Accessibility to reproductive health rights among adolescents in three provinces of Thailand

Purpose – The purpose of this paper is to assess the situation of accessibility to reproductive health rights, and the conditional factors of accessibility to such rights of adolescents. Design/methodology/approach – A qualitative method was used to extract information from 80 informants. Data were collected through in-depth interview, focus group discussion, observation, data recording, audio recording and the review of related documents during August to October 2016. Findings – Adolescents had not accessed to their right on informing of their decision making; information and education; health; confidentiality and privacy; and treating with equity and no discrimination. Also, the conditional factors influenced to the accessibility on such rights were lacking of knowledge on reproductive health and negative attitude toward this matter among the people concerned. There were still no regulations or policies on the performance of authority agencies and the factors on social dimensions, traditions, customs, sexual culture and religion. Originality/value – The findings from this study would be a help to promote the accessibility for adolescents to reproductive health rights under the Prevention and Solution of Adolescent Pregnancy Problem Act, B.E. 2559 (2016) specific on standard criteria reproductive health services from hospitals and the involvement from Ministry of Education for the development of sex life skill and reproductive health for the teacher.


Introduction
Thailand is facing an adolescent pregnancy problem; threats of live births among female adolescents aged 15-19 years increased from 50.1 per 1000 in 2008 to 51.2 per 1000 in 2013 [1].Thai authorities have tried to adopt various measures to prevent and solve the adolescent pregnancy problem but the rate of adolescent pregnancies remains high.The major cause of the adolescent pregnancy problem was that previous measures used to prevent and solve the problem did not focus on reproductive health rights at all.As a result, adolescents had limited access to reproductive health rights, which included reduced knowledge of: the right to make informed decisions; the right to access information and education on the subject; the right to health in terms of attainable reproductive healthcare and relevant social welfare services; the right to enjoy confidentiality and privacy; and the right to be treated equally and without discrimination [2].
In response to the above, Thailand developed legal measures by enacting the Prevention and Solution of the Adolescent Pregnancy Problem Act, B.E. 2559 (2016) to promote accessibility to reproductive health rights among adolescents [3].In order to drive the implementation of this Act at local level, there was a need to have the body of knowledge in place, particularly in relation to accessibility to reproductive health rights in accordance with this Act.This knowledge would serve as the preliminary data for the authorities concerned in developing suitable measures to promote accessibility to health rights among adolescents in accordance with this Act in a manner that was directly related to the actual problems found in each region of Thailand.It was clear from literature reviews that there were still some limitations faced by the target group in some areas under the Act [4][5][6].
In response to this, the researchers were inspired to assess the situation of the accessibility to reproductive health rights among adolescents, and study the conditional factors that affected their accessibility to five core aspects of their rights.The decision was made to focus on the local context by recruiting interested subjects from each chosen site.By promoting accessibility to reproductive health rights among adolescents, it would be possible to assess and further promote the government initiated Act that would further contribute to an achievement of the Sustainable Development Goals [7].

Study design
This was a naturalistic inquiry-based qualitative research study.

Contexts of study sites
Study sites included Kabinburi district in Prachinburi province, a major base of petrochemical industry; Wangnamyen district in Sakaeo province, a major base of agricultural industry and farming; and Makharm district in Chantaburi province, a major base of agricultural farming.These provinces were in the catchment areas of Area Health 6, where the adolescent pregnancy problem ranked among the highest in Thailand.

Informants
The researchers purposively selected 3 groups of 80 interested informants from the government and non-government sectors focusing on the members of the community who have experience of problems with adolescent pregnancy.Group 1 consisted of administrators, nurses and psychologists in hospitals; administrators and teachers in schools; executive and academic officials in local administrative organizations; administrators, social workers, social development officers, juvenile protection officers in social development and human security offices; and administrators, heads of section and nurses in workplaces where adolescents were employed.Group 2 comprised of adolescents seeking services at hospitals, those attending classes in schools, those employed in workplaces and those serving as staff members of children and youth councils.Group 3 comprised of parents of adolescents in the community.

Data collection
The researchers collected data through in-depth interview, focus group discussion, observation, data recording, audio recording and the review of related documents such as the performance report of the implementation.Validation of data was carried out by employing a cross-verification technique (Triangulation) from various sources including interviews, observation, on-site data recording and double-checking against all relevant documents.The data were collected until saturation during August to October 2016.

