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High-level Meeting to Review the Implementation of the Programme of Action of the International Conference on Population and Development and Bali Declaration on Population and Sustainable Development and to Make Recommendations for Further Action, 24-27 March 1998, Bangkok, Thailand

VII. ADOLESCENTS IN CHANGING TIMES: ISSUES AND PERSPECTIVES FOR ADOLESCENT
REPRODUCTIVE HEALTH IN THE ESCAP REGION

Suman Mehta, Riet Groenen and Francisco Roque *

Introduction

1. Adolescence

Adolescence is a distinct and dynamic phase of development in the life of an individual. It is a period of transition from childhood to adulthood and is characterized by spurts of physical, mental, emotional and social development. WHO considers "adolescence" to be the period between 10 and 19 years of age, which generally encompasses the time from the onset of puberty to the full legal age. For the purpose of the International Youth Year, the United Nations has defined "youth" as encompassing the age range 15-24, overlapping with mid-adolescence as in the WHO definition.

While the onset of adolescence is usually associated with the commencement of puberty and the appearance of secondary sex characteristics, the end of adolescence is less well defined. It varies from culture to culture as far as the attainment of adult independence is concerned. It is a time when influences outside the family take on greater significance. Adolescents find themselves facing new opportunities and are eager to assume new responsibilities. It is also a formative stage in terms of sexual and reproductive maturity. During this phase of transition from childhood, adolescents are often confused about the physical and emotional changes in their bodies and feel hesitant and embarrassed to discuss them with anyone. Therefore, adolescence is a critical period which influences one's reproductive health and well-being throughout life. Adolescent girls are especially vulnerable to the biological and social changes taking place during this time and their effects, owing to the existing inequity between the sexes.

2. Changing issues and needs

According to recent statistics, more than 50 per cent of the world's population are below the age of 25 and one fifth are adolescents (WHO, 1995). In the countries of the ESCAP region, adolescents comprise about one fifth of the total population and, when added to the 20-24 year-old cohort, form 29 per cent of the population (Jones, 1997). As this is a large percentage of the population, any change in the pattern of education, behaviour, age at marriage and lifestyle of adolescents would have a significant impact on the societies in which they live.

Despite the importance of this period, not much is known about the knowledge, attitudes, reproductive health-related behaviour and health and social support needs of adolescents in the region. Adolescence in general is a complex period and often not well understood by either adolescents themselves or adults. This is particularly true in relation to sexuality and reproductive health. A number of factors have affected sexual behaviour and reproductive health-related risks in recent years. These include an apparent trend of declining age at menarche, an increase in age at marriage, improved levels of literacy, change in cultural values brought about by rapid socio-economic changes such as globalization, urbanization, widespread availability and use of communication technologies, high migration rates, and decline in the prevalence of the extended family system. As a result, the period between sexual maturity and marriage has increased in most countries of the region. In addition, traditional customs which often discourage premarital sex have started to erode. These changes have also affected the sexual behaviour of boys and girls. Premarital sex for women has been unacceptable behaviour in most countries in the region, although it has usually been condoned for men, or may even be encouraged in some societies as part of "becoming a man". But this too is changing, and sexual activity among unmarried teenagers (both boys and girls) is on the rise.

Although information is difficult to obtain, some broad patterns of sexual and reproductive behaviour can be noticed. In some countries in Asia, premarital sexual activity is uncommon - as are pregnancy and childbirth out of wedlock - but given the early mean age at marriage, adolescent pregnancy rates are high. Studies reveal that a substantial proportion of young people in many countries, however, engage in largely unprotected premarital sex (De Silva, 1997). As a consequence, the risk of unwanted pregnancy and sexually transmitted diseases (STDs), including HIV/AIDS, has increased significantly for adolescents and youth. Regardless of whether the pregnancy takes place in or outside marriage, there are serious biomedical hazards, especially for adolescents living in poor conditions with limited access to health services. Furthermore, since a large proportion of pregnancies are unwanted, they are more likely to end up as induced abortions, often under unsafe conditions with a high risk of serious and long-term complications and even death. Adolescents are especially vulnerable to STDs, including HIV/AIDS, because of higher risk-taking behaviour, less knowledge of preventive methods, greater biological susceptibility to the infections and their sequelae, and limited access to health facilities for treatment. Although adolescents of both sexes face these risks, they are especially paramount for girls, who suffer physically and emotionally the adverse reproductive health consequences of sexual abuse, unsafe sexual behaviour and lack of social and physical access to reproductive health services, including access to information and supply of contraceptives.

3. Consensus at the Cairo Conference

At the Cairo Conference, the international community acknowledged for the first time that adolescent reproductive and sexual health involved a specific set of needs which were distinct from adult needs. With a growing realization of the importance of including adolescents in population and reproductive health programmes worldwide, the Conference highlighted adolescent reproductive health as a priority concern. The Programme of Action states that the needs of adolescents' reproductive health should be addressed programmatically. "Governments, in collaboration with non-governmental organizations, are urged to meet the special needs of adolescents and `to establish appropriate programmes to respond to those needs" (paragraph 7.47).

Moreover, the rights of adolescents to reproductive health information and services were specifically emphasized in the adolescent reproductive health services section of the Programme of Action.

"Countries, with the support of the international community, should protect and promote the rights of adolescents to reproductive health education, information and care and greatly reduce the number of adolescent pregnancies" (paragraph 7.46).
The Conference called for recognizing the rights of adolescents within the broader context of reproductive rights. While recognizing the rights of all adolescents, the Conference specifically highlighted the rights of adolescent women with regard to issues of gender inequality, and their greater vulnerability to unprotected sexual activities, and stressed the rights of young women to reproductive health information and services.

As the international community has agreed upon the importance of adolescents' rights, these rights should be included in all adolescent reproductive health programmes. A substantial effort should be made to improve the accessibility to information and services, recognizing that resources are limited in the region.

For many years, the needs of adolescents have largely been neglected in population and reproductive health programmes, partly because issues relating to adolescent sexuality and reproductive health are extremely sensitive. The countries in the Asian and Pacific region, especially following the Cairo Conference, have, however, become increasingly aware of the importance of adolescent reproductive health. In several countries, especially youth organizations and NGOs are developing culturally appropriate, broad-based adolescent reproductive health programmes with activities in the area of advocacy, IEC and services.

A. Adolescent reproductive health in Asia and the Pacific

1. Socio-demographic profile

The Asian and Pacific region accounts for about 60 per cent of the world population, of which one fifth are adolescents. The countries are experiencing rapid demographic, social and economic changes which affect both the proportion of adolescents in the population and their roles, behaviour and needs in society. The subregions are distinctly different in terms of socio-demographic and fertility patterns, with the countries in East Asia being more advanced in demographic transition than those in South Asia.

(a) Growth of the adolescent population

As can be seen from table VII.1, there are significant variations among subregions in the projected growth of the adolescent population. Overall, the number of adolescents in the region will register an increase for the next 10-15 years, before starting to decline. However, the rate of increase (0.6 per cent a year between 1990 and 2000) has been slower than the growth over the past few decades. While East Asia is more advanced and is already experiencing a decline in the absolute number of adolescents, growth is relatively slow in South-East Asia, and remains rapid in South Central Asia. This differential pattern of growth reflects the fertility decline which has been very pronounced in East Asia and in parts of South-East Asia. Delayed onset of fertility decline is the main reason why the adolescent population is continuing to grow rapidly in South Central Asia. Within the broad subregions, there is considerable variation as well. For example, during the period 1995-2020, the growth is projected to be 85 per cent in Pakistan but only 24 per cent in neighbouring India.


