Adolescent and youth reproductive health Issues, Programmes & Operational barriers Authors: Aparnaa Somanathan, Vindya Eriyagama, Ruwanthi Elwalagedara The purpose of this presentation is to highlight the reproductive health status of adolescents in Sri Lanka. The presentation is primarily based on a study done by my colleagues Aparnaa Somanathan, Vindya Eriyagama & Prof. Indralal De Silva. Health Policy research Associates http://www.hpra.lk

Key questions What are key RH issues affecting adolescents and youth in Sri Lanka? How have the government and NGO sector responded to the needs of adolescents? What are the barriers to ensuring that adolescents have adequate access to ARH services and information? What are some ways of improving government health policy towards A&YRH services? Key questions I hope to address in this presentation are;

Who are Adolescents Adolescence? A transitional period from childhood to adulthood We can define adolescence as a period of sexual maturity that transforms a child into a biologically mature adult capable of sexual reproduction. It is also a period of psychological and socio-economic development. In short, it is a period of transition, growth, exploration and opportunity. (Defining according to WHO) Reproductive health data for young adolescents hardly exist in developing countries, including SL. Therefore, in this presentation adolescents refer to those in the age group of 15-24, and data used (in the presentation) are for this age group.

Outline Background RH issues affecting adolescents and youth Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

Outline Background A & YRH issues in Sri Lanka Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

Background In 2002 19.7% or 3.7 million of Sri Lankan population were adolescents It is estimated that the number will decrease to 3.1 million by 2021 Focus on A & YRH is important in SL context. Knowledge and services will allow adolescents and youth to make informed decisions relating to sexual & RH matters Adolescents comprised one fifth of Sri Lankan population in year 2002. It is estimated that the number will decrease to 3.1 million by 2021.The drop in number is mainly attributed to the significant decline in fertility rates over the past 4 decades (since 1960’s) Focus on A & YRH is important in SL context; (i) particularly with the rising age at marriage and pre-marital sexual activities on the rise. They also experience rapid changes in their socio-economic environment. For instance, processes of globalization and modernization all influence changing lifestyles, attitudes, decision making and behaviors of adolescents and youth. As information on RH services is scarcely available for adolescents, they are vulnerable to many health risks including those relating to Sexual Reproductive Health.

Source: Population projections for Sri Lanka by Prof. I W De Silva Don’t need to explain these as they accompany the slides Source: Population projections for Sri Lanka by Prof. I W De Silva

Profile of Adolescents in SL Education Employment Marriage There are few disparities between young men and women in their educational attainment, although a higher % of young women have received 10 or more years of schooling than young men. Approximately 91.4% & 56.2% of SL As complete primary & secondary education, respectively. Employment –approx. 400,000 SL young men & women are employed in the Middle east and other Asian countries. However, the unemployment rate for females is double that of males. Marriage - During the past century, the age at marriage for females in Sri Lanka has increased by almost seven years. The age at marriage for females increased from 18.1 in 1901 to 24.6 years in 2000. As a result the proportion of unmarried adolescents (15-24 years) is on the rise and with it, the duration of premarital sex.

Years of Education completed 2003/04 (percent) (Ages 15-24) Source: The consumer finance and socio economic survey report 2003/2004. Central Bank of Sri Lanka

Employment by sex, 2003 ('000) (Ages 15-24) Source: Labor force survey 2003. The Department of Census and Statistics. Sri Lanka

Risk Taking Period: Sri Lanka 1901 Age at Age at Menarche Marriage 2000 4yrs 14yrs 18yrs 14yrs 12yrs 26yrs

Outline Background A & YRH issues in Sri Lanka Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

A & YRH Issues Early, High risk pregnancy Unwanted pregnancy Abortion unwanted pregnancy among adolescents in SL is exceptionally low by international standards Abortion Illegal, unsafe, on the rise (150,000-175,000 performed annually) HIV/AIDS/STDs On the rise, and primarily a concern because of poor awareness among high risk groups (i.e. workers in free trade zones, in tourist industry, commercial sex workers, displaced persons) Sexual abuse About 10% of early adolescents and 14% of mid and late adolescents admitted to have been sexually abused Early, High risk pregnancy There is an adverse effect on mother and child, pregnancy related morbidity & mortality. A few reasons are: late reporting of pregnancies, higher maternal morbidity rates for Adolescents, and attitudes & behavior of service providers. Unwanted pregnancy The incidence of unwanted pregnancy among adolescents in SL is exceptionally low by international standards, Primarily due to socio-cultural reasons. The unwanted pregnancies that do occur among unmarried adolescents are thought to end in abortions. In a recent study done by Unicef (2004) indicated that 2.8 percent of unmarried boys said that they had got a girl pregnant (N =4622). Abortion Abortion in SL is illegal and unsafe. Yet there are 150000 – 175000 abortions performed annually. Most of these illegal services are provided by private hospitals and clinics. Eighty one girls out of 4427 female respondents reported that they had been pregnant, 48 of them had resorted to abortion. Of this 81, 11 did not respond to this question asking. HIV/AIDS/ STDs HIV/AIDS : On the rise, poor awareness among high risk groups (i.e. workers in free trade zones, in tourist industry, commercial sex workers, displaced persons) STDs : High prevalence, poor awareness among married adolescents In the same study by Unicef, it was found that, majority of adolescents were not aware of different kinds of STDs and HIV infection. The modes of transmission of STDs and HIV, methods of prevention, common symptoms and signs were known by only a small percentage of adolescents. Even though many attempts have been made to improve the awareness of adolescents and youth on STD and HIV/AIDS, the findings of the study shows that the knowledge of adolescents on the subject was poor.

