non-Formal Education (NRC-NFE), Nepal

Transcription

1 National Resource Centre for Non-Formal Education (NRC-NFE), Nepal UNESCO PROAP Regional Clearing House on Population Education and Communication Bangkok, Thailand, 2000 United Nations Population Fund

2 National Resource Centre for Non-Formal Education (NRC-NFE), Nepal UNESCO PROAP Regional Clearing House on Population Education and Communication Bangkok, Thailand, 2000 United Nations Population Fund

3 CONTENTS PREFACE... DEMOGRAPHIC CHARACTERISTICS OF ADOLESCENTS 1 Population composition of adolescents... 1 Age at marriage... 1 Educational level... 2 Health and nutrition... 4 Fertility, teen pregnancy and abortion... 4 STDs/HIV/AIDS... 5 Practice of contraception and family planning... 6 Knowledge, attitude and behaviour on sexuality and reproductive health... 7 PROGRAMME RESPONSES TO ADOLESCENT REPRODUCTIVE HEALTH PROBLEMS 9 Government programmes... 9 NGO programmes ADVOCACY AND IEC STRATEGIES USED TO PROMOTE ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH MESSAGES 17 Advocacy strategies Information, Education and Communication (IEC) strategies 18 LESSONS LEARNED 21 Success/failure factors for advocacy strategies Success/failure factors for IEC strategies Overall listing of lessons learned i

4 CONTENTS (continued) GUIDELINES FOR FORMULATING AND IMPLEMENTING ADVOCACY AND IEC PROGRAMMES ON ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH 25 Guidelines for advocacy programmes Guidelines for IEC programmes REFERENCES Appendix 1: Directory of Organisations Appendix 2: Glossary... 30

5 PREFACE BACKGROUND Although adolescent reproductive and sexual health education is a new programme area when taken under the context of the ICPD POA framework, not a few efforts had been ventured though by a number of forward-looking countries in the region to implement educational, advocacy and communication activities in the areas of human sexuality, HIV/AIDS, and family life/population education, and of course more recently, adolescent reproductive health. Without doubt, these programmes and activities are characterized by weaknesses and gaps as planners and implementors are usually held back from trying out innovative approaches by opposition and objections from concerned quarters. However, there is also not a dearth of successful innovative strategies and approaches which can documented and shared for others to learn from and even replicate. Sexuality and reproductive health education is an area that generate misconceptions, confusion, fear and unwarranted caution, to say the least. These can be ascribed by many factors. First, policy makers, community members, parents and teachers are reluctant to confront issues of sexual and reproductive health. Teen-agers often get their information from their peers who may be ignorant of the topic or the mass media which may provide sensational and inaccurate information. In many programmes, curriculum and textbooks continue to limit their focus on biological, demographic, population and development and family life education issues. Sometimes, in spite of a well-designed curriculum, an ill-prepared or uncomfortable teacher can render a programme ineffective. Teaching methods used are often not suited to the sensitive nature of sexual and reproductive health education issues. However, the developments in this field have not been held back by a few conservatives and traditionalists. Many organizations, especially the non-governmental and voluntary organizations as well as bold government agencies have taken steps to undertake innovative strategies to introduce reproductive and sexual health messages into their programmes to reach the adolescents and influence them into taking responsible decisions regarding their sexual and health behaviours. i

6 These strategies and approaches range from energizing in-school education through co-curricular or community support from out-of-school sector; setting up counselling services inside a school campus; counselling through telephone hotlines; peer group counselling and discussions; development of IEC materials and interactive Internet discussion forum; youth camps and debates and competitions and campaigns in recreational places. Some of these strategies have worked and some failed. How is it that in one country the setting up of counselling centre for youth within a school campus is acceptable and not in another? Why is it that the use of peer approach in reaching the youth is effective in one cultural setting and not in another? How has religion been an obstacle in the introduction of reproductive and sexual health education in a few countries and how has this been overcome? Some countries and some sectors of society have raised fears and caution in introducing reproductive and sexual health which could be unwarranted. The perceptions could be emanating from their own perspective alone and may not be shared by other sectors or even the recipients themselves, i.e., adolescents. Or even if these fears are justified, these are not really unsolvable. Bold, innovative strategies and approaches are now called for if the ICPD POA recommendations dealing with adolescent health are to see reality. As Dr. Nafis Sadik, Executive Director of UNFPA states: The largest challenge facing us does not lie in resources or delivery systems or even infrastructures, but in the minds of people. We must be sensitive to cultural mores and traditions, but we must not allow them to stand in the way of actions we know are needed. We have to overcome the obstacles of superstitions, prejudices, and stereotypes. These changes may not be easy and we face formidable challenges. They involve questioning entrenched beliefs and attitudes, especially toward girls. Lifelong habits must be given up, but they have to be, because in the end Asia s future depends on all its people: and it will depend as much on adolescents as on adults. In order to document the experiences of the countries in the planning and implementation of best practices and innovative strategies in the field of adolescent reproductive and sexual health, these series of case studies are being commissioned to selected countries which have accumulated a pool of knowledge and experiences which can be shared with other countries. ii