Similarly, during the same period, while the number of adolescents is projected to increase by 18 per cent in the Philippines and 1 per cent in Indonesia, the numbers will decline by 7 per cent in Thailand and 10 per cent in China (Jones, 1997).

Even though the proportion of adolescents in the population and their growth rate will begin to decelerate, as a result of an increase in the elderly population and fertility decline, the next 10-15 years will be an especially challenging period for adolescent health in view of the rapidly changing economic and social environment of the ESCAP region.

(b) Age at marriage

As marriage determines largely the onset of sexual activity - at least for women - in most of the countries in Asia and the Pacific, age at marriage has been considered important in this respect. The age at marriage for women has been low in most of the countries in comparison with that for men, especially in the South and South-East subregions. For example, as shown in table VII.2, in Bangladesh, about 50 per cent of women aged 20-24 were married by age 15 and 80 per cent by age 20. Similarly, India and Nepal show a high rate of adolescent marriages, with 71 and 76 per cent of women aged 20-24 married by age 20, respectively. Sri Lanka is the only South Asian country in which 76 per cent of the women marry in their 20s. Bangladesh shows the most dramatic difference, with 8 per cent of boys compared with 76 per cent of girls married in the age group 15-19 (De Silva, 1997).

Most countries in the ESCAP region have shown a trend towards increasing age at marriage of both sexes. The age at marriage has increased more for women than for men, leading to a narrowing of the age difference between the spouses. In the Republic of Korea and Singapore, marriage before the age of 20 has almost disappeared and has decreased sharply in Indonesia and Malaysia. Most recent data indicate that the percentage of women marrying during the teenage years has fallen sharply in India and Pakistan to levels comparable with those of Indonesia and Thailand. In Bangladesh, teenage marriage, though still prevalent, declined from 75 per cent in 1974 to 51 per cent in 1991.

Socio-economic development, such as improved education, increased urbanization, more employment opportunities and greater access to communication technologies, has a potential influence on age at marriage. This pattern is observed in India, where among rural women aged 20-24, a higher incidence of marriage before age 20 (80 per cent) or in early adolescence - age 10-14 (about 30 per cent) - takes place compared with their counterparts in urban areas (about 50 per cent and 11 per cent for marriage before the age of 20 and early adolescence respectively) (International Institute of Population Sciences, 1995).

The implications of the changing marriage pattern for young men and women are significant, with adolescence becoming an extended period before marriage, raising issues about premarital sexuality and relationships with the opposite sex. A smaller age difference between spouses and improved opportunities for education and employment usually have positive implications as they tend to increase gender equality.

(c) Education

Almost all children in the region start primary school, but many do not complete it. For example, approximately 20 per cent of children do not complete primary school in Indonesia and fewer than 50 and 31 per cent reach grade 4 in Bangladesh and the Lao People's Democratic Republic, respectively (World Bank, 1994 and 1997). There is a wide difference in school attendance between boys and girls, especially in countries such as Afghanistan, India, the Lao People's Democratic Republic and Pakistan, where the school enrolment rate is significantly lower for girls. Enrolment rates for girls are also significantly lower in Bangladesh and Nepal, although an impressive improvement was witnessed in those countries between 1980 and 1993 (ibid.). At the secondary level, gender differences in enrolment and drop-out rates are substantial between the subregions and countries, as well as between socio-economic groups within countries. Though the rates have increased in most countries, especially for girls, substantial gender differences remain. The gender gap is especially wide in South Asian countries, with the exception of Sri Lanka. This situation reflects the lower value attached to girls and the need for educating them, and the traditional roles assigned to men and women with regard to their expected economic contribution (by men) and early marriage (of women). Although it appears that the gender gap in primary and secondary-level education is narrowing in most countries, concerted efforts are called for in order to improve the situation, especially by the South Asian countries.

(d) Fertility patterns

While, in most Asian countries, fertility outside marriage is extremely rare, in the Pacific it is more common. Therefore, in countries with an early age at marriage (South Asian countries), fertility at young ages tends to be high. Newly married couples often find themselves under pressure by the elders in the family to begin childbearing following the wedding. Even in countries or areas with a low fertility rate (Republic of Korea and Taiwan Province of China), such pressure from the parents and family members is prevalent. Age-specific fertility rates are lowest in East Asia and range from four to five births per thousand women aged 15-19, and highest in South Asia, ranging from 71 to 119 births per thousand women (Jones, 1997). The age-specific fertility in most countries has declined over the years. However, it is questionable whether the risk of teenage pregnancy, which is a better indicator of the fertility status, has decreased. It is difficult to collect data on teenage pregnancy in the region on a systematic basis. With the decline in the TFR and the increase in contraceptive use among older women of reproductive age, fertility tends to be concentrated among the adolescent group. For example, in India, the proportion of all births to adolescents between 15 and 19 years of age increased from 11 per cent in 1971 to 13 per cent in 1989 and to 17 per cent in 1992-1993 (International Institute of Population Sciences, 1995). The health and social consequences of adolescent pregnancy are discussed in subsequent sections of the paper.

2. Sexual attitudes and behaviour

With the decline in average age at menarche and the trend towards increased age at marriage, the length of time in which adolescents may experience premarital sexual activities is also becoming longer. The recent socio-economic developments in the ESCAP region have influenced the cultural values that make premarital sexual activities more appealing and acceptable to adolescents. Even though relatively limited information is available on the sexuality patterns of unmarried adolescents, some recent surveys provide useful insights, indicating that sexual attitudes and behaviour are changing rapidly, with serious short- and long-term implications for reproductive health. These studies include information on the prevalence of sexual activity, age at first encounter, and source of knowledge about sexuality issues.

Sexual activity begins in early adolescence for many men and women in Asia and the Pacific. However, unlike other subregions, the onset of sexual activity in South Asia occurs largely within the context of marriage, where age at marriage is relatively low for both men and women. A multi-centre study from India carried out among 15-29 year-olds reported that premarital sex was relatively more acceptable to men (18 per cent) than to girls (4.2 per cent), which is largely the result of the prevalent sexual double standards. As in other age groups, a higher percentage of men aged 15-19 (16 per cent) than women (3 per cent) reported being sexually active. The average age at their first sexual encounter was 16 for men and 18 for women. It was noted that the average age at first encounter was declining with time (Family Planning Association of India, 1995). Sexual abuse of working girls, especially in factories and among domestic workers, is a serious issue and on the rise in countries such as Bangladesh, India, Indonesia and the Philippines (De Silva, 1997). Some of the results from studies among adolescents are highlighted below.

A 1994 survey conducted with questions on premarital sexuality (by the National Statistical Office, Philippines), indicates that never-married women aged 15-19 and 20-24 years reported lower levels of premarital sexual activity than those who were married at the time of the interview (0.4 and 13 per cent for never and ever-married women aged 15-19). Under-reporting by unmarried women is very likely, while currently married women might have less inhibitions at that moment to admit to premarital sex in the past (National Statistical Office, Philippines, 1994).

