|Year : 2014 | Volume
| Issue : 2 | Page : 106-112
Perceived behavior and practices of adolescents on sexual and reproductive health and associated factors in Kathmandu, Nepal
Dillee Prasad Paudel1, Laxmi Paudel2
1 Department of Public Health, Jawaharlal Nehru Medical College, Karnataka Lingayat Education University, Belgaum, Karnataka, India
2 Research Section, Community Action and Research for Development, Kavrepalanchok, Nepal
|Date of Web Publication||1-Jul-2014|
Dillee Prasad Paudel
Department of Public Health, Jawaharlal Nehru Medical College, Karnataka Lingayat Education University, Nehru Nagar, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Adolescence is a period of both opportunities and threats. It is an episode of exploring new options and ideas as opportunity. It is also a phase in life marked by vulnerability to risky sexual behavior and underprivileged reproductive health outcomes. Due to the deficiency of courtesy and proper guidance, millions of adolescents are facing the problems of teenage pregnancy, unsafe-abortion, psycho-social abomination, sexually transmitted diseases (STDs) and HIV/AIDS. The aim of the study was to explore the sexual and reproductive health (SRH) practices, perceived behavior, and associated factors among the adolescents. Materials and Methods: An institutional based cross-sectional study was conducted from January to May 2007 in different educational institutions of Kathmandu. Information was collected from 417 adolescents using pretested and self-administered questionnaire with their informed consent. Analysis was done using computer database SPSS-12.5 version applying appropriate statistical rules. Results were presented in tabular, graphical, and narrative forms. Results: The mean age of respondents was 17.7 0.86 years and 57.9% of them were in grade XII. About 70.9% had good practice on Sexual and reproductive health (SRH). Most of them (83.9%) were informed on SRH via radio, TV or the internet (98.63%) and through books and newspapers (94.52%). About (22.9%) were involved in premarital sex in which 75.0% of them used condom. About 44.2% discussed on the SRH issues with family members. Gender, family income, family types, and knowledge of SRH were found significant (P < 0.05) factors affecting SRH practice. Conclusion: Nearly one quarter of the adolescents under the study had been involved in premarital sexual contact. Half of them were found to discuss on SRH with their family members. Awareness and curriculum based teaching-learning activities will support to reduce the consequences of premarital sexual contact and teenage pregnancy.
Keywords: Adolescents, higher secondary level students, perceived behavior, practice, reproductive health, sexual health
|How to cite this article:|
Paudel DP, Paudel L. Perceived behavior and practices of adolescents on sexual and reproductive health and associated factors in Kathmandu, Nepal. Muller J Med Sci Res 2014;5:106-12
|How to cite this URL:|
Paudel DP, Paudel L. Perceived behavior and practices of adolescents on sexual and reproductive health and associated factors in Kathmandu, Nepal. Muller J Med Sci Res [serial online] 2014 [cited 2020 Apr 7];5:106-12. Available from: http://www.mjmsr.net/text.asp?2014/5/2/106/135736
| Introduction|| |
Adolescence is a critical and sensitive stage of human life. According to World Health Organization (WHO), adolescent is the second decade of life (period between 10-19 years).  The WHO in 2005 estimated that adolescents comprise 20% of the world's total population; accounting to 1.2 billion, of which about 85% lived in developing countries including Nepal. , About 6.5 million (23%) of total population are adolescent in Nepal and estimated to reach about seven million in 2021 AD. 
Adolescence is both a period of opportunities and threats. It is a time when new options and ideas are explored.
It is also a phase in life marked by vulnerability to risky sexual behavior and underprivileged reproductive health outcomes such as unwanted pregnancy, unsafe abortion, sexually transmitted disease (STD) like HIV/AIDS, mental stress, and social abomination. A Large numbers of premature deaths of adolescents occur every year before attaining maturity. Millions of adolescents are exposed to risky sexual behaviors like premarital sex. As a result they are vulnerable to physical and psychosocial problems like teenage pregnancy (adolescent girls), unsafe-abortion, and risk of STD and HIV/AIDS. An estimate of 1.7 million adolescents lose their life due to accidents, gender based violence, and pregnancy related complications as well as other preventable or treatable infectious diseases. 
Reproductive health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, in all matters related to the reproductive system and its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce as well as the freedom to decide if, when, and how often to do so. 
