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Adolescent Reproductive and Sexual Health in India: The Need to Focus

Article · December 2013

DOI: 10.7869/jymr.7

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Brief Communication

Adolescent Reproductive and Sexual Health in India:

The Need to Focus
Bharti Mehta,a Amandeep Kaur,b Vijay Kumar,c Sumit Chawla,d Manisha Malik,e Sneh Khatrif

Abstract
Adolescence is a phase during which tremendous physical and psychological changes occur, along with
changes in social perceptions and expectations. Some of the public health challenges for adolescents include
pregnancy, excess risk of maternal and infant mortality, sexually transmitted infections and reproductive tract
infections, and the rapidly rising incidence of HIV in this age group. Thus it is important to influence the health-
seeking behavior of adolescents as their situation will be central in determining India’s health, mortality and
morbidity; and the population growth scenario. Investment in adolescent reproductive and sexual health will
positively influence maternal mortality rate, infant mortality rate reducing incidence of teenage pregnancy,
meeting unmet contraceptive needs, reducing the incidence of sexually transmitted infections (STIs) and
reducing the proportion of HIV positive cases. The challenges in providing services for adolescent health is not
providing newer technologies or interventions as they would not bring the adolescents in purview of health
care but to make the ‘adolescent friendly health services’ more accessible, equitable, acceptable, appropriate,
comprehensive, effective and efficient.
Key Words: Adolescent, Reproductive, Sexual Health, India.

Introduction extent of problems and issues among adolescents is

The World Health Organization (WHO) defines
adolescence as the second decade of life, between
the ages of 10 and 19 years whereas youth
refers to period between 15 and 24 years age
group. Today, 1.2 billion adolescents stand at the
challenging crossroads between childhood and
the adult world. Nine out of ten people live in the
developing world. India is home to more than 243
million adolescents, who account for almost 20%
of the country’s population.[1] This huge number
itself is a big challenge to address the problems
and issues of all adolescents.. Estimating the true
a difficult task as there is a complete lack of data,
especially for the 10-14 years age group. There is
no consistency in the age group divisions in national
surveys. Adolescents are the citizens and working
force of tomorrow. But they are mostly overlooked
in most health programs as they are basically
considered a healthy group. A systematic analysis
on ‘global burden of disease in adolescents’ reports
that the total number of incident disability adjusted
life years (DALYs) worldwide in the age group 10-24
years is 230 million which constitutes 15.5% of total
DALYs.[2]

a
Senior Resident, PGIMS, Rohtak.
b
Assistant Professor, Department of Community Medicine, Govt. Medical College, Haldawani.
c
Professor, PGIMS, Rohtak.
d,e,f
Junior Resident, Department of Community Medicine, PGIMS, Rohtak.
Correspondence and Reprint Request: Dr. Bharti Mehta, 67/8 Krishna Colony, Bhiwani, Haryana, Pin Code-127021.
Email: drbhartimehta9585@gmail.com
Received: October 24, 2013  |  Accepted: November 06, 2013  |  Published Online: November ?, 2013
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons.org/licenses/by/3.0)
Conflict of interest: None declared  |  Source of funding: Nil