A series of studies on the adolescent and youth population have been carried out in Thailand. The study carried out among young people between the ages of 10 and 24 indicated that parents appeared to play a minor role in informing their children about issues related to sexuality. When in need, adolescents (and young people) sought advice from peers and friends, who might be equally uninformed or incorrectly informed, rather than from their parents, for fear of being punished or not being understood. The adolescents realized that it might not be considered appropriate for young people to be engaged in premarital sex, but they regarded it as normal behaviour. Adolescent men thought it was appropriate for them to have sexual experiences but not for girls (double sexual standards), and those aged 17-19 stated that they had had sexual activities in the past. The double sexual standard was also reflected by girls from rural areas who felt that only men had the right to engage in sexual activities; others felt that regardless of being a man or a woman, adolescents had equal rights to sexual experiences.

Another study conducted in Thailand reported that for about 14 per cent of the urban youth and 22 per cent of the rural youth, commercial sex workers were the first sexual partners. The first sexual experience for many men and women (56 per cent for rural males and 75 per cent for urban women) was reported to be without any contraceptive protection. The study indicated that for women, the first sexual experience was usually within marriage. Other studies conducted among Thai adolescents concluded that the average age at first sexual encounter was between 16 and 18 years and that a significant proportion of adolescent men (34-46 per cent) had initiated a first sexual encounter with a sex worker, which in many instances was reported to result from persuasion by friends (Podhista and Pattaravanish, 1995).

Results of studies conducted in Malaysia in 1994 and 1995 have important policy and programme implications. About half of the adolescents interviewed considered premarital sex to be normal behaviour, and 23 per cent of 13-19- year-old adolescents reported being sexually active. This survey also indicated that dating among the respondents began as early as 13-15 years (40 per cent). More than two thirds of adolescents (13-19) obtained information on sexuality issues through the media. There was confusion among the respondents regarding the meaning of sexual intercourse, though the majority of them (85 per cent) knew that pregnancy resulted from sexual intercourse. Most adolescents knew about the existence of contraceptives (condom 94 per cent, pill 89 per cent) and almost all of them (98 per cent) had heard of AIDS primarily through the media. However, many lacked knowledge of STDs and the mode of STD/HIV/AIDS transmission and its consequences. Knowledge regarding reproductive anatomy and physiology was lacking (National Population and Family Development Board, Malaysia, 1996).

In a survey conducted in Cambodia in 1996, the reported prevalence of sexual activity among adolescents was low, with 40 of the 1,006 respondents stating that they had had sex. Most of the male respondents who reported their sexual activities stated that they had used condoms during the first sexual encounter. None of the sexually active girls who answered this question had used a condom the first time they had had sexual intercourse. These women usually had their first sexual experience within marriage. After the first sexual encounter, many adolescents, both boys and girls, reported being concerned about contracting an STD (Ly and others,1997).

Surveys conducted in some other countries of the ESCAP region (such as the Republic of Korea) reveal a similar pattern of increased premarital sexual activity and a decline in age at first sexual encounter. Association with multiple partners has also been observed.

Information on sexual behaviour in the South Pacific is scarce. Adolescent pregnancy is considered an emerging problem deserving special attention. In some of the countries, more than 10 per cent of the total births are among teenage mothers. A contraceptive prevalence rate of 11 per cent was reported in 1994 among 15-19 year-olds in Marshall Islands, while a 1995 KAP survey among 15-19 year-old girls in Vanuatu showed that only 50 per cent of them had heard of family planning and 9 per cent were using a method. A survey on youth carried out in Fiji, Marshall Islands and Samoa found that 58 per cent of the respondents had ever used a condom. It is, however, noted that access to reproductive health services by young people is constrained (Lee, 1995).

In Mongolia, a recent national survey reported that out of 4,674 adolescent respondents, 30.6 per cent claimed to have entered into a sexual relationship, with 6.3 per cent of the female participants having been pregnant at least once prior to the survey (UNFPA Field Office, Beijing, 1998).

3. Reproductive health issues and concerns

The socio-cultural and health consequences of unprotected adolescent sexual behaviour are more severe for adolescent girls than for boys and are mainly associated with unwanted pregnancy, adolescent childbearing, STDs/HIV/AIDS and the related social repercussions for women, such as forced termination of education, lower economic opportunities and social condemnation by the community. These risks are largely avoidable by developing and implementing broad-based preventive interventions aimed not only at adolescents but also at parents and elders in the community as well as national policy makers and programme managers.

In comparison with the health status of children and adults, adolescent health has largely been ignored. One of the reasons often put forward is that adolescents, as a group, are in general healthier than others, although in various countries the low health status of young girls is observed. This understanding might be correct when comparing the morbidity and mortality patterns of adolescents with those of younger and older cohorts in a given country. However, particular behaviour acquired during adolescence frequently has long-term reproductive health consequences. Given the enormous public health and social implications, including the costs involved in managing the diseases which may manifest themselves many years later, there is a strong argument for investing in adolescent reproductive health.

(a) Unwanted pregnancy

Given the social restrictions on adolescent sexuality and the cultural unacceptableness of premarital pregnancy in many countries of the region, abortion is a likely outcome of an unwanted pregnancy. Adolescents may be unaware of a pregnancy initially or, fearing the social consequences, are more likely to hide it and tend to seek abortion relatively late during pregnancy. Owing to socio-cultural factors, as well as financial constraints, abortion is more likely to be performed under clandestine and unsafe conditions by untrained providers. Adolescents are therefore at a high risk of serious complications (haemorrhage, septicaemia, injuries and infertility) and even death from procedures performed during the second trimester of the pregnancy.

The abortion tends to be kept secret by most adolescents. A study from Viet Nam indicates that only a quarter of women aged 15-24 who underwent an abortion shared the experience with a friend, and only 13 per cent with a family member. Family members are informed only when the pregnancy is late and difficult to hide, or when parents' authorization is required for the procedure (Institute of Sociology, 1996). Data on the prevalence and safety of abortions, especially for illegally performed procedures, are difficult to collect. It is estimated that 1 to 4.4 million abortions a year take place among adolescents in developing countries (Center for Population Options, 1992). In Thailand, the cost to the health system of managing the complications of unwanted pregnancy is substantial, and 25 per cent of women admitted to hospitals for such complications are students (Koetsawang, 1993). In India, 30 per cent of all hospital abortions are performed on women under 20. Although, as in other countries, most abortions in India are carried out in the first trimester, among teenagers most procedures are performed in the second trimester (Solapurkar and Sangam, 1985).

Access to information and services to prevent unwanted and too-early pregnancy is the exception rather than the rule in most countries in the world, including those in the ESCAP region. There are often legal as well as social restrictions on the provision of contraceptive services to unmarried adolescents. Data on contraceptive use are usually available for married adolescents only. As shown in table VII.3, recent data from the Demographic Health Surveys and other surveys on ever-married women indicate that although many adolescents have some knowledge of contraceptive methods, current use among adolescents compared with older women is low. Contraceptive use among adolescents varies markedly, from 7 per cent in India to 36 per cent in Indonesia. Such variation is less marked among women aged 20-24 (De Silva, 1997). These findings highlight the need for spacing methods for adolescent married women, since pregnancy among adolescents is associated with high risk of mortality and morbidity.

