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The Journal of Health, Population and Nutrition
icddr,b
ISSN: 1606-0997 EISSN: 2072-1315
Vol. 28, Num. 6, 2010, pp. 619-627
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Untitled Document
Journal of Health Population and Nutrition, Vol. 28, No. 6, December,
2010, pp. 619-627
Barriers to Sexual Health Services for Young People in Nepal
Pramod R. Regmi1, Edwin van Teijlingen2,3, Padam Simkhada3,4, and Dev Raj
Acharya5
1Section of Population Health, University of Aberdeen, UK,
2Health
and Social
Care, Bournemouth University, UK,
3Manmohan Memorial Institute of
Health Sciences, Purbanchal University, Nepal,
4School of Health and
Related
Research, University of
Sheffield, UK, and
5School of Education and Lifelong Learning, Aberystwyth
University, UK
Code Number: hn10080
ABSTRACT
Although sexual and reproductive health education and services are provided
to young people, current rates of HIV infection and pregnancy are increasing
in Nepal, indicating that young people do not always use sexual health services.
Health facilities have apparently failed to provide young people with specialized
sexual health education and services. This study explored the barriers to using
sexual health services, including condom-use among young people in Nepal. Participants
from 10 focus groups and 31 in-depth interviews, carried out by a same-sex
researcher, reported many socioeconomic, cultural and physical norms that impose
barriers to accessing information on sexual health and relevant services. It
is concluded that the establishment of youth-friendly service centres in convenient
places might help encourage young people to use sexual health services.
Key words: Barriers; Condom; Health education; Health services; Qualitative
studies; Sex behaviour; Sexual health; Sexual health services; Nepal
INTRODUCTION
Sexuality is a fundamental dimension of human life (1), and sexual behaviour
of young people is becoming one of the important social and major public-health
concerns in recent years (2,3). As a re- sult of the HIV epidemic, research on
sexual behaviours of young people has developed rapidly over the past decades
(4-7). It is now widely accepted that sexual and reproductive health issues remain
the leading cause of ill-health among young people worldwide and are a growing
concern in Nepal (8). Nevertheless, research on young people’s sexual health
is lacking in Nepal (9,10).
Sexuality-related topics have largely remained as a taboo in many Asian countries
(10-12). Nepalese societies have also many strong traditional norms and beliefs
relating to sex and sexuality (13,14), and these issues are rarely discussed
within the family environment. Friendships between girls and boys are still unacceptable
in Nepal, and many rural par- ents even discourage their daughters from meet-
ing or talking with boys. Sexual activities outside marriage are not accepted
among the majority of Nepalese societies (15,16). Despite these traditional views,
a significant proportion of Nepalese young people are engaged in pre- and extra-marital
sex (10,17-19). Results of a recent study among college students of Kathmandu
showed that about 40% of young men had premarital sex (10). There is a general
notion that modernization and globalization have resulted in young people waiting
longer before getting married (20-22), and this has created more opportunities
for them to spend time in in- timate (sexual) relationships before marriage
(23) as they spend more years in education and marry later.
It is widely accepted that young people have spe- cific sexual health needs,
which vary according to their age, sex, marital and socioeconomic status. When
young people engage in unprotected sex, it may result in sexually transmitted
infections (STIs) and unintended pregnancies (24,25). Thus, many health workers
around the world are trying to pre- vent, or at least reduce, risk-taking behaviours
of young people (13). However, despite the interest of young people in obtaining
relevant information and friendly services (26), the provision of sexual and
reproductive health services in Nepal is very inadequate (27),
The Nepalese Government is committed to providing a package of sexual and
reproductive health service to young people. The Government has developed the
National Adolescent
Health and Development Strategy and the Young People Development Programme.
These policies have envisaged adolescent and young people as a key target group
for integrated sexual and reproductive health services, with interventions
planned to increase knowledge on sexual and reproductive health issues and
availability of services (27,28).
Nepalese young people gain information and education on sexual and reproductive
health mainly through radio and health-education programmes targetted towards
the general population (29). Most sexual and reproductive health services in
Nepal are provided through private and public-health centres. These include
local pharmacists, public-health practitioners, doctors, nurses, and community
health workers. Young people obtain sexual health services when they visit
health centres, hospitals, or clinics. However, many such programmes are poorly
implemented (28). A very few sexual health services, mainly governmental services
in rural areas of Nepal, are available. On the contrary, urban areas have more
specialized facilities with many sexual health service centres, which young
people can access easily.
