World Population Foundation Pakistan BASELINE ACTION RESEARCH Sexual and Reproductive Health and Economic Status of Adolescent Girls in Sanghar (Sindh) & Gujranwala (Punjab) Baseline Action Research by

 To determine a baseline for knowledge, attitude and practice of Sexual and Reproductive Health and Economic indicators in the adolescent girls of two target districts of Gujranwala and Sanghar, and  To assess the demand for reliable Sexual and Reproductive Health (SRH) knowledge and services among school-going and non- school adolescent girls Why was the Study done? 2

Methods  Policy and literature review  KAP Survey of school going and non-school going adolescent girls  Focus Group Discussions (FGDs)  Collection of School Data Sheets  In-depth interviews with district education and health authorities  Interviews with School Management  Data analysis and report 3

District Fact Sheet Gujranwala Population (1998)3,370,000 Population (2010, est.)4,308,905 Urban Population50.17% Growth rate (p.a.)2.80% Population Density (per square kilometer)172 Reproductive Health Centers78 Basic Health Units53 Fertility Rate7 Family/Household Size7.6 Contraceptive prevalence rate32% Number of registered medical practitioners285 Literacy Rate60% Number of primary schools for girls5,283 Number of high schools for girls85 Source: Population Welfare Department, Government of Sindh, EDO (Health) and EDO (Education) Gujranwala 4

Participation Summary Geographic location: Gujranwala district TotalGujranwala Survey Respondents Non-School Going Girls 7650 Headmistresses/Principals interviewed 5535 Primary Stakeholders: FGDs In-depth Interviews (District Education & Health Officials) 168 5

Variables and Indicators ParameterVariableIndicator Knowledge Knowledge in Adolescent Girls about STDs % age of adolescent girls having knowledge about STDs Knowledge in Adolescent Girls about Prevention from STDs % age of adolescent girls having knowledge about prevention from STDs Desire among adolescent girls to learn about STDs % age of adolescent girls expressing demand to seek knowledge about STDs Guidance received by Adolescent Girls over body changes % age of adolescent girls having received guidance over body changes from any source Ideal age of marriage Attitude Attitude of families towards boys and girls % of families allowing and encouraging boys and girls to have meals jointly Treatment of families with boys and girls % of families giving similar gifts to boys and girls on special occasions Attitude of Adolescent Girls on the onset of puberty Response distribution of girls Perception of adolescent girls about men's roles in household chores % of adolescent girls considering men equally responsible in household chores 6

Variables and Indicators (Continued…) ParameterVariableIndicator Practice Freedom to chose spouse % of adolescent girls given freedom in choice of spouse Freedom to chose a profession % of adolescent girls given freedom in choosing a profession Freedom to chose a friend % of adolescent girls given freedom in choosing a friend Freedom to chose type/field of education % of adolescent girls given freedom in choosing field of education Preferred Strategies of adolescent girls to support their families % girls showing a particular preference such as economic assistance, counseling, household chores Demand amongst adolescent girls for counseling in marital affairs (rights and responsibilities of husband and wife) % of respondents indicating demand for training in marital affairs Demand amongst adolescent girls for training in budget preparation % of respondents indicating demand for training in household budget Demand amongst adolescent girls for counseling in family planning (birth control, birth spacing etc.) % of respondents indicating demand for training in family planning Demand amongst adolescent girls for training in upbringing children % of respondents indicating demand for training in upbringing children 7

Variables and Indicators (Continued…) ParameterVariableIndicator Practice Desired Level of education amongst adolescent girls Distribution of responses with respect to desired highest level of education that adolescent girls have Desirable career choices for adolescent girls Distribution of responses with respect to desired career direction hat adolescent girls have 8

World Population Foundation Pakistan DATA ANALYSIS INDICATORS

Knowledge in Adolescent Girls About Specific STDs Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_ STDs_Spec Knowledge in Adolescent Girls about Specific STDs 1 Hepatitis B/C 10.3%17.8%17.4% 2 HIV-AIDS 20.7%42.9%41.7% 3 Hepatitis B/C & HIV- AIDS 8.6%5.3%5.5% 4 STIs 8.6%11.4%11.2% 5 No Knowledge 51.7%22.7%24.3% Total 100.0% 10

Stakeholders’ Perspective Knowledge in Adolescent Girls About Specific STDs 11  Adolescent girls are often reluctant to share their adolescent issues even with lady health visitors or workers.  LHVs and LHWs can play important and effective role to raise awareness among adolescent girls about STDs

Knowledge in Adolescent Girls About Prevention from STDs Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_Prev Knowledge in Adolescent Girls about Prevention from STDs 0 No 62.1%85.6%84.3% 1 Yes 37.9%14.4%15.7% Total 100.0% 12

