Interview on Adolescent Health in Nepal

Reprinted with permission from Spotlight, December 1-7, 2000

Dr. Shyam Thapa (PhD, Brown University) who served as chief of FHI's research and technical services office of population and reproductive health in Kathmandu until 2002, focused on adolescents and youths in Nepal in an interview with Bhagirath Yogi.

Could you briefly describe who adolescents are and why the term adolescence is sometimes confusing?

Generally speaking, persons in the 10-19 age group are referred to as adolescents. However, adolescence is a phase of life rather than a particular age. It is the second decade in a person's life when important changes occur in different dimensions of life – physical, biological, mental and emotional. These changes may occur at different paces in different sociocultural settings and for different individuals. The sequence and manner of these changes can be different for males and females. Furthermore, some of these changes due to adolescence can be perceived and handled differently in different cultures. That is why it is difficult to pinpoint an age at which adolescence begins or ends. For practical purposes, adolescence can be defined as a developmental period during which a person is "no longer a child, but not yet an adult." This definition allows for culture-specific variations to be recognized for both policy and program development.

Why should Nepal invest in adolescents and young adults?

Let me point out three main reasons. First, adolescents and youths together represent a significant segment of the country's total population. This population subgroup – ages 10 through 24 – in Nepal is currently estimated to be 7.1 million, that is, 31% of the total population. Due to the phenomenon known as "population momentum," the number of adolescents will continue to grow. It is estimated to increase to 12.6 million by 2030 before beginning to decline. Second, behaviors formed during adolescence or young adulthood are known to have profound implications for the rest of the person's natural life. For example, smoking or drinking habit initiated during this period is several times more likely to lead to chronic conditions or result in worse scenarios (such as chain smoking or alcoholism) than habits picked up during later stages in life. Conversely, good habits or positive behaviors formed during adolescence and young adulthood can be expected to have salubrious effect on a person's psychosexual and psychosocial health during adulthood. Third, and finally, adolescents and youths of today are the parents and responsible citizens of tomorrow and the most important resource for community- or nation-building. For these and other reasons, Nepal cannot afford to not invest adequately and deliberately in the health and other areas of life of its adolescent and youth population.

The study was based largely on further analysis of a 1996 national survey in Nepal. Let me summarize the findings in a simple capsule form: low school enrollment, early marriage, early entry into work and early entry into childbearing are the defining characteristics of many adolescents and youths in Nepal. These characteristics, operating in circular rather than linear ways, together constitute a socioeconomic challenge that warrants expeditious response and innovative strategies. If the youths and adolescents present challenges, they also bear huge potentials that need to be carefully cultivated and fully realized. The government, the private sector and the international community each have very important roles to play in meeting the challenges and harnessing the potentials inherent in the adolescents and youths of Nepal.

The objective of the ongoing survey – i.e., Nepal Adolescent and Young Adult (NAYA) Survey – is to collect information relevant to the reproductive and sexual health needs of representative adolescents and young adults, ages 14 through 22, for use in the development of appropriate policies, programs and strategies. The Survey aims at interviewing close to 9,000 respondents in five urban areas and eight rural districts. In terms of scope and representativeness, the Survey will provide first-ever baseline information relating to parental, familial, health and non-health aspects of life among adolescents and young adults in Nepal. Prior to the Survey, we also conducted a qualitative study with adolescents and youths in several communities in Nepal.

What was the purpose of the qualitative study you just referred to?

The qualitative study was carried out with the primary purpose of helping in the development of the NAYA Survey and fine-tuning of the survey instrument. The study included 72 focus-group discussion (FGD) sessions, which were conducted in various parts of Nepal, with over 550 adolescents and youths of ages 14-22 as participants. However, since the study proved to be such a rich source of information about the reproductive health needs of the Nepalese youths in general that its findings are being prepared separately to complement the Survey findings.

It is important to bear in mind that healthcare services were conventionally structured to cater to child and adult health needs, thereby skipping the focus on the special needs of the adolescents. The first question is, therefore, how to add efficient and effective adolescent services to the existing healthcare system, such that the services properly relate to the transition states from childhood to adolescence to adulthood. Once this prerequisite is met, several components would need to be in place to make the services friendly to adolescents and youths. These components should include supportive policies, community involvement, healthcare facility and professionals that respect the need for privacy and confidentiality, and healthcare providers who are cognizant of and sensitive to the needs of this particular population.

How do you view the recent developments in this area in Nepal?

In the public (i.e., government) sector, the National Population Committee, which is chaired by the Prime Minister, has recognized the challenge that adolescents and youths represent and endorsed the need to pay special attention to the needs of that particular segment of the Nepalese population. Accordingly, the Ninth Development Plan stated unequivocally that the Government encourages and supports special programs in population and reproductive health focusing on adolescents and young adults. The Ministry of Population and Development then formed a taskforce to identify the needs and gaps in services to the youth population. Concomitantly, the Ministry of Health has developed strategies specific to adolescents as part of its overall reproductive health strategy. These are important and welcome developments in the public sector.

On its part, the private sector has pioneered innovative pilot projects, involving activities ranging from sensitization, awareness creation and counseling to service delivery, mainly in reproductive health. Most of these activities, however, have been small-scale and somewhat disjointed. Furthermore, very little is known about the effectiveness of the various activities or projects. We need to better know what worked and what didn't, before the projects can be scaled up and expanded to wider areas.

Overall, I consider the initiatives–both in the public and the private sector–very important and commendable. The country now needs to move to the next level, where the effective projects are identified and scaled up and expanded and, at the same time, new and promising projects developed and implemented in a more systematic and coordinated way. The good news is that there is a rich body of experience available to draw on in the region and elsewhere. Nepal should take advantage of this and not lag behind in adapting relevant, appropriate models and strategies to its specific needs.

The momentum that exists at this time can be lost due to the lack of sustained financial resources. Therefore, the resources already available need to be utilized in the most efficient and effective manner. At the same time, resources for new initiatives or for expansion of effective projects would need to be found.

At the implementation level, some groups can be expected to fear that providing knowledge about reproductive health and making related services (for example, contraception) available might lead to increased promiscuity and loss of parental control. I think the "comfort level" is still quite low among the Nepalese public in the area of sexuality. Perhaps there isn't a great deal of disagreement on the need to provide some sex education to adolescents, but public opinion will vary widely on related issues: What is the appropriate age for sex education? What should the curriculum include? Who should provide instructional services? How to reach the out-of-school adolescents?

It is also important to recognize that there is no silver bullet nor any one-size-fits-all approach available for addressing the needs of the adolescents and youths. Adolescents are a heterogeneous group; naturally, their needs are varied. This poses a challenge as regards the scope or type of services. Furthermore, not all adolescents and youths are equally needy or vulnerable. Although the majority of them may be in good health and will likely remain so, they will need services . On the other hand, those in poor physical or psychological health will need more substantial services and support. These are two distinct types of service needs. Finally, the concerns and needs of the adolescents and youths often go beyond reproductive health. How to address these concerns and needs in a holistic manner? That remains a big challenge, but it is not exclusive to Nepal by any means.