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IIHMR Working Paper No.4

Meeting Reproductive and Sexual Health Needs
of Adolescents: A Strategic Approach for
Rajasthan, India







Nutan P Jain
1

S. D. Gupta
2

L. P. Singh
3






























































1. Assistant Professor, Institute of Health Management Research, Jaipur
2. Director, Institute of Health Management Research, Jaipur
3. Associate Professor, Institute of Health Management Research, Jaipur





ABSTRACT

This paper is divided into two parts. The first part deals with a study conducted by
IIHMR to assess the knowledge of adolescent boys and girls aged 10-19 years
from three districts of Rajasthan regarding reproductive and sexual health. The
survey was based on a cross sectional sample of 2325 persons including
adolescents, parents and teachers. The study reports that the adolescents of the
State had very scanty and patchy knowledge about sexual and reproductive
health. An overwhelming majority of the adolescents had heard about puberty,
menstruation, pregnancy, contraception, rape and abortion. More than half of the
adolescents were aware of night emission, safe sex, impotency, homosexuality and
genital hygiene. As many as 15 per cent of the adolescents experienced sexual
intercourse at the time of the survey. The mean age of sexual intercourse was
found to be 14.1 years, the girls being 3.5 years younger than the boys. An
overwhelming majority of adolescents were aware of sexually transmitted
infections. As many as 90 per cent were aware of AIDS whereas only 26 per cent
knew that there was no treatment available for AIDS.

The second part of the study details about systems study of one of the primary
health centres in Jaipur district of Rajasthan. The study shows that the
environment is not friendly for providing services to the adolescents in the State's
primary health care system. The systems study shows that a critical component of
adolescents was neglected under the reproductive health programme. The
services were available either for children or for adults while no special attention
was given to adolescents. Even the service providers were ignorant about the
sexual and reproductive health needs of adolescents. The study advocates a
strategic approach for providing services to adolescents. The study also
emphasises the need for building capability of the service providers towards
adolescents' sexual and reproductive health.

1. INTRODUCTION

Reproductive health as a crucial component of general health has a developmental
and inter-generational impact. It reflects health in childhood and adolescence and
sets the stage for health beyond the reproductive years. Adolescents' reproductive
health is a delicate balance that recognises both adolescents' rights to be informed
and provided services and parents' rights to provide guidance. The ICPD Cairo
(International Conference on Population Development, 1994) outlined two
objectives of adolescents' reproductive health services: (a) to address adolescent's
sexual and reproductive health issues including HIV/AIDS (through the
promotion of responsible and healthy reproductive and sexual behaviour
including voluntary abstinence, and counselling specifically suitable for that age
group), and (b) to substantially reduce all adolescent pregnancies.

The generation entering adolescence is the largest generation in history.
Adolescents form a vital population segment, i.e. one-fifth of the world's
population, and are growing in number. Over one billion adolescents (aged 10-19)
in the world and 190 million in India comprise nearly one-fifth (21.6%) of the
total population. The population of adolescents in Rajasthan is 22 per cent
including those aged 10-14 (12.4%) and 15-19 years (9.6%). Since this group is
perceived as a relatively "trouble free" period by national policy makers, little
attention has been paid to it.


TABLE 1

PER CENT DISTRIBUTION OF ADOLESCENT POPULATION
BY AGE AND SEX IN RAJASTHAN

Adolescents India Rajasthan

Male Female Total Male Female Total
Aged 10-14 11.2 11.0 11.1 12.7 12.1 12.4
Aged 15-19 10.9 10.2 10.5 9.9 9.3 9.6
Source: The basic data is obtained from 1991 Census, Registrar General, India. The Census data is
smoothed to the distribution given in Population Projections for India and States 1996-2016
Registrar General, 1996.


Due to high level of fertility, the age structure of the population is heavily skewed
towards the young, irrespective of the level of mortality, because the birth rate remains
high and a large number of women enter the reproductive age every year. According to
Census 2001, children aged up to 6 years are 18.51 per cent of the total population in
Rajasthan. In the next decade the State will have to cater to the needs of such a large
group of adolescent population.

Adolescents are a highly vulnerable group because they face the risks related to sexual
activity and childbearing the two most serious health risks.

According to the World Development Report 1993, the death of a female adolescent (in
the 10-20 years age group) represents a loss of 34-38 DALYs (disability adjusted life
years). Of the 27 million annual births in India, 8 per cent occur to mothers below the age
of 19 years (Panickar, 1997), and Rajasthan is no exception.

There are huge regional and gender disparities in every measure of adolescence in the
country, and these are more typically exhibited in a traditional and conservative state like
Rajasthan. The singulate age at marriage for females is 17.5 years, less than the legal age;
for males it is 21.3 years. Under these circumstances, adolescent girls suffer from the
health risk of becoming mothers at a tender age and too frequently. It is well known that
there is a tremendous pressure on adolescents to start their families as soon as they are
married (Jejeebhoy, 1996). The fertility rate and marital fertility rate for the15-19 age
group are 90.6 and 162.02 respectively.

The reproductive health risks that adolescents face include sexually transmitted diseases
(STDs) including infection with human immuno-deficiency virus (HIV), which results in
AIDS; sexual violence and coercion; and too early and unintended pregnancy and
childbearing. During the early, middle and late phases of adolescence, young people have
different needs. For example, early on they need to understand the nature of the body
changes occurring in them as well as the new demands and expectations placed upon
them and, perhaps, in that way become aware of anything which may be a cause for
concern as they move through later adolescence. If children move straight from
childhood to adulthood responses and behaviours, they miss a significant portion of their
life. Adolescents often suffer from lack of adequate and appropriate information and
education, especially in relation to their perceived needs (Watsa, 1997).















Meeting the reproductive health needs of today's adolescents and younger people requires
more than solving the problems; they should also be able to prevent and solve problems
for themselves (Panicker, 1997). They also have the right to information, particularly
about issues, which affect their health (Watsa, 1997).

In India, primary health care is the first level of contact of individuals, the family and the
community with the national health system. There is a need to re-organise the health care
system to meet the needs of adolescents' reproductive health with the existing resources.
Dealing with the special needs of adolescents, provision of appropriate services with
limited existing resources is essential. The study identifies the managerial problems and
suggests some possible solutions for efficient implementation of services towards
meeting the reproductive health needs of adolescents.

2. THE OBJECTIVES

The paper has the following objectives:

To review the present status of reproductive and sexual behaviour among
adolescents in Rajasthan
To assess the reproductive health services provided to adolescents through the
health/family planning services system of the State of Rajasthan
To identify gaps between need and supply (services available)
To propose a strategy for strengthening these services

3. REPRODUCTIVE HEALTH AWARENESS AND
SEXUAL BEHAVIOUR STUDY

The Institute of Health Management Research (IIHMR), Jaipur conducted a cross-
sectional study of reproductive health awareness and sexual behaviour among adolescents
in Jaipur, Kota and Alwar districts of Rajasthan during 1996-1998.














3.1 Methodology

The adolescents included school or college-
going boys and girls aged 10-19 years
(divided into the age groups of 10-14 years
and 15-19 years). These adolescents
comprised both rural and urban students.
Except in Alwar, the adolescent students
from the schools located in the slums were
also studied. Government and private
schools (English as well as Hindi medium)
were covered in this survey. It included a
sample of 2000 adolescents aged between 10
and 19 years. The sample was divided into
1500 school-going and 500 college students.

In each place, parents and teachers were also
interviewed. In addition to the adolescents, a
total of 100 parents were interviewed from
the area where schools were situated.
Among these parents, 50, 30 and 20 parents
were from the capital, large cities and small
cities respectively. Likewise, 125 teachers
were interviewed from the schools and
colleges where interview schedule was
administered to the adolescents. An attempt
was made to cover the same number of
teachers and parents from both sexes.
Therefore, in all, a total of 2325 persons
were contacted.
