Despite 20% of the population being in the 10-19 years of age group, the health needs of adolescents have neither been searched nor addressed adequately. Particularly their reproductive and sexual health needs are often misunderstood, unrecognized, or underestimated. As such it is a phase in life marked by vulnerability to health risks, especially those related to unsafe sexual activity which affects reproductive health outcomes. Hence, this study was conducted with an aim to assess the prevailing level of practices and perceived behavior on sexual and reproductive health (SRH) of adolescent studying in higher secondary level in Kathmandu.
| Materials and Methods|| |
A descriptive cross-sectional study was carried out among adolescent students studying in four (33% of total 12) randomly selected Higher Secondary Schools (HSS) of Northern part of Kathmandu during January to May 2007. Ethical clearance was obtained from the Nepal Health Research Council before starting the study. Kathmandu is the capital and largest city of Nepal. It is the cosmopolitan heart of the Himalayan Kingdom which is situated as a bowl-shaped valley in the central developed region of Nepal. The kingdom extends about 885 Km. East to West and 193 Km. North to South. There were 149 HSS registered in the Higher Secondary School Council (HSSC), among which 12 HSS lies in the Northern area of Kathmandu and thousands of students of adolescent age are studying in higher secondary level.
The sample size was calculated by using the proportion based statistical formula; n = z 2 p (1-p)/d 2 considering 5% absolute error and 95% confidence interval (CI) level. On the basis of selecting 35% proportionate level of good practice in earlier similar type of study;  the minimum sample size was estimated as 349. Adding 20% non response rate, the final sample size was calculated to be 417. The proportionate based stratified random sampling technique was applied to select the sample. The strata of the participants were defined on the basis of four different subjects: Education (n = 87), humanities (n = 120), management (n = 120), and sciences (n = 90) studied by the participants in grade XI and XII. Verbal consent was obtained before distribution of questionnaire. Self-administered and pretested questionnaire were used to collect the data. To maintain privacy and confidentiality, all the questionnaire were distrubited with sealed envelopes and suggested to return on the same day or next day after answering the questions. The participats were briefed about the aim of the study and were instructed to avoid putting any identification mark so that confidentiality is not compromized. Out of 417 respondents, 32 (7.68%) did not respond due to the sensitive issues of sexual health. Hence, only 385 data were used for final analyses purpose.
Data accuracy and reliability was maintained by double entry process and analyzed using computer based software Statistical Package for Social Sciences (SPSS) 12.5 version. Percentage, mean, and standard deviation (SD) were calculated as descriptive statistics and chi-square test was employed for observing the association. To find out the level of practice, all the experiences related to SRH and perceived behavior of the participants were compiled and categorized as good and poor. Participants having ≥ 80% knowledge and conducive behavior was leveled as good knowledge and good practice and < 80% as poor. The strength of association was estimated by calculating the odds ratio (OR) with 95% CI (CI = OR 1 ± Zα /√X ). Criterion for statistical significance was set at the value of P < 0.05. The analyzed data were disseminated in tables, graphs, charts, and narrative form according to necessity.
| Results|| |
Coverage of Participants from Different Strata
All together 417 higher secondary level students (45.56% from grade XI and 54.44% from grade XII) participated in the initial phase of the study from different subject wise strata (education = 87, humanities = 120, management = 120, and sciences = 90). Due to the sensitive issue of sexual health behavior, only 385 (92.32%) participants returned the filled questionnaire. The rate of non-responsive participants was proportionally higher in grade XI (response = 42.08%) than the grade XII (response = 57.92%) as shown in [Table 1].
|Table 1: Coverage of participants and final response from different strata|
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Socio Demographic Profile of Participants
Demographic and socio-economic information of the adolescents under study are shown in [Table 1]. The mean age with SD was 17.7 ± 0.86 years where 54.54% were males and 45.46% were females. Majority (57.9%) of them were in grade XII. Most of them (77.9%) were Hindus and very less (0.3%) were Jains. Almost (99.0%) were unmarried and most of them (79.0%) were from nuclear family background. About 50.4% were from the middle economic class (per capita per month income of family Rs.5000 to 10000) [Table 2].