Data analysis
The researchers searched for the statements that implied or indicated the studied phenomena; interpreted or gave a meaning to such statements; and classified the statements with similar meanings into the same category of topics.Then, the researchers wrote down the detailed description of the phenomena in each topic.By doing so, any irrelevant data were excluded.The details of all phenomena were consolidated together for further analysis and synthesis to obtain a thorough understanding in accordance with reality.

Ethical consideration
This study was approved by the Mahidol University Research Ethics Committee (No. 2016/307.0908)on August 9, 2016.The researchers committed to protect the confidentiality and process of informed consent under the rule of research ethics.

Results
The study results were as follows.

The situation of accessibility to reproductive health rights among adolescents
The right to make informed decisions.Hospitals did not have any policy allowing adolescents to make a decision by themselves to use a semi-permanent contraception method or to undergo a safe termination of pregnancy.Prior consent from parents was required of each participant.However, the administrators, nurses, adolescents and parents agreed that adolescents should have the freedom to make decisions on their own to use a semi-permanent contraception method.On the other hand, the opinions about the rights of adolescents to undergo a safe termination to pregnancy remained controversial.Administrators, service providers and parents disagreed with this idea, as reflected in the following statement: I do not agree that adolescents should be allowed to make decision themselves to undergo an abortion.They are not yet mature so consent from parents should be required.(A parent in the community) However, the opinions of adolescents were different from those of administrators, service providers and parents.They agreed with the idea that they should have the right to make their own decisions on this matter, as reflected in the following statement: Termination or continuation of the pregnancy […] It is my own right to make a decision.It's my life; so there is no need to tell my parents.(An adolescent seeking service at a hospital) The right to access information and education.In spite of schools having employed a policy to teach sex education in classes, the topic was not assigned as a separate and specific subject but integrated as part of health education and physical education.Because the teachers were consequently appointed to teach health education and physical education, they did not necessarily have the required experience and skills to teach sex education.This is consistent with comments from a group of students reporting that their teachers did not have any helpful teaching techniques but only went through the contents contained in the books.These were reflected in the following statements: My teacher just taught us following the contents provided in the book.(Adolescents in school)