The Objectives of the IIHMR
Study (1996-1998)

The study aimed at the following
objectives:

to assess the awareness level
of adolescents regarding
various aspects of
reproductive health and to
identify knowledge gaps and
source of knowledge,
particularly regarding
contraceptives;
to assess their knowledge
about STDs / AIDS, their
mode of transmission, etc.;
to study their attitude
towards various
reproductive health issues
and sexual behaviour;
to assess their willingness to
learn more about
reproductive health and sex-
related issues;
to study the views of parents
and teachers about
reproductive health
education, information,
communication and
counselling to adolescents




3.2 Study Tools

Both qualitative and quantitative
information was collected with the help
of various tools, namely structured
interview schedule, focus group
discussions, and case studies. The tools
used were:

3.3 Data Collection

Data for the awareness project was
collected between September 1996 and
February 1997. Before starting the field
work, permission was sought from
relevant higher authorities. The principal
of the schools were visited and briefed about the project and were requested for help.
The principals liked the idea of including the whole class at a time for the survey. The
schedules were mostly administered to the respondents in the classrooms. The
respondents were not allowed to go out before the completion of the schedule. The
supervisors checked that information was complete before the respondents were allowed
to leave the room.













The IIHMR Study Tools:
Interview Schedule

Three kinds of interview schedule were
prepared for adolescents aged 10-14
years, 15-19 years, and parents and
teachers. These schedules were
prepared in English and translated
into Hindi. These tools were pre-tested
before use in the study area.
Guidelines and codes for open-ended
questions were prepared. An
instruction manual for each set of
schedule was also prepared and given
to the field teams.
The IIHMR Study Tools:
Checklist for FGDs
It was decided to conduct a total of six focus group
discussions including those with adolescents (boys and
girls), teachers (male and female) and parents (mothers and
fathers). The topics for FGDs included communication
between generations, premarital sex, contraceptives, media
and sex education and role of parents, teachers and peers
regarding sexuality.
3.4 Major Findings

The study was undertaken with the objective
of obtaining the present status of knowledge
among adolescents about reproductive and
sexual health issues. The adolescents were
asked for information on socio-economic
and socio-demographic status, reproductive
health, sexuality and sex-related matters,
STDs and HIV/AIDS, and family planning.
Some broad patterns of adolescent sexual
and reproductive behaviour based on this
study are discussed below:

Awareness

Physical and Physiological Changes

Except for the obvious physical
changes, the adolescents, particularly
younger ones and slum dwellers
were not aware of night emission or
wet dreams and seminal fluid as an
important change into becoming a
man. The girls were also not much
aware of the changes taking place in
their body. About forty per cent of
younger adolescents were not aware
of genital organs in formal terms.
There was considerable interest
among them to fill this gap in
knowledge (Bhende, 1994).














The IIHMR Study Tools:
Case Study

Ten case studies were conducted on
boys and girls in different schools and
colleges. The potential cases were
identified during data collection and
during discussions with teachers and
parents. The subjects of case studies
were approached later for collecting
detailed information.
CASE STUDY # 1:
Realizing the Responsibility

General Information

Name: xxxxxx Class: VI: Age: 15 years,
Sex : female, Kota

Family background
Large family of seven members mother,
Father, three brothers and one sister. Father
works as a labourer in shifts in J.K Factory,
Kota. He has studied up to high school level.
Mother is illiterate, and education of other
family members is upto intermediate. One
brother is married, but his wife has been living
with her parents for the last seven months.


Only a few girls were informed
about menstruation, prior to the
onset. Even this information tends to
be patchy. They were informed more
about the use of cloth or pads, and
restrictions (particularly don'ts).
However, a few urban girls were told
why menstruation occurs and about
the disposal of cloth or pads.
Besides, a majority of girls knew that
"menstruation is natural" and "it is
essential to become a mother". More
than half of them, aged 15-19 years,
slum based (56%), perceived it as a
burden and disgusting (49%) and a
curse (37%). Consequently, a vast
majority of the girls experienced
problems - general or gynaecological
- with their menstruation. The
gynaecological problems among 25
to 50 per cent girls were watery
discharge, thick curdy discharge,
excessive bleeding, discharge with
foul smell and increased frequency
of micturation. The problem is more
common in rural and slum girls. For
these problems, only one-third of the
girls go to a doctor or nurse
(especially in rural areas). A very
small proportion of girls sought
advice from chemists also,
particularly in the slum areas.

A majority (>75%) of the
adolescents were aware of terms
such as puberty, menstruation,
pregnancy, contraception, rape and
abortion. Night emission, sexual
intercourse,





CASE STUDY # 1 (Contd)

He comes home only for lunch and dinner.
Another brother is working at a shop and a
younger one is studying in ITI. Her sister
dropped out after failing in Class X. The family
belongs to a backward caste.

Home and Social Environment
The family lives in a two-room house. One
room is for sleeping purposes and the other is
used for study. A double-bed is shared by the
parents and both the sisters. In the absence of
the father the brother also shares it. The
locality is very crowded and dirty due to the
factory. Relations with neighbours are
harmonious. The basic requirements of the
children are met but only partially. Intra-
family relations are not very congenial.

School Environment and Surroundings

The school is situated in a colony. It runs
in two shifts. She attends the second shift.
On the way, eve-teasing is usually
practised.

Personal characteristics

The girl is of average intelligence and obeys
school rules, respects her teachers and is
disciplined. She also participates in sports
/games. She thinks she has kidney stones as she
frequently has severe pain. But she is not
taking any treatment. In her class, she has no
friends. Even her classmates do not help her
when she needs class notes. She is very
talkative. She does most of the domestic work.
When necessary, she also goes out to buy
things for daily use.


safe sex, impotency and infertility
are terms which 50 to 75 percent
adolescents were aware of.
Masturbation, incest, homosexuality,
and genital hygiene were known to
adolescents ranging between 25 and
50 per cent. Less than 25 per cent
adolescents were aware of
circumcision (Sunnata or khatna).
Except for menstruation and wet
dreams, urban adolescents were
more aware of these terms in
general, but awareness of
masturbation, incest, and
contraception was found in rural as
well as urban adolescents.

Only the boys were asked about
night emission and masturbation.
Only 44 per cent adolescent boys,
mainly from urban areas, reported
that they had night emission while
eight per cent did not respond to the
question. Perceptions about seminal
discharge were also studied. Most of
them (63%) perceived it as a
hormonal effect.
About 45 per cent boys were aware of the fact that it is natural (46%), a sign of
adulthood (43%), and contains sperms which cause pregnancy (44%). One-fourth
of adolescent boys perceived it as a sign of good health and vigour. They also
perceived that it occurs due to exertion. In general, it was found that wrong
perceptions were more among slum dwellers and correct ones among urban
dwellers. Age had no significant impact on it.











CASE STUDY # 1 (Contd)

Reproductive and Sexual behaviour
She was only 12 when she started
menstruating. She was guided by her
mother and elder sister mainly about
how to use cloth pads, their re-use, and
some do's and don'ts She knows about
MALA-D pills, not as a contraceptive,
but as a medicine for abortion. This had
been conveyed to her by her sister- in-
law living in the neighbourhood.

Her elder sister has a boyfriend who
tries to meet her in the evening when it
becomes dark. She cooperates with him.
She usually meets the boy when she goes
out to throw away household waste. She
believes that they have had sexual
intercourse. The parents of the girl are
not aware of it. Once, when her parents
were away, she was sharing the bed with
her brother and sister; and she was
sexually abused by her brother: Though
she complained to her parents, nothing
happened. She is usually tortured by her
brother. Nobody in the family is
bothered.



