Reproductive Health Package CSR PFI Section III Adolescent Health :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

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Reproductive Health Package CSR PFI Section III Adolescent Health

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Reproductive Health Package CSR PFI Section III Adolescent Health

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Section III

Adolescent Health

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Section III

ADOLESCENT HEALTH

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chapter 13

ADOLESCENT HEALTH

Adolescence (10–19 years), the transition between childhood and adulthood, is a distinct phase of

life with its own special needs. It is a stressful period of life characterized by discernible physical,

mental, emotional, social and behavioural changes, thus bringing about transformation from childhood

to adulthood. While adolescents are generally defined as individuals in the 10–19 years age group and

“youth” as the 15–24 year age group, the Government of India in the National Youth Policy defines

youth as the 15–35 age group and adolescents as 13–19 years.

In adolescence an individual undergoes enormous physical and psychological changes. In addition, the

adolescent experiences bring about changes in social expectations and perceptions. Physical growth

and development are accompanied by sexual maturation, often leading to intimate relationships. The

individual’s capacity for abstract and critical thought also develops, along with a sense of self-

awareness when social expectations require emotional maturity.

Development Characteristics of Adolescents

Physical Development

Rapid and dramatic physical development and growth mark adolescence, including development of

sexual characteristics. In the case of boys, active acceleration in the growth of coarse pubic hair and

facial hair usually precedes other signs of puberty such as voice changes. In girls, development of

breasts, broadening of hips and rapid growth in height usually begins about two and a half years before

menarche (see Table 13.1). Box 13.1 seeks to answer some concerns of adolescent girls about

menstruation. Box 13.2 is on parallel lines about adolescent boys’ concerns about reproductive and

sexual health.

Table 13.1. Physical Changes during Adolescence

CHANGES COMMON TO BOTH SEXES

• Growth spurt occurs

• The skin becomes oily

• Underarm hair appears

• Pubic hair appears

• The external genitals enlarge

BOYS

GIRLS

• The muscles develop

• The shoulders broaden

• The voice cracks

• Chest hair appears

• Facial hair appears

• Ejaculation occurs

• The breasts develop

• The hips widen

• The waistline narrows

• The uterus and ovaries enlarge

• Menstruation begins

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Box 13.1. Adolescent Girls’ Concerns about Menstruation

What is Menstruation?

Menstruation is a natural body function. This is one of the processes which prepares a girl’s body

to conceive a baby in the future. Menstruation is a sign that her reproductive system is healthy

and functioning well.

The periods usually last four to five + 2 days but may be longer or shorter in exceptional cases.

A girl loses 50–80 ml blood on an average during a period. If she soaks more than three to four

pads per day in the initial two or three days, passes lots of blood or if periods last more than

seven days, it may be considered excessive bleeding.

During the first few years after initiation of menstruation, a girl may skip a few cycles. This

should not be of much concern unless she is sexually active, when she may be at risk of

pregnancy.

The service provider’s role: It is important to talk about this normal body function since a

significant number of adolescent girls have concerns related to the menstrual cycle, most of

which require only reassurance or counselling. A number of myths and misconceptions in society

have led to it being perceived as something unclean or polluted. Many traditional cultural beliefs

and practices are not very helpful or sometimes harmful for the growing girl.

Excessive or Scanty Bleeding

It is possible that in the beginning, sometimes a girl may only bleed every few months or have

very little bleeding or too much bleeding. The cycle usually becomes more regular with time.

The service provider can:

• Reassure the girls or their mothers that the menstrual pattern will normalize after the initial

few years.

• If the problem continues after the initial few years, she should be referred to a lady

gynaecologist at the district hospital for investigation and treatment.

Pain with Menstrual Bleeding

During menstrual bleeding, the uterus squeezes to push out the lining. The squeezing can cause

pain in the lower abdomen or lower back. The pain may begin before or just after bleeding starts.

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The service provider can:

• Reassure the girl that the pain will be relieved spontaneously in a day or two.

• Counsel her to keep doing her daily work, exercise and walk.

• If the pain is unbearable, refer to a gynaecologist, who may give some pain killer.

Pre-menstrual Syndrome

Some girls feel uncomfortable a few days before their menstrual bleeding begins. They may have

one or more or a group of symptoms known as pre-menstrual syndrome. Girls who suffer from

pre-menstrual syndrome may notice:

• pain in the breasts

• a full feeling in the lower belly

• constipation

• emotions that are specially strong or hard to control.