As regards the unmet need of unmarried adolescents for information and means to prevent unwanted pregnancy, the Programme of Action clearly states:

The aim of family planning programmes must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices and make available a full range of safe and effective methods.... informed individuals everywhere can and will act responsibly in the light of their own needs and those of their families and communities.... (paragraph 7.12).
Countries now face the challenge of translating the consensus reached and the commitment made in Cairo into action.

(b) Adolescent childbearing

Regardless of whether pregnancy takes place in or outside marriage, there are serious health consequences for adolescent girls, especially those living in poor conditions and where access to health services is limited. Young age is a risk factor for maternal mortality in all countries, but in developing countries, where the risk of death in pregnancy and childbirth may be as much as 100 times compared with the developed countries and where pregnancy at young ages is common, maternal mortality makes a significant contribution to the total number of deaths during this period of life. Table VII.4 indicates that births among teenagers are common in many countries of the ESCAP region and require special attention for appropriate policies and programmes.

It has been shown that in several countries, including Bangladesh and Indonesia, a large proportion (26-37 per cent) of deaths among female adolescents can be attributed to maternal causes (WHO, 1995a). A study in Bangladesh showed that girls aged 10-14 and 15-19 were five and two times respectively, more likely to die from maternal causes compared with women aged 20-24 (Chen and others, 1974). In Bangladesh, the excess of female deaths over that of men in the age group 15-24 can be attributed to maternal mortality (Fauveau and others, 1989). In addition to the risk of death, adolescents face a high risk of serious complications, some of which have long-term consequences. In contrast, in Sri Lanka, as is the pattern in the developed countries with low fertility and maternal mortality levels, death rates are lower among women than men (United Nations, 1991).

The causes of higher levels of maternal mortality and morbidity among adolescents are:

Medical factors. Adolescents are more prone than older women to develop some specific complications. A study from Bangladesh shows that deaths from hypertensive disorders of pregnancy and abortion are twice as high among teenagers as among women aged 20-34 (Fauveau and others,1988). Similarly, adolescents are more likely to suffer from prolonged and obstructed labour since their pelvic growth is incomplete. This results in higher rates of operative deliveries and long-term sequelae such as obstetric fistula.

Service-related factors. Because adolescents are less likely to avail themselves of antenatal or delivery care, for a variety of reasons, they are at increased risk of death.

Reproductive risk factors. Age and parity, which are risk factors for maternal mortality and exert an independent effect, place adolescents at a higher risk.

Social factors. Since adolescents are more likely than older women to be unmarried and lack social support, they are at substantially increased risk of mortality. For example, in Bangladesh, deaths from violence (including suicide, homicide, complications of induced abortion) are four times higher among 15-19-year-old adolescents than among women aged 20-34 (ibid.).


(c) Sexually transmitted diseases, including HIV/AIDS

STDs were until recently a widely ignored aspect of health. However, with the advent of the AIDS pandemic, the attention of the world's community has focused on other STDs as well. Young people have been recognized as a high-risk group, for both high-risk behaviour and, possibly for young women, for susceptibility to STD infections. It is estimated that about 50 per cent of HIV infection is among people aged 15-24 and that many of the sufferers contract the infection before they are 20 years of age (UNFPA, 1997a). Young people who become sexually active early are more likely to change sexual partners, and risk greater exposure to STDs. Young women are particularly at risk owing to biological factors and greater vulnerability to abuse and forced sex. In the ESCAP region, a large number of adolescent girls are working in prostitution. In Thailand, it is estimated that there are 800,000 sex workers under 20 years of age, of whom 200,000 are below the age of 14. Many of them were forced into prostitution, live and work in slavery conditions, have little power to negotiate condom use with their clients, are usually uninformed and ignorant of basic reproductive health issues, and have little access to services. Even if the services were available and they had freedom of movement, they would be more reluctant to seek help from health services for financial and social reasons in fear of being turned away or looked down upon by health providers (International Planned Parenthood Federation, 1992). Since many STDs are asymptomatic, adolescent women may not even realize that they have an infection. As the cervical mucus of young women is different than that of their older counterparts, they are more susceptible to certain types of STDs.

While it is recognized that STDs/ HIV/AIDS is an emerging issue of great magnitude, knowledge about the epidemiology of STDs by the public in the region is limited. There are no surveys to indicate the prevalence of different STDs among different sub-populations, or how the pattern is changing over time. There is a common misconception that STDs can affect only a small proportion of the population, usually commercial sex workers. Since it is a sensitive issue and was considered taboo until very recently, accurate data are lacking in most countries. Prompted by the efforts to understand and address the spread of HIV/AIDS, the few studies that have been undertaken make it clear that the risk of STDs extends to other groups as well, and not only to commercial sex workers. In a study conducted in 1992 among 450 sex workers in Calcutta, it was found that only 1 per cent used condoms on a regular basis. Laboratory tests confirmed that HIV and STD prevalence in this group was 1 per cent and 80 per cent, respectively (All India Institute of Hygience and Public Health, 1992). Data on HIV prevalence tend to be better documented, although information on distribution of the disease by age is not collected systematically. In spite of the lack of data on age and specific subgroups, it is clear that the issues of STDs and AIDS cannot be separated. Comprehensive strategies are needed that reinforce the interlinkages between STDs and HIV/AIDS.

4. Special gender considerations

Although gender issues have been addressed throughout the paper, the present section focuses on some specific gender considerations relevant to the region which deserve special attention.

In order to improve adolescent reproductive health, it is imperative to include a gender perspective in all such programmes and policies. Whereas "sex" refers to the biologically determined universal differences between men and women, "gender" refers to the social differences between men and women, that are learned, changeable over time and have wide variations both within and between cultures. The gender roles in a given society condition which activities, tasks and responsibilities are perceived as male and which as female. This has major implications for the reproductive health status and needs of adolescents. Prevalent socio-cultural views affect the way in which adolescents approach sexuality and reproduction, the way adolescent sexuality is perceived, and whether they have access to information and services and are able to protect themselves from unwanted pregnancies and STDs.

As children grow up, boys and girls receive different attention and different messages from their social surroundings about how to behave and what to do. Some behaviour is expected from boys but not accepted from girls. Especially in the area of sexuality, major differences exist in gender roles between men and women. In the Asian and Pacific context, the double standard in attitudes and behaviour related to sexuality is one of those expressions. Men, or boys for that matter, have much more freedom to experience and express their sexuality, while for women and young girls, the enjoyment of sexuality is not considered appropriate and their sexuality is often under the control of men. The promotion of gender equality in reproductive rights is one of the areas which appear to have been neglected in government and international community programmes and will command major attention in the future.

Many cultures in the ESCAP region place a higher value on males than on females, which results in girls receiving substantially less food and education than boys while growing up, and less medical attention when sick. Existing gender norms may place girls at higher risk of sexual abuse and violence. Throughout the world, many pregnancies during adolescence are therefore the outcome of forced intercourse. Because women and girls often lack the ability to control when they have sex and with whom, there is an urgent need to incorporate gender sensitivity and empowerment of girls in all adolescent reproductive health programmes. Boys need to be involved in these programmes in order to make them more gender-sensitive and responsible. Health-care providers need to be aware of the different gender values placed on boys and girls and the different options each of them has with regard to access to information and services and control over their own sexuality and fertility.