Journal of Young Medical Researchers, Vol. 1, No. 1, Aug-Jan 2013, e1 1

 Bharti Mehta and Others

When we think deeply on the word adolescent then
certain characteristics and problems emerge from the
same word and these characteristics are as follows:[3]
• A–Aggressive, anemic, abortion
• D–Dynamic, developing, depressed
• O–Overconfident, overindulging, obese
• L–Loud but lonely and lack information
• E–Enthusiastic, explorative and experimenting
• S–Social, sexual and spiritual
• C–Courageous, cheerful and concern
• E–Emotional, eager and emulating
• N–Nervous, never say no to peers
• T–Temperamental, teenage pregnancy
Reproductive and sexual health is a major area of
concern as the adolescents do not have adequate
awareness and knowledge about these. The chances
of having STIs, teenage pregnancy and unsafe
abortions are much higher among adolescents. In
India, although traditional norms oppose premarital
sex, some studies indicate a growing trend towards
premarital sexual activities among adolescents.
[4] Most sexual activities begin in adolescence;
for example 3% of adolescent males and 8% of
adolescent females had sex before age 15, 1%
female and 63% males aged 15–19 had high risk
sex with a non-marital, non-cohabitating partner
and 31% adolescent males and 20% adolescent
females used a condom during their last high risk sex.
[5] There are 49,000 adolescent males and 46,000
adolescent females with HIV positive in India. The
adolescents need to know how to protect themselves
from HIV/STI/RTI and should have means to access
the adolescent friendly health services. Around 35%
adolescent males and 19% adolescent females have
comprehensive knowledge of HIV.[6] As was reported
in DLHS–3, 2007-08, only 30% of unmarried
women aged 15 to 24 have heard about RTI/STI.
[7] According to the National Family Health Survey-3
(NFHS-3) almost 11% of females and 7% of males
in age 15-24 had a history of STI in the preceding
1 year of the survey. Among men, self-reported
prevalence of the two STI symptoms—abnormal bad
smelling genital discharge and genital sore or ulcer–
is higher among adolescents than among men aged
20-24,[8]
The fertility pattern and contraceptive use among
adolescents gives insight to the future fertility situation
in the country. Knowledge of contraception among
adolescents was more than 90% in NFHS-3; despite
this high percentage, only a little more than 10% of
adolescent girls were found to be using any form of
contraceptive.[4] Many of these married women may
choose not to use contraception because they wish to
bear a child. Others do not wish to bear a child, and
among these, fully one quarter have an unmet need
for family planning.[9]
An important aspect of neglected adolescent girls is
that they are married early and have their first child in
their teens. Although the legal age for marriage is 18,
the majority of Indian women marry as adolescents.
Recent data show that 30% of girls aged 15-19 are
currently married or in union, compared to only 5% of
boys of the same age. The figure is the eighth highest
in the world. There are considerable disparities
depending on where girls live. For instance, while the
prevalence of child marriage among urban girls is
around 29%, it is 56% for their rural counterparts.
[1] NFHS-3 shows that 12% of all women (married
and unmarried) aged 15-19 years and 44% of
currently married women in the same age group
have begun childbearing.[8] Young women in the
poorest households are seven times more likely to
give birth before age 18 than young women from
the rich households in India.[1] Along with prevailing
illiteracy, ignorance and poverty; these adolescent
mothers are neither able to take care of themselves
nor their child. This vicious cycle goes on and the result
is high maternal and infant mortality, chronic ill-health
and increased burden of disease for the nation. This
cycle can be broken with comprehensive care during
adolescence including nutrition counseling, health
education, delaying age of marriage and family
planning.
Menstrual irregularities and hirsutism are emerging
as a major reproductive problem due to defective
lifestyle and increasingly prevalent insulin resistance
and concomitant increase of polycystic ovarian
disease among females and diabetes among both
sexes, especially in urban areas and affluent families.
More than half had experienced dysmenorrhea
and around 40% reported passing of clots during
menstruation. However, it is not surprising to note that
of the adolescent girls who experienced menstrual
problems, only 26% had any consultation.[10]

