Sexual and Reproductive Health Needs and Priorities of the Adolescents in Northern Pakistan: A Formative Evaluation

: The vast majority (90%) of the world’s young people aged 10–24 years live in low and middle-income countries (LMICs). Pakistan has one of the world’s largest populations under 30 years. Adolescents’ access to basic sexual and reproductive health (SRH) services, such as family planning and sexuality education, remains low, especially in rural areas such as the Gilgit-Baltistan (GB) province of Northern Pakistan. This study addressed these gaps by exploring the SRH priorities and health information needs of adolescents living in GB. A cross-sectional survey was conducted with adolescents and healthcare providers. A total of 216 adolescents and 22 healthcare providers completed the survey forms. The ﬁndings pointed out that adolescents in GB have unmet SRH needs and are more interested in learning about SRH, human immunodeﬁciency virus (HIV) and sexually transmitted infections (STIs), and sexual abuse. The majority of the participants highlighted that their age, fear of being judged/stigmatized, and society’s attitude toward sex hinder them from opting for SRH services. The majority of healthcare providers reported that they are not well-equipped to tackle SRH-related issues and require training to better serve the adolescent SRH needs. The ﬁndings from this study have highlighted that there is a need to formulate robust interventions and strategies to raise knowledge and awareness about SRH needs among adolescents.


Background
Adolescents (aged 10-19 years) comprise one-sixth of the world's population and account for 6 percent of the global burden of disease and injury [1]. The vast majority (90%) of the world's young people aged 10-24 years live in low-and middle-income countries (LMICs) [2]. Adolescence is a foundational phase for establishing the physical, emotional, cognitive, and social capabilities essential for adult life. It is when lifelong health behaviors are formed and future health trajectories take shape. Sexual and reproductive health (SRH) is an important aspect of adolescents' health and well-being and interconnects with various aspects of physical, mental, and social well-being [3,4]. The WHO defined sexual health as "a state of physical, emotional, mental, and social well-being related to sexuality" [5]. The National Consensus on Adolescent Sexual Health additionally emphasized that, for adolescents, these dimensions are closely linked with "sexual development and reproductive health, as well as physical and social well-being" [6].
Pakistan has one of the world's largest populations under 30 years (68%) [7] and the highest total fertility rate (3.6 children per woman) in South Asia [8,9]. Approximately 50% of all births in Pakistan occur among girls younger than 20 years, mostly living in rural areas [9]. This has implications for maternal and perinatal morbidity and mortality levels in the country, as adolescent mothers are at higher risk for complications, eclampsia, puerperal endometritis, and infections [10]. At the same time, their newborns are more likely to be born prematurely and have low birth weight [10]. The prevalence of early marriage among girls is an important contributing factor to high levels of teen pregnancy, maternal morbidity, and mortality and places girls at a significant disadvantage compared to boys [11]. Close to 15% of 15-19-year-old girls were married in 2018 compared to 3% of boys in Pakistan [8]. Access to basic SRH services, such as family planning and sexuality education for adolescents, remains low, especially in remote rural areas in the country, such as Gilgit-Baltistan province [12]. One of the five provinces in Pakistan, Gilgit-Baltistan (formerly known as 'the Northern Areas') is situated at the geostrategically sensitive border area between Pakistan, China, India, and Afghanistan and covers 72,400 square kilometers, is comprised of ten administrative districts and is home to approximately 1.8 million people [13]. The region is situated at the intersection point of the world's largest mountain ranges, the Himalayas, the Hindukush, and the Karakoram, making for challenging terrain, particularly during winter. In 2017, around 7% of women in Gilgit-Baltistan aged 20-24 years reported being married before 15 years, while almost 30% reported being married before reaching 18 years [13]. The highest unmet need for family planning in Pakistan [8]. According to the country's most recent Demographic & Health Survey data, only 30% of married women (15-49 years) reported modern contraceptive use in Gilgit-Baltistan. Despite 70% of the population being under 25 years in Gilgit-Baltistan [14], data on reproductive health needs, access to information, and levels of service use by adolescents in this province of Pakistan are scarce.
Despite many adolescent populations living in remote rural areas of Northern Pakistan, research on SRH information needs and access to SRH services is nearly non-existent. This study addressed these gaps by exploring the SRH priorities and health information needs of adolescents living in Gilgit Baltistan (GB), Northern Pakistan. This study aimed to examine the SRH knowledge, information needs, and access to SRH services among adolescents in GB, Pakistan. The specific objectives were to understand the SRH knowledge, needs, and priorities among adolescents in GB, Pakistan; their access to SRH information and the barriers to accessing SRH information and services; their preference for modes of SRH learning and information; and their experiences on adolescent-friendly SRH services in GB, Pakistan.

