Reproductive Health for Married Adolescent Couples Project (RHMACP)

The ecological model used by the RHMACP reflects the observation that the options and actions of young people in cultures such as Nepal (with strong, aged-based hierarchies) are integrally connected to, and affected by, adults. Thus, adult approval and buy-in underpin both youth participation in interventions and behavioural change, meaning that efforts to influence adult behaviour and attitudes as well as community perceptions are crucial for achieving and sustaining an impact on young people's reproductive health.

Consistent with the project's ecological model, the implementation strategy used 3 mutually reinforcing approaches to meet the project goal:

1. Educate married adolescents as peer educators to provide reproductive health information by organising individual and group educational events.

Peer educators took part in a training programme with 4 principal components:

• basic training on reproductive health and dissemination skills (3 days), conducted at the village development committee (VDC) level with 18 participants per event.
• facilitation and communication skills training (2 days), again held at the VDC level. Village health workers (VHWs) and maternal and child health workers (MCHWs) also participated, which increased the workers' individual capacity as well as their understanding of peer educators' roles and responsibilities.
• leadership development training (5 days). One peer educator from each of the 69 project VDCs was trained in leadership skills. Major topics included coordination and networking skills, problem solving, social inclusion, community mobilisation, good governance and transparency, women's rights, and volunteerism. To facilitate ongoing peer education and community advocacy, participants were provided with a flex chart with reproductive health messages, a documentary on early marriage and the dowry system, the Local Government Act, 2055 (1999), and the Interim Constitution of the Government of Nepal.
• street drama performance arts training (7 days). Twenty-five peer educators were trained to develop and perform street theatre that incorporated messages on the reproductive health needs and rights of adolescents, on HIV and AIDS and sexually transmitted infections (STIs), on child marriage, and on dowry practices. The workshop was conducted with technical assistance from the locally celebrated drama collective Mithila Natyakala Parishad. Following the training, participants established theatre groups in both districts.

Once trained, the peer educators disseminated reproductive health information to married adolescents, especially young women with restricted social mobility, and acted as key actors and advocates within their communities to promote services for married adolescents. Peer educators also referred married adolescents to health services, distributed condoms and contraceptive pills, and ensured that condoms were restocked at designated community locations. In addition, a campaign called Teen Saathi Abhiyan (TSA) was organised, in which peer educators identified 3 close friends and met with them regularly to share the knowledge and skills they had gained through their training and community activities. TSA participants in turn supported peer educators in hosting events, and in some cases replaced peer educators who dropped out of the project.

Specifically, peer educators conducted door-to-door visits to the homes of married adolescents in their wards to provide information and counseling on reproductive health and organised a variety of communal activities (such as group counseling and interaction sessions for married adolescents, pregnant mothers' gatherings at health facilities, advocacy workshops for influential family and community members on the reproductive health needs of married adolescents, wall painting, street theatre, and community rallies). Activities implemented in VDCs were based upon local needs and priorities identified by peer educators during their community outreach work and were selected and planned in collaboration with health workers and sexual and reproductive health facilitators at monthly review/reflection meetings. These meetings were conducted at the VDC level to provide a forum where peer educators could share their feelings, experiences, problems, accomplishments, and lessons learned. The peer educators also updated their records of married adolescents in their localities and planned activities for the upcoming month. Sexual and reproductive health facilitators and in-charges from local health posts facilitated these meetings.

2. Create an enabling environment for married adolescents to access essential reproductive health information and services by working with influential family and community members to raise awareness of adolescent health needs and rights.

The RHMACP conducted community talk programmes, street theatre, wall painting, video shows, rallies, and outreach through radio, television, and newspapers. In addition, peer educators (along with project and health facility staff) led discussion sessions with mothers-in-law and sisters-in-law. Sessions focused on the serious health risks of early marriage and childbearing, the benefits of family planning to delay first pregnancies and space births, and the importance of using maternal health services. The RHMACP also carried out ilaka-level advocacy workshops with influential community members - including religious leaders, school teachers, and politicians - to promote the reproductive health needs and rights of married adolescent couples. A total of 703 community members participated in 19 workshops. These workshops were a key platform in securing community support to establish and strengthen child marriage eradication committees. One-day sensitisation workshops with female community health volunteers focused on the reproductive health needs and rights of married adolescents. The workshops were also designed to foster working relationships between the health volunteers and the peer educators. In some communities, the two groups collaborated to make condoms more readily available by placing boxes of condoms in public areas.

3. The RHMACP carried out 4 types of major activities to strengthen youth-friendly services at local health facilities:

• training to health service providers - staff were trained on the concepts, characteristics, delivery, and monitoring of youth-friendly services, using a curriculum developed by EngenderHealth. Some providers were given an additional 2 days of training on couples counseling.
• provision of essential equipment to health facilities.
• technical support visits to health facilities - during the visits, project officers and sexual and reproductive health facilitators coordinated activities with peer educators, developed joint work plans, and monitored the availability and quality of youth-friendly reproductive health services, including staffing levels, condition of equipment, display of reproductive health information, facility layout, and availability of counseling space.
• ilaka-level meetings with health service providers - these semiannual meetings were used to review targets and achievements in client utilisation and to discuss ways to improve reproductive health indicators, including the provision of youth-friendly services.

In addition, the project published a variety of information, education, and communication (IEC) materials to facilitate dissemination of reproductive health information by project staff, peer educators, and health facilities. Materials included a poster-sized flex chart with reproductive health and family planning messages, a handheld flipchart with detailed reproductive health information for use in group discussions, and a reproductive health training manual. Other materials were produced for project publicity and advocacy at district, national, and international levels, including a video entitled "Waves of Change" that documented the experiences of several outstanding peer educators and "Lifting the Veil", a photojournal with case stories of changes observed in the lives of married adolescent couples in the project area.

Reproductive Health, Youth.

The Nepal Demographic and Health Survey (2006) indicates that almost one-third of women aged 15–19 years in Nepal are married, and more than two-fifths of women are already mothers or pregnant with their first child by 19 years of age. Among women under 20 years of age, only 22% of births were delivered by a skilled birth attendant, and more than 1 in 4 adolescent women in Nepal aged 15–19 dies of pregnancy-related causes. Only 9% of Nepalese adolescents have ever used a modern method of contraception. Women in Nepal generally marry men who are 3 years older and have already commenced sexual activity, and only 28% of women aged 15-24 have comprehensive knowledge about HIV transmission and prevention. More than half of Nepalese women have never been to school, and 46% are illiterate. With little access to institutionalised structures (schools and health services) and reduced exposure to peers and the media, married adolescent women are extremely vulnerable to poor reproductive health outcomes.