Overview of Adolescent Health in India
I would like to start my writing with three stories having a similar ending. Story #1 is of Reshma, who is a rural adolescent. The story #2 is of Neena, who is an urban adolescent and she is experimenting sexually. The story #3 is of Chetan, who is an urban adolescent boy.
Now, let us come to the ending which is similar, and the end is death. I will start in reverse order. Chetan died at the age of 18 due to myocardial infarction. Neena died because of the complications because she went for abortion to an RMP. Reshma, she also died because she was carrying the existing anaemia, which precipitated a lot of complication and the result was death. All these events are the example of system failure, the system which is insensitive to the needs of the adolescent. I say adolescents have got disadvantages. They have got the double disadvantage.
- They carry the burden of pre-existing diseases of the childhood.
- They are developing rapidly and having an extreme degree of pressure from peers, from parents, from society, and self. They lack knowledge and skill to cope up with pressure.
Adolescent has been defined by WHO as the period of life spanning between 10-19 years and the youth as between 15-24 years. Young people, when referred to as such, are those between 10-24 years of age. They are no longer children, but not yet adults.
Population Profile: Ages 10-24 Years India
|Population age: 10 - 24 (Millions)
|10 - 24 years as % of Total Population
|%Males enroleld in Secondary School
|%Females enrolled in Secondary School
|Average age at First Marrige
|Total Fertility Rate
|%TFR contributed by 15-19 yrs
|% Using Contraceptives
India is a big country with diverse conditions:
- 5,000-year-old civilization,
- 325 languages spoken - 1,652 dialects
- 18 official languages,
- 29 States, 5 Union Territories
- 3.28 million square km- area
- 7,516 km - coastline
- 1 billion people in the year 2000 and
- 207 million adolescents.
Similarly, adolescents, they are a very diverse population segment because (1) they are in the different stages of development. They may be in the stage of early, mid, or late adolescence. (2) They are living in different circumstances i.e. they may be living in urban area or in rural area or in slum area or they may be street children and those living in specially different circumstances. They may be married adolescents, they may be unmarried adolescents. (3)They have different needs and (4) they have diverse problems.
Now the question which comes to the mind is why should we focus on adolescents?
- Because of the shear number; they constitute more than 22% of the population.
- Adolescence is the period of rapid physical growth, sexual and psychological changes.
- Habits and behaviour picked up during adolescence (risk taking behaviour, substance abuse, eating habits, conflict resolution) have lifelong impact.
- Adolescence is the last chance to correct the growth lag and malnutrition.
- Many adolescent boys and girls are sexually active but lack information and skill for self-protection (low level of information on Family Planning, low contraception use)
- They have simple but wide pervading crucial reproductive health needs- menstrual hygiene, contraception (including emergency contraception) safety from STI and HIV and
- Communication gap exists with parents and other adults (lack of family "Connectedness")
All these facts have got important public health implications:
- The 70% of the mortality in adulthood is linked to habits picked up during adolescence (risk-taking behaviour, substance abuse, eating habit and conflict resolution.);
- Prevailing malnutrition, anaemia, stunting and lack of immunization have adverse impact on MMR, IMR, morbidity and have intergenerational effects. The story is well known that a stunted adolescent getting married giving rise to a low birth baby, that too female, again unable to develop or develop in to a stunted female and the cycle keeps on repeating;
- Adolescent sexuality: leads to adolescent pregnancy, unsafe abortion, RTI, STI/HIV and social problems;
- Adolescent pregnancy, the risk of ADVERSE outcome (IMR, MMR LBW babies) again is higher;
- Lack of "connectedness" with parents and other adults prevents transmission of health messages and crucial skills leading to adoption of risky behaviour, substance abuse, early sexual debut and STI, HIV etc.
The question, which comes to mind, is why adolescent behave in this manner and adopt risky behaviours. The meaning of word adolescence is "to emerge". When we think deeply on the word adolescent then certain characteristics and problems emerge from the same word and these characteristics are:
- A - Aggressive, Anaemic, Abortion
- D - Dynamic, Developing, Depressed
- O - Overconfident, Overindulging, Obese
- L - Loud but lonely and lacking information
- E - Enthusiastic, Explorative, and Experimenting
- S - Social, Sexual and Spiritual
- C - Courageous, Cheerful, and Concern
- E - Emotional, Eager, Emulating
- N - Nervous, never say no to Peers
- T - Temperamental, Teenage Pregnancy
They are more concerned about their body image and few of the females may be having an Aishwarya Rai syndrome and few of the boys may be having Hrithik Roshan syndrome. They have got a ‘dil maange more' life style. They want more of everything. They want more of excess dietary fat, they want more of tobacco and alcohol. They want more of sedentary habit, but they never want more of vegetables and fruits, they indulge in eating energy-dense food and they indulge in sexual behaviour.
A hypothetical common scenario in a big city:
- How a 14-year-old school girl in a big city acts?
- Out of 100 girls,
- 60 never had sex,
- 15 had sex but are not currently sexually active,
- 25 are sexually active more or less regularly,
- 8 have had health problems
- 2 have been forced into having sex.
All these girls have different needs for health information services and social support.
Now, let us see the evidence of common roots, what are the risk and the protective factors for adolescents. So I will be talking about the protective factors, what factors protect them from indulging into early sex or substance abuse or going into depression. If you look at this, what you find that a positive relationship with parents, a positive school environment and spiritual beliefs goes a long way in preventing all the problems of adolescents.