The service provider can:

• Reassure the girl that there is nothing to worry as these symptoms are due to changes in

the hormonal pattern every month and will go once her periods start.

• Counsel her to continue doing her regular work and exercise.

Hygiene and Cleanliness during Menstruation

To maintain menstrual hygiene, girls can use clean cloth or sanitary pads.

Using cloth: Clean cotton cloth should be used to soak the menstrual blood. Cotton has a good

absorbing capacity. A synthetic cloth should not be used as it may not absorb well and may

cause skin reactions. The cloth can be used along with the underwear. Never use dirty cloth or

the same blood-soaked cloth again and again. The cloth should be changed two or three times

a day. The cloth and the panties should be properly washed with soap and water and dried in

the sun. Sunlight kills all bacteria. After every period, the washed and dried cloth should be

stored in a clean bag, in a clean place till the next period.

Using pads: The pads can be used along with the underwear. The pads should be changed two

or three times a day. Used pads should be wrapped in a paper bag and disposed.

During menstruation, the girl should take a bath every day.

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Box 13.2. Adolescent Boys’ Reproductive and Sexual Health Concerns

Erection of the Penis

In response to thoughts, fantasies, temperature, touch or sexual stimulation, the penis fills with

blood and becomes hard and erect for sexual intercourse. In young adolescents erections may

take place even in the absence of thoughts or stimulation.

Ejaculation

The release of semen from the penis after sexual excitement is called ejaculation. This may occur

at night and is commonly called a wet dream or nightfall (Hindi equivalent: swapna dosh). It

is a natural and normal phenomenon.

During ejaculation, the urethra is closed to urination.

Genital Hygiene

• Wash genitals daily.

• Gently retract (pull) the foreskin back and wash the tip of the penis. Secretions accumulate

under the foreskin and could cause infection if not cleansed regularly.

• Change underwear daily.

• Use cotton undergarments only. Synthetics do not absorb moisture and also increase the

temperature.

• Wash undergarments everyday and dry in the sun.

Some Myths about Adolescent Boys’ Sexuality

Myth 1: It is wrong to masturbate as it is a sin. Fact: Masturbation is stimulation of genitals

for sexual pleasure without penetrative sex. It is a not a sin to satisfy one’s sexual urge oneself.

People feel guilty after masturbation as they do not have correct information and are surrounded

by many myths related to it.

Myth 2: If an adolescent boy masturbates too much, his adult sex life will be affected. Fact:

Masturbation does not affect sexual life.

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Myth 3: Most boys masturbate, but very few girls masturbate. Fact: It is natural for both boys

and girls to masturbate as both have a sexual urge.

Myth 4: Most people stop masturbating after they get married. Fact: Not necessarily. There may

be situations when the partners are not together or one of them does not want to have sex. Then

one may satisfy one’s sexual urge by masturbation.

Myth 5: Masturbation can cause pimples, acne, and other skin problems in teens. Fact: Acne

and pimples are due to oily skin and go away after a few years.

Myth 6: Loss of semen in nightfall leads to weakness of the body. Fact: This is normal among

adolescent boys. It does not cause weakness or any other abnormality.

Myth 7: Those who masturbate a lot during young age have mental problems later on in life.

Fact: Masturbation does not cause mental problems. However, many people have guilt due to

misconceptions about masturbation.

Myth 8: Masturbation is a dangerous behaviour. Fact: Masturbation is a safe way to satisfy one’s

sexual urge as it does not cause pregnancy or STIs.

Myth 9: If the penis is touched time and again, it becomes longer or bends. Fact: Masturbation

has no effect on the size or shape of the penis.

Myth 10: If the penis is small, the man cannot have sex. Fact: The man can have sex even if

the penis is small.

Emotional Development

Bodily changes and other factors cause emotional stress and strain as well as abrupt and rapid mood

swings. Getting emotionally disturbed by seemingly small and inconsequential matters is a common

characteristic of this age group. Some of the emotional and social changes in adolescents are:

• preoccupied with body image

• want to establish own identity

• fantasy/daydreaming

• rapid mood changes, emotional instability

• attention-seeking behaviour

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• sexual attraction

• curious, inquisitive

• full of energy, restlessness

• concrete thinking

• self-exploration and evaluation

• conflicts with family over control

• seek affixation to counter instability

• peer group defines behavioural code

• formation of new relationships.

