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Indian Journal of Medical Sciences, Vol. 62, No. 11, November, 2008, pp. 465-472 Practitioners section Adolescent friendly health services in India: A need of the hour Nath Anita, Garg Suneela Tietze Research Fellow, Population Council, New York City, NY-10065 Code Number: ms08086 Abstract Adolescents account for almost one third of India's population. They are prone to suffer from reproductive and sexual health, nutritional, mental and behavioral problems. Health services which cater exclusively to the needs of adolescents are scanty and concentrated in urban areas. Adolescent Friendly Health Services (AFHS) which provide a broad range of preventive, promotive and curative services under one roof can help to ensure improved availability, accessibility and utilization of health services. AFHS is being initiated by governmental, private and non-governmental organizations. Lessons to improve the quality of AFHS could be further learnt from evaluation of pilot projects and success stories of similar initiatives in other countries.Keywords: Adolescent, Health Services Needs and Demand or Health Services Accessibility, India Introduction About 30% of India′s population is in the adolescent age group of 10-19 years. It is estimated that there are almost 331 million adolescents in India. [1] They represent a resource for the future whose potential can either be wasted or nurtured in a positive manner. Sexual and reproductive ill health is one of the major causes of morbidity and mortality in young people. [2] In a conservative society where reproductive and sexual health related issues are taboo for discussion, young people are hindered from actively seeking counsel for their needs. Even though programs and policies directed towards improvement of adolescent reproductive health exist, there is a paucity of Adolescent Friendly Health Services (AFHS), the expansion of which is still in the nascent stage. Moreover, very few programs have been able to differentiate between the special reproductive health needs of married and unmarried adolescents. [3] In addition, there is less focus on adolescent boys by these programs and policies. The significant features of an Adolescent Friendly Health Center/Clinic (AFHC) encompass provision of reproductive health services, nutritional counseling, sex education and life skills education. [4] It is a kind of ′one-stop′ shopping approach which means that the different needs of adolescents can be met under one roof, by a team of professionals who understand their needs and are trained to address them effectively. Adolescents continue to remain at risk, thus calling for development and strengthening of need based interventions.Unmet Need of Adolescents in India Reproductive and sexual health problems The adolescent poses a distinct array of reproductive and sexual health challenges. These challenges include the consequences of early marriage, unsafe abortions, high-risk behavior, lack of awareness about contraception and reproductive health issues, reproductive tract infections (RTIs) and sexually transmitted infections (STIs) including HIV/AIDS and non-consensual sex. This creates an "unmet need" for reproductive and sexual healthcare. This unmet need varies among married and unmarried adolescents. The health seeking behavior also depends upon the marital status of the adolescent. Moreover, reproductive health services under the public sector are more oriented towards adult married women, while unmarried adolescents hesitate to seek health services due to the fear that these services are not confidential, inability to pay, requirement of parents′ approval and negative or insensitive attitude of health providers. [5] Even married adolescent girls shy away from seeking healthcare due to sheer embarrassment and the taboo associated with reproductive and sexual health problems. [6] Another study has shown that programmatic constraints in the form of non-availability of health personnel at the health facility and poor client provider interaction posed as an obstacle in the utilization of reproductive health services by married adolescents in rural areas. [7] Other factors leading to poor health seeking behavior include limited mobility and lack of decision making power in the household. [8] Never-married adolescents When it comes to consultation about reproductive health problems, the adolescent prefers to seek help from a relative or friend rather than a health provider. A study conducted in rural Haryana observed that in such an instance, girls preferred to consult parents (49.2%) followed by doctors (44.6%). [9] Regarding the experience of menstruation in the socio-cultural context in an urban slum in Delhi, it was seen that a culture of silence surrounds menarche, an event that took the most of the adolescent girls by surprise. [10] A number of studies have exposed unhygienic practices such as use of unclean old cloths during menstruation. [11],[12],[13] Contraceptive use in both the genders is very less. According to the National Family Health Survey (NFHS-3) findings, only 14.1% (14.7% urban versus 13.9% rural) of unmarried sexually active adolescents females used a contraceptive. [14] Even though condom awareness among youth is as high as 83.8% on an all-India level, actual condom usage is reported to be less. [15] In a study, only four in ten students from Delhi University reported occasional condom use during