A girl, who only got married a few months ago, is sitting in front of a blazing fire in a rural Chepang home. Pregnant at only 17 with her first baby, she cannot discuss her problems or complications with her in-laws. She is afraid, embarrassed, and most of all, physically and mentally unable to heed her life. Her husband is a migrant worker, toiling in the scorching heat of the mid-eastern part of the world. She talks with him on the phone sometimes. One of her friends put her in contact with a primary health care center nearby. There, what she experiences is a whole new world. The health worker patiently listens to her, provides her all necessary information confidentially and with comfort. She is able to take counseling from a female health worker on her pregnancy. Clinic times are convenient for her. This anecdote of a girl visiting an adolescent friendly health center reflects how impactful it is for adolescents.
Adolescents are people between 10 and 19 years of age and marks a psychological, biological and social transition. In a country where 24% of the population are adolescents, the adolescent health is severely compromised. Nepal ranks 3rd among countries on child marriage, after India and Bangladesh, even though the legal age at marriage is 20. Seventeen percent of girls aged 15-19 years are already mothers or pregnant with their first child. Only 15% of currently married adolescents use a modern method of contraceptives. Sexual and reproductive health needs of adolescents, although high, are not rightly addressed. In response to affirming the rights of adolescents to comprehensive, non-judgmental and confidential counseling and services, Adolescent Friendly Service (AFS) was introduced in Nepal. With first National Adolescent health and development strategy in 2000 and its revision in 2018, adolescent sexual and reproductive health (ASRH) program primary target is to make all health facilities as adolescent friendly as per the envision of National Health policy (2014) and National health sector strategy (2016-2021) to ensure universal access to ASRH services. It is a priority program of Nepal with programs already being covered in 75 districts of Nepal.
Even with adolescent friendly health centers in almost 75 districts, the utilization of AFS is very low. Recent surveys suggested that only about a quarter of the respondents had utilized the AFS. Also, in another study on SRH (Sexual and Reproductive Health), utilization was 9.2% among the higher secondary students. Limited adolescents had knowledge about AFS.
So, what are the barriers in utilization of AFS? A mid-term review of the ASRH program in 2013 and a study in 2014 found several barriers to its implementation, including poor ownership at the local level and poor integration with other health programs. Study among adolescents found barriers as poor SRH knowledge, strict gender role in community, stigmatization of SRH services, lack of AFS in community, lack of information on SRH for adolescents and challenges in disseminating information on SRH to unmarried adolescents by care providers.
Let’s move on to existing modality in adolescent friendly health services. Is it adequate? Different recommendations were made in regional and national review meetings for improving adolescent friendly services focused on improving monitoring, trained human resource, adequate link with other programs, logistic, community awareness aimed at access to family planning services. Yes these are the suggestions, but will it be able to improve the look at the problems of adolescents at micro level.
To make adolescent friendly health services more effective, we need to explore the problem through an intersectionality approach. What is the intersectionality approach and how will it work? The concept of intersectionality was developed by social scientists seeking to analyze the multiple interacting influences of social location, identity and historical oppression. It has been broadly taken-up elsewhere and intersectionality as a research paradigm has a longer and more substantive history in the theoretical literature. Its application in public health is emerging. It offers a lens via which we can move beyond a unidimensional focus on social class or socioeconomic position to recognize the multiple systems of privilege and oppression with relevance for health.
It is increasingly recognized that different axes of social power relations, such as gender and class, are interrelated, not as additive but as intersecting processes. Intersecting stratification processes can significantly alter the impacts of any one dimension of inequality taken by itself. Studies confirm that socio-economic status measures cannot fully account for gender inequalities in health. A number of studies show that both gender and class affect the way in which risk factors are translated into health outcomes, but their intersections can be complex. Other studies indicate that responses to unaffordable health care often vary by the gender and class location of sick individuals and their households. They strongly suggest that economic class should not be analyzed by itself, and that apparent class differences can be misinterpreted without gender analysis.
At first, it might seem adolescent girls have higher SRH problem than adolescent boys. Going further into disparity and exploring other factors that exacerbate the utilization, it can be found that geographic location, race, ethnicity plays a huge role. For instance, using the intersectionality lens, the problem of adolescent boys in rural Dalit community setting with disability might be even higher than adolescent girls in Brahmin in Kathmandu District.
Intersectionality at its core says the interaction of multiple social identities creates the problem. We cannot just point out what is apparent on a societal level and say if someone is facing a problem or not. It is a major cornerstone in understanding health inequities and studies have called for an intersectionality approach in ASRH programs. It is well aligned with the equity and social justice goals of public health, within which contemporary work on inequalities must be located. Hence, in planning and designing adolescent friendly services programs if we could use an intersectional approach it would be a new way of learning about problems at the micro level. It would allow us to access hard to reach adolescents. Health research in AFS through the intersectionality approach is hence essential to bring a new dimension to the AFS program by the government. Insufficient attention to intersectionality in much of the health literature has significant human costs, because those affected most negatively tend to be those who are poorest and most oppressed by gender and other forms of social inequality