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Indian Journal of Community Medicine

Vol. 26, No. 4 (2001-10 - 2001-12)

Editorial

Editorial - Reaching Adolescents for Health & Development

Sunder Lal Prof. & Head

Deptt. of SPM Pt. BDS PGIMS, Rohtak

Adolescents represent about a fifth of India's population. Second decade of life (10-19 years) is a crucial decade of life cycle. During this phase of growth and development, most significant changes occur which need the supportive environment of family, teachers, community, health personnel and peer groups.

The health needs of the adolescents have seldom been addressed. National Family Health Survey data revealed that over 50% of girls marry below the age of 18, the minimum legal age of marriage for women set by Child Marriage Restraint Act of 1976, resulting in a typical reproductive pattern of "too early, too frequent and too many"1. Teen-age pregnancies being high-risk pregnancies result in unsafe abortions, low birth weights and high maternal morbidity and mortality. The age group 15-19 contributes 19 per cent of total fertility in India1. Highest unmet needs for contraception have been reported in the age group 15-19 years. Around 30% of adolescent girls and 18% of boys suffer from malnutrition. Several studies show varying levels of premarital sex among male and female adolescents. The median age of initiation of sexual debut is 15-16 years. Ambient attitude, lack of information on HIV/AIDS and sexually transmitted infections, as also substance abuse can promote high-risk sexual behaviour among young people. Around 40% of HIV infection is centered around teenagers.

Though as many as 27 beneficiary oriented programmes for women were launched in rural and urban areas between 1975-85 (United Nations Decade for Women) but adolescents group was covered marginally2. Women and adolescents in rural area are too busy and their workload is tremendous, home visits and contact with adolescent girls is limited, no organized adolescent group exists for regular contact. School health programme is weak. Vocational training programme and income generation activities attracted most adolescent girls and were far more rewarding than literacy activities launched as an experiment to empower young girls (1989-91) but nothing worthwhile in the form of a programme has come up on the ground. ICMR interventional programme of two years for adolescents in rural areas could achieve marginal success on mothers' perception, awareness, attitudes and ambitions about their daughters in respect of menstruation, ideal age of marriage, health risks associated with early marriage and child birth and food distribution within family. Similarly, interventions through school health services have made half hearted efforts3.

A little less than half (48%) of mothers felt that their daughters could study as long as they desired. About one third of mothers considered that literacy levels of 9th or 10th standard were good enough and barely 2.4-6.2% of mothers desired that their daughters should attain graduation and post graduation level. Illiteracy level of 43% amongst girls aged 13-21 years was distressingly quite high (1991). Most common reasons for not favouring higher education for girls included; economic considerations/ compulsion using girls for household and economic activities; prefer to marry them at young age and no facility for higher education within the village.

While most daughters (93-96%) were found to communicate with their mothers in respect of their daily needs of life, only 15% of the mothers talked to their daughters on the subject of menstrual cycle. Over 66-73% of mothers in different villages either felt shy to talk on this subject or felt that their daughters were too young to be talked about on this issue. Opinion for nutritious food distribution within the family did not find favour for female children and adult females as they ranked at the bottom, which corroborated with real practice as well. The response of equal food for all appeared to be socially acceptable response and should be considered as deceptive statement. Though 50-60% of mothers favoured marriage of their daughters above the age of 18 years but in practice over 67% of marriages occurred below 18 years of age. Paradoxically, though 73-82% of mothers in different villages knew the health risks associated with early marriages, yet 67% of marriages occurred below the age of 18 years in rural settings. Only 53% of mothers were aware of legal age of marriage3.

The bold initiative taken by the Department of Women and Child Development in 1991-92 to include 11-18 years below poverty line school drop out girls and girls deprived of school enrolment into ICDS programme in 507 blocks of the country, was a landmark in adolescent health4,5. The objectives of the programme were to improve the nutritional and health status of the girls, to provide them the required literacy and numeracy skills through non-formal stream of education, to improve and upgrade their home based skills as also to build awareness on health, hygiene, nutrition, family welfare, age of marriage, child care etc. Anganwadis and Mahila Mandals were the key institutions, identified to achieve these objectives. The anganwadi centre was the focal point for delivery of all the services and building capacity of adolescents for 6 months programme. The adolescent girls scheme was implemented through two sub-schemes viz. girl to girl child approach for 11-15 years belonging to below poverty line and Balika Mandal Scheme for the age group 11-18 years irrespective of income level of family.