Outline Background A & YRH issues in Sri Lanka Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

A&YRH programmes School – based health education Community – based interventions National Youth Campaign Telephone hotlines Peer education The existing A & YRH programs are implemented through the department of health, the department of education, the national youth service council and NGOs. Components of the school health prog include; School medical services & counselling for adolescents Healthy school environment Health education & development of life skills School community participation FPASL initiated a programme in 1998 to provide RH information, counselling and health care services to adolescents and youth. One objective of the project was to provide community based sexual & reproductive health information and services to adolescents, with special focus on those living in vulnerable or under-serviced areas. FPASL launched hotline service to provide medical information on RH issues. Although the hotline was specifically launched to introduce emergency contraception to the at-risk population, there are many young callers who are using the service every day.

Programs beyond health NGO programmes Operations research Programs beyond health NYSC launched Reproductive Health Information Project to provide leadership training for youth and peer groups. The training covered issues such as HIV/AIDS and STDs, drugs, family planning, and empowerment of women. Peer education programmes in universities were introduced to raise awareness on RH issues The NGO sector provides an important supportive function to government programs, especially in the areas of family planning, adolescent health and STI/HIV prevention.

Outline Background A & YRH issues in Sri Lanka Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

Operational Barriers to A & YRH Lack of knowledge and public awareness about ARH issues REASONS: Lack of human resources with necessary skills and experience on RH issues Cultural factors have limited open discussion of issues  difficult for “safe” channels of information to develop There is a need for greater dissemination of information about sexual and reproductive health issues. The lack of counseling and information services is associated with the fact that there is a dearth of health workers and professionals who have the necessary skills and experience to counsel on ARH issues and provide advice on HIV/AIDS and STI. Though there are school health programs and various other awareness building programs taking place, its coverage and quality is quite low and unsatisfactory. This is mainly due to two reasons: 1) a lack of human resources with necessary skills and experience in RH issues. 2) cultural taboos Most parents are uncomfortable about discussing sex with their children because of taboos on openly dealing with sex related issues. This situation also applies to teachers and health care providers. In addition, because many parents themselves have had little education about sex, and teachers may not have sufficient training to teach reproductive health education properly, neither parents nor teachers necessarily have the appropriate information to convey to adolescents. Beyond issues of discomfort and social taboo, many adults do not want to discuss sex with unmarried adolescents and youth because they worry that providing information will encourage premarital sexual activity. Therefore, adults prefer to maintain the ignorance among adolescents and youth, believing that they will get the information they need at the “PROPER” time- which is, of course, just before marriage. HOWEVER, married couples often remain uninformed because sex is still a sensitive topic and there are few opportunities for discussion or education. Due to these facts, adolescents and youth often turn to the media and peer groups for their information, which in most cases leads to misinformation, causing great health risks.

Inability to obtain services There are very few, if any, reproductive clinics or centres from which adolescents can obtain services. Public provision of contraceptives targets married couples almost exclusively REASONS: Lack of public awareness  lack of understanding of the gravity of the issue in the community  little impetus for strong policy action General lack of resources in the health sector Although there are reproductive health clinics or centers in Sri Lanka, research reveals that adolescents almost never or rarely seek services from them. Also public provision of contraceptives is almost exclusively targeted to married couples. Lack of community awareness of the reproductive health needs of adolescents; limited availability of reproductive health services to them, and inadequate opportunities for them to learn about reproductive health issues are significant operational barriers to ARH services

Lack of research Lack of research on A&YRH and the needs of adolescents and youth, particularly among underserved and minority groups CONSEQUENCES: Scarce data and knowledge  severity of A&YRH issues is not known to public  weak political commitment for coherent policy initiatives There is an obvious lack of reliable data on A & YRH issues, such as teenage pregnancies, abortions, contraceptive use, child abuse, and gender-based violence. As long as data is scarce and the severity of ARH issues is not made known to the public, political commitment for a coherent ARH policy initiative will be difficult to achieve. In the long run this could prove to be the greatest operational barrier to ARH in Sri Lanka.

Existing programmes and policies on A&YRH Outline Existing programmes and policies on A&YRH Operational barriers to A&YRH Policy recommendations

Policy recommendations A more holistic approach to A&YRH : health and education sectors + legislative action to influence risk taking behaviour Capitalizing on political support in establishing programmes that support A & YRH services. Provision of information to adolescents: Importance of school-based programmes cannot be overstated Improve pre-marital counselling Work through the pharmacy network Conduct research on sexual behaviour and special population groups In conclusion, policy recommendations need to consider the following: Adolescents and young people are at the onset of their sexual and reproductive lives; they are also the next generation of parents. How they undergo preparation for this journey has tremendous implications for their own lives as well as for national reproductive health outcomes, including fertility, safe motherhood, and sexually transmitted infections, particularly HIV/AIDS.

References De Silva, W.I., Somanathan. A., and Eriyagama. V. 2003. “ Adolescent and youth reproductive health in Sri Lanka. Status, Issues, Policies and Programs” Hardee K, Pine P, Wasson, L T. 2004. ”Adolescent and youth reproductive health in the Asia and Near East Region. Status, Issues, Policies and Programs” Thalagala N.I. , Rajapakse L. 2004 National Survey on emerging issues among adolescents in Sri Lanka. UNICEF Colombo. Department of Census and statistics Sri Lanka. Sri Lanka demographic and health survey. 2000, LFS 2003. Central Bank of Sri Lanka. 2003/2004. The consumer finances and socio economic survey report Family health Bureau, Ministry of Health Sri Lanka. Annual report and other publications.