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Reproductive and sexual health awareness among adolescent girls: a micro study in Churachandpur District of Manipur.

Adolescence is a time of opportunity and change. The major concern during this period is adolescent health. Adolescent health involves professional perspectives and is of high public health concern, particularly reproductive and sexual health. Programs that can provide information, ensure access to services, and develop life skills are crucial to the future of the adolescents. Holden and Nitz (2006) were of the view that rapid changes in the demography of the adolescent population, however, lend substantial support to the notion that we should invest even more resources in developing an informed understanding of health issues in adolescents in the near future.

Defining adolescence within a social construct is not possible as it varies across cultures. Adolescence, therefore, cannot be defined only by age, puberty, sexual intercourse or marriage so, to have a clear understanding of the meaning of adolescents across cultures, events need to be viewed within the context of gender relations, age hierarchies and social class as well. According to WHO (2002) sexual health is a state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Thus, there is an evident need to address sexual health needs at all the levels of the health system starting from the individual to the health care institutions. Unfortunately, the overall lack of acceptance of adolescent's sexuality translates into a lack of information and services in this realm. Not only does this make adolescent vulnerable to infection, it also restricts their capacities to make decision around sexuality. The causation in most of the health problems of adolescents is multifactorial in nature. Information leads to better and more responsible choices among the adolescents however, this information is more or less denied.

Rationale of the Study

In India, traditionally, the period from childhood to adulthood has been always sudden. As a result of the poor nutritional status of the average Indian adolescent, menarche occurs later than in other region of the world, therefore the biological onset of adolescence at least among females, may be later in India than elsewhere (Jejeebhoy, 1996) On the other hand, marriage and consequently the onset of sexual activity and fertility, occur far earlier in India than in other regions of the world, thrusting adolescent girls early into adulthood, frequently soon after regular menstruation is established and before physical maturity is attained (Jejeebhoy, 2000) Little information is available on this significant section of the population and that adolescent is rarely considered a distinct group with special needs apart from those of adults and children. Health programmes generally make provisions for adults and young children, but adolescents have largely been overlooked. There are an estimated 300 million young people in India today; representing almost one-third (31 percent) of the population. Specifically, 22 percent of the population falls into the adolescent age group (aged 10-19) (IIPS, 2000). In spite of adolescents being a huge segment of the population, policies and programs in India have focused very little effort on the adolescent group. The situation of adolescents varies widely by gender and region in terms of not only educational attainment and economic activity but also in terms of sexual and reproductive risk behavior. Adolescents' needs for reproductive health services are often misunderstood, unrecognized or underestimated. This may be because the information about the adolescent health services is not available or the attentions of the health care provider have not seen a shift towards adolescent health care.

The overall lack of understanding and acceptance of adolescent's reproductive and sexual health needs translates into a lack of information and services in this realm. This ignorance on the part of the care providers be it parents, medicals authorities, policies makers as well as the care seekers--adolescents themselves in this respect, make them vulnerable to infection and undesirable health results, it also restricts their capacities to make decision around reproductive health and sexuality. Information and awareness leads to better and more responsible choices among the adolescents however, this information is more or less denied.

Profile of Churachandpur District

Churachandpur is an advanced tribal town. It is the fastest growing district headquarters and hill-town of Manipur. The Paites are dominant in Lamka Town of Churachandpur of Manipur state. The word Paite means "a group of people marching" (pai-march; te-people). The Paites are a recognized scheduled tribe in northeastern India, primarily in the state of Manipur. Though Churachandpur is a developed district, yet development has not resulted in the improvement in the delivery of health services and it still fails to meet the health needs of the people. As far as the reproductive health care of the adolescents are concerned, although the demand for sexual and reproductive health programming for adolescent in developing countries is growing, yet there is a dearth of evidence on the characteristics of effective programs especially in India's Northeast. A Large number of adolescents as per the NFHS 1998-99 data are observed to be engaging in unsafe sexual practices as well as early marriages, though across culture the age of first sexual activity or contact varies it usually begins at 15-16 years which further increases the risk of reproductive health problems and sexually transmitted infections.

The study was conducted in order to assess the social context of risk and protection for the adolescents. Today Churachandpur district of Manipur presents a major challenge to public health in terms of misconception regarding adolescent sexual and reproductive and sexual health and the lack of infrastructure to meet the needs. The study district was purposively selected. Churachandpur district is one of the most developed districts in Manipur. The study has been conducted in the village Moldenphai and Lamka town to represent rural and urban scenario respectively. The familiarity of the area and the knowledge of the culture and socioeconomic and political condition of area were the main criteria in selecting the area.

In order to ensure the ethical aspect and voluntary nature of the interview with all respondents, they were asked for prior appointments to ensure their convenience and were also given the choice of opting out of the interview. Moreover, even on the day of contact it was ensured that respondents could opt out. The purpose of the research was always explained and interviews lasted for 30-120 minutes. Semi structured questionnaire was used for interviewing. Most of the interviews were carried out in the local dialect called Paite. It was designed to elicit spontaneous replies to open ended questions. The interview covered the subjects concerning awareness about ARSH (Adolescents Reproductive and Sexual Health), programmes and policies related to ARSH, steps taken in the district to address ARSH, etc. The interview also sought to find out the respondents view on the medical facilities for the adolescent regarding their reproductive and sexual health, constraints in accessing and providing these facilities, if available.