Accessibility to reproductive health rights
Also, the content of sex education did not cover semi-permanent contraceptive methods that were suitable for adolescents in preventing a repeated pregnancy despite the fact that the rate of repeated pregnancy is currently very high.In some schools, the distribution of condoms or the installation of a condom dispensing machine was not allowed.This is contrary to the fact that using a condom could help prevent pregnancy, sexually transmitted infections, and HIV/AIDS.Despite the school policy to adopt and manage a system to provide assistance to students who became pregnant, most pregnant students decided to drop out of the school permanently and chose to continue their education following the non-formal education system, in which the duration of the study was flexible, allowing them to have time to raise their baby as well as earn a livelihood.This is reflected in the following statement: Yes, some schools allow the pregnant students to study but they chose to drop out.(An adolescent in school) If they are of school age, most of them will not go back to study at the same school.They will study through the non-formal education program instead.(An academic officer in the local administrative organization) Workplaces were found to have a policy for providing education to all employees about methods of birth control; however, through interviews with adolescent employees, some of them reported that they had not been provided with knowledge about contraception.
The right to health in terms of attainable reproductive healthcare.The service delivery in adolescent clinics had been accredited for standards.However, these clinics opened during office hours from Monday to Friday which are also school days making it unsuited to the needs of adolescents attending school.As a result, most adolescents did not avail themselves of the services on offer but only attended when they became pregnant and wanted to terminate their pregnancies.According to interviews with service providers, some hospitals had not set up any services for the safe termination of pregnancy.The result was that in the case of most pregnant adolescents who were from poor economic backgrounds, they were unable to afford the cost of attending a health facility that provided services for a safe termination of pregnancy, and might have to find a place for terminating their pregnancies elsewhere, which might be unsafe, as reflected in the following statement: If adolescent asked for termination of pregnancy, we provide optional counseling before referring them to another hospital in the province.(A nurse in a hospital) Regarding the pharmaceutical products for contraception, service providers reported that some hospitals had not purchased any products for semi-permanent contraception.The variety of contraceptive supplies was not diverse enough to meet the needs of adolescents.
Also, the number of healthcare workers who were knowledgeable and skilled at performing a semi-contraceptive maneuver was limited and did not meet the demands.The interviews with service providers and adolescents revealed that most adolescents attended an antenatal clinic after several months of gestational age because they were afraid to tell their parents and/or did not have any knowledge about their pregnancy.This suggests that they did not have access to proper knowledge and information about pregnancy.
Furthermore, the pregnant adolescents attending antenatal clinics in some hospitals were migrating workers from a neighboring country; so both the service providers and clients had a problem with communication.The delivery of reproductive health services in a workplace had a counseling service available for all employees.However, from the interviews with service providers and adolescent employees, the delivery of contraceptive services in the workplace did not cover all methods of contraception.
Regarding access to social welfare services related to reproductive health, the findings showed that a policy had been adopted for encouraging and supporting the Children and Youth Council of Thailand to organize educational activities and develop the leaders of the youth and children in local areas.The surveillance of problems among adolescent mothers and the provision of care and assistance were implemented by making a home visit to adolescent mothers in each local area studied.However, operational workers reported that the "family development centers" and "the Children and Youth Councils" only existed in some sub-districts; and the term of office for the volunteers in the Children and Youth Council was only two years, which was too short for ensuring the continuity of the work related to social welfare services for the prevention and solution of adolescent pregnancy problems, as reflected in the following statement: I think, the term in office of the volunteers in the Children and Youth Council is too short.The first year is for learning, and the second year is for learning to do the work; then you have to leave or finish your term.You have not been able to contribute any considerable or tangible improvement to processes at all.(A member of the Children and Youth Council) Furthermore, at district level, there was no designated agency responsible for coordinating and operating a referral network, despite the fact that the allowable period of stay in a temporary shelter for pregnant adolescents (and families) was too short and not exceeding three months for each case.
The right to enjoy confidentiality and privacy.The study found that hospitals emphasized the importance of maintaining the confidentiality of their clients.However, according to the interview with service providers, the process of service delivery for adolescents consisted of many steps; hence, it might not be possible to maintain confidentiality and privacy.Also, the counseling services for pregnant adolescents were conducted together with the other adolescents in general; so the pregnant adolescents felt reluctant to disclose their status because the counseling room was not separated in favor of privacy, as reflected in the following statement: More process for receiving a counseling here.The place is not comfortable and includes many people.I'm not sure whether my secret could be kept confidential […].(An adolescent seeking service at a hospital) In schools, counseling services were given in a classroom and the topics related to counseling were primarily related to the issues of learning performance; and did not specifically cover the issue of students' sexual behavior at all.Separate counseling rooms in favor of privacy were not available.These were reflected in the following statements: There is no separate room for exclusive counseling on this issue (the sexual problems of adolescents).We have to share the common room for counseling with other general problems.The room doesn't look welcoming at all […].(An adolescent in school) The right to be treated equally and without discrimination.In general, adolescents who terminated their pregnancies, and were still studying at schools, had been stigmatized as a bad or spoiled person.But in fact, most pregnant adolescents were adolescents who focused on their study and had not kept up with the complicated situations of society.They were therefore lacking in the knowledge and skills relevant to the prevention of pregnancy.The interview with related workers and students revealed that in most reputable schools, the administrators would worry about the reputation of the schools, as reflected in the following statement: Some factors are that the administrators are always concerned about the bad reputation for the school.(A nurse in a hospital) Also, people around the pregnant adolescents such as teachers and friends were lacking in support and expressed detest for their condition.In some instances, parents and the school Accessibility to reproductive health rights community would not accept pregnant adolescents who were still studying.This resulted in pressure on the adolescent to drop out of school before completing their studies.Once they quit school, the local community stigmatized them further by blaming them for losing their opportunity to be educated due to their pregnancy.In other cases, shopkeepers in convenient stores tended to show their disapproval of adolescents who purchased condoms from them making the adolescents feel self-conscious: People in the community still stigmatize the adolescents who were pregnant and those who underwent an abortion; seeing them as a bad person, and being of the opinion that their parents did not teach them well […].(A parent in community) When adolescents went to buy condoms at the store, some shopkeepers looked at them thoroughly from head to toe.So, the adolescents felt reluctant to go and buy a condom there […].
(A nurse in a hospital) Conditional factors regarding accessibility to reproductive health rights Personal factors.With regard to knowledge and skills, it was found that teachers were not prepared to teach sex education.They did not have any teaching techniques to attract the students' attention.Teachers, parents and adolescents did not have knowledge and understanding about the rights of students.As a result, they were incapable of working out how to organize a comprehensive teaching and learning process of sex education.The administrators in business entities were not aware of nor had an understanding of the Prevention and Solution of the Adolescent Pregnancy Problem Act.With regard to attitude, it was found that the majority of school administrators, teachers, parents, the community and society had a negative attitude toward adolescent students who got pregnant.Also, it was unacceptable to distribute condoms or have a condom dispensing machine in schools.
Structural factors.The applicable laws and policies of hospitals were not favorable to adolescents regarding their access to reproductive health rights regarding the freedom to make informed decisions.With regard to social dimensions, traditions, customs, sexual culture and religion, there were problems regarding broken families; the values of families and society in general where they objected to the idea of birth control methods and declined to accept adolescent pregnancy during school age; and the social norm defining that sexual matters should not be openly discussed.However, adolescents did not see sexual matters and pregnancy as a problem but as a natural occurrence.Also, Thailand is a Buddhist country where most healthcare workers believe in the law of karma.As a result, they were reluctant to provide pregnancy termination services to adolescents.

