Promoting Female Sexual and Reproductive Health among Young South Asian Women
Introduction
All over the entire globe, young people, especially women, face stigmatization and discrimination in relation to their reproductive and sexual health. The violation of human rights, discrimination and stigma are three intimately connected scenarios that jeopardize the formal structure of handling this class of people in most societies (Bott, 2003). Their manifestations across the social divide are diverse, occurring in health service facilities, at homes, in schools and places of work. The World Health Organization gives a definition of adolescents as the age group comprising the ages of 10-19 (Ege, Akin, Kültür & Ariöz, 2011), which is used throughout this paper as a point of reference. These adolescents have sexual and reproductive health needs that largely differ from that of the adults in many pertinent ways, but which are more often than not, grossly misunderstood in social, cultural, educational, and medical settings. Furthermore, social, political, and economic factors are rapidly altering the manner in which the adolescents transcend their juvenile lives to join adulthood (Oosterhoff, White & Aggleton, 2011; Seims, 2011). These changes have had enormous implications on the education, employment, childbearing, marriage, and health of adolescents. These implications have affected particularly, the access to quality sexual and reproductive health and information by this category of individuals.
Across a wide range of settings, young women are often discriminated and stigmatized for involving themselves in sexual activities before their marriage, or for engaging in some sexual behaviors, or being oriented to some forms of sexual practices which are generally considered as non-normative by their wider societies, such as transgender practices, homosexuals and such like orientations (Lottes, 2013). Moreover, in other settings where pre-marital sex among the youth is considered non-normative, various manifestations of unprotected sex such as sexually transmitted infections, unplanned pregnancies, and being HIV-positive, may face strong criticism and stigma (Chen, 2008). All these forces can limit active access to good healthcare service, which generally endanger the lives of young women.
This precedence of stigma and discrimination against young women has serious ramifications, especially in the livelihoods of the youth (Lusti-Narasimhan, Collin & Mbizvo, 2009). Particularly, it instills into young women the notion and feeling that they need to conceal their sexual practices away from the adults, including health workers, parents, and teachers (Oosterhoff, White & Aggleton, 2011; Seims, 2011). This shame and fear of identification is the primary barrier to access of quality and sound healthcare among the youth, which would otherwise be crucial in making informed decisions regarding their sexuality, sexual health, and implementing remedial actions to correct faults (Singh & Judhistari, 2012). In places where resources are available, they are usually scarce, and inadequate in addressing the needs of young women. In some cases where information is offered to young people, it is usually biased, focusing on reproductive biology, but lacking in life essentials which involve real-life situations (Griffiths, Prost & Hart, 2008). Such information is devoid in the ability to address the complexity of a young woman’s sexual and reproductive lives, as open discussions focusing on such matters are usually considered ‘taboo’ (Webber & Spitzer, 2010).
Difficulty in accessing sexual and reproductive services such as contraceptives and treatment of STIs is yet another challenge face by young women, due to the discrimination from some healthcare providers (Bott, 2003). Such discrimination is fuelled by stigma which is associated with the sexuality of young people. It is manifested in a number of ways, such as verbal abuse, confidentiality breaches, withholding of care, and lack of privacy (The Reproductive Health Report, 2011). In schools settings, young women who are pregnant, or who are known to be having STI infections or HIV may face stiff discrimination from their teachers, peers, institutional authorities, and even parents (Chen, 2008).
In order to promote sexual and reproductive health among young women, it is an important step to recognize the diversity of the young race, and that such caliber is not homogenous (Pachauri, 1998). The youth have varying degrees of experiences, in relation to their cultural backgrounds, socioeconomic status, gender, ethnicity, and level of education. In most cases, particularly in South Asia, it is a fact that the stigma, discrimination, and difficulties that young women face in relation to access to healthcare is an intersection in the course of societal way of living, exemplified in different kinds of discrimination and stigma derived from different forms of social inequalities.
Socio-demographic profile of young people In South Asia states 26% of all girls who are currently aged between 15-19 years were married at the age of 14, or even younger. Still, a significant proportion of the selected population is largely illiterate, and wide disparities exist in school attendance, particularly secondary and middle school enrolment. Gender disparities are twice as stark, with the number of young females who are illiterate doubling that of the males of the same age-set. Despite the strict laws prohibiting marriage at an early age, it is estimated that half of the women in South Asia are married at an age of 20-24, while a quarter of them are married at 15 years of age. In contrast, it is documented that boys rarely get married during their adolescence, where empirical data shows that only 6% of the total number get married at tender ages (Regmi, van Teijlingen, Simkhada & Acharya, 2010). Over the past decade, it is reported that adolescent fertility has decreased, but persistence in juvenile marriages is further exacerbating this situation. In Bangladesh, it is estimated that 14% of 15-year old women are either pregnant, or already mothers with single children. Many girls become pregnant before attaining the age of physical maturity, which has continually posed adverse health consequences to them. While marriage is seen to mark the onset of sexual liberty and faithfulness to partners, there is increasing evidence showing that a majority of young women engage in extramarital and premarital sex. This data shows the tender age at which young women are initiated to sexual practices, though any sexual and reproductive health information, services and information for these adolescents are viewed as unnecessary (Hindin & Fatusi, 2009). Worse still, some regard them as morally dangerous, a notion which fuels proliferation of sexual taboos.