7 OBJECTIVES To document the experiences of countries engaged in planning and implementing adolescent reproductive and sexual health in the areas of advocacy and IEC (information, education and communication), the UNESCO Regional Clearing House on Population Education and Communication carried out an activity whereby selected countries were asked to document their experiences in order to: 1. Identify the profile and characteristics of adolescents in various areas such as demographic profile, fertility, teen pregnancies, sexual behaviour, STDs, contraception, etc. 2. Describe the policy and programme responses of the country to address the problems and issues dealing with adolescent reproductive and sexual health 3. Document the strategies, best practices and innovative approaches used in undertaking advocacy and IEC activities on this topic and the results or impact of these strategies on the target recipients 4. To examine and bring out the factors/conditions which have contributed to the success of these best practices or failure of some strategies and from these highlight the lessons learned or guidelines for future consideration 5. To identify organizations which have achieved successes in carrying out programmes/activities on adolescent reproductive and sexual health This third series covers the following countries: Cambodia, China, People s Republic of, India, Lao PDR, Maldives, Nepal and Vietnam. The first series covered also seven countries, namely, Bangladesh, Iran, Malaysia, Mongolia, Philippines, Sri Lanka and Thailand. This volume presents the experiences of Nepal in planning and implementing the advocacy and IEC strategies for promoting adolescent reproductive and sexual health programmes. It was compiled by the National Resource Centre for Non-formal Education, Lalitpur, Nepal. iii

8 DEMOGRAPHIC CHARACTERISTICS OF ADOLESCENTS A. POPULATION COMPOSITION OF ADOLESCENTS In Nepal, the total population is estimated to be 22 million, consisting of more than 60 caste and ethnic groups. The growth rate was 2.66 per cent in and remained more or less the same at 2.11 per cent between 1981 and However, this increased to 2.38 per cent during The adolescent population growth rate followed the same trend. Nepal s adolescent population was 1.5 million in 1971 and increased to 18.5 million in 1991 (Table 1). Adolescents ages constitute a sizeable proportion of the total population of the country. They accounted for per cent of the total population in From 1991 to 1996, the number of adolescents kept increasing by the rate of per cent. Based on this trend, the number is estimated to reach 5.14 million by the year However, the percentage share remains almost equal through the period. Table 1. Adolescent Population of Nepal from 1991 to 1996 Category Male Female Total Male Female Total Adolescents 2,090,939 2,121,947 4,212,887 2,317,044 2,354,711 4,671,754 Total Population 9,220,974 9,270,123 18,491,097 10,393,913 10,437,731 20,831,644 Adolescents Share 22.67% 22.89% 22.78% 22.29% 22.55% 22.42% Source: Statistical Yearbook 1999, CBS, Nepal. B. AGE AT MARRIAGE Early marriages are very common in Nepal. According to UNICEF, 7 per cent of marriages take place at ages below 10. Almost 41 per cent of marriages take place at ages below 15 while 52.2 per cent represent marriages among young people below 16 (Literacy Watch Bulletin, 1997). Because of early marriages, married adolescents become sexually active at an early age. Unfortunately, this deprives the girls from educational opportunities and exposes them to more health risk because of lack of knowledge on safe sex, hygiene during menstruation and danger of early pregnancies. 1

9 Parents make all the decisions regarding marriages. This is still practised in villages and other rural areas. However, in the cities, due to socio-economic changes, the age at marriage has gone up over the years. The mean age at marriage for females had increased from 15 years old in 1961 to 18 years old in The data showed that from 1961 to 1991, the greatest change in age at marriage was found to be among girls ages Marriages at this age group decreased significantly from 25 per cent to 8 per cent (CBS Report, 1995). In the same period, the percentage of girls who got married within the age group of also declined. The Family Health Survey conducted by the Ministry of Health (MOH) in 1996 revealed that 47 per cent of women were married by the age of 18 and the percentage of those married increased rapidly between 15 and 18 years. Most of the women were compelled to marry by their parents. The legal age at marriage in Nepal is 16 years for females and 18 years for males (with consent of guardians) and 18 years for females and 21 years for male (without consent of guardians). Traditional folks, however, do not find themselves bound by this law. According to the MOH, about 60 per cent of marriages take place below 18 years of age (MOH, HMG, Nepal 1993). C. EDUCATIONAL LEVEL Nepal is one of the countries which has a very low rate of literacy. Illiteracy is commonly prevalent among poor people, those in rural areas and among disadvantaged groups. Although a lot of efforts have been undertaken to provide primary education under foreign-aided projects like the Basic and Primary Education Project (BPEP) and the Primary Education Development Project (PEDP), illiteracy rates have not improved drastically. The number of illiterate people remained very much the same from 1980 to 1998 (Table 2). The increase in the proportion of literate people is due to the increase in the total population and not as a result of improved literacy rates. The literacy rate increased only by 0.86 per cent (males by 1 per cent and females by 0.53 per cent), while the population grew at the rate of 2.6 per cent every year (BPEP Master Plan ). The literacy level of adolescents ages seemed to be progressing more than the other age categories (Table 3). Literacy rates among the Table 2. Literacy Rate in Nepal in 1980, 1990 and 1998 Category Population above six years of age 12,180,000 15,148,000 18,047,000 Literacy rate 23% 39% 48% Literate population 2,801,400 5,907,720 8,662,560 Illiterate population 9,378,600 9,240,280 9,384,440 2