Information on masturbation was
sought by asking, "Do you stimulate
your genitals for sexual pleasure?"
About 51 per cent of the adolescents,
mainly rural and older boys, reported
that they did, and of them, 56 per
cent found it pleasurable or exciting,
and one-fifth maintained that it was a
harmless practice. The younger
adolescents aged 10-14 years showed
a negative and unfavourable attitude
towards masturbation.

About 70 per cent adolescents
knew the legal age of marriage for a
boy and a girl. Sixty eight per cent
adolescents reported that the
marriage of a boy was performed in
the family at the age of 21 years and
above, and in 80 per cent of cases
marriage of a girl at the age 18 years
and above. About two thirds of the
adolescents preferred arranged or
semi-arranged marriages (68%),
while love marriages were preferred
by the rest. On being asked when a
women should conceive, about 22
per cent said that a woman should
conceive one year after marriage,
while about one fourth (26%) said
that she should conceive after two
years.











CASE STUDY # 2:
Knowledge about Contraception

General Information

Name: xxxxxx,' Class: 1 year at college, Age: 17 years,
Sex: Female," Jaipur

Family Background

The family members are mother, father and two
brothers. She is the second child of her parents, but has
been living with her aunt since her childhood. Her
father is a railway employee and her mother a
housewife. The elder brother works in a private factory
and the younger one is studying at college. The father
is relatively open-minded, while her mother is
conservative, traditional and stereotyped.

Home and Social Environment

The girl lives with her aunt (Bua), a widow with no
children. Her aunt works as Branch Manager in a
private company, and has to go on tour (outside the
city) at least twice a month. There is a separate room
for the girl. There is good relationship between the
landlord and the tenant. In the absence of the aunt the
landlady takes care of the girl. The parents hardly
come to see her, but the brothers do so regularly. She
goes to her parents only once a month. Her parents
belong to the middle socio-economic status, while the
aunt maintains a better status as she is alone. Her aunt
is open-minded and does not bother about friendship
with boys and girls. But if a boy comes to meet her (the
girl), he is not allowed to go inside the girl's room.




A majority of adolescents preferred
two children one boy and one girl
in the family and about 55 per cent
were of the opinion that a couple
should have a spacing of three years
between two children.

Sexually Transmitted Infections

A majority of adolescents (85%)
were aware of certain infectious
diseases that could spread through
sexual intercourse. Among those
who were aware of them, less than
one fourth could identify gonorrhoea
(16%), warts (18%), hepatitis-B
(17%), herpes (10%), and lympho-
granuloma venereum (11%), while
about a third were aware of syphilis
(28%), genital ulcers (30%), urinary
tract infections (35%), infertility
(42%) and white discharge (33%).
The adolescents living in slums were
more aware of syphilis, hepatitis-B
and herpes than their peers living in
rural and urban areas.

AIDS is the most commonly known
disease. Regarding AIDS, in general,
more urban adolescents were aware
of it followed by those in rural areas
and slums. In general, about 90 per
cent adolescents were aware of HIV/
AIDS, but when they were asked
about their treatment, about 26 per
cent were aware of the fact that no
treatment was available yet.





CASE STUDY # 2 (Contd..)

Personal Characteristic
The girl is a good student at a girls'
college. She is fond of having friends (both
boys and girls). Most of her friends are of
a higher socio-economic status. All her
friends come to her place, but she does not
want to be with her friends on Sundays.
She is used to going out e.g. to movies,
picnics, restaurants, etc., with her friends.
She has a moped. She misses classes
sometimes to meet her friends.

Reproductive and Sexual Behaviour
She has many friends, but she is
particularly interested in one boy. She
meets him when nobody is around and
goes to a restaurant with him at least once
a week. She has not told her aunt about
this friend. She misses classes for him.
After two or three months, the boy started
calling her to his friend's place, and
sometimes to a hotel. The girl got involved
with him sexually. In the beginning she
was afraid, but slowly she came to enjoy
such encounters the frequency of which
increased (3-4 times a month). They never
used the family planning methods. Once
her friend advised her, but the girl
dismissed it lightly (yaar kuch nahi hota).
Once she went to Goa for three days with
the friend without intimating her aunt. She
asked a friend (girl) to go with them but
she refused. She was again advised to use
precautionary measures to avoid
pregnancy. She did not take it seriously as
she had not conceived after so many
encounters.




However three-fourths (75%) knew
that a full-blown case of AIDS led to
death.

Modes of Transmission

About various modes of transmission
of HIV / AIDS infection, the results
revealed that more than three-fourths
(77%) were aware of the fact that
transfusion of infected blood, having
sexual relations with an infected
partner, injection with non-sterilised
needles, from infected pregnant
mother to foetus are the modes of
transmission. 24 per cent of the
adolescents were aware of breast
feeding as a mode of transmission.
More urban adolescents were aware
of these modes.


Awareness of Preventive Methods against STDs and AIDS

When asked about various methods of preventing STDs and AIDS, it was found
that many of the adolescents (40%), mainly the urban ones, were aware of
practising safer sex and use of condoms (15%) as a method of prevention. About
10-11 per cent adolescents gave their view on checking blood samples from time
to time and ensuring the use of sterilised syringes and needles. About four per
cent adolescents suggested the use of disposable syringes and needles. About five
per cent were in favour of abstinence from sex.











CASE STUDY # 2 (Contd..)
After coming back, the boy did not meet her.
She missed her periods (menses) and she felt
that she was pregnant. She went to a lady
doctor. She was asked to sign some papers,
but she refused and came back. The
boyfriend was aware of it. He gave her Rs.
1000/- to get rid of this problem, while the
actual charges were Rs.6000/-. The boy had
disappeared since. Then she went to the
doctor with her married girl friend. The
doctor refused because by the time she had
pregnancy of five months. The doctor also
told her about the risks. After requesting the
doctor, the friend was asked to fill the
consent form and finally she took the
responsibility. This time her aunt was out of
station. Before going home, the girl cut her
hand with a piece of glass, and told her
landlady that she had met with an accident.




Older adolescents knew that
practising safe sex is the best
preventive method but younger
adolescents were not informed on
the issue. About 60 per cent older
adolescents suggested practising
safer sex, while the younger group
suggested many other alternatives
too, which shows that the younger
ones did not have a clear view
about it. On being asked how to
avoid STDs and HIV/AIDS, the use
of condoms was suggested by 58
adolescents, mainly the urban ones,
and restricting sex to a single
faithful partner by about a quarter
of them. Abstinence till marriage
was suggested by only 10.5 per
cent adolescents.

There was a decline in the
percentage of girls' responses
stating sexual abstinence as a
method of preventing STDs, AIDS
and HIV infection with increase in
age, whereas among the boys there
was an increase in responses stating
abstinence as one of the methods.
Another interesting finding of the
study is that more slum and
younger adolescents believe that
avoiding deep penetration during
sexual intercourse is one of the
ways of preventing these
infections.







CASE STUDY # 3:

Availability of Opportunities

General Information
Name: xxxxxx; Age: 20 years; Sex: Female'
Jaipur

Family Background

There are six members in the family: father,
mother, two sisters and one brother. She is
the second child, followed by a sister and a
brother. Previously, both the parents were
working. But a year ago her younger sister got
burnt in an accident at home, and the whole
family was disturbed. Consequently, the
mother resigned her job. Presently, she is a
housewife. Her father is a govt. officer. Her
elder sister is also working in a private
concern. The younger sister is studying in
Class 12 as a private candidate, and the
brother is in Class IX. He is a regular student.

