Objective: This paper describes different approaches and results of the holistic integrated model of Rahnuma Family Planning Association of Pakistan(R-FPAP). The model seeks to provide sexual and reproductive health (SRH) services to adolescents and young people based on their rights as opposed to simply on their needs.
Methods: Combined methodical efforts were performed by the organization for the provision of SRH services to adolescents and young people including youth-friendly services at clinics, outreach interventions, youth empowerment, and advocating for youth sexual and reproductive health rights (SRHR). Service delivery statistics available in the organization from 2007-2011 were utilized for estimating the results of these efforts.
Results: An increase of 157.5% in the total number of SRH services received by adolescent and young clients aged 10-24 years was observed during a span of five years. About 310.8% more human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and reproductive tract infection (RTI)/sexually transmitted infection (STI)-related services were received by the clients of the same age group. The integration of different methodical efforts helped in reaching one of every 100 adolescents and young people in Pakistan aged 10-24 years during 2011, which was an increase from four of every 1,000 adolescents and young people of the same age bracket served in year 2007.
Conclusion: The unmet need of the SRH rights of adolescents and youth, especially underserved young clients, can be addressed comprehensively through rights-based integrated approaches by providing clinical services, involving them through outreach initiatives, advocating for their SRHR, and facilitating them by establishing conducive environments for the promulgation of supportive laws and policies.
Keywords: Sexual and reproductive health rights (SRHR), Adolescent, Young people, HIV/AIDS, RTI/STI.
In 2011, the world\'s population crossed the seven billion mark with 177 million inhabitants living in Pakistan, which is rated as the sixth most populous country in the world.1,2 63% of Pakistan\'s population is less than 25 years of age, 53% is below 19 years, 35% is between 15 and 24 years, and 24% is 10 to 24 years of age.3
Adolescents and young people in Pakistan experience illiteracy, unemployment, child trafficking, nutritional deficiencies, and gender inequalities. In addition, they do not have access to sexual and reproductive health (SRH) information, education, and services.4,5 Adolescent girls are more likely to receive their SRH knowledge from women within their families. Open discussion on this subject is strongly discouraged. Boys have comparatively more access and exposure to diverse sources of sexual information.6 It is estimated in a study that 90% of boys and 80% of girls discuss bodily changes with peers and family members.7 Adolescent girls are more commonly restrained in their mobility and access to these services. Parents do not feel comfortable talking to their children about puberty and biological changes, which make them [children] unguarded against sexual exploitation, vulnerable to unintended pregnancies, sexually transmitted infections (STIs) and reproductive tract infections (RTIs). It is also evident that specially-trained staff, respect for adolescents and young people, honouring privacy and confidentiality, providing adequate time for client-provider interaction, and peer counselling, are not given much attention in service delivery models designed for young people.8-10 Education and the media are considered effective mediums to reach and empower adolescents and young people with the information they need to protect themselves. The use of these channels in Pakistan is still limited due to social taboos that discourage discussion of such subjects publically. As a result, reproductive health information is made available only through a small number of non-government organizations (NGOs) or health practitioners with limited outreach.11 The socio-cultural impediments and traditional and religious taboos drive adolescents to secretly contact equally unaware peers and fake healers who, in most cases, provide poor information and services.12,13
The Rahnuma Family Planning Association of Pakistan (R-FPAP)i has a history of working for and with adolescents and youths based upon the International Planned Parenthood Federation\'s (IPPF) policy on creating a \'safe environment for young people\'14 and its own policy, \'empowerment and protection of children and young people\'. The organization\'s adolescent and youth focus evolved over decades in terms of content, scope, quality, and outreach. Youth Involvement through project-specific interventions in the organization was initiated in 1972 with the realization that physiological and emotional changes taking place during adolescence, a lack of communication with parents on sexuality, and the absence of authoritative information on SRHR, expose adolescents and young people to erroneous sources of information and unsafe sexual practices. They are therefore vulnerable to greater risks of infections, disorders, and different types of abuses. The organization introduced youth-friendly services, gender-sensitive healthcare facilities, outreach interventions, youth empowerment initiatives, and advocacy efforts through concrete and proactive efforts to augment adolescent knowledge of SRHR and increase their access to skilled healthcare providers.
Research has proven that young people are more likely to seek services from healthcare providers they feel they can trust and who respects their privacy. However, due to traditional customs and cultural norms, a lack of youth-focused services continues to create barriers for young people around the world in seeking SRH services.15 Rahnuma-FPAP has stimulated, cultivated, and educated young people by creating a conducive environment which enables them to become young advocates and leaders in their communities to contribute to community welfare and to act as points of referral to R-FPAP\'s healthcare facilities. Likewise, communities are taken into confidence regarding activities with young people by holding orientations/dialogues with parents, teachers, and political leaders.
The purpose of this study is to present a pattern of utilization of SRH and HIV/AIDS and STI/RTI services at R-FPAP service delivery points from 2007 to 2011 as a result of the integrated approach adopted by the organization for increasing the provision of SRH services to adolescents and young people.