Methods
A cross-sectional survey was conducted to assess the SRH information needs, level of knowledge, and current state of available SRH services for adolescents in GB, Pakistan. Survey questions asked the youth about their SRH knowledge, sources of information, their information needs, the availability of SRH services, and barriers to accessing those services. A cross-sectional survey was also conducted with healthcare providers working in government and private hospitals in GB to identify the type of SRH services available for adolescents in GB and if the healthcare facilities provide adolescent-friendly SRH services. Toronto Teen Survey (TTS) guided the development of the adolescent survey questionnaire (Appendix A, adolescent SRH Survey), and the healthcare provider survey was adapted from the WHO quality assessment toolkit [15]. (Appendix B Healthcare Providers survey). The survey forms were pilot-tested on 5% of eligible participants to ensure that participants understood the questions accurately before implementing the full survey.

Participants and Sampling
Study participants were adolescents (boys and girls ages 15 to 19) and healthcare providers currently living in GB, Pakistan. While the developmental stage of adolescence encompasses a broad age range between 10 and 19 years, we recruited adolescents aged between 15 and 19 years because they are generally mature enough to answer survey questions and meet the minimum age requirement of 15 years to use social media platforms. Adolescent participants were recruited from community settings and government and private schools in GB. Flyers describing the study were posted on the school's notice boards and Facebook page. In addition, community workers hired as part of this project assisted in participant recruitment. Healthcare providers were recruited from government health Adolescents 2022, 2 265 facilities in GB. Six schools in central GB provided the approval to recruit participants from their schools. Two hundred sixteen surveys were collected from adolescents and 22 from healthcare providers from various healthcare facilities in central GB.

Recruitment Procedure
After obtaining permission to access the population and ethical approval to conduct the study, the research assistants (RAs) were hired as part of this project. They visited the classes of participants aged between 15-19 years. The nature of the study was explained to students in the class using a fixed script. RAs left the survey forms at the school administrative desk in an opaque envelope. Participants interested in participating picked up their survey questionnaire from the administrative desk and were asked to return the survey forms sealed in an opaque envelope at the administrative desk. The RAs picked up the forms from the administrative desk. The time required to complete the survey form was approximately 30-40 min. Written consent was not required/requested, as participants were informed that completion of the survey was considered implied consent for participation in the study.
Recruitment posters were posted on the government hospital's notice board to recruit healthcare providers. RAs visited healthcare facilities for four weeks to recruit participants. Participants were asked to fill out the survey forms and return the completed survey forms sealed in an opaque envelope at the administrative desk. The RAs picked up the forms from the administrative desk.

Data Analysis
Using SPSS version 23.0, data were entered twice to ensure accuracy in the data entry protocol. Each survey form was numbered, and 10% of all instruments (forms) were randomly picked (every 10th form) and manually checked against the existing database. A descriptive analysis was conducted for the demographic variables and the other variables of interest, as all the variables were measured at the nominal scale. Percentages were calculated for participants' knowledge of different aspects of SRH, and charts/graphs were prepared where required.
The study received ethics approval from the Ethics Review Board of the participating university and administrative approval from government private schools and government health facilities to recruit the participants. Participants were informed that participation in the study was completely voluntary. Confidentiality was ensured using code numbers. Participants were apprised that the findings would be used in publications and presentations.