The role of private and non-governmental organizations is crucial as they
engage young people at a grassroots level in sexual health initiatives. These
organizations
have mainly focused on service and education, particularly on STIs and HIV/AIDS,
family planning, and safe motherhood (29). However, sexual and reproductive
health programmes are scattered, and there is a lack of a common forum and
coordinating mechanism, which could play a significant role in strengthening
the programmes with better output (30). Moreover, many young people do not
seek information or services because they think that they are at little or
no risk of health problems. Results of a recent study with college students
showed that, 48% of sexually-active young people had used condoms during their
first sexual intercourse (31). Lack of information, social stigma, and logistical
and policy barriers have made it difficult for them to use sexual and reproductive
health services (32).
Although young people are provided with limited sexual and reproductive health
information and services through different media, rates of HIV infection (33)
and teenage pregnancy (34) show that many of them do not frequently use sexual
and reproductive health services. Health workers and teachers are reluctant
to discuss sexuality and reproductive health issues (28,35). As the teaching
of sexual health is often very poor, it is directly associated with teacher’s
embarrassment, lack of knowledge, and poor teaching techniques. Teachers are
confused as the existing courses are insufficient to address the needs of young
people (36,37). There is also a notion that Nepal’s political instability
and recent political conflict remains a threat to the delivery of healthcare
information and service (38). These findings clearly suggest that young people
face different forms of barriers to using sexual health services. This qualitative
study aims to explore the major barriers faced by young people to using sexual
health information and accessing relevant services in Nepal.
MATERIALS AND METHODS
Data-collection tools
The topic being sensitive in Nepal, we adopted a qualitative approach. Over
the past two decades, there has been a notable increase in the use of qualitative
methods to explore sensitive issues, including sexuality (39). Although combining
quantitative and qualitative methods is becoming very popular (40,41), few
have explicitly addressed the implications of combining qualitative data-collection
methods (42-44). Lambert and Loiselle argued that combining these methods
may help generate complementary views (45). Besides, multiple qualitative
methods enhance the analysis of a phenomenon and broaden its conceptualization
(43).
In 2007, 10 focus groups and 31 in-depth interviews of individuals were carried
out among young people in Nepal. In-depth interviews were conducted to get
responses from those participants who were either unable or unwilling to attend
the focus groups. It was also intended to explore more personal experiences
from the participants.
A Nepalese version of the questioning route (46,47) was designed for the focus groups.
It is assumed that the questioning route approach helps provide consistent
information, improves the comparability of information among groups, and overcomes
the need for a moderator to formulate unprepared questions (46). Similarly,
a topic guide was used for conducting semi-structured in-depth interviews.
A same-sex researcher conducted focus groups and in-depth interviews as, in
less-developed settings, the interviewer’s gender does have a significant
influence on responses to sensitive questions (48). All focus groups and interviews were conducted in Nepali in a comfortable
environment, i.e. a closed room to assure confidentiality. They were tape-recorded
with
participants’ permission and generally lasted for 1-2 hours (49).
Study areas and participants
Participants for the study were selected purposively
(50) from major urban and rural areas of Kathmandu and Chitwan districts. We
selected four colleges and one youth club from Kathmandu and three colleges
and two youth clubs in Chitwan district. Most focus-group and interview participants
were aged 18-22 years. Educated participants were gathered with the help
of colleges/universities whereas school/college drop-out participants were
found with the help of communities and local youth clubs. Both college-based
and school drop-out focus groups were largely drawn from pre-existing groups,
i.e. members of the focus groups already know each other. One advantage of
using a pre-existing group is that they may feel more at ease taking an active
part in the discussion and/or contradicting each other (7,51). Hennink argues
that the composition of pre-existing groups can generally promote debate
among group members and enrich the discussion (46). However, there is also
a fear that familiarity between participants can also lead to group members
being afraid of being challenged by other group members due to the shared
knowledge of their experiences. Finally, the research team checked participants
for their eligibility. Those who fulfilled the eligibility criteria, such
as residence (urban-rural), age (15-24 years), education (school going/school
drop-out), and sexual history, were invited to participate in the study.
Coding and analysis
Transcriptions were made based on the original tape-recordings (52). Thecompleted
transcription was compared with hand-written notes to fill in inaudible phrases
or gaps in the transcription. Data were organized using the NVivo software
(version 8) (QSR International, Southport, UK). One of the main advantages
of applying the NVivo software is its ability to ensure the processes of coding;
so, the management of data becomes more visual and more flexible (53). A thematic
approach was used for analyzing data using categories (or themes or codes)
from the dataset (54,55). Relevant quotes are also provided in the text to
illustrate these categories.