10 Table 3. Literacy Rates by Age and Sex from 1971 to 1991 Literacy Rate Age Male Female Total Male Female Total Male Female Total All Source: CBS (1995:348). adolescent population of age groups and have increased, respectively, from 38.8 per cent and 33.6 per cent in 1981 to 63 per cent and 54 per cent in The literacy rate of older adolescents was lower than that of younger adolescents. Again, the literacy level of female adolescents is much lower than that of the male adolescent population. For example, the literacy rate among male adolescents (15-19 years old) was 71.5 per cent in 1991 whereas the literacy rate among female adolescents of the same age group was lower by almost half (38.6%). In schools, the enrolment rate declined drastically from the primary level to the secondary level, indicating that relatively fewer adolescents attend school beyond the primary level. About half of the adolescents population do not attend secondary education in Nepal. The female enrolment in secondary school is much lower than that of male adolescents. For example, net enrolment of male adolescents in secondary education was 22.3 per cent in 1991, while female adolescent enrolment in secondary education was only 12 per cent in the same year. The net enrolment in primary education was only 67.5 per cent in 1995 (Table 4). The picture is even worse in the lower secondary and secondary levels. This was because survival rate at the end of primary education was only about 30 per cent and repetition rate was very high. Due to the weakness of primary education and the high population growth rate, the number of the illiterate population continues to increase especially among girls and women. Although the growth of schools, colleges and the number of students between 1950 and 1990 was remarkable, many people, especially girls and children, from the disadvantaged population were not able to avail of educational opportunities. Table 4. Net Enrolment Rate in Schools in 1995 Category Primary Lower Secondary Secondary Total Boys Girls Total

11 D. HEALTH AND NUTRITION Babies born to adolescent mothers have the lowest chance of survival for various physiological and sociological reasons. The next table shows this fact. The infant mortality rate among the live births of adolescent women (below 20 years of age) was 35 per cent higher than that of women in the age group. In the case of neonatal mortality, the rate among the live births of adolescent women is 30 per cent higher than that of women ages This shows that adolescent mothers are at more risk than adult mothers during pregnancy. A hospital-based study carried out in Kathmandu revealed that about half of maternal deaths are caused by consequences of induced abortion (Pandey et al., 1996). Table 5. Neonatal, Infant and Child Mortality Rates by Age of Mother at Birth Mother s Age Neonatal Infant Under Five at First Birth Mortality Rate Mortality Rate Mortality Rate < Source: National Family Health Survey, E. FERTILITY, TEEN PREGNANCY AND ABORTION Childbearing among adolescent women, despite a great risk to the health of both mother and child, is very common in most countries of South Asia. Nepal is in no exception to this. For example, 44 per cent of those aged are married. Fortunately, between 1961 and 1991, teenage births declined significantly. Fertility rates among women ages and were only 1.31 and 2.71 per cent, respectively. The total fertility rate (TFR) also declined from 6.33 per cent in 1976 to 4.6 per cent in This decline was mainly due to awareness building programmes, population education and the success of the family planning programme. Due to early marriages, 24 per cent of adolescent women of the age group are already mothers or are pregnant with their first child. Cross-country comparison showed that the TFR of the age group was 14 per cent for Nepal, 20 per cent for Bangladesh, 17 per cent for India and 8 per cent for Sri Lanka in 1996 (National Family Health Survey Report, 1996). Maternity mortality rate in developing countries is high, i.e. about 450 per 100,000 live births, compared to 30 per 100,000 live births in developed countries. Research findings revealed that pregnancy-related complications are the main cause of death for adolescents belonging to the age group of women. The 4