UNICEF describes the ways in which different societies make a woman suffer for her reproductive role as follows:

As a menstruating girl, she may be set aside as unclean, polluting, and made to feel dirty and ashamed. As a teenager, she may be married to someone she does not know, and made pregnant before her own body is fully grown. As a woman unable to bear children, she may be abused and abandoned, even though it may be the husband who is infertile, or even if her infertility is caused by a sexually transmitted disease originally contracted by her partner. As a pregnant woman, she may be denied the basic consideration, the rest and the food and the antenatal care, to which she is entitled. As a woman in labour, she will run the risk of dying from the lack of obstetric care, and of sustaining injuries and disabilities for which she will not receive treatment. As a woman enduring a prolonged childbirth, she may be left to die alone and in agony. ..... As a woman suffering from a childbirth injury.....she may die because her husband will not allow her to be seen by a male doctor. As the mother of a baby girl, she may be blamed and beaten despite the fact that it is the chromosomes of the male that determine the sex of the baby. As a wife, she may be forced to submit to sex within a few days of giving birth, or subjected to violence if she refuses. As a new mother, she may be expected to become pregnant again before her body has recovered. And finally, even if she has sustained an injury or infection that is serious and treatable, and even in those rare cases when health workers seek her out knowing that she will not come to them, she may still not be allowed to go into hospital because there will be no one to cook the meals (UNICEF, 1996).

UNICEF reports in the same publication that the major reason for the level of child malnutrition, which is markedly higher in South Asia than anywhere else in the world, is the poor care that is afforded to girls and women by their husbands and by their elders, owing to the lower value placed on women in society.

The vulnerability of young girls to sexual abuse and exploitation is another area which needs urgent attention in the region. The Executive Director of UNFPA recently drew attention again to the recommendations of the Programme of Action regarding the elimination of violence against women and the girl child by reiterating the commitment of UNFPA and its United Nations partners to the elimination of gender-based violence. She reiterated that UNFPA would develop a conceptual framework and plan special activities linking gender-based violence with reproductive health, to further strengthen UNFPA support on these issues.

Under-reporting of gender-based violence in the region, especially against young girls, is widely acknowledged. (De Silva, 1997; UNFPA/Country Support Team Kathmandu, 1998; United Nations, 1997). Adolescent girls are in need of special protection and an enabling environment should be created for the realization of human rights and empowerment of adolescent girls, while adolescent boys should be educated in order to make them more gender-sensitive. For Pakistan, it is recommended that the legal framework for dealing with cases of domestic violence, rape and prostitution among adolescent girls be strengthened, and that the number of legal aid centres be increased throughout the country (Rafiq, 1997).

In the last few decades, a dramatic increase in the commercial sex trade (including trafficking) of women and children has taken place in various countries in the region. According to the 1996 report of the United Nationals Special Rapporteur for the Sale of Children, Child Prostitution and Child Pornography, about one million children in Asia are currently victims of the sex trade (Calcetas-Santos, 1996). The ILO/IPEC report prepared for the World Congress against Commercial Sexual Exploitation of Children, held at Stockholm in 1996, noted that trafficking of children, especially of young girls among the neighbouring countries of Thailand, was on the rise. Girls from Cambodia, China, the Lao People's Democratic Republic, Myanmar and Viet Nam are reported to be sold to brothels in Thailand. In South Asia, the problem is becoming more visible in countries such as Bangladesh, India, Nepal and Sri Lanka, where NGOs and governments have reported that extensive trafficking of girls across national borders takes place; for example, young girls from Nepal are being lured and forced to work in brothels in major cities of India (ILO/IPEC, 1996). The State of the World Population, 1997, by UNFPA, reports an estimate of 300,000 Nepalese women having been sent to brothels in India. UNFPA Sri Lanka reports of the "alarming sexual exploitation of youth, especially in the vicinity of the western and southern coastal belt. It is estimated that there are approximately 30,000 child prostitutes" (UNFPA Field Office, Colombo, 1998). The ILO/IPEC report states that commercial sexual exploitation is one of the most brutal forms of violence against children as it results in life-long, and in many cases, life-threatening consequences for the future development of children as they are at risk of early pregnancy, maternal mortality and STDs, including HIV/AIDS. References are made to case studies and testimonies of child victims which reflect traumas so deep that the children are often unable to return to a normal way of life, while many children are reported to have died before they reached adulthood (ILO/IPEC, 1996).

UNICEF reports that as many as 20,000 children in Cambodia are trapped in the spiral of child prostitution, while a conservative estimate indicates that girls aged 12-17 years represent a startling 35 per cent of all sex workers in the country; the clients are mostly local men. Recent NGO studies found that over half of all sex workers were forced into the trade and an alarming 86 per cent said they were deceived or sold by people they knew. Younger and younger children are caught in the sex trade in Cambodia and in the South-East Asian region. Many clients seek out young children in the belief that sex with a virgin rejuvenates them or brings good fortune, or that sex with a young child confers protection from AIDS (UNICEF, 1995 and 1997).

The Programme of Action, with reference to the girl child, urges governments to take the necessary measures to prevent infanticide, prenatal sex selection, trafficking in girl children and the use of girls in prostitution and pornography (paragraph 4.23).

In paragraph 6.9, it states that countries should take effective steps to address the neglect, as well as all types of exploitation and abuse, of children, adolescents and youth, such as abduction, rape and incest, pornography, trafficking, abandonment and prostitution. In particular, countries should take appropriate action to eliminate sexual abuse of children both within and outside their borders.


B. Current adolescent reproductive health programmes in the region

The countries in the Asian and Pacific region were aware of adolescent health needs long before the 1994 Conference and have responded in various ways to meet those needs, mainly through IEC, population education, family life education programmes, and out-of-school interventions. The overriding emphasis of those programmes and interventions during the 1970s and 1980s was the relationships between population and development, the dominant theme that ran through the various educational and training curricula. The programmes paid little attention to the needs of the youth and skirted addressing the issues of reproductive health and human sexuality which were beginning to emerge (particularly in the 1990s) as a result of the economic and social changes taking place.

The concern of most countries (for example, China, India, Indonesia, Malaysia, the Philippines and Thailand) during the early years (1970s) of the population and family planning programme was filling in the knowledge gaps among the youth. It was thought that knowledge of the impact of rapid population growth would translate into individual reproductive health behavioural change. But a review of the approaches used to provide information to the young showed that health-seeking behaviour was not inculcated into many of the IEC and population education programmes during the 1970s and 1980s. Learning was passive; the youth, including the adolescents, were not taught how and where to seek information and services. Because of perceived cultural sensitivity on the matter, this knowledge change was not supported with the appropriate programmes and services tailored to the needs of the young. Rather, the gap created left the adolescents to seek information about reproductive health from peers whose knowledge of such matters might be inadequate or even inaccurate.

