Although sexual and reproductive health education and services are provided to young people, current rates of HIV infection and pregnancy are increasing in Nepal, indicating that young people do not always use sexual health services. Health facilities have apparently failed to provide young people with specialized sexual health education and services.
This study explored the barriers to using sexual health services, including condom-use among young people in Nepal. Participants from 10 focus groups and 31 in-depth interviews, carried out by a
Sexual health sheffield publications international ltd researcher, reported many socioeconomic, cultural and physical norms that impose barriers to accessing information on sexual health and relevant services. It is concluded that the establishment of youth-friendly service centres in convenient places might help encourage young people to use sexual health services.
Sexual health sheffield publications international ltd is a fundamental dimension of human life 1and sexual behaviour of young people is becoming one of the important social and major public-health "Sexual health sheffield publications international ltd" in recent years 23.
As a result of the HIV epidemic, research on sexual behaviours of young people has developed rapidly over the past decades 4 — 7.
It is now widely accepted that sexual and reproductive health issues remain the leading cause of ill-health among young people worldwide and are a growing concern in Nepal 8. Nevertheless, research on young people's sexual health is lacking in Nepal 9 Sexuality-related topics have largely remained as a taboo in many Asian countries 10 — Nepalese societies have also many strong traditional norms and beliefs relating to sex and sexuality 1314and these issues are rarely discussed within the family environment.
Friendships between girls and boys are still unacceptable in Nepal, and many rural parents even discourage their daughters from meeting or talking with boys.
Sexual activities outside marriage are not accepted among the majority of Nepalese societies 15 Despite these traditional views, a significant proportion of Nepalese young people are engaged in pre- and extra-marital sex 1017 — There is a general notion that modernization and globalization have resulted in young people waiting longer before getting married 20 — 22and this has created more opportunities for them to spend time in intimate sexual relationships before marriage 23 as they spend more years in education and marry later.
It is widely accepted that young people have specific sexual health needs, which vary according to their age, sex, marital and socioeconomic status. When young people engage in unprotected sex, it may result in sexually transmitted infections STIs and unintended pregnancies 24 Thus, many health workers around the world are trying to prevent, or at least reduce, risk-taking behaviours of young people However, despite the interest of young people in obtaining relevant information and friendly services 26the provision of sexual and reproductive health services in Nepal is very inadequate 27.
The Nepalese Government is committed to providing a package of sexual and reproductive health service to young people.
These policies have Sexual health sheffield publications international ltd adolescent and young people as a key target group for integrated sexual and reproductive health services, with interventions planned to increase knowledge on sexual and reproductive health issues and availability of services 27 Nepalese young people gain information and education on sexual and reproductive health mainly through radio and health-education programmes targetted towards the general population Most sexual and reproductive health services in Nepal are provided through private and public-health centres.
These include local pharmacists, public-health practitioners, doctors, nurses, and community health workers. Young people obtain sexual health services when they visit health centres, hospitals, or clinics.
However, many such programmes are poorly implemented A very few sexual health services, mainly governmental services in rural areas of Nepal, are available. On the contrary, urban areas have more specialized facilities with many sexual health service centres, which young people can access easily.
The role of private and non-governmental organizations is crucial as they engage young people at a grassroots level in sexual health initiatives.
However, sexual and reproductive health programmes are scattered, and there is a lack of a common forum and coordinating mechanism, which could play a significant role in strengthening the programmes with better output Moreover, many young people do not seek information or services because they think that they are at little or no risk of health problems. Lack of information, social stigma, and logistical and policy barriers have made it difficult for them to use sexual and reproductive health services Although young people are provided with limited sexual and reproductive health information and services through different media, rates of HIV infection 33 and teenage pregnancy 34 show that many of them do not frequently use sexual and reproductive health services.
Health workers and teachers are reluctant to discuss sexuality and reproductive health issues 28 As the teaching of sexual health Sexual health sheffield publications international ltd often very poor, it is directly associated with teacher's embarrassment, lack of knowledge, and poor teaching techniques.
Teachers are confused as the existing courses are Sexual health sheffield publications international ltd to address the needs of young people 36 There is also a notion that Nepal's political instability and recent political conflict remains a threat to the delivery of healthcare information and service These findings clearly suggest that young people face different forms of barriers to using sexual health services.
This qualitative study aims to explore the major barriers faced by young people to using sexual health information and accessing relevant services in Nepal. The topic being sensitive in Nepal, we adopted a qualitative approach. Over the past two decades, there has been a notable increase in the use "Sexual health sheffield publications international ltd" qualitative methods to explore sensitive issues, including sexuality Although combining quantitative and qualitative methods is becoming very popular 4041few have explicitly addressed the implications of combining qualitative data-collection methods 42 — Lambert and Loiselle argued that combining these methods may help generate complementary views Besides, multiple qualitative methods enhance the analysis of a phenomenon and broaden its conceptualization In10 focus groups and 31 in-depth interviews of individuals were carried out among young people in Nepal.
In-depth interviews were conducted to get responses from those participants who were either unable or unwilling to attend the focus groups. It was also intended to explore more personal experiences from the participants.
A Nepalese version of the questioning route 4647 was designed for the focus groups. It is assumed that the questioning route approach helps provide consistent information, improves the comparability of information among groups, and overcomes the need for a moderator to formulate unprepared questions Similarly, a topic guide was used for conducting semi-structured in-depth interviews.
A same-sex researcher conducted focus groups and in-depth interviews as, in less-developed settings, the interviewer's gender does have a significant influence on responses to sensitive questions All focus groups and interviews were conducted in Nepali in a comfortable environment, i. They were tape-recorded with participants' permission and generally lasted for 1—2 hours Participants for the study were selected purposively 50 from major urban and rural Sexual health sheffield publications international ltd of Kathmandu and Chitwan districts.
We selected four colleges and one youth club from Kathmandu and three colleges and two youth clubs in Chitwan district. Most focus-group and interview participants were aged 18—22 years.
Both college-based and school drop-out focus groups were largely drawn from pre-existing groups, i. Hennink argues that the composition of pre-existing groups can generally promote debate among group members and enrich the discussion However, there is also a fear that familiarity between participants can also lead to group members being afraid of being challenged by other group members due to the shared knowledge of their experiences.
Finally, the research team checked participants for their eligibility. Transcriptions were made based on the original tape-recordings The completed transcription was compared with hand-written notes to fill in inaudible phrases or gaps in the transcription. One of the main advantages of applying the NVivo software is its ability to ensure the processes of coding; so, the management of data becomes more visual and more flexible A thematic approach was used for analyzing data using categories or themes or codes from the dataset 54 Relevant quotes are also provided in the text to illustrate these categories.
Ethical approval for the study was granted by the Nepal Health Research
Sexual health sheffield publications international ltd, and consent was taken from participants before conducting the study. The following themes were identified in the data: We are aware that there is a difference between the terms but this is the way the young Sexual health sheffield publications international ltd in our studies were portrayed. The participants felt embarrassed while talking about sexual and reproductive health matters with friends of the opposite sex, family, and even with their sexual partners.
They thought that girls found it difficult to initiate a discussion about it with their sexual partners. Boys argued that it was difficult to keep condoms as they felt embarrassed when caught by family or friends.