Discussion
Adolescents found it difficult to exercise their rights because regulations governing hospital policy did not support adolescents to make their own decisions regarding pregnancy termination and required parental permission instead.This is consistent with previous research relating to barriers to reproductive health service and rights being caused by the lack of explicit legislation on getting safe pregnancy termination.Similar studies found legislation and policy that required parental approval for getting reproductive services as well as policies that reduced access to contraceptive methods [8,9].Also, pregnancy termination is a sensitive issue impacting on culture, belief and religion, which, in turn, impacted on access to rights for reproductive services including abortion.This is consistent with the study of Chaba Chaichest in 2002 [10] and Renu Chunin and Wanapa Naravage in 2015 [11] and remains an ongoing challenge.
Despite the right to access information and sex education, and despite the fact that assisting and protecting students who got pregnant was part of the government system, some schools had asked their pregnant pupils to drop out of school, thereby depriving them of their right to be treated equally and without discrimination.This was compounded by the stigmatization by administrators and teachers, the fear of losing the good reputation of the school involved, and the failure of the community and parents in opening their minds enough to accept any adolescents who got pregnant while studying and allow them to continue their study further.Another contributing factor was related to the sexual values among parents who thought it was unacceptable for adolescents who had engaged in a sexual relationship and got pregnant during their schooling to continue with their school education.This is consistent with the literature where it was evidenced that barriers to reproductive health service and rights were increased by society [6,8].
The problem concerning the accessibility to the right to health still exists.The access to reproductive health services provided in adolescent clinics was hindered by the fear that their secrets would be disclosed.This was consistent with the findings of a study on "the accessibility to the right to joy, confidentiality and privacy" which revealed that the counseling service was not favorable enough to secure the confidentiality of adolescents.Hence, they felt reluctant to seek the counseling services and ultimately sought antenatal care when they were advanced in their pregnancy due to the fear of disclosing their secret pregnancy.This is consistent with the literature, barriers to reproductive health service and rights regarding the lack of privacy and confidentiality [9,12,13].

Conclusion
This qualitative study was conducted to describe the situation of accessibility to reproductive health rights and the conditional factors of accessibility to such rights among adolescents.An in-depth interview method was used to collect the data from 80 informants.The results illustrated that some problems still exist regarding accessibility to the five aspects of reproductive health rights among adolescents.The conditional factors hindering the accessibility to these rights included knowledge and negative attitudes among administrators, operational workers, parents and adolescents; and not systematically applying the laws and policies of authorized agencies due to social dimensions, traditions, customs, sexual culture and religion.
Therefore, the concerned sectors should make more effort to promote accessibility to reproductive health rights among adolescents by the measurement of law/policy provided to adolescents.By doing so, they can then make their own decisions regarding contraception use and pregnancy termination as well as have better access to social welfare and reproductive health service.In order to develop a comprehensive sex education program that includes the correct education techniques and skill in education on reproductive health rights for adolescents in the context of their community, it is important to ensure the confident, positive thinking attitudes of adults and peers with due respect for beliefs and culture of the community.This would then result in the promotion of reproductive health rights literacy among adolescents.
This research was completed in a selected area comprising of three provinces.It is not an accurate representation of the whole country.It is therefore advisable that the next step for future research should be to implement this study across the country.