Evidence of Common Roots*
* "Broadening the Horizon" Evidence from 52 countries
So the priority health problems of adolescents can be categorized into:
[CIRCLE - Negative Risk; TRIANGLE - Positive Risk]
- Sexual and reproductive health problems,
- Nutritional problems,
- Mental health problems,
- Substance abuse,
- Accidental and intentional violence.
So there is a clustering of problems. The studies given below signify the health problems of the adolescents:
- In Meerut an interesting study is carried out on anaemia in adolescent boys and the prevalence of anaemia in adolescent boys was found to be 42%, which is quite high.
- Large number of adolescents are malnourished and anaemic (56% from the Baroda study, 95% from SWACH study) or stunted, (59% boys and 37% girls - NNBB 2000).
- Obesity is increasing, 8% to 10% in the public schools of Meerut and Delhi.
- Adolescent pregnancy - Common (50% of women in India had a child before reaching the age of 20. (Indian Paediatrics, January 2004).
- A large number of adolescents are still unimmunized (TT, Rubella).
- One out of ten children in India is sexually abused at any given point of time.
- Sexual problems, 25% of the patient attending government STI clinics are younger than 18 years old (Ramasubban- 1995).
- Increasing vulnerability to HIV/AIDS, over 50% of all new cases in India are among 10 to 24 years of age (UNAIDS - 2002)
- Substance abuse is quite common. Number of studies have found out that tobacco, alcohol and other substances, even the injectables are commonly used.
Now let us have a look what are the various program for adolescent health:
Programmes for Adolescents
- Kishor Shakti Yojana - To Improve health and nutritional status of girls
- Balika Samridhi Yojana - To delay the age of marrige
- Nehru Yuva Kendra - Act as the Awareness Unit - Through active participation of youth
- Mahila Samakhya Programme - Equal access to educationi facilities for adolescent girls and young women
- School AIDS education
- University Talks AIDS
- Training of Rural Youth for Self Employment
- Reproductive and Child Health Programme
WHERE ARE THE BOYS?
NO COMPREHENSIVE PROGRAMME ADDRESSING ALL NEEDS OF ADOLESCENT
Kishori Shakti Yojana is to improve the health and nutritional status of the girls; Balika Samridhi Yojana is to delay the age of marriage; Nehru Yuva Kendra acts as an health awareness unit through active participation of the young; Mahila Samakhya Programme - stresses on equal access to education facility for adolescent girls and young women; school age education, university talk AIDS, training of rural youth for self-employment, and RCH. But where are the boys? If you look closely, where is the emphasis on boys? Because when you are going to develop model, you will be talking about peer educator and so on. So there is no comprehensive programme for adolescents and if one has to develop the programming, then what is to be done as recommended by WHO is to promote health development to meet needs and build competency to meet the needs of safety-belonging self-esteem and caring relationship and to build competency and physical, psychological, moral and vocational skills, as well as to prevent and respond to health problems from early unprotected and unwanted sex, use of tobacco and misuse of alcohol and other substances, accidents, violence, poor nutrition, and endemic diseases.
What could be the strategies for the promotion of adolescent health:
The meaning of the word adolescence is to emerge and when we think again deeply on this word, this word gives us the answer and the answer is:
STRATEGIES FOR PROMOTION OF ADOLESCENT HEALTH:
- A =ADOPTION OF HEALTHY LIFE YSTLE
- D=DEVELOP APPROPRIATE I.E.C. STRATEGY DISCOURAGE EARLY MARRIAGE AND TEENAGE PREGNANCY
- O=ORGANIZE ADOLECENT/ YOUTH FRIENDLY CLINIC
- L=LIFE SKILL TRAINING, LEGAL SUPPORT, LIAISION WITH PEERS , PARENTS
- E=EDUCATE ABOUT SEXUALITY, SAFE SEX, SPIRITUALITY, RESPONSIBLE PARENTHOOD
- S=SAFE, SECURE AND SUPPORTIVE ENVIRONMENT TO BE PROVIDED
- C=COUNSELLING / CURRICULM IN SCHOOL INCLUSIVE OF FAMILY IFE EDUCATION
- E=ENABLE & EMPOWER FOR RESPONSIBLE CITIZENSHIP
- N=NETWORKING FOR EXPERIENCE SHARING
- T=TRAINING FOR INCOME GENERATION,TEEN CLUBS
In my opinion, the existing health facilities must be made adolescent-friendly. I think the IAPSM people have got the insight. Let us join together and take appropriate action. Let us work with youth, not merely for youth and make them change agents. The challenges are there, but potential is far greater.
- Adolescence - The Critical Phase, The Challenges & Potential, WHO 1997
- Adolescent friendly health services-An agenda for change. W.H.O.
- Course manual for adolescent health-Part 2 IAP-ITPAH.
- Meeting the needs of young clients; Family Health International.
- My changing body-Fertility awareness for young people-Institute for Reproductive Health of Georgetown University and Family Health International in collaboration with Elisa Knelbel.
- Nair M.K.C. Adolescent sexual and reproductive health, Indian Pediatrics, Journal of the Indian Academy of Pediatrics, Volume 41- January 17, 2004
- National Youth Policy-2003
- SAHYOG, Department of Paediatrics, Hindu Rao Hospital, Delhi.