Ethics
Ethical approval for the study was granted by the Nepal Health Research Council,
and consent was taken from participants before conducting the study.
RESULTS
The following themes were identified in the data:
(a) embarrassment and poor negotiation skills; (b) poor youth-friendly services;
(c) poor knowledge on sexual and reproductive health; and (d) influence of
alcohol and the role of peers.
This paper uses the terms ‘young women’ and ‘girls’ and
also ‘young men’ and ‘boys’ interchangeably. We are
aware that there is a difference between the terms but this is the way the
young people in our studies were portrayed.
Embarrassment and poor negotiation skills
The participants felt embarrassed while talking about sexual and reproductive
health matters with friends of the opposite sex, family, and even with their
sexual partners. They thought that girls found it difficult to initiate a discussion
about it with their sexual partners. Boys argued that it was difficult to keep
condoms as they felt embarrassed when caught by family or friends.
We cannot keep condoms in our pocket because, if anyone knew about it [condom],
it is not taken positively. When we get the opportunity, we cannot arrange
condoms at that time as we do not have time for that. We do [sex] without it
[condom] (a rural married male aged 23 years).
Most unmarried boys and girls felt shy and uncomfortable while buying condoms
and other contraceptives from local stores, although urban participants claimed
that the large number of urban stores provide an opportunity to them to buy
condom anonymously. Rural boys argued that the local shopkeepers and health
service providers know them and their family; hence, they fear service providers
who may share information about them with their friends and family members.
This leads to stigmatization, and they may feel too embarrassed to visit health
service centres. They also argued that such embarrassment also appeared with
doctors or nurses in sexual health clinics.
We know that condoms hould be used but we cannot buy these easily. Even if
you go to a shop for this purpose, the shopkeeper looks at you differently
(urban females of focus group).
We have a belief that doctors may ask different questions. We always feel
fear when answering these questions; so, we rarely go to them [clinics]. We
especially
feel too shy to share our sexual behaviours with those doctors (rural married
females of focus group).
However, some claimed that they would visit the clinic, if there is a service
provider of the same gender. They also believed that young people might share
their problems with younger service providers.
I am not aware of such services but we may feel more comfortable if there
are young service providers. We cannot show parts of our body to male doctors
(laughter)
(a female school dropout of focus group).
I do not think that most young people go there for services because there
are a very few young service providers. How can we express our feelings to
the
people who are similar to our parents’ age? (an urban unmarried male
aged 21 years).
Most clinics were thought to have limited integrated health-related services
while other clinics offer sexual health services. In such cases, the respondents
were more concerned about being recognized in the clinic by someone whom they
knew already.
These services are delivered only in specific places and times. If you appear
there at that time, people think that you have some sex-related problems (rural
males of focus group,).
Most participants agreed that young people, especially girls, have poor negotiation
and decision-making skills which sometimes lead to unsafe sex. Girls further
reported that it is not easy to talk about sexual matters with their boyfriends.
They concluded that there is less chance of refusing sex if boys ask explicitly.
We cannot wait long for that [sex]. We always rush for fun. When we get the
opportunity, we cannot control ourselves. When he sees me, he always expects
that [sex] (laughter). I cannot decide what is right and what is wrong (an
urban unmarried female aged 22 years).
Poor youth-friendly services
The urban participants reported that there are many sexual health clinics
in town while the rural participants mentioned that they are aware of availability
of few health services in the rural areas.
I really do not like to go there [health post] because I know that I cannot
get all services there. If we have a serious problem, we go to the hospitals
in the town because we know that health post staff eventually transfer us there
(a rural married male aged 23 years).
They reported that young people have to rely on these health posts. Most
rural participants also highlighted that rural health posts do not provide
youth-friendly
services. The participants argued that rural young people rarely visit health
posts to seek sexual health services. However, they reported that they go there
to seek other health-related services. Some participants also reported that,
if the sexual health problems become serious, only then they visit health posts.
Most participants believed that service providers at health posts do not keep
information confidential and do not behave nicely if sexual health problems
are shared with them.
Once, I had a pain in my younanga [penis]. My friend advised me to visit
the health post. When I dared to share my problem, the health service provider
shouted at me. Later, I went to another hospital for check-up (a rural unmarried
male aged 18 years).
Sexual health services were perceived to be neither sufficient nor youth-friendly.
The participants stressed the need for youth-friendly services in all the areas.
