"There are several major contributing factors for reproductive 'ill health' among young Nepalese couples. They are early marriage, early and frequent childbearing, lack of adequate knowledge...about the health risks involved in teenage pregnancies and closely spaced births, poor inter-spousal communication, social barriers, and lack of supportive environment for increased involvement of young couples, particularly young married women, in family planning and reproductive health decisions. Despite this fact, programs aimed at increasing access to reproductive health and family planning information and services to youth and young married couples are grossly inadequate..."

This 74-page report summarises the findings of a 2-year operations research (OR) study that sought to address the above-mentioned problems by increasing access to and use of reproductive health services on the part of married couples under the age of 24 in Nepal. The intervention drew on community-based interventions, and emphasised strategies for fostering the involvement of young married women in family planning and reproductive health decisions.

This study explored the impact of two models implemented in the Udaypur district of Nepal, where the Nepal Red Cross Society (NRCS) had been carrying out its Reaching and Enabling Women to Act on Reproductive Health Decision (REWARD) project with support from the United States Agency for International Development (USAID) and the Center for Development and Population Activities (CEDPA). The two communication-based models examined in this study are:

• the Youth Communication Action Group (YCAG) - based on a strategy developed by NRCS to establish village-level communication action groups (CAG), members of which are usually spouses of migrant men. They are empowered with information, education, and communication (IEC) materials and communication skills to negotiate condom use with their spouses when they return home and to openly discuss with their friends the dual advantage of condoms in preventing sexually transmitted infections (STIs) such as HIV/AIDS and providing birth spacing. As shaped to fit the youth context, the idea is that such groups "can facilitate youth-to-youth communication through an entertainment and education approach about reproductive health issues and help them share experiences during group meetings. Membership in YCAGs will also provide opportunities for young married women to gain reproductive health knowledge and contraceptive negotiation skills."
• the Mother's Group (MG) - under the government's health system, Aama Samuha (MGs) are formed at the ward (sub-village) level throughout the country. Members of these groups are married women. They interact with outreach health workers and health volunteers at their monthly meetings about antenatal care, childhood immunisation, and various social problems in the village. Female community health volunteers (FCHVs) are present in each ward of the VDC-facilitated group meetings.

The OR interventions included group formation, basic and refresher training (communication skills, group counselling, and referral), group interaction and mobilisation, and networking young couples with the community-based health care delivery system. YCAG and MG group members were encouraged to collectively organise special events such as health fairs, Condom Day, Safe Motherhood Day, World AIDS Day, National Vitamin A Day, and monthly talk programmes in the village marketplace to gain community support for the intervention.

The study used a quasi-experimental design with two experimental and two non-equivalent control groups. The baseline survey, conducted in October 2000, covered a total sample of 1,000 respondents from the two experimental sites and 800 from the two control sites. The endline survey, conducted in October - November 2002, covered 744 respondents in the two experimental sites and 268 from one control site. A separate survey of 237 YCAG members was also conducted as a part of the endline study.

Excerpts from the Executive Summary follow:


Contraceptive Knowledge and Practice

"...The endline survey recorded an increase in all three study sites in the number of family planning methods that respondents were aware of. The increase was greater in the two experimental sites (YCAG, 7.5% and MG, 6.4%) as compared to the control site (5.9%). Likewise, the proportion of those who were able to cite all three temporary family planning methods (condom, pills, and the injectible DMPA) increased significantly in the YCAG (96%) and the MG (94%) areas as compared to the control area (83%).

Respondents' knowledge about the correct use of pills, DMPA, and awareness about sources of information on family planning in the village increased significantly in both experimental sites as compared with the control site. The contraceptive prevalence rate (CPR) among young married women increased in all three study areas. The increase has been sharp in the MG area (19% in the baseline survey compared to 37% in the endline survey) and modest in the YCAG area and the control site...

Safe Motherhood Knowledge and Practice

There was near universal awareness of the need for antenatal checkups (ANC) during pregnancy in all three study sites. However, the proportion of respondents who knew that a pregnant woman should have at least four ANC visits increased in the experimental sites only, and knowledge remains low overall (below 40%). The proportion of respondents who were able to cite at least three danger signs during pregnancy, labor, and delivery also increased significantly among the respondents in both of the experimental sites but remained low in the control site.

The increase in safe motherhood practices has been greater in the YCAG area than in the MG site or the control site. The proportion of deliveries assisted by trained birth attendants (TBAs) increased threefold (from 14% to 43%) in the YCAG area while remaining modest in the other two sites.

Awareness of HIV/AIDS

At endline awareness of HIV/AIDS among young married women in the YCAG area was almost universal (97%). Awareness increased sharply in the MG area (45% to 71%) but recorded only a modest growth in the control site (50% to 63%). The proportion of respondents who cited at least two high-risk behaviors for HIV/AIDS increased dramatically in the YCAG area (21% to 89%). In the control area, the proportion of such respondents remained at less than one quarter. The knowledge that "condom use prevents HIV/AIDS" is quite high in both of the experimental areas (72% in the MG area and 94% in the YCAG area). In contrast, knowledge is low in the control site (46%).

Knowledge About and Participation in Community-Based Groups

At endline over two-thirds (68%) of respondents in the YCAG area were aware of the presence of...CAG...and YCAG...in their villages, as compared to only 15 percent at baseline. Likewise, awareness among the respondents in the MG area about the presence of...MG...in their villages increased sharply from 21 percent at the baseline to 89 percent in the endline survey. In contrast, fewer than 30 percent of the respondents in the control site are aware of...MG...in their villages...

The results of the YCAG survey are encouraging. Members of the YCAG demonstrate a very high level of awareness about different family planning methods, and almost all of them (98%) had received family planning information from the leaders and fellow members of the group. One third of the members are currently using a method.

Nearly all of the YCAG members (95%) thought that they benefited by enrolling as members. Most of them (79% to 97%) discussed a wide range of topics related to sexual and reproductive health, including the right age for marriage (65%), abortion (48%), and infertility (41%). Members shared information that they gained with their friends and neighbors (79%), husbands (76%), and to some extent, within the group (39%) and among other family members and relatives (36%). It is encouraging to find a very high percentage of YCAG members (70%) who have correct knowledge about how many times pregnant women should have ANC visits (four or more). Moreover, awareness about HIV/AIDS (97%) and some of the preventive measures against HIV/AIDS are nearly universal among YCAG members...

Conclusions and Lessons Learned

This OR study...has shown how these two models can be effective in reaching young couples with reproductive health information and services. The YCAG model has proven relatively more effective in enhancing knowledge among young married women about family planning and safe motherhood issues. It has helped build confidence among YCAG members, improved members' reproductive health knowledge and behavior, as well as their ability to share and communicate about sexual and reproductive health issues with their spouses, friends, and neighbors.

The MG model has been more effective among young married women in improving acceptance of family planning, enhancing awareness about MG group activities related to family planning and reproductive health, and encouraging their participation in these activities. Both of the models tested can be replicated in Nepal..."