Why Reproductive and Sexual Health of Adolescents is Important?

Life Skills Interventions can effectively raise the Age at Marriage

Adolescent girls are vulnerable to social and health risks that necessitate special attention being paid to this group. One such risk is early marriage. An extensive community based study carried out by IHMP in 1998-99 showed that the median age at marriage for girls in Aurangabad district, rural Maharashtra, was alarmingly low at 14.5 years. Another important issue that emerged from this and other IHMP studies is the lack of educational opportunities for young girls. Due to safety concerns, parents stop formal education for daughters if the school is outside the village. After discussions with parents, IHMP designed and is conducting a one-year life skills course for unmarried adolescent girls. The course aims to improve girls' self-esteem and literacy, and delay marriage.

The Life Skills Program at a Glance
Objectives:

1. Improve the social status of adolescent girls by developing skills related to gender, legal literacy, and team-building.
2. Improve adolescent girls’ health status by increasing their cognitive and practical skills in health and nutrition.
3. Promote self-development and increase self-confidence and self-esteem.
4. Delay age at marriage for adolescent girls by achieving all the above.

Structure:

A one-year course, 1 hour each weekday evening, taught by a trained village woman with at least a 7th grade education. A total of 225 one-hour sessions, divided into 5 sections: Social Issues & Institutions; Local Bodies; Life Skills; Child Health and Nutrition; Health.

Target group: Unmarried adolescent girls ages 12-18 years, with a focus on out-of-school and working adolescents.

Current status of program:
Till date 6000 girls have already participated in the course from villages and slums in Pune city.

UNMARRIED ADOLESCENT GIRLS

Data and Methodology:
Data were collected at baseline in 1998-99, using both qualitative and quantitative methods. A quasi experimental design is being used to study the impact of the life skills intervention. For the first round of the intervention, 17 study and 18 control villages are being compared. To examine trends over time, annual data on age at marriage has been collected in the study villages since 1997.

Impact of Life Skills Intervention on Age at Marriage :
Attendance in life skills classes: Analysis from the first round of the life skills intervention shows a significant impact on age at marriage. From the sample of 1146 girls , only 9% of the girls who completed the course were married before the age of 18 years, compared to almost one-third of the girls who never attended. Girls who never attended the course were more than two-and-a-half times more likely to get married before age 18 compared to girls who completed the course. Girls who attended partially married earlier than those who completed the course, but even partial attendance provided some protection against early marriage compared to those who never attended.

Exposure to life skills intervention: An analysis of determinants of early marriage among girls in thecontrol and study areas shows that, after controlling for background characteristics, girls in the control area were almost 4 times more likely to be married before age 18 than girls in the intervention area.

Conclusion & Implications
Life skill education results in a measurable increase in knowledge about basic facts that can improve their quality of life. It also results in a measurable increase in self confidence, self-esteem and decision making ability in adolescent girls. Age at marriage can be considerably delayed by providing Life skill education to adolescent girls. Sex education and education on sexuality and conception is an integral part of life skill education and has the potential fo reducing risk and improving reproductive and sexual health of adolescent girls.

Life skill education can be provided to both school going and out of school girls through community based initiative . Not a single parent has objected to education on sex, sexuality and conception provided to their daughters. The intervention has the potential to be replicated in the whole of Maharashtra.

Why Reproductive and Sexual Health of Married Adolescents is Important?

The latest NFHS-3 (2006) data indicates that 45 percent women (20-24 yrs) are married before 18 years in India. The prevalence of early marriage in rural Maharashtra is 48.9 percent; in urban Maharashtra it is 28.9 percent (NFHS-3, 2006). The Institute of Health Management Pachod (IHMP) undertook a study to assess the impact of a pilot intervention for married adolescents that included community level primary care and BCC services.

Description of Intervention
The intervention includes reaching young married couples at a household, group and block level. The interventions are divided into three broad areas Monthly need assessment through a surveillance system, primary level care and BCC (behavior change communication) for creating a demand for services and generating behavioural change.

Areas of Primary Level Care

• Maternal health
• Contraceptive use
• Treatment of RTIs / STIs,
• Abortion post abortion care

Study Design
The pilot intervention included a pre-post test with a post only control, was implemented in villages in Aurangabad district (50, 000 population) and 27 slums (30,000 population). Baseline data on married adolescents were collected at the rural and urban sites in 2003. The intervention was implemented for 2.5 years and an endline survey was conducted in 2006.