Guidance Received by Adolescent Girls over Body Changes SStatus of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_Guidance Guidance received by Adolescent Girls over Body Changes 0 No 58.6%22.0%24.0% 1 Yes 41.4%78.0%76.0% Total 100.0% 13

Stakeholders’ Perspective (Guidance Received by Adolescent Girls over Body Changes) 14  Mothers and teachers can serve as important sources of guidance on body changes among the adolescent girls.  Discussion on body changes, particularly in rural areas, is considered as in indecent topic of discussion.  By and large, girls are not provided any guidance on how to take care of them upon natural body changes

Desire Among Adolescent Girls to Learn about STDs Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_Learn Desire among Adolescent Girls to learn about STDs 0 No 15.5%15.7% 1 Yes 84.5%84.3% Total 100.0% 15

Stakeholders’ Perspective (Desire Among Adolescent Girls to Learn about STDs) 16  Besides family planning, there is a dire need to raise awareness among adolescent girls about STDs and its link with their general and reproductive health.  In urban areas, women who experienced STDs wish to guide their daughters, but they have no means of knowing about STDs.

What Should be Ideal Age of Marriage for men? 17 Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_Ideal _age_men "What should be ideal age of marriage for men?" 1. Up till 20 years 14.8%10.6%10.8% years 63.0%64.4%64.3% years 16.7%15.4%15.5% 4.29 years and above 5.6%9.6%9.4% Total 100.0%

What Should be Ideal Age of Marriage for women? Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Know_Ideal_ age_women "What should be ideal age of marriage for women?" 1. Up till 20 years 45.3%47.8%47.7% years 54.7%46.1%46.6% years 3.7%3.5% 4.29 years and above 2.4%2.2% Total 100.0% 18

With whom do you share your health related issues? Status of Respondents in terms of School Going 0 Not Scho ol Going 1 School Going Total Know_ Source_ Guidance "With whom do you share your health related issues?" 2 Mother 38.1%77.0%76.0% 4 Sister 28.6%12.4%12.8% 5 Relatives/ Cousins 14.3%.8%1.2% 6 Friend 19.0%5.0%5.4% 7 Teacher 4.7%4.6% Total 100.0% 19

Are girls allowed to eat together in their families School_Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Fam_ Eating "Are girls allowed to eat together in their families?" 0 No 37.9%11.6%13.0% 1 Yes 62.1%88.4%87.0% Total 100.0% 20

Are boys preferred over girls on special occasions School_Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Fam_ Occasions "Are boys preferred over girls on special occasions?" 0 No 22.4%3.6%4.7% 1 Yes 77.6%96.4%95.3% Total 100.0% 21

Attitude of adolescent girls on the onset of puberty School_Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Att_Girls_ Puberty Attitude of Adolescen t Girls on the onset of Puberty 1 Nervous 69.0%43.6%45.0% 2 Shy 20.7%20.2% 3 Comfortabl e 10.3%36.2%34.8% Total 100.0% 22

Stakeholders’ Perspective Attitude of adolescent girls on the onset of puberty 23  Upon onset of puberty, usually girls become shy, lose self-confidence and are often prone to having disputes with their siblings on minor issues.  In many cases school-going adolescent girls become students with no interest in studies and decided to stop studying because of this attitude

Do Adolescent Girls enjoy Freedom of Spouse Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Choice _Spouse "Do adolescent girls enjoy freedom over choice of spouse?" 0 No 69.0%39.9%41.5% 1 Yes 31.0%60.1%58.5% Total 100.0% 24

Do Adolescent Girls enjoy Freedom to chose a profession Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Choice _Profession "Do adolescent girls enjoy freedom to choose a profession?" 0 No 63.8%54.1%54.7% 1 Yes 36.2%45.9%45.3% Total 100.0% 25

School Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Choi ce_Friend "Do adolescent girls enjoy freedom to choose a friend?" 0 No 53.4%40.0%40.7% 1 Yes 46.6%60.0%59.3% Total 100.0% 26 Do Adolescent Girls enjoy Freedom to chose a Friend

School Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Prac_Choice_ Education "Do adolescent girls enjoy freedom to choose type/field of education?" 0 No 63.8%52.5%53.1% 1 Yes 36.2%47.5%46.9% Total 100.0% 27 Do Adolescent Girls enjoy Freedom to chose type/field of education

28 Stakeholders’ Perspective Do Adolescent Girls enjoy Freedom to chose type/field of education  SMCs, through community meetings are engaged in mobilizing parents, particularly male members, to allow their daughters chose the profession of their own choice.  The government is increasing the number of Vocational Training Institutions at district level.