Hormonal Changes

Hormonal changes are likely to result in thoughts pertaining to sex, irritability, restlessness, anger and

tension. Attraction to the opposite sex leads to a desire to mix freely and interact with each other.

But in reality this may not always be possible, partly due to societal restraints on pre-marital sexual

expressions and also because of other priority needs in the period, viz. education, employment, etc.

An inability to express their needs often leads adolescents to fantasize and daydream.

Adolescence is also marked by development of the faculty of abstract thinking that enables them to

think and evaluate systematically and detect and question inconsistencies between rules and behaviour.

Parents as well as service providers often overlook this development, which is one of the basic reasons

for the popularly known ‘generation gap’.

Socially, adolescence consists in shifts from dependency to autonomy, social responses to physical

maturity, the management of sexuality, the acquisition of skills and changes in peer groupings. The

need to be a part of a gang or a large group is replaced by a preference for maintaining fewer, more

steady and binding relationships.

Pubertal development starts one or two years earlier in girls than boys. There is a wide variation in

age and velocity with which growth and development proceeds. In a group of adolescents who are

growing this wide variation leads to development of anxiety – “Am I normal?” and needs a lot of

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reassurance. The appearance of secondary characteristics before the age of 8 years in girls and 9 years

in boys, and non-appearance of secondary sexual characters by the age of 13 years in girls and 14 years

in boys is considered abnormal. Such cases should be referred to higher centre for management. A

girl who does not start menstruation by 16 years age should also be referred.

The Adolescent Scene in India

• Adolescents comprise a sizeable population: There are 225 million adolescents comprising

nearly one-fifth (21.8 per cent) of the population (Census 2001).

• Composition varies by age and sex: Of the total population, 12.1 per cent belong to the 10–

14 age group and 9.7 per cent are in the 15–19 age group. Female adolescents comprise 46.9

per cent and male adolescents 53.1 per cent of the adolescent population (Census 2001). The

present adverse sex ratio in 0–6 years (927 girls for 1000 boys) will affect the adolescent

population in the coming years.

• Malnutrition affects development: More that half of the adolescent girls suffer from anaemia.

Two-thirds suffer from chronic energy deficiency of the third degree with body mass index (BMI)

below 16. Married women aged 15–49 are also reported to have BMI below 18.5 (NFHS-2).

Iodine deficiency disorders can lead to growth retardation and retard mental development.

Anaemic adolescent mothers are at a higher risk of miscarriages, maternal mortality and giving

birth to stillborn and underweight babies.

• Economic compulsions force many to work: Nearly one out of three adolescents in the age group

15–19 years is working – 20.6 per cent as main workers and 11.7 per cent as marginal workers

(Census 2001). Despite the law against employment of child labour employers engage children

and adolescents because of cheap labour.

• Adolescents from rural areas and girls are disadvantaged: Twenty-five per cent of the 15–19 years

age group in rural areas and 10 per cent in urban areas are illiterate. The male-female differences

grow with each level of education (NSS 55th Round, 2001). Rural girls are most disadvantaged.

School enrolment figures have improved, but gender disparities persist. The challenge is to keep

students in schools.

• Crimes against adolescents are prevalent: Sexual abuse of both boys and girls cuts across

economic and social classes. According to one survey, in 84 per cent cases, the victims knew

the offenders and 32 per cent of the offenders were neighbours (NCRB 2001). Crimes against

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girls range from eve-teasing to abduction, rape, prostitution, violence and sexual harassment.

Unfortunately, social taboos prevent these crimes from being reported or registered. Even when

registered, prosecution rarely takes place.

• Drug abuse is emerging as a problem: A major section of drug users are below 20 years. Forty

per cent of them started taking drugs when they were between 15 and 20 years of age (UNDOC

2002). Social factors such as illiteracy, economic background, unemployment, rural residence

and family disharmony increase vulnerability to drug abuse.

• Trafficking and prostitution has increased: Extreme poverty, low status of women, lax border

checks and the collusion of law enforcement officials has led to suicide or increase in prostitution.

Expansion of trafficking and clandestine movement of young girls has also increased across

national and international borders.