Despite considerable efforts to promote sexual and reproductive health among young women in Asia, millions of this endangered group still lack access to these essential services. Several girls and young women continue to suffer from fatalities associated with childbirth, and disabilities of pregnancy (Cockcroft, Pearson, Hamel & Andersson, 2011). The United Nations Population Fund is an example of an initiative which particularly aims to promote equality in access to sexual and reproductive health. It aims to invest in four priority areas, which are believed to be the cornerstones of implementation of SRH initiative: family planning; treatment of STIs and HIV prevention and diagnosis; pregnancy-related services such as skilled attendance during childbirth and emergency obstetric care (Cockcroft, Pearson, Hamel & Andersson, 2011); prevention and early diagnosis of such infections as breast cancer, cervical cancer, and any issue regarding young women’s sexual and reproductive health; and taking care of victims of gender-based violence including rape, with security of reproductive health commodity (Chen, 2008). In addition, the program also focuses on the integration of issues of HIV, including prevention, care and management in sexual and reproductive health services for the adolescents (Bott, 2003). It also provides education on life skills which are gender sensitive, and SHR services in humanitarian crises and emergencies (Setiono, 2013). This initiative has been crucial in promoting SHR services for young women in most nations, as well as South Asia.
A key strategy that has always been used to expand sexual and reproductive health services is the integration and mainstreaming of such services into existing health services. It is believed that integrated services, as opposed to stand –alone service such as HIV prevention and management, promote more efficient service delivery and use of resources. A research done in South Asia on condom use, for instance, showed that the tendency to adopt condom use among single youths is motivated by the desire for contraceptives, rather than as a sole method of protection (Cockcroft, Pearson, Hamel & Andersson, 2011). It is there plausible to state that integration of SHR services with other existing healthcare services would bring better results than approaching it as a single move. The category of SHR is not, however, very clear, and there has been a problem finding an exclusive department under it fits. Most SHR services are provided by the health ministry, while other components of SHR may be incorporated in other ministries such as women’s affairs ministries (Ege, Akin, Kültür & Ariöz, 2011). The most obvious barrier to integration of SHR services with existing frameworks lies on financial and institutional arrangements, as well as international policy.
As an intervention measure, the health belief model has proven to be a very successful tool in conducting health education and promoting the attitude of hospital attendance by women. This model was developed by Becker and Rosenstock (1984), who emphasize the likelihood of behavior intake is predicted by some major cognitive constructs, including perceived susceptibility, perceived severity, perceived benefits, perceived control, and perceived barriers. Researchers have demonstrated that the application of the HBM is effective in changing the attitude of young women with regards to sexual and reproductive health attendance. A research conducted by Setiono (2013), which examined 630 young women using the health beliefs model-based questionnaires revealed that those women who freely sought healthcare intervention had lower chances of facing discrimination, and being victims of marginalization. They overcame their emotional barriers, and showed higher efficacy in relation to SRH services.
Rationale of the study
It is a confirmed reality that the situation in South Asia does not present a perfect environment for addressing the plight of young women concerning reproductive and sexual health. This study aims to come up with innovative ideas and ways in which sexual and reproductive health among this category of individuals can be promoted, so as to allow for equality in access to quality services, fair treatment, and mainstreaming of such issues in policy making structures of the region. Intervention strategies will be proposed for a fairer incorporation of SHR issues concerning women in Asia, where statistical data shows alarming rates of inequalities in access to social amenities, including basics of life such as the healthcare.
Relevance of the study
Numerous researches that have been done in the past all point to a dilapidated framework for addressing female sexual and reproductive health concerns around the globe, particularly in South Asia (Ege, Akin, Kültür & Ariöz, 2011). As aforementioned, various factors of cultural, social, and economic origins have served to jeopardize every effort aimed at promoting SHR practices among this endangered group. With the alarming cases of childbirth complications, maternal fatalities, and HIV among young women, it is justifiable to take a serious step forward that would identify relevant strategies that can be employed to curb the effects of discrimination, prejudice, and marginalization of this group. This study is thus an important move, which will go a long way in identifying such strategies, implementing them, determining any challenges that can be encountered along the implementation line, and carrying out a post-implementation evaluation to test the efficacy of the proposed strategies. This study would then be used as a prototype for a large-scale implementation and promotion, drawing lessons and case studies from previous researches.