Source of Information Related to Sexual and Reproductive Health
As shown in [Figure 1], most of the respondents had used more than one means of sources of information on RSH; 98.63% used radio, TV, or Internet followed by books and newspaper (94.52%), teachers (51.51%), friends (47.95%), guardian (43.84%), and other sources (17.53%).
|Figure 1: Source of information related to sexual and reproductive health|
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Practice and Perceived Behavior on Sexual and Reproductive Health
Practices and behavior on RSH were measured by analyzing the information related to nocturnal emission, masturbation, menstruation, personal hygiene, premarital sexual contact, and use of condom or any other family planning device and discussion of SRH issue with friends and family members of the participants [Table 3]. Regarding the history of nocturnal emission and masturbation (among boys; n = 210), 63.3% reported to have experienced it, of which; 46.6% felt it as normal, 29.3% felt shock, and 24.1% felt enjoyment. Regarding the history of menstruation (among girls; n = 175), almost (94.0%) reported of its experience before 15-years of age. About 20.5% of them felt fear, 32.5% felt it as normal and natural process, and nearly half (47.0%) felt uneasiness and discomfort during their first menstruation (menarche).
Regarding the practice of personal hygiene and rest during menstrual period, 82.85% had positive response. Nearly two-third (63.9%) of the girls did not use the sanitary pad during their menstrual period. More than one-fifth (22.9%) of the participants were found to be involved in premarital sexual contact, almost 15.0% of them had more than one sex partner, and 75.0% of them used either condom or other contraceptive device during sexual contact. Regarding the discussion on SRH issues, it was found that about 90.4% of them had discussed the topic with peers whereas only 44.2% discussed it with family members. The subject matters of discussion with friends were STD and HIV/AIDS (89.95%), family planning (79.32%), adolescent reproductive health (79.31%), safe motherhood (65.81%), child-health (55.74%), infertility (48.56%), safe abortion facility (47.71%), and problem of elderly women (47.42%) as shown in [Figure 2]. Most of the participants (93.2%) perceived the necessity of including SRH subject in school based curriculum as teaching-learning material [Table 3].
Level of Sexual and Reproductive Health Practices
To observe the significant status of different factors associated with SRH behavior, setting a scale of the SRH practice is necessary. Hence, to find out the level of practice, all the experiences related to SRH and perceived behavior of the participants were compiled and categorized as good and poor. Participants having ≥80% knowledge and conducive behavior of SRH was leveled as good practice and < 80% as poor. It was observed that, out of total 385 respondents, 70.91% participants had good practice of SRH; [Table 4].
Factors Affecting to Sexual and Reproductive Health
SRH health practice can be affected by various factors. Sex of the respondent (male vs female), per capita per month income of family ( < 5000 Rs. vs. ≥ 5000 Rs.), type of family (joint vs nuclear) and level of knowledge (poor vs good) were found to be significant factors (P < 0.05 to P < 0.01) for contributing to poor sexual and reproductive practice. Per capita per month income of family and level of knowledge of the students were strong contributors (P < 0.01) to perform SRH practices. Family income having < median level (7500 Rs. /month) were found 1.95 times poorer practice of RSH (χ 2 = 8.70 at df = 1, OR = 1.95, P < 0.01) than the students who had family income ≥ median level (7500 Rs/month). Similarly, students who had poor knowledge on SRH were found two times more likely to perform poor practice (χ 2 = 8.25 at df = 1, OR = 2.0, P < 0.01) than the students having good knowledge on SRH. Similarly male students had 1.5 times more likely to conduct poor practice of SRH (χ 2 = 4.03 at df = 1, OR = 1.58, P < 0.05) than female. Furthermore, students who were from joint family had 1.86 times more likely to perform poor practice (χ 2 = 5.54 at df = 1, OR = 1.86, P < 0.05) than the students from nuclear family. Other factors such as studying grade (XI vs XII), age group (16-17 vs. 18-19), religion (Hindus vs. others), and marital status (unmarried vs married) were not significantly associate (P < 0.05) with the SRH practices [Table 5].