12 practice of early marriage is a major factor responsible for the relatively high proportion of teenage childbearing problems in Nepal. Due to poverty and ignorance, the pregnant adolescents do not get early and adequate prenatal care, which often leads to higher mortality and morbidity. Pregnancies are generally unplanned and unwanted among the adolescents who are victims of forced early marriage, rape and premarital sex. This has forced many of them to undergo abortion that is very risky. Abortion is illegal in Nepal but many are willing to take the risk. The women seek access to abortion for various reasons. The unmarried women who find themselves pregnant have the choice of either getting married rather quickly or terminating the pregnancy to avoid humiliation. Practices of abortion take place at the backdoor. Therefore, few data and information are available on abortion seekers. The Demographic and Health Survey conducted in India and Nepal showed a very low official abortion rate. The abortion rate was only 0.4 per cent of the total pregnancies in Nepal. The same survey reported that the rate of induced abortion was slightly higher at 0.5 per cent among married adolescent women ages than all other married women in Nepal. F. STDs/HIV/AIDS The number of people suffering from sexually transmitted diseases (STDs), including HIV/AIDS is increasing. About half of the HIV-infected people so far have been young persons under the age of 25. It is estimated that each year about one out of every 20 adolescents contract STDs. Many of the patients, especially young adolescent males, do not seek medical help even when they know that they have contracted the disease. More than half of the adolescent female STD patients were found to be involved in commercial sex trade. The first case of HIV/AIDS in Nepal was reported in July Since then, cases of HIV/AIDS have been regularly reported to the National Centre for AIDS and STDs Control (NCASC) under the Ministry of Health Service. The exact situation of STDs in Nepal is not known. The review of existing literature shows that the incidence of STDs is common mostly among commercial sex workers (CSWs), migrant males, businessmen, students, police and army, transport workers and seasonal migrants. The most vulnerable are those belonging to the (75%) and (80%) age groups. As of April 1998, the National Centre for AIDS and STDs Control has recorded a total number of HIV/AIDS cases of 1,050, of which 34.4 per cent are females. HIV/AIDS cases are increasing among the adolescents in Nepal. It is widely believed that adolescents sexual activities are increasing every year. The highest percentage of HIV-positive and AIDS was recorded among the age group at 58.6 per cent followed by the age group at 20.4 per cent. Sixteen per cent of the age group have contracted the disease. More than 50 per cent of the female STD patients in Nepal were found to be commercial sex workers (CSWs) or involved in casual or professional sex trade. They were identified as the source of STDs in 5

13 more than 86 per cent of patients. Girls trafficking is also increasing. At present, it is estimated that between 5,000 to 7,000 girls between the age of 10 and 20 are lured to sex trade in different brothels in India and other South East Asian countries. Those found to have RTI/STD or AIDS are returned to Nepal by force and have the potential to spread those diseases among adolescent males in Nepal. Moreover, there is a custom or tradition in some parts of Nepal like Deuki and Badani that force adolescent girls to prostitution. Under such culture, the parents even though rich and affluent offer their young girls to the temples believing that this practice will open the doors of heaven to them. But in general, due to extreme poverty and unemployment in the rural villages, many adolescent boys and girls migrate from their villages to the urban areas in search of employment. Most often they become vulnerable to sexual exploitation and girls trafficking. The Nepalese girls working as commercial sex workers in India are estimated to be about 200,000 in Some factors responsible for girls trafficking are poverty and hardship in the mountainous region, low status of the girl child and lack of employment opportunities. Over 60 per cent of CSW in Kathmandu valley were unmarried and nearly 45 per cent of them were below 20 years of age. More than 95 per cent had their first sexual intercourse at an age below 19 years (Commercial sex workers in Kathmandu valley: Their profile and health status, 1993). Another study conducted by the Karmic Society of Nepal assessed the knowledge, attitude and practice concerning HIV/AIDS and STDs among the youth in Dang, Kailali and Surkhet. The study revealed that the common type of STDs were a disease called Bhiringi, AIDS scabies, syphilis and gonorrhea in those districts. The study also reported that 78 per cent of the respondents agreed that condom is the best measure to protect them from STDs, while 75 per cent think that the best way to avoid STD is to avoid multiple sex partners. G. PRACTICE OF CONTRACEPTION AND FAMILY PLANNING In order to control the rapid population growth, various family planning services were first initiated as early as 1959 by the Family Planning Association of Nepal, an NGO. Later, His Majesty s Government also started family planning projects under the Ministry of Health in Because of these interventions, the past few years have seen a sharp increase in the knowledge of family planning methods in Nepal, although the level of knowledge differs among the age groups. The Ministry of Health s family health survey indicated that the use of temporary methods of family planning has risen from 14 per cent in 1986 to 33 per cent in Although knowledge of family planning methods among adolescents is equal to that of women of reproductive age, the use of contraceptives by the age group remains significantly low. The use of family planning services among adolescents in this age group was 2.5 per cent in 1991 and increased to 6.5 per cent in 1996 (NFHS, MOH, 1996). 6