• Premarital sexual relations are increasing: Lack of contraceptives or condom use characterizes the

vast majority of sexual encounters among youth (Jejeebhoy 2003). The incidence of unintended

teenage pregnancies and abortions has shown a steady increase. Unsafe abortions are a major

cause of reproductive mortality and morbidity.

• Unmet need for contraceptives: While knowledge of family planning is being promoted, the

availability and use of contraceptives is not publicized. Even amongst currently married women

there is an unmet need of contraception, being the highest in the age group 15–19 years. Nearly

27 per cent of adolescents have reported unmet need for contraception.

• Misconceptions about HIV/AIDS are widespread: There is a high level of awareness about HIV

among young people, especially among those who are more literate. However, misconceptions

on certain modes of transmission are widespread. As many as 73 per cent of young people were

unaware that a healthy looking person could transmit infection. Many are unaware of the correct

way of using a condom. Negative attitudes exist towards HIV positive individuals – only 40.7

per cent of young people were willing to share food with infected persons (National Behavioural

Surveillance Survey 2001).

• Early marriage is common: Fifty per cent of Indian women were married before they attained

the age of 18 years (NFHS 2). While the average age at marriage for educationally disadvantaged

female is 15 years, for women who have completed school it is 22 years. This indicates that

continuation of education results in delayed marriage. Nineteen per cent of total fertility rate

(TFR) is contributed by adolescent mothers in the age group of 15–19 years (NFHS-1 and 2).

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• Female mortality rates are higher than male mortality: A high risk of early pregnancy and

childbirth results in a high level of female mortality in the reproductive age group. Maternal

mortality of teenage mothers is a grave cause for concern.

Rationale for Intervention

The following are some of the reasons for investing in adolescent health and development:

• The behaviour and lifestyles learned or adopted during adolescence will influence the health of

individuals for the rest of their life. The benefits of adolescent health and development accrue

also to future generations.

• To reduce morbidity and mortality among adolescents.

• Investing in adolescents’ health will reduce the burden of disease during this stage and in later

life and avert future health cost.

• In the context of the RCH programme goals, paying attention to adolescents will yield dividends

in terms of delaying age at marriage, reducing incidence of teenage pregnancy, prevention and

management of obstetric complications.

• Lack of economic empowerment among adolescents and youth among the poor curtails their

capacity for decision-making on their age of marriage and other reproductive and sexual health

issues.

• To build self-esteem in adolescents resulting in confident adults in society.

• To develop their capacity to cope with their life situations and deal with them responsibly.

• To prepare them for adult and married life.

• In India, traditionally, the transition from childhood to adulthood amongst girls has tended to

be sudden. The social taboo on the subject of sexuality has resulted in limited vocabulary and

spaces to talk about this issue. Gatekeepers (parents, teachers, policymakers, etc.) do not visualize

that adolescents need to know about sexuality and sexual health issues. Discussion is veiled in

innuendoes and skirts the real issues.

Nutritional Needs

Growth retardation is one of the most important health concerns for adolescents and their parents as

well as healthcare workers. Stunted growth of adolescent girls will lead to stunted women, who are

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likely to give birth to low-birth-weight infants prone to mortality and morbidity. Poor nutrition during

adolescence can impair the work capacity and productivity of adolescents in their later years. Table

13.2 presents the recommended daily dietary allowance of nutrients for adolescents.

Table 13.2. Recommended Daily Dietary Allowance of Nutrients for Adolescents

Energy (kcal)

Protein (gm)

Calcium (mg)

Iron (mg)

Male

Female

10–12 Years 13–15 Years 16–18 Years 10–12 Years 13–15 Years 16–18 Years

2200

2500

2700

2000

2100

600

500

600

500

Adolescent girls often suffer from anaemia because of poor consumption of iron-rich foods and also

worm infestation and frequent infections. Because of severe malnutrition and repeated illness the

growth spurt in early adolescence does not occur and a slower and prolonged pubertal growth period

is seen in adolescents from the lower socio-economic strata. The need for iron increases with rapid

growth and expansion of blood volume and muscle mass. As boys gain lean body mass at a faster

rate than girls, they require more iron than girls. The onset of menstruation imposes additional needs

for girls. Adolescent girls need additional iron to compensate for menstrual blood loss (see Box 13.3).

Box 13.3. Nutritional Deficiencies in Adolescents

Anaemia. The blood contains a red pigment called haemoglobin, which carries oxygen and is

rich in iron. Anaemia is the loss of oxygen-carrying capacity of the blood due to deficiency of

haemoglobin in the red blood cells.