The rural participants often reported that condoms were not easily available
in the rural areas, and they were concerned about other people watching them
while buying condoms. The rural participants argued that only a few shops provide
condoms, and most rural people know them and their family, which hinders them
from buying it.
We have one health post there, and it is very far. The doctors in this health
post know almost everybody. We know that we can get condoms from there but
we do not visit because we feel too embarrassed to get condoms. Some people
even try to get condoms from the hospital but the stocks are not maintained
regularly (rural males of focus group).
On the contrary, urban young men shared that they can easily buy condoms.
However, the fear of being recognized is still a concern for them. Financial
constraints
have emerged as a barrier to user-friendly sexual health services for both
rural and urban participants. They argued that fees in the private clinics
are very high and, as such, young people do not always find it reasonable to
access services.
We are satisfied with services provided by the centres but the fee was
very high …. We had to pay NRs 3,000 for that [abortion] (an urban unmarried
female aged 22 years).
Poor sexual and reproductive health knowledge
Most boys and girls reported that rural youths have poor sexual health
knowledge, which in turn leads to poor sexual health-service utilization.
Most boys reported
that many young people perform sex; however, there is a notion among the
participants that a very few engage in safe sexual practices. Poor knowledge
of young people
about sexual and reproductive health and poor accessibility of sexual health
services forced them to engage in unsafe sexual practices.
I think, in most cases, boys initiate for that [sex], and most of us have
poor knowledge about it. Some girls start sex at the age of 15/16 years
.... I do
not even remember when I started .... 15/16 years? (a female in the school
drop-out focus group).
I cannot remember when I did it first time (laughter). When I shared it
with my friends, they told me that I might have AIDS. I had heard of
some advertisements;
so, I was not serious about it, although I was very scared at that time
(a rural unmarried male school drop-out aged 18 years).
Friends and the media, such as newspapers, radio, and television, were
the main reported sources of information about sexual matters. The
participants recognized that their sources of information sometimes might
be wrong,
and
this could lead to confusion and increased vulnerability.
They also stated that some rural parents prefer child marriage, which
is part of their culture. These cultures also involve boys and girls
engaging
in unsafe
sex since they are not mature enough in their decision-making.
Some rural parents marry off their children at early ages like
14-15 years. We can easily imagine what they do at that age? This is
the time for education
but they are deprived of it and are busy with other household chores.
They become physically poor and even give immature birth. This
all happens because
of unsafe sex (a rural unmarried male aged 18 years).
Influence of alcohol and peers
Most participants stated that alcohol affects sexual behaviours of young people
and might lead to poor decision-making.
We did not use a condom. We could not even remember it. I do not know what
had happened (a rural married female aged 23 years).
Most of the time, the environment creates the favourable situation for sex.
If you are drunk, you feel brave enough to propose sex. You may even force
your sex partner because you do not know what you are doing (an urban married
male aged 23 years).
Most young men agreed that proposing sex when you are drunk is very easy,
and there is less chance of being denied if women are also drunk. Interestingly,
urban women also agreed that drinking alcohol at parties is not uncommon
and
believed that it is also important for socialization. Young men stated
that these habits make them feel more confident but their decision towards
safer
sex could be affected. Young women also shared that alcohol could influence
their decision-making.
Many people may get involved in unsafe sex …. I know about safe sex
but I could not even remember since we were drunk (an unmarried rural female
aged 17 years).
We also found the role of peers to be an important factor in making decisions
on alcohol, drugs, sex, and romantic relationship. Most young people in this
study who were found to have smoking and drinking habits were influenced by
their peers. The participants further explained that young people seek sexual
health advice from their friends first. Sometimes, they receive incorrect information
from their peers.
DISCUSSION
Most young people felt embarrassed talking about sexual health (services)
with parents, relatives, and senior community members; such embarrassment is,
of course, not unique to Nepal (7,56). Rural young people are more likely to
be embarrassed accessing such services than are urban young people since there
is a fear of stigmatization from local people in the rural areas. Such embarrassment
can also be observed among Nepalese sex workers accessing sexual health services
since they are worried about being identified as sex workers by clinic staff
(57). Our findings indicate that the young people of Nepal fear sexual health
service providers to be judgemental and lack confidentiality. Several studies
show that young people choose not to access sexual health services because
they perceive clinic staff to be judgemental and lacking confidentiality (58,59).
Evidence also showed the effectiveness of respecting young people’s confidentiality
in preventing teenage pregnancy (60).