14 The current use of contraceptives among the 15- and 16-year olds in rural areas is 4.4 per cent and 6.7 per cent, respectively (Table 6). The use of contraception among the population of ages 17, 18 and 19 is 2.3, 3.4 and 6.9 per cent in rural areas, whereas in urban areas, this is higher at 6.4, 8.4 and 26.3 per cent for the respective ages. Age of Women Table 6. Current Use of Contraception by Rural and Urban Residents Rural (%) Urban (%) User Total User Total Difference between Users and Total n.a. 2 n.a n.a. 4 n.a Total Source: Calculated from the file data of the Birth, Death and Contraception Survey (BDCS), CDPS. H. KNOWLEDGE, ATTITUDE AND BEHAVIOUR ON SEXUALITY AND REPRODUCTIVE HEALTH The adolescents, especially those in the rural areas, have very little knowledge about sexual and reproductive health due to illiteracy and social taboos. The knowledge of puberty or menarche is virtually lacking among adolescent girls. They are unaware of the accompanying psychological changes that take place during and immediately after menarche. Moreover, they are often unable to discuss these issues with their parents due to social restrictions. These perception and misinformation often continue throughout their reproductive years. Unhygienic practices during menstruation endanger their reproductive health and well being and expose them to reproductive tract infections (RTIs) such as pelvic inflammatory diseases and other complications. A study on reproductive care, knowledge, attitudes and practices among adolescents sponsored by PLAN International in Makawanpur district found that there is a very high level of ignorance among adolescent girls about genital hygiene or safe sanitation practices during menstruation. Over 67 per cent of adolescent girls faced some menstruation related health problems immediately before or at the end of their menstrual period and a large majority of girls experienced some symptoms of urinary tract infection (UTI). Another study conducted by the Valley Research Group, Nepal revealed that there is a widespread lack of knowledge about sexual acts among a substantial number of adolescents. More than 40 per cent of the adolescents admitted they do not know anything about any type of sexual activities. About 72 per cent of male and 57 per cent of female adolescents acknowledged that they understand safe sex to some extent. The most 7

15 commonly mentioned definition of this term was to have sex with only one partner with the use of a condom. Due to social taboos and inhibitions on open discussion about sex, very little data are available on premarital, marital and extra-marital sexual activities among adolescents. But due to migration of adolescents from rural to urban areas for the purpose of working in carpet and garment factories, there is an increasing incidence of premarital sex. Various researches and studies also showed that unmarried adolescents are becoming more sexually active. The Centre for Research on Environment Health and Population Activities (CREHPA) surveyed men in five border towns of Nepal. The survey showed that 41 per cent of unmarried adolescents of the age group were sexually active. Among the sexually active unmarried men, 77 per cent had their first sexual intercourse while they were 19 years old. The same study showed that 10 per cent of adolescent boys of the age group were sexually active; 54 per cent of them had multiple sex partners. About half of the sexually active adolescent boys did not believe that they were at risk of contracting STDs or HIV/AIDS. Only 27 per cent perceived the risk of contracting such diseases. Another survey conducted in three districts (Kathmandu, Makawanpur and Chitawan) found that 19 per cent of adolescents were involved in premarital sex and 16 per cent were engaged in extramarital sex (Gurbacharya and Subedi, 1992). 8

16 PROGRAMME RESPONSES TO ADOLESCENT REPRODUCTIVE HEALTH PROBLEMS A. GOVERNMENT PROGRAMMES The International Conference on Population and Development (ICPD) held in Cairo, Egypt in 1994 was instrumental in raising the awareness and encouraging action on improving the reproductive health and sexual behaviour of Nepalese. The ninth Five-Year Plan developed by the National Planning Commission of Nepal was finalised to include a programme targeted to the population below 25 years of age. Consequently, His Majesty s Government (HMG) of Nepal prepared and approved the National Population Policy and a strategy on RH/IEC to achieve the objectives and targets set by this Plan ( ). The main targets of the National Population Policy are: To reduce the population growth rate from 2.1 to 1.2 per cent by 2002 To reduce the total fertility rate from 4.6 to 4.1 per cent by 2002 To reduce maternal mortality rate from 5.1 per 1,000 births to 4.0 per 1,000 births by 2002 To reduce infant mortality rate (IMR) from 80 per cent in 1997 to 50 per cent by 2002 To increase contraceptive prevalence rate (CPR) from 28.9 per cent in 1996 to 37.2 per cent by 2002 The National Reproductive Health/Family Planning Information, Education and Communication (RH/FP IEC) strategy seeks to improve the quality of family life and family planning services and to increase CPR among the married population. The strategy also aims at increasing cooperation and coordination among different Ministries of HMG and with NGOs and private agencies. The objectives would be achieved through: Focusing IEC interventions on Married Couples of the Reproductive Age (MCRA) group by providing and expanding community counselling services to them Ensuring the development of positive attitude on RH/FP among family members and emphasising the importance of understanding RH/FP by adolescents Promoting appropriate communication among young couples to make family planning decisions on the basis of informed choice Promoting researches on RH/FP communication, concepts of birth spacing, safe motherhood, gender equality, importance of female literacy and equal health status of women Facilitating appropriate behaviours in support of late marriage, delayed first pregnancy and safe sex Increasing demand for and facilitating access to contraceptive through communication campaigns 9