The girls in the age group 11-15 years were identified and attached to one anganwadi centre for a period of six months. In each six monthly round, the three girls received instructions and learnt through participation. Simple and practical messages on preventive health, hygiene, nutrition, working of anganwadi centre and family life education were given through an initial three days training programme followed by six continuing education sessions of one day each every month. These girls participated in the activities of anganwadi centre for two days a week and got supplementary nutrition six days a week. Under the Balika Mandal Scheme, 20 girls in the age group 11-18 years were identified and were enrolled for a period of 6 months. Anganwadi was the focal point for development of these girls. Anganwadi workers acted as instructors and role models for these girls. These girls were provided with supplementary nutrition, besides learning about personal hygiene, environmental sanitation, nutrition, home nursing, first aid, communicable diseases, family life, child care and development and constitutional rights and their impacts on the quality of life. Training on vocational skills was also arranged apart from creative activities as also learning through sharing of experiences. It was envisaged that intersectoral coordination will be generated to fulfill the objectives of the scheme.

The evaluation of adolescent scheme was conducted by NIPCCD. The research findings indicated lack of uniformity in implementation of the scheme. The major thrust was utilization of services offered at anganwadi and the exposure was confined only to anganwadi centre rather than building self esteems and personality development. Intersectoral coordination was weak and mothers/parents were seldom involved in the programme. Anganwadi workers were inadequately trained to act as effective instructors and monitoring was of poor quality. A large number of anganwadi workers were apprehensive of involving adolescent girls in the functioning of anganwadi centres4. Inspite of these weaknesses ICDS created a formal institution for adolescent girls and provided a framework for involvement of NGOs and bilateral agencies for development of adolescent girls. Encouraged from the results of this experiment, the programme was expanded and now the programme covers 2000 blocks of the country taking care of their nutrition, health and education/training needs.

Addressing the problems of adolescents through curricular activities in schools and colleges is a challenge indeed. Curricular and extra curricular activities (NSS) have achieved better results. Universal elementary education lays foundation for secondary education. After the formulation of new policy on education in 1986 (revised in 1992), the education has been diversified. Areas like vocationalization of education, distance education, education technology (computer and internet technology in education) and teachers training programmes hold much more promises to communicate with adolescents on varied and wider issues. Impact of communication through curriculum will be much more focused and sustainability is undoubted. System of private schools has earned much reputation and their involvement can make all the difference.

Adolescents out of schools can be reached through non-formal education system. Total literacy campaign (TLC) targeted at age bracket 15-35 proposes to cover 5 crores adult population in Xth plan period. Past experience of TLC has shown very good results but post literacy campaign and follow-up action has been a weak area6.

Present day school health programme for adolescents is limited to tetanus immunization at age 10 and 16 years and some efforts to provide iron and folic acid tablets to adolescent girls besides cursory health checkup without any purpose. Health workers and supervisors including medical officers have failed to evolve a meaningful school health programme for adolescents. With the implementation of RCH programme the capacity of health teams on reproductive health of adolescents has been built up through in service training. It is distressing to observe that these health teams have not initiated any worthwhile activity on the critical areas of reproductive health needs of adolescents. Similarly, basic initial training programmes and curricula have not incorporated the component of adolescent health. Health information system (routine records and reports) does not have any built in information on reproductive health of adolescents. Health sector should select a few themes such as prevention of anaemia and malnutrition, reproductive cycle, menstrual cycle and hygiene, age of marriage and child birth, risk of teenage pregnancies, prevention/control of RTI/STI (HIV/AIDS), voluntary blood donation, contraception, unsafe sex and unsafe abortion etc. for effective coverage in the schools of their jurisdiction. This should be done in consultation with school teachers, parents and Panchayati Raj Institutions as also students. These areas should be covered by student-to-student programme on regular basis. Health teams and teachers could act as preceptors and guides.

National AIDS control programme has focused IEC activities to build awareness among youth and college students. National AIDS control programme in India has produced a training package titled "AIDS Education in Schools". The training package advocates co-curricular and extra curricular activities, since integration of AIDS education in the school curriculum would have taken much longer time. The package was introduced in 17 states and U.T.s in secondary schools but only half of the projects started in right earnest. Some elementary aspects of HIV/AIDS have been included in the NCERT textbooks. The programme reached mainly to urban schools, rural schools were not covered. The teachers shy away from talking sexuality and reproduction in view of tradition and cultural sensitivity of society. It brought out that teachers preparation and training and advocacy among parents are of crucial importance.

University Talk AIDS Programme was launched way back in 1991 for creating awareness on HIV/AIDS among students and youth in schools, colleges and universities, 3.5 million students have been made aware about AIDS and 4044 institutions have been covered. This massive programme built favourable attitudes for voluntary blood donations as also prevention against AIDS. The credit goes to the department of Youth Affairs and Sports, Ministry of Human Resource Development and National Service Scheme (NSS). The NSS has brought out manual in 7 languages for students on AIDS and sexuality to serve as learning resource material. The critical comments on AIDS education in school and colleges are that the programme focuses on urban youths and the spread effect of AIDS knowledge through youths was limited to college and schools only.