Iron-deficiency anaemia is a major nutritional problem in adolescent boys and girls in India. The

ill effects of anaemia can be seen as:

• reduced capacity to work and thus decreases productivity

• increased risk to pregnant girls/women (In India, 20–40 per cent of maternal deaths are due

to anaemia)

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• increased susceptibility to infections by impairing the immune functions.

To prevent anaemia, increase the intake of green and leafy vegetables and fruits. If an

adolescent looks pale, fatigued or listless and anaemia is suspected, refer to the nearest

PHC. In coastal areas worm infestation is a major cause of anaemia. Anaemia is treated

by giving iron and folic acid tablets daily for two or three months till haemoglobin levels

have returned to normal. In case of worm infestation, deworming tablets followed by iron

supplements should be given.

Other Deficiency States

• Inadequate nutrition during adolescence can potentially stunt growth. Sexual maturation

may be delayed with late onset of puberty. Poor nutrition impairs work capacity and the

adolescent may feel tired all the time.

• Zinc-deficient diet results in growth failure and delay in sexual maturation.

• Iodine deficiency leads to a much wider spectrum of disorders commencing with intrauterine

life and extending through childhood to adulthood with serious health and social implications.

Iodine deficiency disorders include mental deficiency resulting in impaired mental functions,

neurological defects, increased stillbirths and peri-natal and infant mortality.

Reproductive and Health Care

Contraception

Most adolescents begin their sexual activity without adequate knowledge about sexuality or contraception

or protection against STIs. For unmarried adolescents it is sometimes impossible to access contraceptives

and the sexual activity often results in unintended pregnancy. The barriers that adolescents face in

accessing contraceptives are:

• the unexpected and unplanned nature of sexual activity

• lack of information and knowledge about conception and contraceptives and their availability

• fear of medical procedures

• fear of judgemental attitudes of providers

• inability to pay for services and transport

• fear of opposition from partner and parents

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• pressure to have children

• lack of knowledge on modern contraceptive updates.

What Can be Done

• Access to appropriate information and services with confidentiality is absolutely necessary for

all adolescents, especially those who are unmarried.

• To help ensure contraceptive use among sexually active adolescents information and services

must be made easily available through community-based facilities and outreach services. Emergency

contraceptives should be available to adolescent girls who need them.

• Government health service delivery points (CHC, PHC, health sub-centres) should be provided

with privacy for these patients.

Pregnancy

Pregnancy and childbirth in adolescence are risky for the health of both mother and infant.

• Biologically, an adolescent’s body is still developing and not ready to take on the strain of

pregnancy and childbirth. Mentally also she is not prepared for the responsibilities involved.

• The stigma associated with pregnancy outside of marriage deprives the girl of the emotional

support she needs as well as support in terms of nutrition, rest, antenatal check-ups, etc. This

leads to unmarried adolescents hiding their pregnancies for as long as they can and medical help

is delayed at great risk to their lives.

• For married adolescent also the risks of pregnancy and childbirth are high. To begin with, she

may not be aware of the importance of antenatal care. For various reasons, she is more likely

to deliver at home. The older women in the home feel that a traditional birth attendant is

equipped to carry out the delivery, her services are cheaper and she is easily accessible. A trained

birth attendant or a hospital is thought of when things get out of hand and complications have

already set in. Adolescent mothers are most likely to give birth to low weight babies (less than

2.5 kg) and both the mother and child face higher mortality and morbidity.

Pregnancy-related complications that occur more commonly in adolescence than in adults include:

death; pregnancy-induced hypertension; anaemia during antenatal period; STIs; higher severity of

malaria; pre-term birth; obstructed labour; postpartum anaemia; pre-eclampsia; postpartum depression;

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too early repeat pregnancies; low birth weight; peri-natal and neonatal mortality; inadequate child care

and breast-feeding practices.