17 Creating and strengthening the institutional framework for improved coordination, inter-sectoral linkages and networking of activities among agencies involved in RH/FP to develop a synergistic relationship toward these objectives Though the country has developed a reproductive health strategy, it mainly addresses the needs of the adults. There has not been any specific programme for the young peoples health needs. Recently, some efforts have been made in this direction by respecting their right to have information and knowledge regarding their physical development, health and sexual issues. The Ministry of Health, Department of Health Services, Family Health Division has recently developed an Integrated Reproductive Health Care Package to be implemented at different levels from the community to the district. The proposed package is based on the SEARO/WHO Reproductive Health Strategy. It has outlined several activities for the adolescents. A task force has been created for the development of reproductive health operational guidelines and clinical protocol. The activities at the community level include: (1) information on sexuality and gender information and (2) increasing awareness on family planning methods, availability of contraceptives and the danger and risks of teenage pregnancy. At the Sub-Health Post/Health Post (SHP/HP) Level, the activities consist of: (1) free availability of oral pills, condoms and others (2) more accessible antenatal, delivery, post-partum and newborn services, (3) conduct of family life education clinics and (4) school health programme. At the level of the Primary Health Care (PHC) Centre, in addition to the above, the following activities are done: FP/STD/HIV infertility services modified and delivered as a package, e.g., family life education clinics in selected areas Linkage with school system and NGOs Publicity regarding family life education clinics in selected areas Maintenance of privacy and confidentiality Antenatal care, care during delivery, post-partum and newborn care Realising the importance of information to the adolescent youth regarding their health development and the issues related to it, the government has taken steps to minimise health hazards among adolescents. It is most important to develop interaction among family members and in the community. Family and social norms have to be modified to make the environment congenial and trustworthy so that the young could communicate their concerns with their elders and vice versa. Information, education and communication (IEC) among adolescents and their parents can do this most effectively. The Ministry of Health has started to take action toward this direction converting its concept into practice. In order to implement the Reproductive Health Strategy for the adolescents, the government has implemented the following plans and programmes. 10

18 1. Adolescent Reproductive Health Service Programme This programme, under the Ministry of Health aims to provide full information and basic services on reproductive health to prepare the adolescent youth for a more secure future family life. The programme will: Raise consciousness and develop knowledge about reproductive health among the adolescent youth Provide counselling services on reproductive health to the adolescent youth Provide basic reproductive health services, girl child education and delay marriage Emphasise gender equality This programme will be implemented through the following activities: Incorporation of sexuality topics/issues in the secondary education curriculum Launching radio programmes such as Teen Plus Radio Programme, Radio Drama Serial, Distance Education Radio Programme, radio promotional jingles and others Telespots and television programmes Print media 2. Participatory Planning and Management (PPM) of HIV/AIDS Programme (NEP/97/003) The above was a joint programme of the HMG, National Centre for AIDS and STD Control and UNDP. The programme was implemented in the Eastern, Central and Mid-Western Development Regions particularly in the districts of Morang, Sunsaari, Makawanpur, Parsa, Rupandehi, Syanja, Dadheldhura, Doti and Achham. It emphasised the full involvement of local communities and was under the control of the local governance bodies headed by the District Development Committees (DDC). The objective of the PPM programme was to promote a multi-sectoral and community focus on AIDS prevention leading to the minimisation of social and economic impact on individuals, families and communities. The programme included the following: Leadership development leading to credible endorsement and commitment from the community leaders from the Village Development Committee (VDC) levels to the District Development Committee (DDC) level and the national level Community empowerment of the vulnerable sections of the community by providing access to information, advocacy and creating an environment conducive for behavioural change, ensuring access to and use of condom and STD care Participatory approach with multi-sectoral response and involvement Addressing socio-economic issues related to conditions affecting the epidemic and transmission of HIV/AIDS as well as the latter s impact on the socio-economic aspect of individuals, families, communities and nation 11

19 The programme also envisaged to activate micro-level processes by effective decentralisation of programme management involving the community members and local government sectors at the VDC and DDC levels to generate additional locally available resources. The local programme on HIV/AIDS had been integrated with the overall activities of DDC. Awareness development, advocacy, IEC materials production and distribution, local level information, collection and dissemination, operation research and capacity building were the main activities at the micro-level. These activities were implemented through the involvement of different line agencies and NGO personnel, labour unions, elected representatives, community leaders and others targeting behaviour change among the risk persons such as construction workers, factory workers, migrants, truck drivers and sex workers by promoting condom use and safer sex practice. B. NGO PROGRAMMES Many NGOs are partners of government organisations in implementing the adolescent health and youth development programmes. In addition, they also initiate innovative responses to adolescent sexual and reproductive health. These NGOs and their respective projects consist of the following: 1. Community-Based Family Project of the Family Planning Association of Nepal (FPAN) The community-based family planning project was started by FPAN with financial support from the Centre for Development and Population Activities (CEDPA) of Nepal in The focus was on grassroots women with the aim of empowering them. The project has recruited 450 women in the districts of Dhanusha and Dhankuta. Each VDC has nine wards. One woman per ward was recruited in all the 50 VDCs in the two districts. These women were selected on the recommendation of female community leaders. The selected women volunteers were trained in family planning, STDs/HIV/AIDS, immunisation, nutrition, record keeping, reporting and home visit procedure. They are given refresher training every year with focus on antenatal care and counselling. To develop their leadership skills at the grassroots level, women who performed well and demonstrated leadership skills were invited to the district office for quarterly meetings. To further strengthen the programme, FPAN-CEDPA created the concept of Adarhsa Byakti ( Ideal Man ) to produce ideal resource people at the community level. 2. Challenges for Change Project (IPPF-Vision 2000 Fund) Challenges for Change Project was designed to meet the objectives of the strategic plan of FPAN for This project is in operation in two districts of the kingdom. It is implementing community-based reproductive health services and sexual 12