The population and family planning programmes during the 1970s and 1980s reinforced this emphasis by focusing exclusive attention on married couples of reproductive age, thus indirectly ignoring the health needs of the youth. Fortunately, however, this imbalance had been recognized by many countries in recent years (1990s) with the result that the needs of the youth, including adolescents, received special attention in the Programme of Action and are now a major concern of many countries in Asia and the Pacific. The response, however, of many countries in the ESCAP region to meeting adolescent reproductive health needs in terms of policies and programmes was slow and inadequate as well as timid and apprehensive.

An overview of the adolescent reproductive health initiatives undertaken by governments and NGOs shows that previous and ongoing programmes are ad hoc, small-scale and not interrelated. The state of these programmes is at various stages of development. Most countries (except for Indonesia, Mongolia, the Republic of Korea and Sri Lanka) have no policy framework with which to approach adolescent reproductive health needs in a more systematic way. Most of the past/ongoing programmes (except for those of India, Indonesia, the Philippines, Thailand and Viet Nam) deal with the youth in general and do not distinguish between various groups of adolescents and youth (whether married or single, boys or girls, in-school or out-of-school etc.). India is the only country which claims to focus mainly on female adolescents. Since September 1994, many of the countries in the ESCAP region have started to introduce programmes to address the reproductive health needs of the youth, while some others (such as Bangladesh, Myanmar, Nepal and Pakistan) still have no programmes at this time.

Countries in the ESCAP region which have introduced youth programmes following the Cairo Conference employ a variety of strategies to reach the youth, including adolescents, mainly through IEC, conventional population education and family life programmes. Some innovative approaches have been developed, particularly by NGOs, to reach out-of-school youth and adolescents, but the role and utilization of NGOs are still limited. Only a few countries (such as Malaysia, the Philippines and Thailand) started their interventions with an assessment of adolescent reproductive health needs with a view to developing adolescent-specific programmes, including training, messages and materials. Except for the programme on adolescents under the EC/UNFPA Reproductive Health Initiative for Asia, in Cambodia and Viet Nam, most of the programmes are UNFPA-inspired and funded. All of these programmes for adolescents and youth were mainly formulated by adults with very little (or token) participation from the youth, including adolescents.


C . Constraints in meeting adolescent reproductive health needs

The lack of available data about adolescents, and existing ideas and views, often misconceptions, among adults, including parents, planners, policy makers, teachers, religious leaders and health staff, and adolescents themselves, about actual adolescents' sexual behaviour, knowledge, views, needs and problems will be examined in this section. Misconceptions often lead to ignorance, neglect of the real situation, inadequate approaches, moral judgments and stereotyping. Furthermore, the range of misconceptions about what adolescent reproductive health really entails will be explored, as well as the inadequacy or lack of appropriate services and information on reproductive health.

1. Lack of data and information on adolescents

As mentioned earlier in the paper, the lack of information (qualitative and quantitative) on actual adolescents' behaviour, knowledge, views, needs and problems in most of the countries in the region poses serious problems for any programme or activity to be developed in the field of adolescent reproductive health. In view of the major differences in behaviour and needs of various subgroups within the adolescent population, such as young adolescents (10-14) and older adolescents (16-19), between boys and girls, rural and urban adolescents, married and unmarried youth, and various ethnic groups, adolescents should not be addressed as if they formed one homogeneus group.

There are many reasons for the scarcity of information on adolescents, particularly unmarried adolescents, in the region, such as the following:

Young people, as a group with its own identity and needs, are not considered relevant or important, or addressed as a special target group in current reproductive health programmes. As they are between child and adult, and have a limited power base, they are generally not represented or reflected in the usual national statistics, policies and programmes. Their reproductive health needs have been seriously neglected.
Lack of forums for interaction between youths and adults (teachers, parents etc); and limited "positive" attention given to adolescents in the media.
Unmarried adolescents are not expected to be sexually active; if they are, it is frowned upon and in the case of a girl may result in serious repercussions from the social environment. Premarital sex is still taboo and to be avoided at any time. Research under-taken in this field remains highly sensitive, and under-reporting of the sexual experiences of unmarried youth also poses serious problems.
The concept of adolescence and adolescent reproductive health is relatively new for most countries in the region. Lack of information and understanding inhibits the formulation of effective policies and appropriate programmes, including the undertaking of research.
Major socio-economic changes are taking place in the region, which also have an impact on the lives and views of many groups of adolescents (increased education, later age of marriage, AIDS, labour migration, urbanization, sexual exploitation).
Youth themselves are seldom asked about their views, needs and ideas (in a non-judgemental way).
Lack of available funds from government and others for adolescent reproductive health issues.
As adolescent reproductive health is a new area for the region, it is essential to raise the level of awareness and understanding of policy makers and the general public in order to create an enabling and supportive environment for the development of effective adolescent reproductive health policies and programmes in the Asian and Pacific region.


2. Misconceptions

Throughout the Asian and Pacific region, where information on adolescent reproductive health and sexuality is virtually non-existent and many taboos continue to prevail about discussing sexuality, adults share the strong belief that providing family life or sexuality education1 in schools leads to earlier or increased sexual activity by young people. A recent review of 35 studies shows that sex education was found to lead to an increase in the adoption of safer sexual practices by sexually active youth, and that young people delayed starting sexual activity or decreased their overall sexual activity. It was also found that sex education was most effective when given before a young person became sexually active, and those which promoted a choice of options, including postponement of sex and protected sex, were better received and more effective than those which promoted abstinence. As not all adolescents are "in school" at that period in life, particularly girls, "out-of-school" education approaches need to be developed (International Planned Parenthood Federation, 1994).

The knowledge of adolescents, whether married or unmarried, of a variety of reproductive health issues, including sexuality, reproductive functions, contraceptives, safe sex etc. appears to be limited in the region. In the Philippines, the findings of the Young Adult Fertility and Sexuality Survey revealed that respondents actually know less than they think they do. Close to half of the respondents (11,000 in total) did not know that a women could become pregnant as a result of only one intercourse, more than 20 per cent did not know how the menstrual cycle related to the reproductive function and only 2 per cent of all the youth interviewed could tell exactly when the safe and unsafe periods were in a woman's cycle. Yet, 18 per cent reported that they had engaged in premarital sex and 74 per cent of those did not use any method to prevent pregnancy (or STDs for that matter) (UNFPA Field Office, Manila, 1998).

In Viet Nam, 40 per cent of young persons are reported to have no knowledge of contraceptive methods. Together with the general lack of understanding about human reproduction and sexuality, and the increasing premarital sexual activity, this makes young people in the country particularly vulnerable to unwanted pregnancy and abortion and to the risks of STDs, including HIV/AIDS. Although no figures exist on abortion rates, abortion rates among unmarried women in Viet Nam are considered to be high (UNFPA Field Office, Hanoi, 1998).

In some of the countries, programme developers consider parents to be the most appropriate channel for providing reproductive health education to adolescents. In reality, they often lack accurate information on the subject or do not know how to communicate with their sons and daughters on such a sensitive topic. Studies also reveal that young people in general prefer to receive information on reproductive health from persons and sources (media) other than their parents. Youth themselves are seldom asked what their reproductive health concerns and needs are: it is often assumed that adults - whether they are parents, health workers or policy makers - know what the adolescent reproductive health needs and concerns are and what is best for them. This might have been the case in the past, but with the current rapid socio-economic changes taking place in the countries, this can no longer be confirmed.