Evaluation surveys in many parts of the country revealed different story altogether, as the major sources of information to youth and adult population on the issues of HIV/AIDS were television and radio as also print media. Students and health workers were mentioned as sources of knowledge only by 25% of the adults. Teachers were not at all mentioned as source of knowledge and students' peers were seldom mentioned as source of information. Phase II of National AIDS Control Programme envisages covering all the schools in the country targeting students of class IX and XI through school education programme and all the universities through University Talk AIDS programme. The adolescent health communication should be integrated with this programme.

Family health awareness campaign is yet another attempt to reach 15-49 years population to generate awareness and provide services delivery for control of STI/RTI infections in rural areas. The major attempt was inter personal communication by health team to communicate effectively the messages on RTI/STI including HIV/AIDS. However, adolescents were left out of the purview of the programme. Messages were delivered at family level and adolescents had access to printed information (card) but no discussions were held with adolescents.

Govt. of India recognized adolescents as vulnerable group and intended to improve the outreach services for vulnerable groups of population who have till now been effectively left out of the planning process. Reproductive and Child Health Services (RCH) would take up special programmes for urban slums, tribal population and adolescents by involving non governmental organizations, practitioners of Indian system of Medicine, Panchayati Raj Institutions besides government health and development system. RCH makes the beginning of initiating health programmes for adolescents. National population policy 2000 has identified adolescents as under served population group7,8.

Adolescent health programmes and policies are fragmentary and work in isolation. The Reproductive and Child Health Programme and National Population Policy 2000 and Health Policy 2001 intend targeting adolescent group for definite programmes. Ensuring for adolescents access to information and services, including reproductive health services needs concerted efforts to strengthen primary health centres and subcentres to provide counselling. This requires reorientation and training of health staff under RCH, especially on the issues related to adolescents. Under RCH programme health workers, supervisors and the medical officers have been imparted in service training, as to how to address the problem of adolescents in urban and rural areas. It has been observed that after the training programme the activities for adolescent health have not yet taken off, however, it may be too early to draw such conclusion because of recency of the programme. Communication with adolescents on sensitive issues like sexuality, reproduction, sexually transmitted diseases, age of marriage and child bearing etc. requires good communication skills. Definite programme for adolescents needs to be evolved in primary health care set up to address their problems. Regular contacts with adolescents through school health programme can be one approach and teachers training programme can be quite rewarding. Similarly, peer training programme and student to student approach pays rich dividends as demonstrated through the results of various research endeavours. Learning resource material for adolescents in local languages tends to be inadequate or not available, it needs to be produced locally for wider dissemination.

Issue of adolescent girls and boys needs to be addressed separately, self help groups in rural areas, NGOs and voluntary organizations apart from public sector can be most effective. These should strive for:

  • universalization of education for girls.
  • Expansion of ICDS to include children between 6-9 years of age specifically to promote and ensure 100% school enrolment particularly for girls. Promote primary education with the help of anganwadi workers, ANM, gram sevika and encourage retention in school till 14. Education promotes awareness about late marriages, small family and quality of life.
  • Vocational training of adolescents in schools and out of school will further enhance the capabilities of girls as also enrolment and retention in school.
  • Providing adolescents the nutritional services of supplementary nutrition, nutrition education and nutrients under the expanded programme of ICDS.
  • Promote formation of Balika Mandals (organized adolescent girls) through ICDS, which could act as youth wing of women group as a distinct entity. Community or government should encourage such activities through regular funding on the pattern of Mahila Mandals.
  • Teachers training programme on adolescent health and development should be undertaken on massive scale in the next three years. Male and female teachers to address the problems of boys and girls separately.

Adolescent health and development is primarily a communication strategy to ensure all adolescents have access to information and counselling services. National communication strategy for RCH programme clearly focuses on adolescents' reproductive health. The strategic framework for health communication among adolescents which will facilitate responsible behaviour, includes increasing knowledge and awareness on Reproductive Health issues and delayed age of marriage. The key tenets of the strategy for behaviour change are interpersonal communication, advocacy interventions by use of mass media, decentralization for IEC to states and districts, increased involvement of NGO and private sector and capacity building at all the levels9.

Information, education and communication needs of adolescents require urgent attention through mass media, interpersonal communication and formal and informal education system. Area specific material on IEC in local languages needs to be developed for effective communication and action with active support of parents and community to inculcate moral values and responsibilities of adolescents towards their village and community besides self care and development.