Alternative Hypothesis, Ha
- Based on the previous efforts and interventions that have been targeted towards promoting sexual and reproductive health among the adolescents, particularly women, it is hypothesized that proper planning, including the use of health beliefs model (HBM) integration of SHR issues into existing formal structures, would be able to provide better results as concerns improvement of access to information, quality healthcare, and related SHR services by young women in South Asia.
- Proper management of HIV issues including testing, diagnosis, and subsequent management would serve to reduce cases of fatalities and maternal complications among young South Asian women, as well as increasing their confidence in the medical structures available.
Methodology
Data
This study will be a mixed methods intervention, and will collect information from a cluster sample of 500 women, aged between the years 15-26 years. It will be conducted by use of face-to-face interviews, to assess the significance of using health belief model as an intervention, socioeconomic status, and demographic factors. Given the importance of sexual behavior as a basis for discrimination and marginalization, as well as in HIV transmission, only women who have had sexual experiences will be selected for the participation (N=500). An oversample of women who have been diagnosed with HIV and other STIs will be made, representing an additional figure of 238. To compensate for this oversample of STI and HIV-diagnosed women, so as to make this data representative nationally, individual sample corrections will be employed, and adjustments for clustering effects made.
Measures
This is a mixed method intervention which aims to find the relationship between various promotional strategies and their effect on sexual and reproductive health of young Asian women. It adopts the use of the health belief model as an intervention method to promote SRH among young women. The dependent variables are whether changes to health beliefs are capable of promoting access to sexual and reproductive healthcare; and whether the management of cases of marginalization and discrimination brought about by HIV infections, pre-marital sexual practices, and misinformation can be a positive move towards adopting a changed approach towards young women’s sexual and reproductive health. The respondents will therefore be categorized into those who are infected with HIV, and those that are not infected, or whether they have been diagnosed with STIs or PID.
The key explanatory dependent variable in this study is whether young women who are sexually active and have been diagnosed as HIV-positive have differing experiences in accessing sexual and reproductive healthcare services from their counterparts. Thus, volunteers in this study will be asked to provide their testing cards, which show their status, and the sample will be divided into those women with official testing cards and those without, or uninfected.
The study will also examine six other specific measures related to sexual behavior and reproductive health. These are the independent variables, which will mainly be measures of health belief model. Thus, the independent variables for this study will include perceptions of severity, perceptions of susceptibility, perceived benefits, perceived barriers (such as skills and emotions), and self-efficacy. Other variables will include demographic factors, HIV status, educational level, marital status, and demographic factors.
In a nutshell, the study will examine socioeconomic factors affecting young women’s access to SHR services including measures of education, wealth, place of residence, social and familial networks, and culture. Women with higher education levels and have wealth are more likely to attend regular medical services, including pregnancy check-ups, STIs’ diagnosis, and better maternal care as opposed to their counterparts. Women’s educational attainment will thus be categorized as college enrollment, secondary education completion, and primary level. Wealth, which is predominantly viewed to have a protective effect on health, will be categorized based on a composite measure of at least 10 amenities in a household. Following Bollen et al strategy, one will be added to the total number of amenities, and natural log of the result will be used as a continuous measure.
Sampling
A total number of 500 participants will be chosen, have an age range of 15 to 26 years. An additional number (oversampling) of 238 women will be sampled, based on the independent variable of HIV status, as it is considered a key factor influencing the promotion of sexual and reproductive health among young women in South Asia. Random but careful sampling will be done, selecting women who represent the above mentioned variables. Participant consent will be highly valued, and no one will be forcibly driven into the study. Assurance of privacy of information and confidentiality will be made to each participant, and a binding the researchers will enter into a binding contract with them, signing a form to bolster it. Permission to carry out this study will be sought from the South Asian Ministry of Health and Family. There will a clear distinction between the unmarried and married participants, as this will be used to analyze the effect of premarital sex in fuelling stigma and discrimination against young women.
Materials
The study will employ the use of questionnaires, and face-to-face interviews. Questionnaires will be based on the main components of the health belief model which have been mentioned above, and will be confidential and manifest aspects of anonymity, where respondents will not be required to reveal their names and any personal information. Simple yes or no answers will be used across the entire questionnaire, so as to simplify the evaluation process for participants, who include semi-illiterate individuals. Face-to-face interview will not be used on all participants, but only the willing ones, who are ready to share their experiences regarding access to sexual and reproductive healthcare. This will be used as descriptive data, and as documentary evidence to show the effects of independent and dependent variables in the case title. The 7-point Likert scale will be used, as well as other customized questionnaires in line with study specifications.