Adolescent Sexual and Reproductive Health
A total of 216 adolescents with a mean age of 17.67 ± 2.42 years, grades 11-12 (58.8%), and mostly females (79.4%) participated in the study. The most commonly spoken local language was Burushaski (40.6%), followed by Urdu (32.8%), and English (12.8%). Most participants were living with family (88.8%) and had parents who attained their education to up to Grade 10 (mothers 46.9% and fathers 34.6%) ( Table 1). While assessing the sexual activity of the participants, 3.8% reported having sex, 1.7% of the girls reported getting pregnant, and 1.0% got someone pregnant (Table 1).
For SRH information and sources, most of the adolescents received information from youth groups (25.4%) and high school (19%) (Figure 1a). They were taught information related to HIV/AIDS (29.1%), STIs (16.4%), sexual abuse (11.2%), etc. (Figure 1b). Most of the adolescents reported referring to friends (21.3%) and media (17.6%) in cases where they had questions related to SRF, and very few referred to doctors/nurses (14.1%) and parents/caregivers (13.5%) (Figure 1c). Their preferred reported sources are books (14.6%) and family members (13.3%), and they require more information on HIV/STIs (23.9%), healthy relationships (18.5%), contraceptives (17.2%), etc. (Figure 1d,e). Of all participants, 2.8% referred to SRH services for HIV testing, while 8.4% for hormones ( Figure 2a). The majority of the time (44.8%), adolescents are referred to a specialist (obstetricians and gynecologists), followed by a walk-in clinic (32.8%) and a family doctor (15.5%) (Figure 2b). The common barriers that stopped the adolescents from accessing SRH services were that they thought they were too young (18%), fear of being judged (13.6%), and society's attitudes towards sex (11.23%).       Figure 3 depicts adolescents' responses regarding the friendliness of SRH services. The majority of adolescents agreed on statements including that the services were private and confidential, the waiting room was friendly, the sensitivity of staff towards adolescent gender, and their availability for assessment.
and face more problems regarding [SRH-related] things (n = 6); • Sexual health education and knowledge should be provided at our educational institutions. As girls, we must know about the importance of sexual health. We want to know about sexual health issues through different camps and sessions in schools or colleges (n = 105); • We need to ensure the staff and services are sensitive to LGBT people and provide the [youth] information about healthy sexuality (n = 5); • We our parents should be trained and support their children to talk about sexual health issues with them without any pressure. It will be good if parents get education on healthy sexuality (n = 18). We want sexual health resources to be more public and readily available (n = 6).

Healthcare Providers
A total of 22 healthcare providers participated, most of whom were females (81.8%), nurses/midwives (54.5%), and had an average of 11 years of experience ( Table 2). 19 healthcare workers reported that their healthcare facility provided adolescent-friendly SRH services, and of these, 15   The survey form also included an open-ended question to allow the participants to provide free-text comments on issues related to SRH and access to SRH services. Below we present a summary of some of the narratives that most participants reported in the free-text comment section.

•
Due to cultural barriers, people don't discuss sexual or reproductive health issues and face more problems regarding [SRH-related] things (n = 6); • Sexual health education and knowledge should be provided at our educational institutions. As girls, we must know about the importance of sexual health. We want to know about sexual health issues through different camps and sessions in schools or colleges (n = 105); • We need to ensure the staff and services are sensitive to LGBT people and provide the [youth] information about healthy sexuality (n = 5); • We our parents should be trained and support their children to talk about sexual health issues with them without any pressure. It will be good if parents get education on healthy sexuality (n = 18).
We want sexual health resources to be more public and readily available (n = 6).

Healthcare Providers
A total of 22 healthcare providers participated, most of whom were females (81.8%), nurses/midwives (54.5%), and had an average of 11 years of experience ( Table 2). 19 healthcare workers reported that their healthcare facility provided adolescent-friendly SRH services, and of these, 15 reported ensuring maintained privacy during the visit ( Table 2). The common sites where youth was referred for the healthcare services included CMH Gilgit (n = 22), DHQ (n = 12), AKHSP (n = 4), and either Islamabad or Karachi (n = 2). All healthcare providers reported giving enough time for consultations and felt the need for healthcare providers to be trained in providing SRH services to adolescents in their communities ( Table 2). The services provided to the youth included care during childbirth (35.1%), followed by abortion care (26.3%) (Figure 4a). Health care providers informed having skills and knowledge related to pregnancy diagnosis (19.8%), care during pregnancy (22.1%), childbirth (19.8%), and after childbirth (20.1%) (Figure 4b). The circumstances in which the healthcare workers reported not following the procedures and policies mostly included the child's young age (Figure 4c). When asked about the reasons for denied services by the adolescent, the characteristics included being female (32.5%), very young, aged less than 11 years (25%), disabled (20%), emergency cases (15%), and unmarried (7.5%) (Figure 4d). The type of SRH services offered to adolescents by health care providers is provided in Figure 4e.