20 education model. The project was started in Baitadi in the far western hills and in Kapilbastu in the Western Terai. The programme has the following goals: Improvement of access to reproductive health care services in low performing areas Improvement in contraceptive choice with greater use of spacing methods Reaching adolescents and the youth to achieve a lower mean age of acceptance Improvement in the static participation and development of women Development of a sustainable approach for the continuation of the project Provision of an effective and replaceable model for other areas The project has envisaged a high level of community involvement and considerable efforts are made to foster the ability of Local Volunteer Groups (LVGs) to sustain the momentum of the project activities after a phase out stage in The project is providing reproductive health services including antenatal and post-natal services and education, delivery services, family planning and MCH services, unsafe abortion, prevention education, STD/HIV/AIDS care and education and pathological services in the project areas. Different training and orientation programmes were conducted for various groups to strengthen and popularise RHSE activities. Women and youth development activities are emphasised as one of the programme areas. Service centres have also been set up at different levels. Such district now has a full-time static clinic serving as the main centre and as well as a resource centre. These clinics are located at the district headquarters and are manned by qualified doctors and other staff. At the VDC level, outreach clinics are staffed with either an auxiliary nurse midwife (ANM) or a community medicine auxiliary (CMA) who also provides technical backstopping services. 3. Reproductive Health Services and Education Project of FPAN and Tribhuvan University (TU) The project was established in 1996 as a joint collaboration of TU, Population Education Department and FPAN. It covered 35 VDCs and the communities in the Palpa Municipality. The targets were mainly women of reproductive age (ages 15-49) and the youth/adolescents of the age groups and The project was planned for The major programme thrusts of the project were reproductive health services, sex education through integrated programmes and women empowerment. The goals were as follows: To raise the contraceptive prevalence rate from 20 to 50 per cent by the end of the project To provide family planning/mother child health (FP/MCH) education and services to 100 per cent of the MWRs in the project areas To provide reproductive health education to 75 per cent of the adolescents in the project areas To develop a sustainable and cost effective system for the supply of contraceptives to those in the rural areas 13

21 Under this programme, sex education was introduced to adolescents. Topics covered included anatomy and physiology of the reproductive system, changes during adolescence, sexual relationships, sexual abuse, unwanted pregnancy and abortion, safe motherhood, sexually transmitted diseases including HIV/ AIDS, infertility and family planning. A curriculum was designed to educate adolescents on sexual and reproductive health. A Handbook for Educators was developed based on this curriculum. Flip charts on family life education, a booklet on teenager s sexuality, a poster of the reproductive system, wall charts on family planning and other related pamphlets and posters were used extensively as teaching learning materials. Youth educators and organisers were trained in sexual and reproductive health. The contents as well as the methodology were designed to upgrade the knowledge and enhance the skills of educators on sexual and reproductive health. The methodology used was participatory discussion along with problem identification and solving. Lectures, demonstration, role play, group discussion and story telling methods were also used extensively to educate the adolescents. The project also provides different services in the areas of family planning, safe motherhood, non-health approach, RTI/STDs and infertility care, prevention of abortion and complication management of abortion. 4. Programme of the Nepal Red Cross Society (NRCS) NRCS has been implementing community-based family planning project in the five districts of Doti, Kailali, Salyan, Siraha and Udayapur with the support of CEDPA. The project has been using a community-based depot holder developed by NRCS in cooperation with FPIA/USA over the course of twelve years. After the end of the FPIA funding in June 1993, CEDPA took over and has been providing technical and financial assistance to the project. NRCS has been mobilising adolescents and the youth through Youth/Junior Red Cross to educate young people on reproductive health and sex education including HIV/AIDS since It also has provided messages on basic facts about HIV/AIDS to 100,000 students in 15 districts. Every year, NRCS also celebrates Condom Day in different parts of the country. 5. ABC/Nepal Youth Programmes ABC/Nepal s youth and adolescent programmes were initiated in 1993 following the realisation that the youth/adolescents were being left out from most of the programmes offered by other NGOs and the government. Furthermore, apart from educational and employment needs, the youth have other significant needs such as the need for authentic knowledge and information about sexual and reproductive health. They constitute one of the largest groups whose educational needs are unmet. The major concerns are those that cover topics on consequences of unsafe sex, unwanted sex, STDs, early/unwanted pregnancies, unsafe abortions, early childbearing and early child rearing. The increasing number of HIV infected people has also added urgency to the learning needs of the youth. Therefore, it implemented two programmes, namely AIDS Education and Family Life Education. With these programmes, the implementing organisations aim to 14