Adolescent pregnancies and deliveries require much more care than adult pregnancies. This includes

early diagnosis of pregnancy, effective antenatal care, and effective care during labour and delivery and

during the postpartum period. Information and counselling support is the right of every pregnant

woman who reaches a health centre. They must be given an opportunity to raise and discuss these

issues confidentially. Since adolescents are more at risk of STIs including HIV/AIDS, voluntary counselling

and testing services should be made available to them. If the adolescent is severely anaemic, postpartum

haemorrhage can be a dangerous possibility. In very young adolescents, pre-term labour as well as

obstructed labour are more likely to occur. Case management at village and remote areas through

collective action is important. Postpartum care includes the prevention, early diagnosis and treatment

of postnatal complications in the mother and her baby. It also includes information and counselling

on breast-feeding, nutrition, contraception and care of the baby and care of herself. Adolescents,

especially if they are unmarried, need ongoing contact through home visits on their return with their

infants. Family counselling is therefore vital and provides a lifeline to the adolescent and her

baby.

Abortion

• Delay in seeking abortion is the leading cause of complications and death among adolescents.

• The judgemental and unwelcoming attitude of health providers can also lead to delay in reaching

them.

• It is commoner among adolescents to go to untrained and unskilled providers (quacks).

• Use of dangerous methods is also common in adolescents, such as inserting foreign bodies into

the cervix or ingesting certain potions or drugs.

• Most clients feel that privacy and confidentiality is difficult to maintain in the pubic system.

• Even after a spontaneous abortion, an adolescent would need medical attention.

Identification of Gaps

Although the Reproductive and Child Health Programme II includes focus on adolescent reproductive

and sexual health, the implementation has not kept pace with the promises. Healthcare providers need

to be sensitized and trained in how to provide adolescent-friendly services. Adolescents need:

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• a safe and supportive environment that offers protection and opportunities for development;

• information and skills to understand and interact with the world;

• health services and counselling – to address the local health problems and deal with personal

difficulties;

• reproductive health services and counselling;

• information and counselling.

A Framework for Adolescent-friendly Services

• Adolescent-friendly reproductive and sexual health services can be delivered in health centres,

Anganwadi centres, in the community, through outreach services or at school.

• Hospital- or clinic-based services can become more adolescent-friendly.

• Community settings include services provided at community or youth centres, in shopping malls

or even over the Internet.

• Outreach services are needed in cities to contact adolescents who do not attend clinics and

those, like street children, who are marginalized.

• Outreach services in rural areas can be devised to reach young people living in isolated communities

through community health workers, peer educators and change agents.

• Schools offer a critical entry point to bring services to young people who are in school.

• Young workers, including adolescents, can be reached with health education or screening services

targeted at the workplace.

• Services can be located anywhere where young people go – no single setting should become the

only model.

Table 13.3 presents the characteristics of adolescent-friendly reproductive and sexual health services.

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Communication and Counselling

Role of Family and Community Counselling

Adolescents seek information and clues about sexual

life from a variety of sources such as parents, siblings,

peers, magazines, books, the mass media, etc. Not all

of the information they receive is correct and complete.

Many adolescents lack information concerning the

physical changes that occur during adolescence, their

implications, and how to take care of themselves.

This happens often because discussion of sexuality is

taboo in Indian society. Failure to provide adolescents

with appropriate and timely information causes missed

opportunity for reducing the incidence of unwanted pregnancy and STIs, including HIV/AIDS.

The Need for Counselling

Adolescents must often make significant decisions on the following sexual and/or reproductive health

matters:

• How to discourage and prevent unwanted sexual advances?

• Whether to engage in sexual relations or not. If yes, when?

• How to prevent pregnancy and STI?

• Whether to conceive a child or not? If yes, when?

• Whether to continue or terminate a pregnancy?

• What kind of antenatal care to seek and where to go?

• How to deal with sexual abuse and/or violence?

Most of these decisions can be worked through during counselling sessions that follow the prescribed

approaches.

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The purpose of counselling the adolescent on sexual and reproductive health issues is to help the

adolescent to:

• exercise control over her/his life

• make decisions using a rational model for decision-making

• cope with her/his existing situation

Achieving control over behaviour, understanding of oneself, anticipating consequences of actions, and

making long-term plans are characteristics of maturity, which is one of the goals of adolescent

counselling.

Good communication and counselling to adolescents about sexuality requires:

• considering the client’s age and sexual experience;

• demonstrating patience and understanding of the difficulty they have in talking about sex;

• assuring privacy and confidentiality;

• respecting the client and her/his feelings, choices, and decisions;

• ensuring a comfort level to ask questions and communicate concerns and needs;

• responding to expressed needs for information in understandable and honest ways;

• exploring feelings as well as facts;

• encouraging to identify possible alternatives;

• leading an analytical discussion of consequences, advantages, and disadvantages of options;

• assisting the client to make an informed decision;

• helping to plan how to implement her/his choice.