Discussion
In the free-text comment section, many of the healthcare providers reported: • We think SRH education should be mandatory in every school and college to make students aware; in hospitals, there should be services available regarding sexual health issues (n = 4).

•
There should be proper counseling for adolescents, and more sessions should be conducted in schools and colleges using multi-media and books to be fully aware of everything (n = 1).
The findings from our study have highlighted the SRH needs of the adolescent population living in GB, Pakistan. The results from this study underscored that sexual activity is not a common practice amongst the teenage population from GB. This is consistent with the earlier findings from a report on Asian and Pacific countries that highlighted that only 1% of the adolescent population has had sex before marriage in South Asian countries, including Pakistan [16]. Our study pointed out that adolescents' access SRH information mainly from youth groups and friends and are more interested in learning about HIV, STIs, and sexual abuse. The findings are consistent with the report presented by UNESCO that states the need to address HIV-related concerns in the adolescent population; however, it is not fully achieved because of the social stigma [17]. Other factors that hinder HIV-based strategies include policy-related factors, including the inclusion of sex education in the school curriculum, lack of resources, and school-level barriers [18].
Most adolescents reported going to a friend and using the internet/media to seek SRH information and avoided seeking help from healthcare professionals and older family members. Though the idea of digital literacy in SRH is not a novel concept, it holds many concerns about the credibility and authenticity of the adolescent population's information from online media sources [19]. Since adolescents, particularly young adolescents, are not intellectually robust, they are vulnerable to unauthentic content and misinformation [20]. However, the use of the internet for such purposes is still at its peak due to easier accessibility and approach [21]. Another study highlighted that healthcare professionals and parents are not the preferred sources of contact in obtaining SRH-related information; of those who do, most of them are girls [22]. The main reason highlighted for not referring to parents for SRH knowledge is because of the socio-cultural and traditional taboos attached; the parent-child communication on sexual matters is considered unacceptable in many Asian countries. Other reasons include lack of SRH knowledge in parents, gender discrimination, cultural beliefs, and faith that directly hinder building open communication about the subject matter [23].
Moreover, many adolescent participants mentioned that they do not seek healthcare services for the SRH; of those who do, most of them seek them for hormonal purposes only. The findings are a bit contradictory to a study conducted in Kenya. In the Kenyan adolescent population, the participants acknowledged the importance of hormonal therapies such as contraceptives. However, they highlighted that adolescents perceived this to be reserved for married only and are reluctant to seek hormone services [24]. Most of the participants highlighted that their age, fear of being judged/stigmatized, and society's attitude toward sex hinder them from opting for SRH services. Similar barriers were identified by studies highlighting a range of barriers to accessing SRH [25,26]. These included lack of knowledge and education about the available services, shame as part of culture's negative perception, society's attitude towards pre-marital sex, fear of them being caught by their parents for seeking these services, and lack of privacy and confidentiality provided by the healthcare providers [25,26]. This shows that the services offered by the healthcare providers are not user-friendly [26], which varied from the findings of our study in which the adolescent population stated that the services were private and confidential. The lack of SRH education can also be attributed to the children's socioeconomic status. A study conducted in Sindh on HIV knowledge and belief highlighted that the children educated at least at a secondary level and allowed to meet their friends had significantly higher HIV knowledge than those with lower education [27].
Regarding the healthcare provider's perception, the majority of them felt that they were not well-equipped to tackle SRH-related issues and thus required consultation training to better serve the adolescent SRH needs. These findings are consistent with a study conducted in Cape Town in which nurses highlighted that they are not skilled enough to address the SRH-related concerns of the adolescent population. However, few also highlighted that healthcare system constraints such as lack of time hamper providing the care required by the teenage population [28]. Of those who highlighted that they could provide the services, the majority of those were skilled in providing antenatal care. This highlights that the healthcare providers in GB, Pakistan, can address reproductive needs but are poorly equipped to tackle the sexual needs of the adolescent population. Literature supports the idea that though nurses consider responding to the adolescent's SRH needs, many face difficulty initiating the conversation. Some highlight that the discussion based on sexual health is a prime responsibility of parents rather than the healthcare providers [29]. This results in the lack of service provisions, especially those related to contraception and abortion; they have widely accepted that they lack the skills to address the SRH needs of the unmarried adolescent population as a whole [30,31].
Amongst the many barriers, the young age of the adolescent population was highlighted by most of the healthcare providers in addressing the SRH needs. The findings are consistent with a study that highlighted that the person's age seeking SRH services does matter in the provision of services offered to them [32]. This gives rise to the importance of adolescent-friendly services. As part of the WHO global consultation on 'adolescentfriendly health services, three basic aims need to be considered, and at least one should be achieved. These include providing a supportive environment, improving the overall knowledge, attitude, and behavior, and increasing the uptake/utilization of the healthcare services [33,34].
To the best of our knowledge, this is the first study from GB that has assessed the needs and capability of SRH knowledge and service delivery. Moreover, these findings can serve as a basis for bringing attention to the stakeholders and policymakers in proposing SRH-related services available and accessible for the adolescent population of GB. Despite the strengths, our study has fewer limitations. First, the study lacks representation from GB as most of the participants recruited were from central parts of GB because we received approval from schools located in these areas only. Similarly, it lacks representation of health care workers providing services in other parts of GB. Second, the sample was one of convenience, and most of the participants were female. Therefore, sampling bias may have existed, limiting generalizability. In addition, testing bias may have been a factor in this study, as participants may understand and interpret the questions differently. Moreover, self-report questionnaires may be affected by participants' moods and attitudes and thus impact their completion, which may, in turn, result in low external validity of the study.