22 develop understanding among the youth on transmission and prevention of sexually related diseases. The AIDS Education Programme started in 1993 and focused on information dissemination on STD/HIV/ AIDS, their modes of transmission, risk behaviour, risk reduction and safe behaviour. A special condom promotion session and responsible sexual behaviour session were designed for campus students. ABC/Nepal used two strategies. The first strategy was to conduct the programmes in the schools and campus by using the project staff in the education process. Some students with leadership qualities were mobilised as peer educators in the school. However, the school authorities were not involved. This weakened ABC/ Nepal s scheme to mobilise the students because they lacked planning and management skills. The second strategy was conducted by using different approaches that involved principals, headmasters, teachers and students in the education process. Parents and teachers were also made a part of the project clienteles. Teachers were trained to conduct education sessions. The trained teachers were used to carry out the education activities in their respective schools. Teachers, students (from Grades VII-X) and their parents were also educated. In the third strategy of the programme the trained students were assigned to teach at least four other adolescents/youths. The ABC/Nepal s Family Life Education Programme was initiated for adolescent girls and young women of the age group This addressed education, reproductive health and economic needs of the target group. It helped the girls improve their lives by defining options for their future. The programme was implemented in the districts of Nawalparasi and Ramechhap. It built a model to reach out to adolescents and the youth especially with regard to reproductive health. Savings and credit schemes, skill training and income-generating activities were promoted along with the programme. The main focus was given to reproductive health, safe motherhood, girls trafficking, gender sensitisation and women s status. 6. Programme of Plan International, Nepal Plan International is implementing adolescent reproductive health programme in 15 VDCs of the district of Makawanpur. It is being implemented in close collaboration with the district health office (DHO). The programme seeks to empower adolescent girls and boys through the enhancement of information and awareness concerning their reproductive health to enable them to make informed choices and change destructive behaviour. The programme activities include family life education for adolescents through peer group education, strengthening the capacity of the government health networks in the villages through training and logistics support, establishing mobile clinics for counselling and screening for STDs as well as for ANC/PNG services and youth activities. 7. Programme of Redd Barna, Nepal For the past four years, Redd Barna has been implementing adolescent girls programme (Kishori Karyakram) in the four districts of Udaipur, Palpa, Lamjung and Tanahun. The programme seeks to make adolescent girls aware of reproductive health and reduce reproductive risks, as well as empower 15

23 them by developing their confidence and self-esteem. Both in- and out-ofschool adolescent girls ages are covered by the programme. 8. Programme of BPMHF The B.P. Memorial Health Foundation (BPMHF) has conducted various youth-related activities. It has implemented school-based AIDS/STD awareness building programme through peer education model and has also provided technical assistance to other local organisations. Besides this, it has promoted reproductive health and AIDS/STD programme for migrant workers of carpet factories. It has also included reproductive health counselling (both face-to-face and by telephone) and a radio programme targeting the youth. 16

24 ADVOCACY AND IEC STRATEGIES USED TO PROMOTE ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH MESSAGES A. ADVOCACY STRATEGIES 1. Advocacy seminars, meetings, and conferences The Ministry of Population and Environment (MPE) in collaboration with the Family Planning Association of Nepal organised a seminar on Sexual and Reproductive Health of Adolescents and Youth on Population Day in July During the seminar, then Minister of Population and Environment, The Honourable Mr. Purna Bahadur Khadka had assured the participants that the MPE will pay special attention to the problem of adolescents and asked the GOs and NGOs to prepare a concrete plan. The seminar focused on two aspects of adolescent reproductive behaviour, namely adolescent reproductive health and sexuality. 2. Passing of legislation A private bill was tabled by The Honourable Sunil K. Bhandari, member of Parliament and President of FPAN in Enacted on the same year, it was passed to inform and educate the general public on the bill and generate their support toward its implementation. FPAN carried out the following activities to implement this bill: Organised a press meeting for dissemination of the content of the bill Mobilised the press and media by encouraging publication of articles and interviews through the electronic media Raised the issues of ICPD Cairo and the Fourth World Women Conference (FWWC), Beijing as a follow-up to reinforce the commitment Organised a discussion programme on the bill Broadcast interviews of the members of parliament, social workers, teachers and women leaders to highlight their views on the bill 3. Forums/rallies/campaigns Many campaigns and rallies were organised both by the government and the non-government organisations of Nepal during Population Day and in other occasions to advocate public awareness and educate adults and the youth alike on sexual health issues. Special effort was done in Kavrepalanchok and Sindhupalchjok where most victims of girls trafficking come from. The efforts were in the form of discussion among women groups and in schools. The topics were mainly on raising awareness on HIV/AIDS. Similarly, several campaigns were organised in collaboration with campus students, police personnel and local people of the districts where the 17