Tips for Good Communication

• Allow sufficient time for the client to become comfortable enough to ask questions and express

concerns.

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• Do not express judgmental views about the client’s needs and concerns.

• Show an understanding of and empathy with the client’s situation and concerns.

• Exhibit confidence and professional competence in addressing adolescent reproductive and sexual

health issues.

• Be genuinely open to an adolescent’s question or need for information (ranging from “Where

is the toilet?” to “Should I use birth control?”).

• Do not be judgemental in words or in body language that suggest disapproval of her/him being

at the clinic, of her/his behaviour, or of her/his questions or needs.

• Understand that the young person has various feelings of discomfort and uncertainty.

• Be reassuring in your responses, making him or her feel more comfortable and confident.

• If sensitive issues are being discussed, ensure that the conversation is not overheard.

What the Corporate Sector Can Do

Focus on adolescent health calls for comprehensive collaborative programming to include:

• information on sexuality, fertility and contraception, as part of their reproductive rights;

• development of self-awareness, as positive self-image, assertiveness and an understanding of

gender-based discrimination and control of women’s sexuality;

• development of psycho-social skills such as decision-making, problem solving, effectively

articulating, and coping with emotions and stress;

• development of survival/practical skills such as literacy and training for an occupation. This is

especially important in our setting where the majority of adolescents are out-of school, illiterate

and have limited work opportunities;

• designing of locally relevant interventions that contain the mortality that girls in this age group

suffer.

3 Pages 21-30

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3.1 Page 21

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Prioritizing Issues of Adolescents

• access to quality education and information (primary as well as legal literacy, non-formal, sex

education);

• sexuality and reproductive health issues;

• services (accessible, quality and youth-friendly);

• skills (leadership skill, life skills training, negotiation skills).

Programme Recommendations

• Disseminate family life education to in and out of-school youths.

• Address the need for quality education of all adolescents.

• Include adolescents’ needs while formulating policies and programmes.

• Intensify efforts to increase collaboration.

• Address the nutritional needs of adolescent girls.

• Respond more sensitively to special needs of unmarried adolescent girls and boys.

• Investigate reproductive health needs and decision-making authority amongst married adolescent

girls.

• Investigate premarital sexual behaviour, awareness and attitudes amongst representative samples

of adolescents.

• Describe the levels, patterns and context of abortion behaviour among both unmarried adolescent

girls and awareness of its legal status.

• Conduct community-based studies on obstetric and gynaecological morbidity amongst girls, and

sexually transmitted infections amongst boys and girls.

• Investigate adolescents’ access to healthcare and the constraints they face in acquiring good

health.

3.2 Page 22

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• Use rigorous, in-depth, and at the same time sensitive and culturally appropriate research designs

to elicit data about adolescents.

• Document successful programmes.

• Prepare youth-friendly programmes.

• Include adolescents in planning and implementation.

• Economically empower adolescent girls to take decisions on their body.

Advocacy needs to be an integral part of the programme and linkages need to be established with the

government and relevant partners. Partnership with the media should be built in order to reach out

to youth by developing role models, promoting healthy lifestyles, providing accurate information, etc.

The media are an important partner in disseminating information not only to the target audience but

to the community as a whole. Sensitizing and involving the media, including print, audio, visual,

street plays and so on, is an important step in setting the stage for information dissemination and

initiating a dialogue on a hitherto neglected topic.

References

GOI, May 2006. “Orientation Programme for ANMs/LHVs-Handouts”, National Rural Health Mission.

Seminar, 2003. Special issue on ‘Abortion’, New Delhi, December.

Siddhivinayak, Hirve, May 2004. “Abortion Policy in India”, published by CEHAT.

VHAI, 2001. “Where Women Have No Doctor, A resource guide for women’s health”, Chapter 4 :

Health Concerns of Girls, New Delhi: Voluntary Health Association of India.

3.3 Page 23

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POPULATION FOUNDATION OF INDIA

B-28, Qutab Institutional Area, Tara Crescent, New Delhi 110 016

Tel. No : 42899770, Fax : 42899795

Website : www.popfound.org, E-mail : popfound@sify.com