The earlier sections have shown that there has been an increase in sexual activities among unmarried adolescents in almost all countries in the region. De Silva therefore states:


Marriage in the Asia-Pacific region countries has long been used by researchers as a determinant of exposure to sexual relations. The age at entry into first marriage is often viewed as the age of initiation into sexual intercourse. More recent information collected from many surveys indicates that this assumption is no longer valid in Asian societies. The increase in age at marriage tends to increase premarital activities and use of contraceptives (De Silva, 1997).

The difference in sexual behaviour between boys and girls is, however, very obvious and, as mentioned earlier, is partly the result of the existing double standards which condone premarital sex for boys but condemns it for girls. Several researchers note that in various countries in the region a substantial proportion of boys experience their first sexual activity with commercial sex workers, most of these encounters being without the use of any form of protection against STDs.

The rapid increase in STDs and HIV/AIDS in most of the countries in the region has made the need for effective adolescent reproductive health programmes even more urgent, especially in view of the limited knowledge of effective protection among teenagers. Various governments, including those of the Philippines and Thailand, have taken measures to inform the youth about STDs and HIV/AIDS by developing prevention programmes, including condom promotion, targeting various groups of youth and developing special policies. Others still struggle with the cultural sensitivity of the issues involved.


3. Inadequacy or lack of appropriate information and services

In order to be effective, information and education on sexual health must be linked with service delivery. Providing education and counselling alone without access to reproductive health services, including contraceptive services, could be considered an infringement of the rights of young people to take care of their own sexual health. Similarly, providing services without information and education ignores the factors that determine usage.

(a) Access to information

Providing information and education on reproductive health is necessary to help young people explore their own attitudes, values and options, as well as increase their knowledge and understanding of reproductive health issues. Although there exist great variations between different cultures, studies have shown that adolescents in many developing countries rarely discuss sexual matters (e.g. sexual intercourse, sexuality and sexual preferences, menstruation) explicitly with their parents or with adults older than themselves. Most information on these subjects comes either from their peers, who may be equally uninformed or incorrectly informed and are likely to be relatively inexperienced themselves, or from the media, which tend to represent either sexual and gender stereotypes or extremes.

Young people are often very ignorant of how their bodies function in terms of sex and reproduction, and frequently express a strong desire for the opportunity to discuss such issues with an informed, non-judgemental adult. Unmarried adolescents often have no knowledge of, or access to, family planning services and are at risk of an unwanted pregnancy or acquiring an STD, including HIV/AIDS. Providing young people with information on sexuality and reproductive health is a delicate subject in all countries of the region. Adults do not like to discuss sex, and too often do not want to face the fact that adolescents might be sexually active. Many take the position that only abstinence before marriage is acceptable, even though this contradicts what is actually happening among a growing number of adolescents.

Most young people in the region simply do not have access to education and training on reproductive health as this does not form part of their school curriculum or because they leave school at an early age. Experience with adolescent education so far has shown that in addition to the normal school curriculum, what they need are life skills to empower them. Adolescents need clear information, in non-medical terms, about sexual development; reproductive health and family planning; gender issues and the need for gender equality; and STDs and HIV/AIDS, as early as possible. They need skills to learn to handle social and peer pressure, ambivalence, assertiveness and reproductive protection. They need help in developing skills for responsible behaviour, gender equality, the ability to anticipate, analyse, plan, make decisions, learn how to communicate with others and to share. These skills can be taught to adolescents within school, out of school and in the workplace through teachers, parents, peers, the community and the media. Out-of-school adolescents especially comprise a varied and frequently hard-to-reach group, and are at much higher risk of becoming pregnant or acquiring an STD. Each subgroup of adolescents has its special needs for which different approaches are necessary. However, a recent evaluation of 70 UNFPA-supported projects on adolescent reproductive health throughout the world found that most projects focus on the easy-to-reach, in-school youth, while the poor, unemployed and rural youth are almost completely neglected and seriously under-served. In Asia, a strong bias was found towards addressing older youth, well above 20 or university-based, while the actual adolescents were overlooked (UNFPA, 1997a).

The population/family life education which currently forms part of the school curriculum in only a few countries in the region is usually not designed to prepare adolescents for their future roles and demands, does not correspond to their experience of sexuality, seldom includes subjects such as contraceptives, STDs/HIV/AIDS, sexuality, sexual violence and abuse etc. but mainly focuses on macro-demographic issues. The present education system teaches mainly cognitive skills but pays little attention to developing the life skills of adolescents. The majority of adolescents are, however, out of school and simply receive no basic information on reproductive health during those years at all. Teachers are seldom trained in such issues, or feel uncomfortable to talk about them, or try to avoid the subject altogether. If some form of family life education is provided it tends to focus on girls - although important subjects such as sexual violence and abuse and sexual harassment are notably absent - while boys are left out and do not receive any information to make them more responsible and gender-sensitive. Gender stereotyping is the usual pattern in the educational materials used, which further discriminates against girls, while gender empowerment is lacking (UNFPA, 1997a).

(b) Access to services

Many countries are becoming increasingly aware of the importance of adolescent reproductive health and have started action to address the issues concerned. However, most of the action is limited to (i) the collection of data/information by conducting quantitative and qualitative research on knowledge, attitude and behaviour patterns among adolescents, and (ii) as mentioned earlier, addressing the information and education needs to some extent. As regards the services, little if any action is evident at the country level. As the existing reproductive health services/clinics in the countries of the region focus on married women/couples, managed by the government or religious organizations (for example, in Indonesia), it is not surprising that adolescents are very hesitant to seek professional services or information at these centres.

NGOs throughout the region have usually been the first to offer information, and often also services, related to adolescent reproductive health. These interventions are, in most instances, on a project basis, covering a small number of individuals. For example, in the Philippines, some NGOs have set up health centres specifically for youth, but these are very limited in number and are mainly concentrated in urban centres. In the recent past, the provision of information and services to adolescents/youth through the regular health channels was implemented in the Philippines on a pilot basis. The results were disappointing owing to the "adolescent-unfriendliness" of the centres. These services failed to reorient the focus on youth but continued to deliver reproductive health and family planning care in general, disregarding the typical psycho-social aspects of adolescents and their main concerns, while services were delivered by staff with no training on how to deal with adolescents and their problems (UNFPA Field Office, Manila, 1998).

The provision of appropriate and accessible reproductive health information and services is needed in order to prevent the use of non-effective or harmful/unsafe remedies to which adolescents might turn when in need. The essential components of reproductive health services include family planning, STD and HIV prevention, testing and care and pregnancy-related care. In order to address the reproductive health needs of adolescents effectively, service providers, in both the public and the private sectors, need special training and skills in order to be sensitive to the needs of adolescents, to respond to their questions and doubts and to provide the necessary advice and treatment, including making appropriate referrals.

The role of the private sector in reproductive health service delivery is of major importance in the field of adolescent reproductive health as it enhances access to contraceptives. In some countries, pharmacists, retailers and private doctors form the only access for unmarried adolescents to contraceptives. Existing social marketing programmes are often aimed at increasing access by offering contraceptives at subsidized costs, using innovative, straightforward approaches, and having unmarried adolescents as one of their target groups.