Home and Social Environment
The family lives in government
accommodation. There are no separate rooms
for each child. The relationship between the
parents is not congenial. They live in the same
flat but hardly talk. On Sunday or any other
holiday, when the father is at home, because of
the strained relationship between the parents,
the environment remains tense. There is
another conflict in the family. The elder sister
wants her marriage to be delayed, but, as
usual, parents do not agree. They have a
computer at home. Mainly it is the girl who
works on the computer but the others are also
computer literate.



Family Planning

Adolescents were asked
about their awareness of
family planning methods.
Their knowledge varied a
great deal. It was as high as
52.6 per cent for vasectomy,
followed by tubectomy and
oral pills (branded MALA-D)
(46%), condom (41 %) and
IUD (3%). They were well
aware of the availability of
family planning methods.
Three-fourths - more of them
from urban areas - were
aware of family planning
clinics and health centres.
About a quarter of them
knew that one could get them
from friends, while one-fifth
of them said they were
available at chemists or paan
shops. More rural adolescents
got them from friends while
more urban ones said they
could get them from the
health centre. A few
adolescents (11%), older and
rural, were aware of the most
risky period of the menstrual
cycle as far as pregnancy was
concerned.











CASE STUDY # 3 (Contd..)
Personal characteristics
The girl is a student of Indira Gandhi National Open
University (IGNOU), New Delhi. At home, she does paid
work on the computer. She has also done a course in
beauty care. She does not want to marry. She is very
religious and goes to temple daily. She is very reserved.
She has only one fast friend, but now she is married. She
is a good table tennis and basketball player. She was
selected at the state level when she was at school.

Reproductive and sexual behaviour
The girls do not enter the kitchen during their menses.
The girl did not know about menses. She said that she
was very shocked when it occurred the first time and did
not mention it to her mother or sister. When it continued,
she told her sister. Presently, she suffers from severe pain
during these days, but never takes treatment. She
perceives it as a disease and says that it should happen to
boys rather than girls, so that they are forced to stay at
home for at least two or three days (yeh bimari ladkiyon
se choot kar ladkon ko lag janni chahiye jis se woh log
ghar mein to baithenge).

The girl had a boyfriend, but now he is married. The boy
lives in the same colony. When she was in class VIII, she
used to go to the stadium for practice. The boy had also
joined the same. Gradually, they were attracted towards
each Other. The boy is rich and has his own car. They
used to go to restaurants. Her parents thought that she
was with her friend (girl). Once the subject and her boy
friend got drenched due to heavy rains and hired a room
in a hotel to dry their clothes. That day they had sexual
intercourse for the first time. After this incident, they met
in a pre-determined hotel before the 10th of every month.
These days were fixed keeping in view the girl's menses
dates.




During focus group discussions, it as
found that procuring condoms from
chemists is difficult because of
embarrassment (dukandar kya
sochega). Generally, chemists do not
give them to adolescents (hamari
umra ke logon ko nahi dete hai).
Girls mostly buy pills, but when they
feel shy, the boys buy them.
(ladkiyon ko sharm aati hai tab
ladake kharidate hai). The girls said
that they generally knew about FP
methods (sabako jaankari hai).
Mainly, nirodh is used, though pills
(they used the term tablets) are also
used. According to them, chemists
welcome them (medical store waale
unhe welcome karate hai). The girls
also take the opportunity to steal
them from their parents. (ghar mein
maata-pita ke laane par usme se le
sakate hai). Only 31 per cent
adolescents were aware that
pregnancy could be legally
terminated under certain conditions.

Abuse

The term "sexual abuse" included
physical as well as non-physical acts,
but most of the adolescents
understood sexual abuse in terms of
rape (38%), followed by sexual
harassment (21%) and molestation
(20%). However, 14 per cent also
considered eve teasing as sexual
abuse. A majority of the adolescents
(88%) had heard about the term
"rape".




CASE STUDY # 3 (Contd..)

They did not use any family planning method
except taking care of the most risky period. She
knew about this from her sister-in-law. She said
that if her partner did not want her to get into
trouble he should take care of it. When she was
asked how, she said that the partner should
control himself.

However, the parents came to know about it and
the mother reached the same hotel where they
were present. The girl came away with her
mother and a complaint was made to the boy's
parents. Even after this, they met frequently near
her residence. The boy asked her to marry him
but she refused. She said that she was not
confident enough to decide by herself and that
she was afraid of her parents' opposition. Now,
she avoids meeting him. If he again requests her
to come and meet him, she would not refuse. She
was asked about knowledge of other types of
sexual acts. She knew about oral sex but had
never practised it. Two or three years ago, she
once went with her cousin (sister) to hire video
cassettes. She also rang up the shopkeeper to
book two cassettes for her. When they went to the
shop, the shopkeeper was not there and his wife
gave them two cassettes. When they had played
one cassette, she inserted the other one. They
saw something different from the other movies.
Gradually, they understood that they had been
cheated. But, there were no other family
members at her cousin's home and both of them
enjoyed that blue film. Now, she can say that the
act played out in that film may be defined as oral
sex.

According to her, in friendship with boys a girl
should protest when they touch her. She should
avoid meeting them at lonely places. Friends are
the best source to impart this type of in
formation



Sexual Behaviour
Besides their liking, exposure to sexual activities was assessed by asking them
direct questions. More than a third (37%) were involved in some form of body
touching. This occurred more among elderly, rural and urban people than among
slum dwellers. However, about
20 per cent, especially the rural
ones also had some experience of
touching the private parts. About
one-third (30%) experienced
kissing. About 15 per cent
adolescents had an experience of
sexual intercourse.
Adolescents living in rural and
slum areas were sexually active
more than their urban
counterparts. Out of those
adolescents who had sex, 21 per
cent reported to have had a
homosexual relationship. About
half of the unmarried girls
examined for MTP services and
treatment of vaginal infections
showed evidence of having had
sex (Bang, 1997).

Out of the sexually active
adolescents, almost 15 per cent
were married. The results show
that in case of the boys who were
sexually active, the wife was the
partner only in 10 per cent cases
while, in a majority of cases, girl
friends were reported as partners.










CASE STUDY # 4: Incest
General Information
Name: xxxxx; Class: II year in college; Age: 18
years; Sex: Female; Jaipur

Family Background
The family is joint in nature, consisting of seven
members. Besides grandmother, grandfather,
mother and father, there are three sisters. The
family is of middle class status. The father is a
businessman and the mother a housewife. The
elder sister is married and working. The
respondent is the middle one, and her younger
sister also studies in the same college. The
father often goes out of station on business.

Home and Social Environment
The two sisters are very close to each other
because the elder sister has gone to another
city to study. The parents badly desired a son,
but they did not get one. The mother is more
dominant than the father: There is also a
culture gap between her parents as her mother
is Maharashtrian while her father belongs to
Rajasthan. The grandparents have no say in the
family. Though the mother is a housewife, she
remains very busy in her social visits. The
sisters have to do all the daily work at home.
Contd



The mean age of initiation into
sexual intercourse was found to
be 14.1 years. On an average the
girls were younger by 3.5 years
than the boys when they had their
first sexual experience. The mean
age in case of the girls was 11.3
years whereas it was about 14.8
years among boys. Out of those
who had vaginal sex, the younger
adolescent girls reportedly had it
with their boy friends. More slum
dwellers reported having had
vaginal sex as compared to their
urban and rural peers. Of the
older boys, more than half (57%)
reportedly had it with their
girlfriends. Only one rural boy
reported having had it with a
commercial sex worker (CSW).
Married boys had it with their
wives. Sex with relatives was
found to be more common in
slums.