| Discussion|| |
The mean age of the participants was 17.77 ± 0.860 years. There was no significance difference in level of practice of RSH in different age groups which was in line with a study conducted in Iran.  Regarding the source of information, most of the respondents used more than one means of communication. Almost all have used radio or TV and internet as major sources of information followed by books and newspapers (90%) and teacher (nearly 50%) which was consistent with similar studies carried out in other parts of Nepal and Ethiopia. ,
Because of physical and hormonal changes, adolescence is also a formative stage in terms of sexual and reproductive maturity. Decisions made during adolescence can affect reproductive health and well-being throughout life. Almost 90% of the girl participants (n = 175) in our study had experienced the first menstruation (menarche) before 15-years of age. One-fifth of them had perceived it as dreadfulness, nearly one-third felt it normal and half of them felt discomfort at their menarche. Most of them did not have any practice of using sanitary pad though they used simple water for cleaning the vagina during menstruation. This finding was somehow different with a similar study conducted in West Bengal, India. Among the 160 adolescent girls;  about 67.5% of them were aware about menstruation prior to attainment of menarche. Most of them (86.25%) perceived it as a physiological process and nearly half (48.75%) practiced the use of sanitary pad during menstruation. For cleaning purpose, 97.5% girls used both soap and water. Such variation might be due to the open practice of discussion on SRH issue in family, friends, school teachers, and seniors who were already exposed to such situation in West Bengal. Another important cause might be the impact of the youth friendly reproductive health (RH) programs focusing on women empowerment and policy implementation with an aim to reduce of gender discrimination in all sectors.
Marriage and social expectations for fertility in Nepal, the legal age of marriage, with parental consent is 18 years for males and 16 years for females. Without parental consent, boys can marry at age 21 and girls at age 18. The National Demography and Health Survey (NDHS)-2006 report  of Nepal showed that 40% of adolescent girls of age 15-19 years were currently married compared to 11% of young men in the same age group. The mean age of marriage was 16.8 years for girls and 18.7 years for boys. Most of the respondents (99.0%) in present study were unmarried which showed disparity with the NDHS report. The contrast might be due to the selection of respondents in different social, cultural, and geographical setting. There was no significant difference of RSH practice between unmarried and married individuals. More than three-quarter of both groups had good practice of RSH. This could be due to good awareness on RSH in both groups. 
One-fifth of the participants in this study were found to be exposed with premarital sexual contact which was in line with the finding reported by Centre for Research on Environment, Health and Population Activities (CREHPA). from different parts of Nepal but two times higher than the study reported from Makwanpur district.  Almost 15.0% of participants, who are already exposed to premarital sexual contact in this study were found to be more than one sex partners and three-fourth of them used condom as contraceptive device during each contact. This finding was in line with the study report of Simkhada PP et al., and Shrestha N et al., in different parts of Nepal. , Despite of using the condom rate was 75%, one-quarter were found out of the coverage. This was due to either neglected behavior or lack of awareness. Such behaviors increase the risk of sexual disease transmission and unwanted pregnancy in teenage.
Most of the young people (90.4%) in this study were found to have discussed with peers on SRH issues, whereas almost 44% had discussed with parents, which was somehow lesser than the study finding of Simkhada PP et al.,  Research suggests that the more parents discuss such issues with their children, the more likely young people are to delay their sexual debut and practice safer sexual behavior. ,
Participants having lesser per capita per month income of family ( < median level income; Rs 7500) had significantly poorer practice of RSH (P < 0.05) with compare to those having strong economic status which was supported by the similar study conducted in Bangladesh.  The relationship between socio-economic status and SRH is well established in the public health field. Socio-economic disadvantage is both a cause and an outcome of poor SRH (WHO, 2010). Socio-economic disadvantage can be indicated by low-income, poor levels of educational attainment, employment in relatively unskilled occupations, and high unemployment. 
Male were found more likely to perform the poorer SRH practice than the female in this study which was in line with the study reported by Wellings et al. This stated that, gender norms have a powerful influence on people's sexual identity, practices, sexual behavior, and the way in which they enact their sexuality. The cultural ideology of masculinity and what it means to be a 'man' sees young men encouraged to actively engage in sexual activity to prove their virility.