Health Services in the Churachandpur District

In the district the only major hospital is the district hospital located in the Lamka town. The village in and around the town does not have a hospital or even a small clinic therefore for any minor or major illness the people would come to the district hospital as specialized doctors were available in the hospital on a particular day and till a particular time. This meant that people belonging to different villages within the district would come to this hospital as health care centres or hospital outside the district prove to be expensive for them. Moreover, the hospital has an Out Patient Department (OPD) system which ensured that people with low income or people living below the poverty line were able to get treatment at a low cost or at times almost free. However, people who are able to afford would go beyond the district for the treatment and this would vary from Imphal, the capital city of Manipur to even the United States of America. Thus, in regards to the health sector and its affordability and accessibility there is a wide gap within the district itself. In regards to the Adolescent Reproductive and Sexual Health (ARSH) care there were no enough health personnel who were well trained in this field. However, in order to gather information about the health services in the district and the facilities available, 5 health personnel were interviewed.

The Study Area and Sample

For the purpose of research two area were selected within Churachandpur District, one in the town i.e. Lamka and the other Moldenphai village.

Adolescent girls: Moldenphai Village and Lamka Town

Adolescent girls residing in the village and the town have been taken for the study. The adolescent girls are in class XI or XII. Drop outs from schools; the educational levels of those who have dropped out were only 6th pass or 8th pass and within the age range for the study so they have also been taken. Among them there are also some adolescent girls who are married, such married adolescent girls have also been taken for the study. The WHO age range for adolescent is 10-19; however, the present study will take age ranging from 15-19 years when referring to adolescent unless stated otherwise. A total of 104 female adolescent girls (i.e. 89 from Lamka town and 15 from Moldenphai village) were taken for the study.

Adolescent Girls: Moldenphai Village

In village Moldenphai, with a total population of approximately 250 people, the adolescent group were about 45 (both males and female). Of the total adolescent in Moldenphai village 15 of them were selected for the study using the snowballing technique. Frequent visits were made to the village as it was difficult to trace all of them at a time. However, after much effort it was possible to collect information from the adolescent girls in the village through face-to-face interview.

Out of the total girls interviewed 46 percent of them dropped out of school citing monetary problems including the distance of the village from the nearest school, which is about 9 km. There is no proper transportation and a few that are available do not ply according to the people's convenience but per the transport owners convenience. 20 percent of the respondents were totally illiterate and therefore they have be explained each and every question in the native dialect with certain examples so that they are able to relate to the question and able to provide appropriate answers. 34 percent of the respondents were going to regular school and of which 27percent of them are in class XI and only one among them is in class XII. They, during school days stay in the village near to the school at their relatives place and come home on the weekend. Of the total respondents from Moldenphai village only 20 percent of them were married.

Adolescent Girls: Lamka Town

The adolescent group of Lamka was much more in numbers as compared to the Moldenphai village. Comparatively the girls in the town were less withdrawn however they did not come across as too overbearing. It was observed that girls of this particular age group regardless of their environments do tend to have similar behaviour and anxiety such as hesitance in the initial meeting; some of them are shy while the others were extrovert, conscious about their answers, etc.

In total 100 questionnaires were administered to the adolescent in the Lamka town. They were identified using the snowballing method. However, only 85 filled in questionnaire was received. Therefore, the total number of adolescent girls taken for the study was 85 in the Lamka town. The adolescent girls who responded to the questionnaire in Lamka town were between 16-19 years of age. The filled-in questionnaires were received from the class XI and XII as well as first college students and from those who have dropped-out. 8 percent girls who dropped-out of school had been educated till class X and after that they did not join school again. When asked the reason most of them said that they were no longer interested in studying and wanted to pursue some professional course and only 1 of them cited financial constraint as the reason for dropping out of school. Of the total girls taken for the study, 7 percent of them have been married recently or have been married since the past one year and one of them have an 8 month old baby.

It can be concluded that the research in the study district namely, Churachandpur was not an easy task due to the unavailability of many of the respondents who had prior commitments nevertheless, the research was undertaken using both the qualitative and quantitative method of data collection. The research was done from the month of October to December, 2007.

Discussion

Status of the Adolescents Reproductive and Sexual Health in Manipur

The years that have gone by did not see any major initiative taken in regards to ARSH care. The initial effort towards disseminating health services for the adolescent group in the state of Manipur came about with the introduction of the Integrated Child Development Services (ICDS), which was introduced in the state on 2nd October 1975 with a pilot project at Ukhrul T.D. Block. The Scheme has been successfully implemented by the Department of Social Welfare as the nodal department. Now, the scheme is expanding throughout the State with 34 projects covering 9 C.D. Blocks, 24 T.D. Blocks and 1 Urban Area. 4501 Anganwadi Centres are also actively functioning under these projects. It is one of the most ambitious and comprehensive survival and child development schemes for enhancing the health, nutrition and learning opportunities for pre-school children and their mothers by simultaneously providing all the requisite services at the village level. The significant factor is that the deprived and underprivileged children are the target groups of this scheme. (1)

Another scheme which focused health care of adolescents is the Adolescent Girls Scheme (AG Scheme) renamed as Kishori Shakti Yojana (KSY).It deals with the school drop-out girls in the age group of 11-18 years and attempt to meet the nutrition, health, education, literacy, recreational and skill development needs of the adolescent girls. It also makes an effort to make the adolescent girl a better future mother and tap her potential as a social animator. The scheme relies on center-based instructions, training camps and hands-on training. This scheme for adolescent airls has been sanctioned in 13 blocks in Manipur.