Results

Age at Marriage and First Conception
The median age at first conception at the time of baseline was 15.8 years and at end line was 17 years at the rural site. The mean age at first conception increased from 16.2 years to 17.6 years from 2003 to 2006 at the urban site.

Use of Temporary Contraceptives
The proportion of Married Adolescent Girls using temporary contraceptives at the time of the survey increased from 11 to 23 percent at the rural site. The proportion of Married Adolescent Girls using temporary contraceptives at the time of survey increased from 8 to 30 percent at the urban site. Current use of temporary methods was only 7 percent at the control site (2006).

Birth Weight
There was a reduction in the proportion of low birth babies from 36 % baseline (2003) to 25 % endline (2006) whereas the prevalence of low birth weight babies continued to be 56 percent at the control site even in 2006. In the urban site prevalence of low birth weight babies reduced from 27 % to 18 %.

Postnatal Morbidity
At the rural site, Post Natal Care coverage increased from 9 to 16 percent. At the urban site, Post Natal Care increased significantly from 28 to 75 percent. There was a significant reduction in post natal complications.

Exposure to BCC and Its Correlation with Use of Temporary Contraceptives & Wife-Husband Communication
About 48 percent of the sample had high exposure to the intervention. The data indicate a significant association of high BCC exposure and husband-wife communication. Similarly, a significant association is seen with high BCC exposure and use of temporary contraceptives.

What Next? : A Randomized Control Trial with the Government of Maharashtra in 10 Districts Where Prevalence of Early Marriage is High

The National Rural Health Mission and the RCH-2 policy, emphasize the need to meet the health of married adolescents in India.The Maharashtra PIP (Programme Implementation Plan) recognizes that there are no evidence based strategies or models that demonstrate how to effectively reach married adolescents in rural areas.

The aim of the study, jointly undertaken by the Directorate of Health Services, Government of Maharashtra and the Institute of Health Management Pachod (IHMP) is to conduct an RCT (randomized control trial) to assess the efficacy of a community level reproductive health and BCC intervention for married adolescents in 20 primary health centers (PHCs) in 10 high risk districts in Maharashtra. The study focuses on testing a pilot intervention for married adolescents in 10 randomly assigned primary heath centers. The study will provide an evidence base to scale the intervention to all districts in Maharashtra.

Conclusion

Whether due to lack of awareness or social, economic and cultural restrictions adolescents do not receive sexual and reproductive health services. As will be agreed this is likely to affect the most productive demography of the population and thus affect the development of the country for years to come. It is now being recognized that in order to reduce risky sexual behavior and empowering adolescents to make informed decisions for facing the challenges of life. They need to develop the necessary life skills.

YOUTH- A Neglected Population

In the field of health initiatives there are a number of health policies in the government domain for adolescent girls like Kishori Shakti Yojana, Balika Samridhi Yojana etc. when compared to boys. Only the Nehru Yuva Kendras serve them, and the girls, by acting as a health awareness unit. A large number of qualitative research studies have suggested that most risky sexual behaviours among young men occur around the time when they get married. Performance anxiety on the part of the young boys leads to premarital sexual activity to verify their sexual prowess. Further when intercourse with their wives is not socially permitted eg. due to advanced pregnancy or in the post-partum period, they are again likely to indulge in extramarital sexual activity. A large number of qualitative studies indicate that this behaviour is related to low self confidence and a lack of sexual self esteem. Studies undertaken to measure the impact of information dissemination and counselling on these young men demonstrate a reduction in these risky behaviours.

About IHMP

The Institute of Health Management Pachod (IHMP) strives for the health and development of communities through grassroots programmes, training and policy advocacy.

IHMP has adopted a life cycle approach for programme implementation. This approach considers the holistic development of the individual, household and the community. Information, education and communication (IEC) and community organisation are IHMP's core programmes.

Training and audio visual materials are available at IHMP in the following areas:
Adolescent health and life skills, women's health, child health, water and sanitation, child change agents. Please write to IHMP's Pune Centre for a copy of the catalogue.

Contact Persons:
Dr. A. Dyalchand (Director), dyalchand@gmail.com
Ms. Manisha Khale (Assoc. Director), manisha.khale @gmail.com
Dr. Nandita Kapadia-Kundu(Addl Director), nanditakk@gmail.com
Lt. Col. (Dr) Anil Paranjape (Retd), Prog. Director (Urban Health) anil.ihmp@gmail.com