Conclusions
The adolescent population has unique SRH needs that remain unmet primarily due to a lack of awareness and knowledge, societal stigma attached to accessing SRH services by young people, policies and laws that prevent the provision of abortion and contraception use by the unmarried adolescent population, and the negative judgmental behavior of the healthcare professionals. This study's findings have highlighted a need for adolescentfriendly SRH services in GB, Pakistan. The fact that the adolescent population prefers friends and the internet as a medium for accessing SRH-related information rather than healthcare providers needs close attention. This populace must be given access to accurate knowledge about the SRH services and provided the autonomy to make informed choices to foster the SRH needs of the adolescent population. The adolescent population must be empowered to identify their SRH needs and attend to those needs regardless of their age, gender, and marital status.
Given adolescents' social and biological vulnerability to high-risk sexual behaviors, STIs, and less access to SRH services, it would be prudent to access appropriate sexual health services before they become sexually active. Healthcare providers should consider developing age-appropriate outreach models to reach young people and provide appropriate age-related SRH education, information, and decision-making skills. There is a need to inform all young people on the types of sexual health services available in their community, confidentiality policies and legislation, navigating the health care system, and the location of linguistically accessible services. There is a strong need to introduce capacity-building programs for teachers related to comprehensive sex education and how they can integrate the aspects of sexual health education into their teaching methodologies and practices. In addition, it is important to involve parents in providing sexual health education to young people. Healthcare providers should give parent-focused programs that can raise parents' awareness of the importance of SRH for their young children. In addition to this, there is a need to formulate robust interventions and strategies to raise knowledge and awareness about SRH needs. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions. Adopted from: Toronto teen Survey [35] Thanks so much for filling out our survey! 11. Health-care providers use evidence-based protocols and guidelines to provide health services. Please indicate whether you use protocols and guidelines at your health facility for the following health services: a. Information and counselling on reproductive health, sexuality and safe sex b.
Testing and counselling services for HIV c.
STI/RTI diagnosis d. Pregnancy diagnosis d.
Treatment for STIs/RTIs e.
Care during pregnancy f.
Care during childbirth g.
Care after childbirth h.
Abortion services (where they are legal) i.
Information and counselling on contraception, including emergency contraception j.
Information and counselling on condoms k.
Care and support to HIV-positive adolescents l.
Care and support to adolescent clients who have been physically or sexually assaulted m.
There are NO protocols or guidelines available to provide these health services to adolescents at my health facility.
12. Health-care providers are able to dedicate sufficient time to work effectively with their adolescent clients. In your opinion, do you think you have enough time for your consultations with your adolescent clients? 13. Do you think health care providers should be trained to provide sexual and reproductive health services to adolescents in your community? Thanks so much for filling out our survey! Adopted from: WHO Quality assessment guidebook [15].