Our findings suggest that negotiation and decision-making skills are necessary
for these young people to abstain from unprotected sexual practices (61).
However, many Nepalese young people lack such skills. Jha and colleagues found
that
many young people in Nepal lack the power and skills to use sexual and reproductive
health services (8). Hence, programme designers should also focus on developing
negotiation skills in young people.
Youth-friendly services for young people have a significant role in disseminating
sexual health information and services (37,62). In the contemporary Nepal,
many rural young people rely on government health services, which open at the
same time as schools and colleges. In such situations, young people need to
be absent from school/college if they require some sort of sexual health information
and services. Such barriers to using sexual health services have also been
reported from many developed countries. Opening hours for many clinics were
identified as a barrier for young people in the UK (59) and in Africa (32,58).
This suggests the opening of the sexual health clinics during weekends and
holidays for school-or college-going adolescents and young people. Establishment
of such service centres in convenient places and time would encourage young
people to visit the service centres. Similarly, providing essential materials,
such as condoms, educational leaflets, booklets, and pamphlets through the
youth-friendly service centre would encourage young people to use these services
frequently.
Nepal is one of the poorest countries in the world, and the economic constraints
of the young people affect their ability to buy contraceptives or seek sexual
and reproductive health services (22,24). For most young couples, economic
issues play a central role in sexual healthcare decision-making. High costs
associated with pregnancy-related healthcare services result in lower participation
by women in decision-making about antenatal services in Nepal (63). This
suggests that clinics for sexual health service should be free or at a discounted
charge
as many young people do not have enough money to spend on their healthcare.
A study in Africa reported that poverty was a powerful agent in preventing
young people from purchasing condoms (64).
Studies in Nepal have documented that knowledge about sexual and reproductive
health, particularly about STIs and condoms, is inadequate and that knowledge
among male and urban young people was generally better than females and
rural young people (8,9,65). Poor knowledge about many aspects of sexual health
is unlikely to encourage the use of sexual and reproductive health services.
Interestingly,
awareness of HIV/AIDS is higher than that of other STIs (65,66). Perhaps
this must be considered a success as dissemination of information on HIV/AIDS
is
a relatively new phenomenon in Nepal, advocated widely only in the previous
decade. This suggests that mass media would be a possible means of disseminating
information on sexual health to urban youths. Sexual health education through
trained peer educators could be an effective method of improving the knowledge
of young people on the issues of sexual and reproductive health (67).
The use of drugs and alcohol creates a barrier to accessing sexual health
services among young people while it encourages involvement in unsafe
sex. Previous
studies with Nepalese young people and Nepalese trekking guides also
documented similar findings (14,31,68,69). We suggest that young people and
the community
as a whole need to be better informed of the serious negative sexual
health consequences of smoking and drinking.
Limitations
This study had several limitations. The study was conducted in two districts,
namely Chitwan and Kathmandu; hence, it is difficult to generalize
our findings across other areas of the country. Being a multi-cultural
and
multi-ethnic
society, different cultures and ethnic groups of Nepal have their
own norms and values around sexuality. However, we could not analyze our
data based
on ethnicity and religion. Finally, although it is widely accepted
that sex and
sex-related issues are not openly discussed in Nepal, most young
people in this study actively discussed sex-related issues. It can be argued
that many
sexual and reproductive health programmes in the media encouraged
them
to participate in our study. Having researchers of the same sex as
the participants
for the
focus-group discussions and interviews and assuring confidentiality
may also have contributed to the good response from young people.
Conclusions
The key barriers to the use of sexual health services in Nepal do not
vary greatly from both developed and developing countries as
revealed in similar
studies. What seems to be needed is a sexual health service which
maintains confidentiality, treats young people with respect, and
ensures that
their voices are heard. They should be provided with all the
necessary negotiation
skills
to avoid the future risks of HIV/STIs and unwanted pregnancy.
Perhaps, free and discounted sexual health services from governmental, non-governmental
and community-based organizations would motivate young people
to
use these services.
Similarly, incorporating peer-education programmes on sexual
health through educational and community-based organizations and the establishment
of
youth-friendly
service centres in convenient places and time would help encourage
young people, especially those living in rural areas, to use
sexual
health
services more
frequently.
ACKNOWLEDGEMENTS
This study was supported by a grant to the first author from the University
of Aberdeen and the Carnegie Trust for Universities of Scotland.
The authors thank all participants in Nepal and the interviewers and focus-group
facilitators. They are thankful for the useful comments made by the reviewers
on their initial submission.
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