This is a descriptive study relying on two sets of information, the number of services provided to adolescents and young people and the interventions introduced by the organization. Data on total numbers of services provided by the R-FPAP to adolescents and young people aged 10-24 years from 2007-2011, was retrieved from the organization\'s annual service statistics. The following interventions were simultaneously adopted by the organization to support adolescents and youth in attaining information about SRHR and HIV/AIDS and RTI/STI, to access the desired treatment and referral services and to obtain skill-building and leadership opportunities (Figure-1).
Youth-friendly service delivery at clinics
According to IPPF, youth-friendly service delivery is about providing health services based on a comprehensive understanding of what young people in any given society or community want and need. It is also based on an understanding of, and respect for, the realities of young people\'s diversity and sexual rights.16
Following the same description, youth-friendly services at R-FPAP clinics necessitate the provision of integrated packages of SRH services. These include SRH counselling, contraceptive counselling, product provision (including emergency contraception), STI/RTI and HIV/AIDS prevention, testing and counselling services, pre-natal and post-partum services, sexual abuse counselling, relationship counselling, and safe motherhood services.
Adolescent and youth-friendly SRH services are offered to all young clients without discrimination irrespective of their age, gender, or marital status. They are offered at convenient timings for young people and are either free-of-charge or offered at an affordable cost. Accurate information is provided to young people in a non-judgmental environment with guaranteed confidentiality and privacy. Service providers have been oriented to dealing with young people, particularly with reference to privacy and confidentiality in order to make them feel welcome, safe, secure, comfortable, and facilitated. The organization has six cancroids for youth-friendly services in its six family health hospitals, each in Islamabad, Lahore, Gilgit-Baltistan (GB), Karachi, Peshawar, and Quetta.
Outreach to young people: Youth resource centres
Rahnuma-FPAP is operating 36 male and 16 female youth resource centres (YRCs) to provide young people with an opportunity to express themselves independently of their elders and be involved in activities ranging from learning to recreation. These YRCs are managed by youth themselves with community support, which gives them the freedom to organize different events such as debate competitions and celebrating international days. The YRCs provide sufficient space to discuss SRH rights, community issues, and topics of common interest. These YRCs are outfitted with books, computers, and indoor games for attracting youth.
Outreach to young people: Youth helpline
Six youth helplines with toll-free numbers have been established in Lahore, Karachi, Quetta, Peshawar, Islamabad and GB. These helplines are adequately equipped to provide counselling on SRHR-related matters, HIV/AIDS, domestic abuse, and gender-based violence to both male and female adolescents and youths, in a confidential manner. Qualified male and female psychologists are hired as youth counsellors who offer online and face-to-face counselling and make referrals from 9.00am to 5.00pm five days a week. The data about numbers of calls, duration of discussion, and topics of counselling services, is maintained on a daily basis by counsellors.
Outreach to young people: Comprehensive sexuality education through peer educators
Comprehensive sexuality education (CSE)ii is essential for young people to access information and education about sexuality and the knowledge and skills necessary to enjoy life in a healthy and positive way. Rahnuma-FPAP advocates age-specific CSE with relevant ministries to include it in school and college curriculums so that information on puberty, reproductive processes, adolescent issues, health and hygiene, HIV/AIDS and STI/RTI, sexual abuse, violence, SRHR, and relationships can be provided. The important outcome of this approach is that adolescents and young people access accurate information on SRHR. While R-FPAP continues to advocate for the provision of this information and education on a mass level through public institutions, it is simultaneously providing the same through its peer educators at YRCs. Rahnuma-FPAP has developed a comprehensive framework for CSE in Pakistan for in-school and out-of-school adolescents and young people.
Empowering young people: National youth network
A national youth network (NYN) has been established to empower young volunteers to advocate adolescent and young people\'s SRHR and concerns that need to be addressed by policymakers. Members of the NYN are democratically elected from all over the country under the NYN constitution, which guides its functioning. In addition, 20% confirmed youth participation in the organization\'s governance structure paves the way for their learning and meaningful involvement in policy and decision making processes. In recent years, NYN along with other R-FPAP coalition partners have strongly raised collective voice for young people\'s SRH rights and demand for specific SRH programs at national and provincial level.
Advocating for youth sexual and reproductive health rights
Linkages are developed and strengthened over a period of time to provide a conducive environment to NYN and other youth volunteers to advocate for young people\'s SRHR. These include linkages with government ministries, partnerships with international donors, and networking with like-minded civil society actors. Provincial-level alliances have been established with partner organizations as well. These alliances advocate for youth-friendly SRH services, CSE, and ending early/child marriages. They pursue and push federal and provincial governments for the inclusion of the SRH of adolescents and young people in different policies and programmes.
Standardized mapping by accumulating different kinds of services was done to facilitate an understanding of the overall patterns of SRH services in a simplistic manner (Table-1).
The involvement and focus on adolescents and youth through integrated approaches resulted in 157.5% increase in overall SRH services disbursed to young clients aged10-24 years from 2007 to 2011.
