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.
References
All India Institute of Hygiene and Public Health
(1992). Community based Survey of Sexuality Transmitted
Diseases/HIV Infection and Sexual Behavior Among Sex
Workers in Calcutta (Department of Epidemiology, Calcutta).
Asia Week (1997). The Lost Children, Asia Week Magazine,
7 February 1997.
Calcetas-Santos, O. (1996). Report of the Special
Rapporteur on the Sale of Children, Child Prostitution
and Child Pornography.
Center for Population Options, International Center
on Adolescent Fertility (1992). Adolescent and Unsafe
abortion in developing countries: a preventable tragedy,
based on the Proceedings of the International Forum
on Adolescent Fertility, Washington, D.C.
Chen, L.C. and others (1974). "Maternal mortality
in rural Bangladesh". Studies in Family Planning,
vol. 5: pp. 334-351.
De Silva W. (1997). "Socio-cultural factors,
changing marriage patterns and policies affecting
adolescents and youth, including their reproductive
health", paper prepared for the ESCAP Expert
Group Meeting on Adolescents: Implications of Population
Trends, Environment and Development, 30 September
- 2 October 1997.
Economic and Social Commission for Asia and the Pacific
(1997a). Report of the Expert Group Meeting on Adolescents:
Implications of Population Trends, Environment and
Development, 30 September - 2 October 1997, Bangkok.
____(1997b). ESCAP Population Data Sheet (Bangkok).
Family Planning and Population Division, Department
of Health, Ministry of Public Health, Thailand, and
World Health Organization (1997). Situation Analysis
of Adolescent Reproductive Health in Thailand.
Family Planning Association of India (1995). Youth
Sexuality: A study of Knowledge, Attitudes, Belief
and Practices Among Urban Educated Indian Youth, 1993-94
(Bombay, Sex education Counselling Research and Training/Therapy
Department).
Fauveau, V. and others (1988). "Causes of maternal
mortality in rural Bangladesh 1976- 85", WHO
Bulletin, vol. 66, No. 5: pp. 643- 651.
____(1989). "Deaths from injuries and induced
abortion among rural Bangladeshi women", Social
.Science and Medicine, vol.29, pp. 1121-1127.
International Labour Organization/International Programme
for the Elimination of Child Labour (1996). Strategy
and Action Against the Commercial and Sexual Exploitation
of Children, report prepared for the World Congress
against Commercial Sexual Exploitation of Children,
Stockholm, 27-31 August 1996.
Institute of Sociology, Hanoi, Viet Nam (1996). Youth,
Premarital Sexuality and Abortion in the Hanoi Region:
Result of a Survey, a esearch report presented to
UNFPA by Daniele Belanger and Khuat Thu Hong.
International Planned Parenthood Federation, London
(1992). Open file.
____(1994). Report on Young People's Sexual and Reproductive
Health Needs. Understanding Adolescents.
International Institute of Population Sciences (1995).
National Family Health Survey: MCH and Family Planning
(Bombay).
Jones W. G. (1997). "Population dynamics and
their impact on adolescents in the ESCAP region",
Asia-Pacific Population Journal, vol.12, No.3.
Koetsawang S. (1993). Illegal Induced Abortion in
Thailand, paper presented at the IPPF/ South-East
Asian Office Regional Programme Advisory Panel Meeting
on Abortion, Bali, Indonesia, 29-30 October.
Lee S. (1995). "Reproductive health and family
the way forward", Country Support Team Discussion
paper No. 14 (Office for the South Pacific, Suva).
National Statistical Office (1994). Republic of the
Philippines National Demographic Survey, 1993 (Manila).
Ly S. and others (1997). Young people, HIV/AIDS,
STDs and Sexual Health Project. Survey of Knowledge,
Attitudes and Practices (Phnom Penh, Save the Children
Fund (UK) Cambodia).
National Population and Family Development Board,
Malaysia (1996). National Study on Reproductive Health
and Sexuality of Adolescents in Malaysia, Executive
Summary.
Podhista C., and U. Pattaravanish (1995). Youth in
Contemporary Thailand: Results From the Family and
Youth Survey (Institute for Population and Social
Research, Mahidol University, Bangkok).
Rafiq M. (1997). "The adolescent girl in Pakistan",
paper prepared for the SAARC (South Asian Assocation
for Regional Cooperation) Ministerial Conference on
the Adolescent Girl.
Singh S. and others (1996). "Early marriage
among women in developing countries", International
Family Planning Perspectives, vol. 22, pp.148-157.
Solapurkar M.L., and R.M. Sangam (1985). "Has
the MTP act in India proved beneficial?" Journal
of Family Welfare and Marriage, vol.31, No.3.
Time Magazine (1997). "Nepal's lost daughters,
India's soiled goods", Time Magazine, 27 January
1997.
United Nations (1991). Demographic Yearbook 1991
(New York).
____(1997). "Adolescent girls and their rights",
paper prepared for the Expert Group Meeting on Adolescent
Girls and Their Rights, Addis Ababa.
United Nations Children's Fund (1995). The Trafficking
and Prostitution of Children in Cambodia.
____(1996). The Progress of Nations.
____(1997). Toward a Better Future: An Analysis of
the Situation of Children and Women in Cambodia.
United Nations Population Fund (1997a). Thematic
Evaluation of ARH Programmes, Evaluation Report No.13.
____(1997b). The State of World Population.
____Field Office, Beijing (1998). Correspondence.
____Field Office, Colombo (1998). Correspondence.
____Field Office, Hanoi (1998). Correspondence.
____Field Office, Manila (1998). Correspondence.
____Country Support Team, Kathmandu (1998). Correspondence.
World Bank (1994). World Development Report (New
York, Oxford University Press).
____(1997). World Development Report (New York, Oxford
University Press).
World Health Organization (1995a). "Adolescent
health and development: the key to the future",
paper prepared for the Global Commission on Women's
Health.
____(1995b). A Picture of Health: A Review and Annotated
Bibliography of the Health of Young People in Developing
Countries.
|