Despite wide inter-study
variations in site, design,
methodology, and population,
available studies show,
relatively, the same picture of
considerable sexual activity and
considerable high-risk behaviour
among adolescents in India. The
age of initiation into sexual
activity among males is found
relatively early i.e. 16 years
(Savara and Sridhar, 1994;
Goparaju, 1993). Many of the





CASE STUDY # 4: (Contd..)

The girl is more responsible as she is older and
sometimes her younger sister takes advantage
of it. There is little conversation between the
parents and the children.

Personality Characteristics
The girl is very reserved and shy. She is
committed to her work. Besides studies, she is
interested in painting, embroidery, and
cooking. She is very slow according to her
parents. She has only one friend who comes to
her. Her sister has many friends, and as the
difference in age is not wide, she enjoys their
company. She is a science
student.

College environment and surroundings
The girls who go to this college are considered
more modern and smart than those who attend
other colleges of this area. The staff of this
college is quite competent.

Reproductive and sex behaviour
Before her menarche, she was aware of this
phenomenon. In her house, many restrictions
are observed during this period. But these girls
have minimized them gradually. The family has
close relatives near their house. They are a
small family consisting of three members
mother; father and son. Because of the close
relationship and a small number of members in
the family, these girls go to the relatives
frequently. Her uncle shows much affection for
the girl (called her meri pyari beti by
embracing,and petting her and sometimes
peering at her breasts.
Contd.



males who report premarital
sexual contacts admit having
relations with commercial sex
workers or older women in their
neighbourhoods (Bhende, 1994;
Watsa, 1993). One in four
adolescent males who have had
sexual relations has reportedly
experienced a homosexual
relationship (Savara & Sridhar
1991).



When the adolescents were asked
whether they were for pre-marital
sex, about a quarter of them
(24%) replied in the affirmative.
It was more acceptable among
younger adolescents and more
particularly among boys. A vast
majority of them who favoured
pre-marital sex, preferred to have
it with one partner, while the rest
of them, more urban than others,
preferred more than one partner.

















CASE STUDY # 4: (Contd..)

Though she did not like it, she never protested
as she thought she was only imagining things.
One day she got very angry when he tried to
put his finger into her vagina. She escaped,
but she never told anyone about this, not even
to her sister. She thought, "His son is also in
his adolescence and if he behaved like this, it
can be considered curiosity or something". In
her view, the peer group is mostly conscious of
it. If the partner agrees, they indulge in sex
by mutual consent. But these so-called
relatives are very dangerous.
Focus Group Discussions:
Issues Emerged

In a focus group discussion with adolescent
girls, the girls said that they were welcomed by
doctors for availing themselves of abortion
services as the latter charged a very high fee
for this. If a girl agrees once, she may be
forced / blackmailed to undergo this again and
again with or without her consent. The girls
also reported during discussions that once a
girl is involved by mistake, she may be
exploited repeatedly (yadi ek baar galati se yaa
anjaane mein kuch kar liya to usei blackmail
kiya jaata hai).














































CASE STUDY # 5: Homosexual Relationship

General Information

Name: xxxxx Class: X; Age : 15 years; Sex: Male; Jaipur

Family background

Small family of five members mother; father and three brothers. The father has
passed Class XII and is a station master in the railways. The mother is a housewife,
and is educated upto primary level.

Home and Social Environment

The family lives in a government flat in the railway colony. The environment of the
family is congenial. The brothers are mostly out playing or studying. There is an
almost free atmosphere.

School Environment

The school is situated in a colony. It has a big building and has both girls and boys.

Personal Characteristics

The boy is a good cricket player; he plays football also. In general, he reads semi-
pornographic magazines like Sacchi Kahaniyan, Manohar Kahaniyan, and Satya
Kathayen. He said that he is very fond of reading sex and rape stories. He also
watches English and Hindi movies, especially those meant for adults.

Reproductive and Sexual Behaviour

He experienced a wet dream at the age of 12 and he usually has them at night.
Though he has not had intercourse with a girl, he dreams of it. He is involved with a
male friend in anal sex. He felt pain in his genitals after this act. He knows this is
not a healthy practice, and feels that he is short and weak due to this. He has also
had oral sex with his friend. He feels that oral sex is better than anal sex. But, after
experiencing oral sex, he feels so excited that he will have an uncontrollable urge to
have anal sex. He wants to give up this practice, but feels unable to do so. He learnt
about this from magazines / films and his own experiences. He has no heterosexual
experiences other than touching breasts, genitals, etc.





Contrary to the general perception of the people of the Indian middle class, one-
quarter of the students believe in getting pleasure where and when they get an
opportunity for sexual intercourse, while 28 per cent have a liberal view that it is
all right for two people to have sexual intercourse before marriage if they are in
love. Only 51 per cent of students believe that unmarried people should not have
sexual intercourse (Nag, 1993).

3.5 Learning about Sexual and Reproductive Behaviour

































CASE STUDY # 6: Healthy Adolescence

General Information

Name: xxxxx Class: XI; Age: 16 years,. Sex: Female; School: Govt. Girls
Senior Secondary School, Ramgarh, Alwar.

Family background

A large family of eight members consisting of mother, father, two brothers and
four sisters. One elder sister is married. The younger sisters and brothers are
studying. The father's occupation is agriculture and his education is up to high
school.

Home and Social Environment

The home environment is congenial, having good relations with neighbours.
The family enjoys middle class status.

School Environment

The school is situated in the centre of the village and near the boys' school.
There is very low incidence of eve-teasing in general. The school runs in two
shifts.

Personal Characteristics

She is intelligent and is an active participant in sports, debate, etc. She is very
fond of reading books and magazines. That's why she knows about some of the
health issues. She does most of the domestic work.
Contd






















About 70 per cent of adolescents, more from rural and urban areas than from
slums, reported that they would like to get more information on these issues.
Mothers were identified by 40 per cent adolescents followed by guests/experts or
doctor as potential resources who could provide them such knowledge.




3.6 Parents' and Teachers'
Perspective
Almost all the parents and
teachers contacted during
group discussions felt that
information on reproductive
health should be provided to
adolescents. However, only a
few said that there was no
need for this type of
education and that
adolescents knew all these
matters (Woh sabjaante hai.
Jab pahle chhoti umrmein
shadiyan hoti thi to kaise
sabko pata hota tha).
CASE STUDY # 6: (Contd..)

Reproductive & Sexual Behaviour

She is also exposed to sex magazines and films, because her sister-in-law in
the neighbourhood shares them with her. She has some general problems
during menses, which she discusses with mother and a friend. They have told
her not to worry as they are common to all.

She was asked about the consequences of early marriage and she talked about
abortion, lack of education and employment opportunities. She has no boy -
friend. Although she can have one, social fear comes in the way. In a small
village everybody knows everyone. According to her, there is no harm if the
relations are limited to kissing and touching. If they share each other's feelings
in a healthy way there is no harm But people do not have healthy minds and
Case Studies: Issues Emerged

The following typical issues emerge from the case
studies presented elsewhere:

Realising the responsibility (#1)
Proper knowledge about contraception (#2)
Inability to say "No" .
Availability of opportunities to adolescents (#3)
Issue of exploitation by elder relatives and its
repercussions (#1,2,4)
Misconceptions about anal and oral sex (#5)
Incest, issue of unnecessary suspicion about
adolescents and its consequences (#6)




Fathers thought that such education was needed because it would enable
adolescents to discriminate between "right" and "wrong". They felt that the
adolescents should be informed about diet/nutrition, personal hygiene, and bodily
changes in girls and boys. About three-fourths of them were in favour of
informing adolescents about sex organs (76%) and ante-natal and post-natal care
(68%). The least preferred topics included the process of conception (65%), use of
contraceptives (65%), masturbation (37%), teenage pregnancy (43%), and
abortion (36%).