sexual intercourse. [16] More alarming is the reported condom use rate of 7% by sexually active youth in a town in Assam state. [17] The unmarried female adolescent is highly vulnerable to unwanted pregnancy, mainly as result of lack of contraceptive use and high-risk sexual behavior. Also, a large number of abortion seekers become pregnant as a result of rape or sexual coercion. A study conducted in Rohtak city among 83 adolescents attending recognized as well as unrecognized MTP centers observed that as many as 90% of them were unmarried and 42% of them were seeking abortion for second trimester pregnancy. [18] Reproductive tract infections (RTIs) and sexually transmitted infections (STIs) account for a growing proportion of reproductive morbidities. The prevalence of RTIs has been observed to be as high as 70% among unmarried adolescent girls in Kolkata. [19] Adolescent males also face reproductive health concerns. A study among college going adolescent boys in Delhi has reported that three out of eight male students who opted for testing were found to be strongly positive for mixed STD infections. [20] Similarly among a group of urban school going adolescent males in Mumbai, genital itching and urinary problems constituted major reproductive health complaints. [21] Married adolescents Despite the rising age at marriage and laws prohibiting marriage before 18 years for women and before 21 years for men, the majority of women marry as adolescents. According to NFHS-3, as many as 44.5% of the married women aged 20 to 24 years reported being married by the age of 18 years. [14] The survey also shows that 16% of the women in the age group of 15-19 years were already mothers or pregnant at the time of the survey. Maternal morbidity rates have been especially high for the adolescent. Pregnant adolescents are more likely to suffer eclampsia and obstructed labor than women who become pregnant in their early twenties. [22] The married adolescent has a high unmet need for contraception. According to NFHS-3 results, only 13% (16% urban versus 12.4% rural) of currently married adolescents reported contraceptive use. [14] The unmet need for contraception is 27.1% (25.1% spacing versus 2% limiting). [14] A baseline survey conducted in the states of Bihar and Jharkhand reveals that only 12% of married girls and 15% of married boys use any method of family planning while 20% of married girls and 23% of married boys have expressed a desire to delay the first birth. [23] The married female adolescent is also prone to unplanned and mistimed pregnancy resulting from low contraceptive use. A study in rural Maharashtra has shown that married adolescents account for 13% of the induced abortion seekers. [24] The adolescent′s vulnerability to RTIs and STIs can be attributed to the early onset of sexual activity and failure to use barrier contraceptives. A high prevalence of RTIs has been reported among the young married women belonging to a rural community in Tamil Nadu wherein as many as 53% reported gynecologic symptoms out of whom two thirds had never sought treatment. [25] A study conducted in Ahmednagar in Maharashtra shows that married adolescent girls often went untreated for menstrual complaints and RTI. [26] Other health problems Apart from reproductive morbidities and sexual health needs, adolescents face other health problems as well. Nutritional disorders such as anemia and obesity are widely prevalent. According to NFHS-3 reports, while 56% of adolescent girls are anemic, boys too are falling prey to the disease. Around 30% of adolescent boys suffer from anemia. [14] A cross-sectional study involving school-going children from 9 to 15 years shows the overall prevalence of obesity and overweight to be 11.1 and 14.2% respectively. [27] Adolescents are prone to substance abuse, as seen from the prevalence of smoking which has been found to vary from 6.9 to 22.5% among male school and college students but considerably low among the girls, varying between 0-2.3%. [28],[29] Psychological and behavioral problems also account for a considerable proportion of the morbidities. In a study conducted in Chandigarh, 60% of the health complaints in adolescents were seen to be psychological in nature. [30] AFHS in India The Pan American Health Organization and a WHO consultation held in Africa in October 2000 have recommended provision of the following package of services at an Adolescent Friendly Health Centre: [31]
An Adolescent Friendly Health Service should be accessible, equitable, acceptable, appropriate, comprehensive, effective and efficient. [32] The Indian scenario has gradually witnessed an emergence of AFHCs run by governmental, private and voluntary health agencies. The World Health Organization (WHO) has supported development of AFHCs in the country out of which many are being sustained with government support and the institution′s own efforts. Also, WHO is supporting the government of Tamil Nadu in using Mapping Adolescent Programming and Measurement framework (MAPM) in developing converged district action plans focusing on adolescents. [33] A commendable step in setting up Adolescent Friendly Health Services was first undertaken by the Safdarjung Hospital in New Delhi that is providing a wide range of services such as clinical, mental health services, nutritional and reproductive health counseling, growth and monitoring development and immunization. [34] This was evolved along a multi-sectoral approach