Except for contraceptive services, the continuous percentage increase was acknowledged in all other services during the last five years. The minimal percentage decrease of 2.26% and 1.17%in contraceptive services for 2007-2008 and 2009-2010 picked up with a percentage increase of 23.67% and 26.70%in subsequent years (2008-2009 and 2010-2011). The most significant percentage increase was noted for HIV/AIDS and STI/RTI-related services, whereas a minimal increase over a period of five years was observed for total contraceptive services i.e. 51.36%, which seems to be due to a dip in services during 2007-08 and 2009-10.
It was estimated that overall, the population of 10-24 year-olds provided SRH services by the organization in 2007 was 0.44% which increased to 1.05% in 2011. Overall, the percentage increase in young people served over the last five years is 1.39%, which can be attributed to the organization\'s comprehensive approach towards meeting SRH requirements.
Three of eight Millennium Development Goals (MDGs) are linked to SRHR. This is similar to the International Conference on Population and Development (ICPD) which shifted its focus from family planning (FP) to SRHR. Unfortunately, despite international commitments, the SRHR situation in Pakistanis still poor, especially that of adolescents and young people who are usually considered underage to need SRH information, education as well as services. Policy implications, operational barriers, a lack of correct information, and socio-cultural taboos and stigma associated with adolescents and young people seeking SRH, are major constraints. Keeping these impediments in mind, R-FPAP strategically elaborated its focus on providing these services to young clients in order to respond to their unmet needs.
Various efforts helped enhance services at clinics, outreach interventions, youth empowerment, and advocacy efforts over a period time. These include an increase in the number of YRCs from 38 in 2007 to 52 in 2011,784 young people and peer educators trained in 2011, an increase in calls from 3,456 in 2007 to 11,906 in 2011, and the representation of 30 elected members in governing body of the organization.
Analytical findings are supportive of the integrated approach and composite efforts which show an overall 157% increase in SRH services, including both contraceptive and non-contraceptive SRH services, and a 311% increase in HIV/AIDS and STI/RTI services provided to young people over a span of five years. These approaches also equipped the organization to serve nearly 1.4% more young people in 2011 than in 2007.
An integrated rights-based intervention implemented by R-FPAP for approaching adolescents and young people clearly demonstrates a model for expanding SRH, HIV/AIDS and STI/RTI services. Awareness raising and information sharing mechanisms and service seeking and service providing behaviours related to SRH and HIV/AIDS and STI/RTI can be modified through capacity building and by providing encouragement and a conducive environment to adolescents and young people.
We are thankful to all donor organizations that supported R-FPAP in the cause of initiating and expanding services for young people in Pakistan.
Conflict of interest
There are no conflicts of interest.
1. World population data sheet. 2011. Washington (DC), Population Reference Bureau (US).
2. State of World Population. New York (NY): United Nations Population Fund (UNFPA); 2011.
3. Mehnaz A. State of children in Pakistan - confronting reality. J Pak Med Assoc 2011;6:518-9.
4. A research study on status of sexual and reproductive health and rights of young people in Pakistan. Islamabad: World Population Foundation, Pakistan; 2010.
5. Khan A. Adolescents and Reproductive Health in Pakistan: A Literature Review. Research Report No. 11. Population Council, Pakistan; 2000 Jun.
6. Khan A, Pine P. Adolescent and Youth Reproductive Health in Pakistan: Status, Issues, Policies and Programs. Washington (DC): United States Agency for International Development (USAID)/ Futures Group International; 2003.
7. Adolescent Reproductive and Sexual Health: An Exploration of Trends in Pakistan. Karachi: Pakistan Voluntary Health and Nutrition Association (PAVHNA); 2000.
8. Senderowitz J. Making Reproductive Health Services Youth Friendly. Washington (DC): United States Agency for International Development (USAID); 1999.
9. Reproductive Health Programs for Young Adults: Health Facility Programs. FOCUS on Young Adults; 1998.
10. Adolescent Fertility and FPA Service Provision in the IPPF/ESEAO Region. London: International Planned Parenthood Federation (IPPF); 1998.
11. Khawaja Z, Gibney L, et al. HIV/AIDS and its Risk Factors in Pakistan. AIDS 1997;11:843-8.
12. Khan A. Female Mobility and Access to Health and Family Planning Services. Islamabad: Ministry for Population Welfare/ London School of Hygiene and Tropical Medicine; 1998.
13. Khawar M, Rauf F. Woman to Woman: Transfer of Health and Reproductive Knowledge. Lahore: Shirkat Gah; 1996.
14. Strategic Plan 2010-2015. New York (NY): International Planned Parenthood Federation (IPPF); 2010.
15. Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of Physician Confidentiality Assurances on Adolescents\' Willingness to Disclose Information and Seek Future Health Care: A Randomized Controlled Trial. JAMA 1997;278(12):1029-34.
16. Young People and Adolescents. 2012. London, International Planned Parenthood Federation (IPPF).
17. US Census Bureau International Programs. 2012. Washington (DC), US Department of Commerce.
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