Parents and teachers also suggested possible topics for health and sexual
education, which included malnutrition, "safe" and "risk" periods vis--vis
menstruation, sexually transmitted diseases and wet dreams. They felt that this
type of education should only be provided to the adolescents of 14-18 years).
Most of the adolescents (40%) preferred mothers as the best suitable source to
provide information on reproductive health issues, followed by teachers (15%)
and the media (8%). However, the mothers (who participated in focus groups) felt
themselves incompetent, as they did not have complete knowledge about these
issues. Secondly, they also felt hesitant to talk about such issues with their sons.

On the possible role of teachers, one of the fathers in a group discussion said that
they had little faith in teachers saying that a teacher can impart such education but
it should be done with a pure heart (Teacher is prakar ki shiksha to de sakte hai,
par shiksha dene waale ka man bhi to saaf hona chahiye).

The mothers showed ignorance
about adolescents' indulgence
in pre-marital sex (Hamne
kitabon mein pada hai, dekha
nahi). However, the fathers
agreed during discussions that
there was one or two per cent
chance of this kind of
occurrence in middle class
families.









Solution
Some of the parents made some important
remarks. According to them, the media should
be used properly for reproductive health issues;
the focus should be on counselling. More and
more group discussions (including seminars and
lectures) should be arranged; social, moral and
ethical values must be taken care of in this
context; and boys and girls should be informed
about these issues separately.

A majority of parents and teachers were of the opinion that one should discourage
adolescents from having pre-marital sex. This is mainly due to its being against
social, moral and cultural values and also its potential contribution in contracting
AIDS, and STDs.

It was found from the discussions that the teachers knew that the incidence of pre-
marital sex was on the increase. According to the lady teachers, adolescents have
curiosity, but do not have proper knowledge (Jigyasa hai par gyan nahi hota.
Isliye aisa hota hai). It is an emotional thing, and sometimes they may have
knowledge but find it difficult to have control over it (Jinhe knowledge hoti hai
phir bhi bhavana mein bahjaate hai). They also mentioned that elderly persons
hug and kiss adolescent girls but the children might not differentiate their real
love from lust (bade aayu varg ke log god mein lete hai aur kiss karate hai par
bina knowledge ka bacche samajh nahin paate). The teachers were also aware of
incest. As one of the lady teachers puts it, "Chacha, Mama aisa karate hai".
Others accused male physical training Instructors of such conduct (PTIs games
mein aisa karate hai).

II
4. MANAGING ADOLESCENTS' REPRODUCTIVE
HEALTH

This part of the paper is a systems study of primary health care at one primary
health centre at the block level. The diagnosis of the system - BPHC Watika in
Jaipur district reveals that the environment is not friendly. Adolescents' talking
about sexual and reproductive health is considered a social taboo. The health staff
is not trained in the reproductive health concept in general and adolescents'
reproductive health needs in particular. There is lack of awareness of their
reproductive rights and the legalization of these rights is mere rhetoric.

It has been learnt that family planning and maternal health services focusing on
this group cover only married adolescents aged 15-19 years and that there is no
programme which targets a group of both the unmarried and the married ones
under the prevailing Family Welfare Programme.













The reproductive health services
package in practical terms consists of
family planning, ante-natal, natal,
and post-natal services targeting
adult women. As a result, these
services have neglected the critical
segment of the population called
"adolescents". The family planning
and reproductive health services
have a shortcoming, which affects
adolescents as well as adults. It is
that they have usually been designed
and implemented without
acknowledging the linkages with
'sexuality, sexual behaviour and
partner communication.

As a consequence, the access to services remains limited. The worst-off are the
unmarried adolescents, who are neglected in the group because they are too old
for health services meant for children and do not qualify for maternal health
services as they are meant only for married people. Equally, services are not
available to address the information needs of adolescents. In brief, the
reproductive needs of adolescents have not yet been seriously considered. Even
medical and health professionals continue to remain ignorant of the subject of
reproductive health in general and how to deal with adolescents in particular.

Though the providers in the system are technically competent, in their present
bureaucratic set-up they are not using their skills regarding reproductive health
issues fully. It was also observed that their technical know-how has to be updated
in this area. It will help process or implement the programme.














Watika Block Primary Health Centre:
A Profile
Population (1997) 196,391
Adolescents'
(10-19 year) Population 43,206
District Headquarters Jaipur
# PHCs 08
# Sub-centres 41
# Eligible Couples (1997) 31,650
# Villages 211
# Ayurvedic Dispensaries 19
# Schools 133
MTP CHC, Sanganer
Effectively married adolescents are
being focused as eligible couples














































Evidence about Current Status versus Adolescents' Needs

In India, neither services nor enough research focused on adolescents' health
and information needs. In a country in which adolescents (10-19 years of age)
represent almost a quarter of the population, the consequences of this neglect
take on enormous proportions (Jejeebhoy, 1996). Programme experience in
reaching adolescents is extremely limited. These direct or indirect efforts are
as follows:

The Integrated Child Development Services (ICDS) programme has
extended its activities to include adolescent girls (11-18). This
programme is limited to the provision of nutritional supplementation
and health check-ups, along with some health education. While training
is a major component of the programme for 15-18-year old
adolescents, the content of this training is focused on motherhood
skills, such as nursing, first aid, child health and nutrition care
(Pachauri, 1995). However, in Rajasthan, it is in the initiative process.
At the school and college level, 15 states have submitted a proposal to
NACO for the inclusion of HIV/AIDS education in Standards IX-XII,
mainly as a co-curricular activity. The initiative for such activities has
primarily come from the health sector, with NGOs as the implementing
agencies. NCERT imparts adolescent education as a part of existing
population education activities (Anand, 1993).
In general, education related to sex focused mainly on school students
is vague and incomplete in addressing their questions concerning their
bodies, their physical development, or their curiosity about sexual
activity adequately. Some students complain that their school
programmes teach partially and omit the part on sexuality and
reproduction (Jeejobhoy, 1996).
The "University Talks AIDS" project was first undertaken to discover
the extent of students' knowledge about HIV/AIDS, to raise awareness
of HIV/AIDS among the student population, to develop a series of
targeted messages for students, and to sensitise and mobilise student
youths to initiate peer group and community discussion on AIDS
prevention.
UNICEF has initiated the "AWARE" programme among school
students in Jaipur city.
Under Information Education and Communication (IEC) activities,
Kishor Kishori Sammelans (adolescents' meetings) are being held to
make the adolescents aware.
NGO efforts towards family life education of adolescents are
increasing.



It is evident from the previous discussions that adolescents are not being focused
on in the prevailing health and family welfare services. There is a poor fit
between current initiatives and the needs of adolescents. Though the existing
services are being provided to those who are effectively married clubbing them
with the adults, they are being served under the Maternal and Child Health
Programme. The focus has not been shifted to the new approach of reproductive
health. The present services cover married adolescent couples under the
registration of eligible couples (15-44 years) in the family planning programme.
To identify the factors responsible for the current state of these services a system
diagnostic approach (Jain's model) has been used. This approach has the
advantage of being able to accommodate almost all possible factors related to the
problem.

Strategic Approach

From the point of view of the adolescents' reproductive health programme, it is
evident that there is almost no delivery of services for them. Service delivery is
controlled by three factors - need, demand and supply. In brief, the paradigm shift
towards reproductive heath, including adolescents, should be addressed carefully.
Health need is the ability to benefit from a health intervention, and is distinct from
Both demand and supply, although there is a relationship between the three
concepts as shown below:

There is a perceived health problem, which requires treatment.
People with that health problem believe that the resultant health gain is worth
their input of time, effort and/or money to receive that treatment.
An effective treatment or intervention for that health problem is available.