Indian Association of Adolescent Health as an institution promotes the activities of adolescent health in the country by organizing continuing education for life members, developing IEC material and advocacy for adolescent health. However, the activities and impact have been of limited extent.

  • Adoption of schools by NGOs in different areas more so in rural and urban slum area for generating awareness amongst adolescents.
  • Girls out of schools could be covered through ICDS model as also through education programme.
  • Strengthening of primary health centers and subcentres in terms of educational material and services for adolescents in the next plan period. It could be clinic for adolescents on fixed days and days fixed for school health and regular meetings, say once a month with adolescents on the pattern of Mahila Swasthya Sanghs. Subcentre monthly monitoring report should have regular information on coverage and quality of services provided to adolescent boys and girls. This step is essential to have accountability and judge the performance standards with a view to improve services for adolescents.

Registration of marriages and age of girls at marriage should become a routine record with subcentre to enforce the child marriage restraint act (1976) with a view to reduce the incidence of tenage pregnancies and preventing marriages of girls below the legally permissible age of 18.

Similarly, the annual campaigns of family health awareness camps (FHAC), which is a nationwide activity, should focus on adolescent girls to build awareness on reproductive health. FHAC and RCH should be integrated, as isolated activities will not have much impact. Adolescents must be included or targeted in the programme of FHAC as a national strategy to prevent and control HIV/AIDS.

School health programme should address to the needs of adolescent boys and girls in a meaningful manner. Distt. school health programme should be restructured, hitherto approach of detection of defects through periodic medical check-ups should be done away and sound awareness programmes on relevant issues should be addressed with focus on action, group demonstration, peer group involvement and preparation of relevant communication material. Health education activities of PHC under primary health care should focus on the needs of adolescents in an organized manner.

Women development functionaries in rural areas like Gram Sevikas, Mukhya Sevikas should take the responsibility to organize adolescent group alongwith Mahila Mandals to generate awareness among rural adolescents. Similar tasks can be entrusted to female volunteers of national service scheme in urban slums as also some adopted villages. Mahila Swasthya Sanghs (organized women groups) fora in rural areas could take up this honorous task in rural areas and health workers female and anganwadi workers could act as group animators.

Experiences of different models of adolescent health and development should be disseminated in the form of case studies and bulletin to replicate the same in totality or with some modifications in different regions of the country as one uniform strategy for our country may not be suitable.

Different sectors like Health and Family Welfare, Women and Child Development, Education, Social Welfare, Human Resource Development, Youth Affair and Sports and Information and Broadcasting to address one or the other component of adolescent needs but these tend to work in isolation. These programmes and efforts need to be integrated in terms of finances and other resources. Best way to integrate is through institutional mechanism of schools and non-formal system of education.

Applied and action research in the field of adolescent health is another area where lot remains to be done. Rural and urban models of adolescent health, different intervention models, multi sectoral and integrated approach, women organization and adolescent health, school system and non formal education model for adolescents are some of the areas which can be taken up for action research programme.

References:

  1. India. National Family Health Survey (NFHS-2) Key findings. International Institute for Population Sciences, Govandi Station Road, Deonar, Mumabi, India.
  2. Programmes and functionaries reaching women. Indian Women in Development, NIPCCD Bulletin Vol 2 No. 7 & 8 July-December 1989. New Delhi.
  3. Lal S. Mother's perception and ambitions about their daughters in rural areas. IJCM 1992; XXII (1): 22-8.
  4. Schemes for adolescent girls launched. NIPCCD news letter. National Institute of Public Cooperation and Child Development, New Delhi 1991; 12: 4-6.
  5. Adolescent girls' scheme - an evaluation. National Institute of Public Cooperation and Child Development (NIPCCD). Published by NIPCCD 5, Siri Institutional Area, Hauz-Khas, New Delhi - 2000.
  6. Government of India. Ninth Five Year Plan 1997-2000. Volume II. Thematic issues and sectoral programmes. New Delhi: Planning Commission; 1997.
  7. Government of India. National communication strategy for reproductive and child health project. New Delhi: Ministry of Health and Family Welfare.
  8. Government of India. National policy for the empowerment of women 2001. Department of women and child development. New Delhi: Ministry of Health and Family Welfare; 2001.
  9. Green ME. Population council south and east Asia "Watering the Neighbour's Garden. Investing in Adolescent Girls in India. Regional working papers No. 7, New Delhi 1997.

Sunder Lal
Prof. & Head, Deptt. of SPM
Pt. BDS PGIMS, Rohtak

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