Regarding the association between the level of knowledge and level of practices, our study showed that participants having poor knowledge were more likely to perform the poorer practice of SRH. This could be due to the fact that good knowledge makes the people more aware on consequence of poorer and unsafe sexual and reproductive practice and encourage the use of preventive measures in time. Similarly, participants from joint family were found more likely to perform poorer sexual practices. This could be due to the reason that the parents of nuclear family provide enough care to their child and continued till their teenage than the child of a joint family.
| Conclusion|| |
Nearly one-quarter of the adolescents had been involved in premarital sexual contact and three-forth of them used condom in each contact. Eight out of ten participants were informed on RSH via radio, TV, or internet and books or newspapers. Though, half of the adolescent had good practice of discussing on SRH issue with family members, the rate was very low as compare to the discussing practice with peers ( > 90%). Per capita per month income of family, family type, sex of the participants, and level of knowledge on SRH were found to be the major factors affecting to SRH behavior. Youth friendly RH programs, behavior change communication (BCC) and curriculum based teaching-learning system will support to minimize the poor practice and misconception of RSH issues. Sexual health practice or behavior is a sensitive issue. So, only observational study of single episode cannot address such sensitive behavioral issue perfectly. Hence, detail qualitative study may support to address the limitations.
| Acknowledgement|| |
The study team wants to put the sincere thanks to all the academic institution and the participants involving in this study procedure.
| References|| |
|1.||World Health Organization. The second decade: Improving adolescent health and development. Geneva: WHO; 2001. p. 2. |
|2.||INCLEN. International clinical epidemiology network 1998-2001. Available from: www.inclen.org [Last accessed on 2010 Dec 20]. |
|3.||WHO /FRH /AD. Improving adolescent health and development. The second decade of life. WHO /FRH /ADH. Vol. 18, DCAHD, Geneva, Switzerland; WHO: 1998. p. 2. |
|4.||Central Bureau of Statistics (CBS) Report, Nepal; 2012. |
|5.||Sutthida M. Health-asia: Sex education can be creative. Say experts. Kualalumpur; 2000. |
|6.||Blum RW, Mmari KN. Risk and protective factors affecting adolescent reproductive health in developing countries. Department of child and adolescent health and development family and community health, WHO, Geneva; 2005. |
|7.||Building demand for RH awareness among adolescent girls in conflict affected districts of Nepal done by Centre for Research on Environment, Health and Population Activities′ (CREHPA). Kathmandu Nepal; 2004. |
|8.||Gupta RB, Khan ME. Teenage fertility - some results from a baseline survey in Uttar Pradesh. J Fam Welfare 1996;42:14-20. |
|9.||Ayalew T, Meseret Y, Yeshigeta G. Reproductive health knowledge and attitude among adolescents: A community based study in Jimma town, Southwest Ethiopia. Ethiop J Health Develop 2008;22:143-51. |
|10.||Simkhada PP, Edwin R, Teijlingen V, Acharya DR, Schildbach E, Silwal PR, et al. Sexual and reproductive health of adolescents in rural Nepal: Knowledge, attitudes and behavior. Nepal Popul J 2012;17:3-10. |
|11.||Mohammadi MR, Mohammad K, Farahani FK, Alikhani S, Zare M, Tehrani FR, et al. Reproductive knowledge, attitude and behavior among adolescent males in Teharan, Iran. Int Fam Plan Perspect 2006;32:35-44. |
|12.||MOHP Nepal and New Era, National demography and health survey report, Nepal; 2006. |
|13.||Shrestha N, Paneru DP, Jnawali K. Sexual health Behaviour in Pokhara, Nepal. Indian J Community Health 2012;24:73-9. |
|14.||Leland NL, Barth RP. Characteristics of adolescents who have attempted to avoid HIV and who have communicated with parents about sex. J Adolesc Res 1993;8:58-76. |
|15.||Palatnik A, Seidman DS. Survey of opinions of mothers and teenage daughters on sexual behavior and contraception: Descriptive study and literature review. Int J Womens Health 2012;4:265-70. |
|16.||Md. Abbas Uddin RN, Sang-arun Isaramalai RN, Jeranoun Thassari RN. Knowledge and attitude regarding HIV/AIDS prevention among adolescents in Bangladesh. 2nd Int Conf Humanities and Social Science; April, 10th 2010. |
|17.||World Health Organization. Social Determinants of Sexual and Reproductive Health: Informing future research and programme implementation. Geneva, Switzerland: WHO Press; 2010. |
|18.||Wellings K, Collumbien M, Slaymaker E, Signh S, Hodges Z, Patel D, et al. Sexual behaviour in context: A global perspective. Lancet 2006;368:1706-28. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]