The decision to use health care reflects a combination of both normative and felt
needs, because, for consumption decisions in the health sector, the consumers
often rely on information provided by the supplier, in addition to supplementing
it, according to providers' own preferences. The ideal is for any services to be
needed, demanded and supplied. This focuses on three basic tasks:













demand generation;
supply of services or service delivery; and
resource mobilisation.

A strategy is a unified approach focused on the manipulation of a selected few but
vital factors influencing the system's performance (Jain 1997). Therefore, the task
towards development of a strategy is to identify those few vital factors, which
tend to manipulate themselves. A diagnosis of the system (Watika BPHC), based
on the available data, brings out many factors, which influence the performance or
the situation of the prevailing services towards adolescents. The most important
one is defining the desired output (DO) since it is the central point of the
programme. It directs the whole programme, including training and other factors.
Once the DO is set, each and every effort should contribute towards its
achievement. In designing a program for a particular group, it is essential to use
specific and measurable objectives.

The system diagnosis reveals that there is a strong need to establish a sound
desired output (DO) towards meeting adolescents' reproductive health needs.

It is also important to avoid treating adolescents as a homogeneous group. Age,
school status, marital status, geographical location, sex or gender roles and other
social factors often define the group. This helps in analysing the needs of the
target group and in developing appropriate strategies to meet those needs. Puberty
marks the biological beginning of adolescence, but the markers of its completion
are many and not well-defined. This paper defines adolescence between 10-19
years and it can be further divided into two groups, 10-14 years and 15 years and
above, according to their needs based on age. A concern about the older age group
may be more interesting because most of them are either already married or going
to get married in the very near future. They are in a better position to understand
their needs as they have experienced menarche and other physical changes. The
other division may be into sexually active and inactive adolescents.














Education is another approach to be considered while dealing with the problems
of adolescents related to reproductive health issues. It can be segmented into: (i)
for school going and (ii) for out-of-school adolescents. More than half of the
adolescents are out of school; they are the most needy and under-served.

Marital status is particularly important in the present context because effectively
married couples are being served through the primary health care system.
However, both married and unmarried adolescents have common biological and
developmental issues regarding reproductive health. Thus, the need for
information about sexuality, contraceptives, pregnancy and other issues is alike in
both the cases. The effectively married adolescent couples are treated as adults for
healthcare provision also. Unmarried and married (other than gauna) adolescents
often face more obstacles in having access to the services. Therefore, they fall
between these two extremes, as they are too old for the paediatric clinics and too
young for others.

Geographical location - rural and urban - is also an important factor while
addressing the reproductive health needs of adolescents. Relatively more
resources are available in urban settings. However, it is also true that there is a
system (primary health care system) to address the health problems of adolescents
in rural areas, but a similar system does not exist in urban areas.

Hughes and McCauley (1998) have proposed dividing adolescents into three
groups depending upon their stage of individual development as well as their
socio-cultural environment because they cause variations in adolescents' sexual
experience and activity. The groups are:

Adolescents who have not yet begun having sexual encounters (intercourse)
Adolescents who have engaged in sexual intercourse but have experienced no
hazardous consequences
Adolescents who have engaged in sexual intercourse and have experienced
hazardous consequences
This desegregates the strategy into two components: demand generation and
service delivery. Mobilisation of additional resources will be done with the help
of the stakeholders. The system is already getting resources from the government
for other programmes. The identified critical factors are responsible for the low
demand and committed and competent services cannot be provided. On the other
hand, if the services are not provided, awareness will not increase and this vicious
cycle will go on and on.







It is necessary to open demonstration clinics and let the adolescents know about
the availability of these services. Though the adolescents who come to the clinic
will know about these clinics, for more demand generation more efforts will be
needed.

Therefore, for generating demand, the desirable outcome can be defined as: to
make the adolescents aware of the facility of adolescent health clinics, and to
change their reproductive health behaviour significantly.

The indicator for measuring the desired output will be: Per cent of adolescents
who know about the availability of the services provided, together with their
location by the end of the project.

It is also felt that services should not be focused on reproductive health only.
These clinics will provide not only reproductive health services but also general
health services. Provision of services to adolescents is a highly contentious issue
and requires will-trained trainers. The wider spectrum of services is necessary to
avoid the stigma associated with the receiving of specialized services. It would be
ideal to have them designated as "adolescent clinics", assuming that they have
health problems.

Therefore, it is important that, in order to achieve the output we need to open
demonstration clinics (adolescent health) for attracting more adolescents to
change their reproductive health behaviour significantly.

Achievement of this DO can be measured by using the following indicators:

Number of times and per cent special clinics held by the end of one year
Per cent of adolescents (new patients) receiving services in the centres by the
end of one year.














The DO needs to be acceptable to all stakeholders. Those who have an interest or
stake in the success of the programme are referred to as stakeholders. Each
stakeholder discussed in terms of their interests in and activities for the
adolescents' health programme. These stakeholders will decide what per cent of
adolescents should be targeted. Presently there is no base-line data available to
set specific percentages. They will also decide what services are to be provided.
For generating demand, other resources and help will be needed, which will be
provided by the stakeholders because there is a reciprocal relationship between
the system and other organisations, groups, and individuals. They may help the
senior medical officers in various ways, e.g. organising meetings, motivating
adolescents to come to the centres, imparting information about the special
adolescent clinics, etc. The following is a brief discussion of the expected/actual
role of various stakeholders, and a detailed analysis with ratings on the
importance, favourability and manipulability.

Stakeholders Analysis

There are many important groups
in managing the adolescents,
especially their reproductive
health. It is worth noting that
importance means their support
in providing resources to the
system, while favourability
includes the current status of
support given to the system.
Schools are most favourable
towards both the adolescents and
the system.

In addition to the external clients
(i.e. adolescents), internal clients
(health care providers) also have
a stake. If the adolescents are
aware of their needs and services,
but there is no support from the
providers, it can create a lag.

The providers (government
providers working under the
primary health care system) are not


1. Stakeholders Analysis: Adolescents
It was found that 24 per cent adolescents
favoured premarital sex and as many as 69%
also showed interest in getting more
information about sexual and reproductive
health. According to them, Guest speaker
/experts/doctors/ counsellors (44%), mothers
(416%), friend (40%), and media (27%)
were suitable for giving sex education. Sixty-
four per cent adolescents thought that
school/college should have counseling
facilities. They identified issues of health
problems (85%), family planning methods
(77%), safer sex (72%), decision-making
(68%), and reproductive system and
reproduction (56%) as shown in the IIHMR
study. They showed interest in the subject,
but the subject being a social taboo, they feel
hesitant and reluctant to talk about it
because if they became more aware, they
would come forward and avail of services at
the health centres.





much concerned about adolescents.
But they do not exclude them
purposefully. In their system, they
are more particular about orders
coming from the higher-ups. They
have conducted adolescent meetings,
but quality-wise they are very poor.
They have not understood the
concept of reproductive health.
Moreover, they have not been trained
to provide such services.

The providers should know how this
group is different from others, how
girls are to be treated differently
from boys within the health centre,
what constraints there are on girls'
time that might prevent them from
seeking health services, whether the
services should focus on improving
the health of girls solely or whether
boys should also be involved,
whether a clinic should offer
separate services for youths, and how
adolescents in a specific target group
would respond. The providers, who are mostly adults, may have personal or
religious views about sexuality that influence how they assist adolescents. Most
providers have difficulty in considering
the situation from the point of view of
young persons. So adolescents often
hesitate to tell them that they are
sexually active and to talk about
contraception. Besides, the timings of
the health centre, the degree of
confidentiality, and the style of






2. Stakeholders Analysis: Parents
In the IIHMR study, the parents were
interviewed about what information on
reproductive health should be provided to
adolescents, and who should provide this
information. According to their views,
bodily changes (89%), sex organs (74%),
menstruation (73%), and use of
contraceptives (63%) were the issues, which
the adolescents should know. Less
preference was given to masturbation,
teenage pregnancy and abortion.