Undoubtedly, there is a strong need for high-quality, accessible, and adolescent-friendly services which meet their health needs in general, and reproductive health needs in particular. Such services need to be made available within the framework of "quality of care", and need to involve training of reproductive health care providers who are not only technically skilled but are also non-judgemental in their attitude towards adolescents seeking reproductive health-related preventive and curative care.

The limited accessibility and quality of appropriate adolescent reproductive health information and services is the result of various factors, such as the following:

Existing policies/legislation which do not permit the provision of information and/or services to unmarried adolescents.
Socio-cultural resistance to the provision of adolescent reproductive health information/services from various groups.
Physical barriers to services (location, service hours, privacy) and to information (not available; inappropriate as too medical; not targeted to various groups of youth etc.).
Social barriers when there is no restrictive legislation, but in practice, owing to cultural and religious taboos, health and community workers are hesitant or refuse to provide contraceptive services and information to unmarried adolescents, and in some instances health providers insist on parents' consent to provide such care. Lack of trust/confidentiality (adolescent/provider) is often a significant barrier to adolescents seeking care.
Financial barriers to adolescents using the services.
Lack of knowledge among adolescents regarding the availability of adolescent services (including information).
Existing gender inequality (resulting in lower awareness of and access to reproductive health services and information on the part of girls than of boys).
Lack of linkages between reproductive health/adolescent services and other health and non-health services.
Lack of referral mechanisms.

The active participation of youth during the design of adolescent reproductive health programmes is one of the basic requirements of any intervention in this regard. Most existing projects and programmes have, however, seldom involved adolescents/youth, which seriously affects the appropriateness and effectiveness of the approaches.

D. Challenges and recommendations

The Programme of Action called for the elimination of programme-related barriers to information and services for reproductive health, especially for adolescents, and the attainment of universal access to services by 2015. Many governments have taken initiatives to meet adolescent reproductive and sexual health needs, often in collaboration with NGOs. However, there are several constraints and challenges impeding the pace of progress; these range from the policy level to social and legal issues, and require serious consideration on an urgent basis.

1. Lack of policy framework

In most countries, the provision of reproductive health information and services to adolescents is constrained by the lack of policies. This issue was discussed and especially highlighted during the Expert Group Meeting on Adolescents: Implications of Population Trends, Environment and Development recently convened by the ESCAP secretariat (ESCAP ,1997a). Various socio-cultural and economic factors influence the societal attitudes and legitimacy to address adolescent reproductive health issues, which in many cases affect men and women differently.

Intensive advocacy efforts are needed to begin with, aimed at influential persons, including policy makers, to sensitize them about issues related to adolescent reproductive health and to promote positive societal attitudes towards adolescents. Such efforts would result in the formulation and enactment of legislation, and subsequently in the development and implementation of policies and programmes. Some of the policy issues which are extremely relevant for the adolescents include legislation related to age at marriage; access to reproductive health information and services (contraceptive and pregnancy-related); and universal education at primary and secondary levels. The policies and legislation should reflect the gender differences in a specific country and address them adequately. Advocacy efforts would also be needed to target programme managers, such as teachers, community leaders, and health- care providers, as well as parents and elders in the community. It is hoped that these efforts would take into account the prevailing culture and country-specific gender concerns and ultimately contribute not only to the growth and development of adolescents and increased gender equality, but also towards their participation in national development efforts as responsible citizens.

2. Research and needs assessment

There are significant variations in the socio-cultural context (including gender relations) among and within countries, and these have major implications for the health, quality of life and development of men and women. Therefore, country and culture-specific information is essential to support advocacy efforts and the development of policies and programmes. Unfortunately, at present, the lack of such information poses an immense challenge to the countries in the planning process. Since issues related to sexual and reproductive health in general, and for adolescents in particular, are extremely sensitive, extreme caution is called for in the research, development and implementation phase for the collection of such data. Qualitative and quantitative research to gain insights into young people's attitudes, values and behaviour should be undertaken. Gender analysis should be carried out as part of the baseline research to ensure that the perspectives and different needs of men and women are addressed, including equal access to information and services. A review of the cultural beliefs and practices and information on society's attitude and expectations from adolescents is also important.

3. Programme planning, design and implementation

Issues of concern to adolescents involve many aspects of sexual and reproductive health, such as increased risk of unwanted pregnancy and unsafe abortion, maternal mortality and serious maternal morbidity, STDs, including HIV/AIDS, and issues of sexual relationships. If services and educational programmes are to be effective, they must operate within the realities of adolescent sexual behaviour. However, it is also essential that the programme strategies be designed within the socio-cultural context of the country in which they must operate. As mentioned in the earlier sections of the paper, inadequate understanding of the needs of adolescents, the influence of the socio-cultural factors inhibiting access and adversely affecting their reproductive health status, are the underlying causes which have led to inadequate responsiveness on the part of the policy makers and service providers from the health, social and education sectors.

Many different strategies for addressing the needs of various groups of adolescents, not just one or two models for replication, require to be developed. Programmes should be flexible in the development of strategies to ensure that they can respond to the changing needs of adolescents as well as address the heterogeneous group comprised by adolescents. For example, needs will vary for younger and older adolescent groups, those living in urban and rural areas and for the in-school and out-of-school adolescents, while special care should be given to distinguishing the different needs of adolescent men and women. Similarly, strategies need to vary for married and unmarried adolescents, although the health risks are equally high irrespective of marital status.

The health sector (public and private) is directly responsible for the provision of the appropriate constellation of services for the prevention and management of unwanted pregnancy, STDs, including HIV/AIDS, and antenatal and delivery care. In order to deliver adolescent-friendly services, due consideration should be given to ensuring that service providers have the necessary communication and technical skills, while respecting confidentiality. The education and social sectors have the main responsibility for reaching out to the adolescent population in and out of school with appropriate information and counselling on reproductive health issues. It is, however, recognized that the strategies and programmes developed and implemented by these sectors need to collaborate closely with the health sector to ensure the uniformity and accuracy of the technical content of the information provided. Since NGOs have relatively more experience and success in working with adolescents, their active participation should be encouraged.

4. Participation of adolescents in the planning and implementation of programmes

Active participation at all levels of the various groups of adolescents in programme development and implementation is the most effective way to ensure the relevance, commitment, and gender sensitivity and responsiveness of the programme. This could be done through the active involvement of young people as partners in the process of the development of policies, programmes and strategies. This is in line with the Programme of Action and fits well with the quality-of-care framework, which recommends a client-centred approach.


End Notes

* Suman Mehta, adviser on reproductive health/family planning training and research; Riet Groenen, adviser on population education for non-governmental organizations/organized sector; and Francisco Roque, adviser on adolescent reproductive health and education, United Nations Population Fund Country Support Team for East and South-East Asia, Bangkok

1 Many different terms exist for education for young people on population and reproductive health issues. Sexuality education does not teach young people how to have sex, but explores the wide area of human sexuality, including subjects such as reproductive system, anatomy, conception and the prevention of conception, STDs, friendship and relationships, communication and decision-making, responsibilities, gender aspects of sexuality, violence etc. Family life education usually refers to a broader programme and can cover a wide array of socio-cultural, socio-medical topics but might in reality totally avoid the subject of sexual and reproductive health, including conception, contraceptives and STDs.

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