Procedure
The study will involve the use of various strategies which have been proposed, and are believed to be pertinent in promoting sexual and reproductive health among young women is South Asia. Though it will be a treated as a pilot study, implementing such strategies in small scale, the sample selection method applied and the holistic approach adopted will ensure representativeness of the study in a bigger picture. The current level of access of such services will be assessed, and later used to generate comparative data with new trends after the study. The selected sample of participants will be encouraged to visit the hospital, where clinicians and other health care providers will be instructed to provide information regarding sexual and reproductive health. Charts, booklets and brochures will be given to such participants to facilitate their access to knowledge, in contrast to the evidence presented in literature.
The participants will be asked to complete the availed questionnaires which measure various constructs of the health belief model, study on demographics, and other already mentioned socioeconomic characteristics. As mentioned earlier, this sample will consist of both literate and semi-literate individuals. This practice will take a period of six months, with trends on improvement of attendance, fatality cases, and childbirth complications being closely monitored. The individual experiences of every participant will be evaluated by use of questionnaires and face-to-face interviews. A 7-point Likert scale will be used as part of the interview process. The interviews and analysis of responses given in the questionnaire will be done by the researcher.
To account for the effect of marital status on SHR practices, a questionnaire specific to that line of discussion will be availed, and participants instructed to indicate their statuses. The same criteria will be used for HIV status. Other variables will be determined in a correlational manner, where they will be part of the structured questionnaire. Face-to- face interviews will be organized for those participants who give indication that they have no problem with privacy and sharing their experiences. In this case, a more elaborate questionnaire will be used by the researcher in asking context-specific questions, in line with the above variables. Such factors as access to information, integration of SHR practices into existing health frameworks, and proper management of HIV infection will be analyzed as key methods of intervention for promoting sexual and productive health among young women. This study will not pose as a prototype implementation trial, but will assess the proposed intervention measures and the effect they have had so far in young women participants as regards the topic of research. Information collected will be treated as the resulting study data, which will be treated as per the method of analysis described below.
Data analysis
The descriptive statistics of the whole sample will be calculated, as well as that for the married and single sample population. HIV prevalence will also be calculated with sample characteristics. In order to identify differences across various categories of samples created by variables to be evaluated, detailed two-tailed chi-square tests will be used in analysis of results. Lastly, SPSS will also be used alternatively to analyze the data.
Evaluation
In a quick recap of intervention measures that the study will employ, the researcher would like to state that the use of the health belief model; integration of sexual and reproductive health issues into existing medical structures; promoting access to sexual and reproductive health information by the adolescents; judicious management of the issue of HIV and other STIs; and change of attitude towards premarital sex, or even juvenile marriages are some of the strategies which can be employed in a broader picture to promote female sexual and reproductive health among young Asian women. The success of this study, or simply the intervention methods proposed by the research, will be evaluated in a number of ways. Pertinent questions that every evaluation techniques should be able to ask include: does the method work? How well does it work? And how does it work? (Ege, Akin, Kültür & Ariöz, 2011). Firstly, the appropriateness of the methodology adopted is a great key to knowing whether the method does work. Four measures for methodology appropriateness which have been proposed include reporting pre- and post-intervention data; using a random allocated control group; reporting ‘intention to treat’; and reporting all study outcomes. This study based on the second component of evaluation, works very well since it uses a large size effect or sample to source for data. This is in line with other previous researches, which have proved that an effect size of between 0.20-0.40 is plausible for any intervention study (Ege, Akin, Kültür & Ariöz, 2011). Lastly, the study adopts the theoretical framework of health belief model, which has been largely applauded in previous researches. The use of this model provides a clear roadmap of approaching issues of behavior change to reduce aspects of discrimination, marginalization, and fear related to socioeconomic disparities.
The study has obvious strengths, as it will clearly provide a breakthrough to one of the most pertinent issues among young women in South Asia, with regards to the spheres of sexual and reproductive health. It will be able to prove the importance of behavior change, and application of other intervention measures in promoting access to healthcare by young women. However, as part of the limitations, the study may not clearly define the procedure for implementing such intervention measures, and may be a little biased due to time limitations and lack of adequate funds to finance an extensive research. The research has not taken into account all factors which are considered as barriers to access to SRH programs, thus may not be used as a complete package. Conclusively, the intervention study presents very key theoretical and methodological approach to issues of sexual and reproductive health, and can be used as a guiding line to actual and large scale implementation of promotional strategies.
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