involving the education and voluntary sector. A quarter of the adolescents availing of these services have presented with mental complaints. The National Institute of Research in Reproductive Health (NIRRH), Mumbai in collaboration with the Municipal Corporation of Mumbai started Adolescent Friendly Health Clinics, under the name "Jagruti", for providing specialized reproductive and sexual health services to adolescent boys and girls. A pilot initiative has been undertaken by MAMTA, an NGO to establish a model of AFHS through the public health system in villages. [35] This model comprises community based ′Youth Information Centers′ (YIC) supported by peer educators, health facility based ′Youth Clinics′ at Primary Health Center and ′Youth Friendly Center′ at First Referral Unit. The Family Planning Association of India (FPAI) has set up AFHC as a pilot project under the banner of "Jigyasa" in four districts of Madhya Pradesh. [36] The Reproductive and Child Health Program II (RCH II) has come up with a two-pronged strategy for providing services specifically intended for adolescents at public health facilities at the primary healthcare level during routine hours and on dedicated days and times. Public health personnel such as medical officers as well as Auxiliary Nurse Midwives (ANMs) and lady health visitors (LHVs) would receive training on the provision of sexual and reproductive health services exclusively for adolescents. The Ministry of Health and Family Welfare (MoHFW) has developed guidelines and training package for operationalizing AFHS. Haryana is one of the first states in the country to have launched a distinct Adolescent Reproductive and Sexual Health (ARSH) program providing AFHS at government health facilities. [37] The National Program Implementation plan of the RCH II has proposed to expand this program to 75 districts in the country. Lessons learned and the way forward It is important that Adolescent Friendly Health Services be made an integral part of the health system. Apart from re-organizing the existing public health system, the public-private partnership and linkages with non-governmental organizations (NGOs), schools and various voluntary agencies would be of utmost significance. Inter-sectoral linkage with the National Rural Health Mission (NRHM) and National AIDS Control Program (NACP) will determine appropriate service delivery without any overlapping of services. Setting up an AFHC in school or college premises for easy accessibility should be considered. A comparative study on utilization of adolescent health services found that school based services were better utilized than health facility based services. [38] The school health centers in the United States have adopted such as approach by providing a broad range of reproductive services either on-site or by means of referrals. [38] One could also learn from the experience of other countries like Thailand in which the AFHS is provided under the label of "Friend Corners", these centers being located at attractive sites such as shopping malls, discotheques and cinema theatres. [39] A holistic approach should be adopted which should focus on a broader range of health issues and not just sexual and reproductive health. This would entail convergence of all the appropriate medical specialties. Utilization of such services could be improved by intensive information, education and communication (IEC) and involving the parents/guardians. The Reach Out Youth Centers in Philippines promote their services by means of IEC and outreach activities, press releases, public service advertisements, directional signs, newsletters and partnership with NGOs and government agencies. [40] A performance evaluation of an Adolescent Friendly Health Centre (AFHC) in urban Mumbai has shown that parental involvement contributed to help seeking behavior. [41] Adolescents may be involved in the planning and provision of health services by involving local youth groups and clubs. This kind of peer involvement is likely to attract adolescents. The AFHS project under RCH II in Haryana employs an "Adolescent Action Group" (AAG) to plan interventions with clear targets and roles and responsibilities. [37] The successful role of peer educators in AFHS has been endorsed by evaluation studies in different countries. [38] These studies also confirm that young people prefer receiving adolescent reproductive health information from peers, as opposed to from adults or in a traditional school setting. The important components that make an adolescent health clinic "friendly" should be kept in mind. Development of knowledge, skills and competencies in the area of adolescent health is necessary. Health providers must be encouraged to participate in Quality Improvement (QI) programs. [42] Convenient timings such as after school hours and weekends should be ensured. For example, the Kaugmaon Adolescent and Youth Center located in an urban poor community in Manila provides services from 10 AM to 10 PM throughout the week. [40] In Sweden, the popularity of AFHCs has led to the formation of a national network of such centers; this model may be emulated in India. [43] Promoting adolescent health and development by means of providing Adolescent Friendly Health Services requires complementary action by different stakeholders which are aimed at fulfilling their rights and addressing their special needs. References
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