As most of the mothers do not have any
formal education or training on these issues,
they also feel shy of discussing them with
their children. But, as they become more
aware of the problems and their importance,
their attitude will also change. In the past,
they were not taught these issues, but they
wanted to impart the knowledge to their
children. And they also recognised that the
most favourable source was the mother
(78%). In other terms, mothers create a
supportive environment informally.
3. Stakeholders Analysis: Schools
There are schools where adolescent
meetings are held under IEC activities
for adolescents. At present, they
provide help to the health care
providers in celebrating Population
Day and organising various
competitions for students, rallies, etc.




providing services can all be
important, as can offering
referrals to other services.
Perceptions of gender roles
are a key determinant of the
expectations of male and
female sexuality. Keeping the
above factors in view, there is
a need to build the capability
of health care providers to
handle adolescents'
reproductive health.

The primary input during the capability building sessions is not training per se,
but a sequence of meetings to practise skills necessary for implementing and
planning subsequent activities.
Emphasis on capability building for
action, rather than on training, is
intended to address the widely
recognised gap between knowledge
and application.

This strategy is also adequate to increase concern and mobilise commitment
among the providers with the introduction of an in-built "risk and reward system"
at both individual and organisation levels.

To design effective programmes to
improve adolescents' reproductive
health, planners must take into
account differences in young
peoples' level of sexual activity such
as "not yet sexually active",
"sexually active without unhealthy
consequences", and "sexually active
with unhealthy consequences"
(Hughes and McCauley, 1998).






4. Stakeholders Analysis:
Integrated Child Development Services
Anganwadi Centres (AWCs) in the area are
functional. Under ICDS services, there is a
provision for providing services to adolescent
girls aged 11-18 years. In other states, the AWCs
are in process of training is a major component
of the programme for the 15-18 year old
adolescents, the content of this training is
focused on motherhood skills such as nursing,
first aid, child health and nutrition care.
This programme has not yet been
implemented in the primary health care
system. There is a possibility of
extending this programme to the whole
state.
5. Stakeholders Analysis:
Private Medical Practitioners
There are a number of private medical
practitioners, even non-registered ones,
who provide health care. They are only
interested in making money by whatever
means. Most of them are not well
trained, or well-equipped, and some of
their practices are unsafe.


Besides, religious leaders (e.g.
Kathavachak) can be an important
source for providing information
specially on sexuality, but there is a
strong need to convince these very
important people about the
importance of the topic as a
component of reproductive health
and their contribution. Once they are
convinced of the usefulness of their involvement, the outcome can be morale
boosting and will get social acceptability of this topic which has been a taboo so
far. Even their endorsing that there is a need to make people aware of sexuality
and related issues can dramatically change communitys perception about these
issues. Most of the Hindus pray to Lord Shiva. In most temples, Shivlingas
symbolising Lord Shiva are installed. A Shiv-linga symbolises the power of
creation. If children learn about the relevance of establishing the Shiv-lingas
Yoni (vagina) and Linga (penis) in temples in religious preaching, they will learn
about sexuality in a positive setting.

5. POLICY IMPLICATIONS

Recently, India's reproductive health programme has increased its focus on adolescents,
in addition to improving the quality of care and decentralising services. During
adolescence, there is a change in health concerns with a bearing on certain important
phenomena likely to have not only a physical but also a psychological impact. Due to
certain cultural barriers in India, reproduction-related phenomena in adolescents are not
only beset with taboos and misconceptions, but are also not clearly explained to them.
These gaps have major policy implications, such as the following:
Initiating more focused and concerted research efforts dealing specifically
with adolescents (including their sexuality)
Acknowledging the importance of culture and tradition when advocating the
needs of adolescents
Building community support and involving community leaders, parents, and
teachers to help achieve this difficult balance.
Ensuring more responsible coverage and treatment of sexual behaviour by the
media (both news and entertainment media).
Establishing health care protocols that meet the needs of adolescents.
Creating a constellation of services that are focused on making not only
individual adolescents but all those who interface with adolescents clearly
understand the risks involved.
Evaluating the programmes carefully and documenting the experiences.
6. Stakeholders Analysis: Youth Group
A youth group, named Nav Yuvak Mandal
is working in the area. This group helps
in organizing meetings, rallies and other
activities. If health care providers ask
them to co-operate in the programme,
they will certainly do so.
Using the lessons of behavioural sciences to promote healthy outcomes.
Mobilising commitment towards adolescent reproductive health.
Defining adolescence (in terms of age in years) uniformly such as for legal
aspects, child labour, paediatrics, etc.
Providing services by not considering the WHO defined age groups (e.g. 10-
14, 15-19 years) because there may be a wide range of variations among needs
according to the age.

Primary health care in India has to meet the needs of the adolescents
reproductive health with the existing resources. There is a need to make a
systematic analysis of the factors associated with the reproductive health needs of
the adolescents and also the ways to provide comprehensive services to them
(both boys and girls) through primary health care centres and sub-centres. This
paper is an effort in that direction.


































ACKNOWLEDGEMENTS

We gratefully acknowledge the assistance provided by many people and
institutions who have contributed directly and indirectly to make this document
possible. For encouragement, critical comments and suggestions, we want to
thank Prof. Sagar C. Jain and Prof. G.R. Rao who helped revise version after
version of the manuscript.




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ABOUT THE AUTHORS

Nutan P. Jain

Dr. Nutan Jain has a background in Psychology and Public Health. She is a PhD
in Psychology from the Institute of Advanced Studies, Meerut University. She has
done Masters in Public Health from the University of North Carolina at Chapel
Hill, USA. She has a long experience of working with national organisations like
Central JALMA Institute for Leprosy, Council for Industrial and Scientific
Research, National Institute of Health and Family Welfare and National Institute
of Public Co-operation and Child Development. Her current areas of interest are
reproductive health, capacity building of NGOs and organisational behaviour.

S. D. Gupta

Dr. S. D. Gupta is a public health expert with a distinguished academic and
research career. He obtained his MD (Preventive & Social Medicine) from India
and PhD (Epidemiology) from Johns Hopkins University, Baltimore, USA. The
National Academy of Medical Science, India had conferred MNAMS on him for
his outstanding contribution in the field of public health. He is a fellow of Indian
Association of Preventive & Social Medicine, and a long- term member of the
International Epidemiological Association. He has published several research
papers and reports.

Dr. Gupta has a long experience of working in the health system and medical
colleges in Rajasthan. He has been associated in various capacities with several
national and international research and academic organisations. He chaired the
Sub-Committee on Operations Research in Reproductive Health of the Committee
of Reproductive Health Research Needs Assessment, Ministry of Health and
Family Welfare, Government of India. He is Temporary Advisor to WHO
Scientific Working Group of Research Information Management. Dr. Gupta is
Advisory Member of the Technical Resource Group (TRG) on Epidemiology for
providing technical support in the implementation of II HIV / AIDS Control
Project under the National AIDS Control Programme.

L. P. Singh

Dr. Singh has a background in Human Biology and Anthropology. He is a PhD in
Biological Anthropology from the University of Oxford. Before joining IIHMR,
he worked on the impact of migration on the health of the Sikh Community in
Britain. He has published several papers in various journals. Since joining the
Institute he has conducted research studies in the area of reproductive health and
management of health programmes. His areas of interest are behavioural studies
and evaluation of community based programmes.