2 Journal of Young Medical Researchers, Vol. 1, No. 1, Aug-Jan 2013, e1

 Adolescent Reproductive and Sexual Health in India: The Need to Focus
Adolescent Reproductive and Sexual
Health: The Way Forward
Over the past two decades, rapid economic growth
combined with government programs, has led to the
improved health and development of the country’s
adolescents. However, many challenges still remain
for India’s youthful population.
Around 26% adolescents are less likely to visit public
health facility or camps as compared to women of
older age groups.[11] It was found that private
sector utilization was more prevalent especially in
the urban areas. But why do adolescents shy away
from accessing the health services? We need to
identify the barriers in accessing health services by
the adolescents and the young people. These may
be lack of confidentiality, privacy, odd hours of the
clinics, feeling isolated among adults in the waiting
line, stigmatization of visiting a clinic, etc. Around
50% women face many socioeconomic challenges
in accessing health services. The most common of
these were distance to a health facility, transport,
and concern over non-availability of health provider
especially the female health provider, and/or drugs
at the health facility.[11]
Adolescents lack the services that respond to their
distinctive needs. Interventions for children very often
focus on the younger ages; adolescents ‘age out’ of
pediatric health care and they are often unreached
by programs for adults. Adolescents must be involved
in designing, implementing and evaluating programs.
There should be creativity and mix in program
design. Prevention of adolescent health problems
needs to have a multidimensional approach. Many
stakeholders like the schools, the parents, the
community, and the politicians and most importantly
the role of “health care providers” in providing health
care services cannot be undermined.
Role of parents: Adolescents are vulnerable to
psychological problems owing to pressure of
expectations of parents, friends, teachers and their
own selves and this drives them to premarital sex, risk-
taking behavior and other self-destructive tendencies.
Parents are unaware about their role in improving
adolescent health. Every single day’s influence of
parents helps in shaping up the adolescent’s life. The
World Health Organization states five dimensions
which have an important bearing on adolescent
Journal of Young Medical Researchers, Vol. 1, No. 1, Aug-Jan 2013, e1 3
health. These are: connection–‘love’; behavior control–
‘limit’; respect for individuality–‘respect’; modeling
of appropriate behavior–‘model’ and provision and
protection–‘provide.’[12]
Role of teachers: Socrates characterized youth as
inclined to “contradict their parents” and “tyrannize
their teachers.” The adolescents spend a major
proportion of their time in their schools. Teachers can
play an influential role in shaping up the adolescent’s
health by screening for common disorders, providing
nutritional counseling, reproductive and sex education,
life-skill education, etc. Today, more than ever, school
health programs could become one of the most
efficient means available to improve the health of
our children and their educational achievement. Early
diagnosis of preventable and treatable conditions/
illnesses can be made through school health services.
Government can play a very crucial role in promoting
school health services by capacity building, providing
infrastructure, improved funding and training of
teachers.
Role of community: Proper psychological environment
can prevent risk-taking behavior, unsafe sex and
spread of STIs and HIV. Awareness about harmful
effects of early marriage and childbearing in
community and knowledge of family planning can
help a lot in reducing maternal and infant mortality
rates.
Role of health care providers: Adolescent friendly
health services need to be established which provide
services to the adolescents at a separate timing to
ensure confidentiality. The opportunity should be
utilized not only to treat any medical problem but
to counsel them regarding diet, lifestyle, positive
health practices that needs to be adopted as these
adolescents are the “future” of a country, whose
health should be given prime importance to the
prevent health problems in adulthood.
Government of India Initiative in
Improving Adolescent Health
Adolescent health is the domain of the Ministry of
Health and Family Welfare and the Department of
Health and Family Welfare of the states in India.
India’s National Population Policy 2000 aims at
ensuring that adolescents’ need for information,
counseling, population education, and contraceptive
 Bharti Mehta and Others
services are accessible and affordable; food
supplements and nutrition services are available;
and the legislation on restraint of child marriage is
enforced.[13] The Pan American Health Organization
and a WHO consultation held in October 2000 have
recommended provision of a package of services at
an Adolescent Friendly Health Services Centre that
includes monitoring of growth and development;
management of behavioral problems; offering
information and counseling on developmental
changes, personal care and ways of seeking help;
reproductive health including contraceptives, STI
treatment, pregnancy care and postabortion
management; voluntary counseling and testing for
HIV; management of sexual violence and mental
health services including management of substance
abuse.[14]
The National Rural Health Mission (NRHM), the
Government of India’s (GOI) flagship program,
underscores Adolescent Reproductive and Sexual
Health (ARSH) as a top development priority in its
Reproductive and Child Health (RCH-II) program. The
national strategy of the GOI takes a three-pronged
approach in improving the health of young people:
building awareness among communities; creating
a conducive environment for service delivery; and
providing a comprehensive package of services to
young people. This strategy focuses on reorganizing
the existing public health system to enable it to
meet the service needs of adolescents. The Medical
Officers (MOs), Auxiliary Nurse Midwives (ANMs)
and Lady Health Visitors (LHVs) are required to
ensure service delivery at sub-centers and PHCs
at fixed day and timings. A core package of
services includes preventive, promotive, curative and
counseling services.[15] A first of its kind in setting
up ARSH in the country, Safdarjung Hospital in Delhi
set up Adolescent Friendly Health Services Centre.
It provides a wide range of services which include
clinical and mental health services, nutritional and
reproductive counseling, growth monitoring and
development, and immunization.[16] Haryana was
one of the first states in the country to have launched a
distinct ARSH program providing ‘Adolescent Friendly
Health Services’ at government health facilities.[17]
Conclusion
The well being and the active participation of
4 Journal of Young Medical Researchers, Vol. 1, No. 1, Aug-Jan 2013, e1
adolescents are fundamental to the effectiveness
of a life-cycle approach that can break the
intergenerational transmission of poverty, exclusion
and discrimination. The challenges in providing
services for adolescent health is not providing newer
technologies or interventions as they would not bring
the adolescents in purview of health care but to
make the ‘adolescent friendly health services’ more
accessible, equitable, acceptable, appropriate,
comprehensive, effective and efficient. Moreover,
strong political will and commitment is necessary to
boost up the adolescent health.
References
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