Impact of Reaction to Body Changes on School Attendance Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Att_Girls_ Leaving Impact of Reaction to Body Changes on School Attendance 0 No 55.2%62.5%62.1% 1 Yes 44.8%37.5%37.9% Total 100.0% 29

In Girls’ Opinion, Should Men Have a Role in Household Chores Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Att_Girls_ Household "In girls opinion, should men have a role in household chores?" 0 No 29.3%12.4%13.3% 1 Yes 70.7%87.6%86.7% Total 100.0% 30

Why girls oppose any role for men in household chores Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Att_Girls_ Househol d_ Reasons "Why girls oppose any role for men in household chores?" 1 Social/Traditi onal 44.8%56.7%56.1% 2 Psychological 22.4%20.2%20.3% 3 Religious 32.8%23.1%23.6% Total 100.0% 31

Perception among adolescent girls Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_Traits Perceptions among Adolescent Girls about Personality weaknesse s 1 Lack of Self Awareness 62.1%47.5%48.3% 2 Lack of Decision Making/Probl em Solving 8.6%25.9%25.0% 3 Lack of Creative and Critical thinking 15.5%7.4%7.8% 4 Lack of communicati on and interpersonal skills 13.8%19.2%18.9% Total 100.0% 32

District Distribution-Gujranwala Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_ Support Preferred Strategies of Adolescent Girls to Support their Families 1 Counseling/A wareness about rights, education and health 33.9%22.6%23.3% 2 Economic/Fin ancial Assistance 48.2%42.9%43.2% 3 Assistance in Household chores 17.9%34.4%33.5% Total 100.0% 33

Demand amongst adolescent girls for counseling in marital affairs Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_Skills _Marriage Demand amongst Adolescen t Girls for Counselin g in Marital Affairs 0 No 56.9%7.8%10.5% 1 Yes 43.1%92.2%89.5% Total 100.0% 34

Demand amongst adolescent girls for training in budget preparation Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_Skills_ Budgeting Demand amongst Adolescent Girls for Training in Budget Preparation 0 No 56.9%9.4%12.0% 1 Yes 43.1%90.6%88.0% Total 100.0% 35

Demand Amongst Adolescent Girls for Guidance/Counseling in Family Planning Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_Skills_ Fam_ Planning Demand amongst Adolescent girls for Guidance/ Counseling in Family Planning 0 No 60.3%9.6%12.4% 1 Yes 39.7%90.4%87.6% Total 100.0% 36

Demand amongst adolescent girls for training in Upbringing Children School Status Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Life_Skills_ Upbringing Demand amongst Adolescent Girls for Training in Upbringing Children 0 No 60.3%9.3%12.1% 1 Yes 39.7%90.7%87.9% Total 100.0% 37

Desired Level of Education Amongst Adolescent Girls 38 Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Econ_Emp_ Level Desired Level of Education amongst Adolescent Girls 1 Matric 37.9%6.4%8.2% 2 FA 24.1%10.9%11.7% 3 BA 17.2%19.9%19.7% 4 MA 20.7%62.8%60.4% Total 100.0%

Desired Career for Adolescent Girls Status of Respondents in terms of School Going 0 Not School Going 1 School Going Total Econ_Career Desirable Career Choices for Adolescent Girls 1 Teacher 62.1%48.5%49.2% 2 Doctor 3.4%26.7%25.4% 3 Nurse 6.9%4.3%4.5% 4 Business 20.7%15.2%15.5% 5 Educated Mother 6.9%5.3%5.4% Total 100.0% 39

World Population Foundation Pakistan SUMMARY Stakeholders’ Perspective: Adolescents’ Health and Education

In-Depth Interviews with District Education Officials 41 Policies and Practical Measures—Education:  District Education authorities are engaged in establishing effective monitoring system  District department is trying to increase the stipend amount from Rs. 1,000-1,200 per month  More teachers are involved in campaign aimed at mobilizing community members for maximizing female enrolment and stop drop-out rate  District planning is being done in consultation with the relevant stakeholders.  NGOs and CSOs are being involved in collective effort of improving female literacy rate up to the desired level.

In-Depth Interviews with District Education Officials 42 Major Reasons Female Drop-Out:  Poverty is the major contributing factor, compelling many parents either not to send or pull their daughters out of school.  Girls are often forced into labour to supplement the family income or to arrange for their dowry items.  Early marriages, engagements during studies or migration of families.  Parents concerns regarding security of their daughters while going to school and coming back to home

In-Depth Interviews with District Health Officials 43  District Health Department in collaboration with population welfare department is working for provision of family planning services.  LHVs are working under direct supervision of health department, and in coordination with like-minded NGOs and organizations.  Doctors are often reluctant to serve the rural communities.  Non-availability of medicines at Basic Health Units and Social Dispensaries