The RCH (Reproductive and Child Health) programme was introduced in the state of Manipur in the year 2000. There are still a large section of the women as well as the adolescent girls who have not been able to acquire any information about RCH and its facilities. This may be due to the problems of accessibility or its awareness pattern. The majority who are deprived of RCH and its facilities or information are those belonging to the tribal area of Manipur. With the introduction of National Rural Health Mission, it is hoped to bring about a difference in the health system.

Awareness of Adolescents Girls regarding Reproductive and Sexual Health

When the adolescent girls in the village were enquired about the problems which the adolescents face regarding reproductive and sexual health all of them seem to reply in unison that the lack of information is the main problem. They all answered that in the village no information is given to the adolescent girls group. Most of the respondents confessed that it is for the first time that they have heard about ARSH. Most of them are hardly aware about the Reproductive Tract Infection (RTI) or the Sexually Transmitted Diseases (STI).Some of them even told that the teachers in the schools do not seem to have any information about it as they never inform the student's on such topic. In regards to the knowledge about Reproductive Tract Infection (RTI) and sexually Transmitted Infection (STI), only 10 of them had some information derived from their biology books.

Awareness of Adolescent Girls regarding Menstrual Hygiene and Sexual Health Care

When enquired about their menstrual cycle most of the adolescent girls in Moldenphai village responded that they have started their menarche at the age of 12 and only one of them had it at the age of 14. In regards to the question related to care and hygiene during the menstrual period all of them mentioned using used clothes which they wash it again and dry it. When questioned if they use sanitary napkins during their menstrual cycle they informed that the sanitary napkins are not available in the village and it is also expensive, hence they use used clothes. They had information about using the used clothes during their menstrual cycle from their parents.

The respondent were also asked if they had any menstrual related problems and responding to this, all the respondents did not know whether their cycle was regular or not. However, most of them experienced stomach pain and body ache during their menstruation period and since this was experienced during every menstrual cycle they never felt the need to seek treatment for the problem. From the respondents it was also found out that they did not have any abnormal vaginal discharge or that they may not have been aware about it. However, 6 percent of them responded to having swelling in the groin for about 2 months and 47 percent of them mentioned that their vulva itches most of the time. But none of them have consulted health personnel for any of the problems mentioned by them.

To the same question related to their menstrual period, the adolescent in Lamka town responded with different ages during which their first menstrual period commenced. It ranged from 12 years to 16 years. During these period, 75 percent of them responded to taking care by controlling their diet, do not do household chores, take bed-rest and some even mentioned taking bath three times a day apart from changing their sanitary napkins frequently. They mentioned having learnt care taking process from their mother, sister and some from their friends. The remaining 29 percent of them responded to having a normal routine during their menstrual period and not taking any extra care. During the last period, 89 percent of them responded having use sanitary napkin, 5 percent of them used tampon and 6 percent of them had used and re-used cloth.

When asked whether their menstrual cycle was regular, 80 percent of them replied having a normal and regular flow while the remaining 20 percent of them did not have a regular cycle during menstruation and that during the last 6 months have also faced menstruation related problems such as no flow, painful period, very less flow and foul smell. Some of them have had the menstrual related problem since the last one year. Of the 20 percent adolescent girls having problems 10 percent of them have received treatment for the same in the district hospital, private clinics or even to doctors known to the family due to their parents who have taken them for the treatment. The other 9 percent did not seek treatment for their problems as they relied mainly on their own care pattern and also mentioned that since it usually occur during the menstrual cycle they felt it was normal. Nevertheless, 16 percent of them responded to having abnormal vaginal discharge, 3.5 percent of them had swelling in the groin and 30 percent of them mentioned itching of the vulva. The rest did not have any problem whatsoever. Of the 50 percent girls who mentioned that they have menstrual related problems in Lamka town, only 24 percent of them have consulted a doctor.

Life Style of the Adolescents

(i) Substance use among the adolescents

When asked about the whether there is an increase in the abuse of substance by the adolescent in the village during socials occasion, the group answered in the affirmative and on being probed further they felt that the main reason would be the easy accessibility of the substance to the youth. Here, 13 percent of the respondent commented that since childhood they have seen their parents or relatives smoking or consuming alcohol and the youth probably feel that there is nothing wrong with such an activity. According to all the respondents they felt that cigarette was the most common substance abuse by the youth of the village. Alcohol was not as common as cigarette but during winter and especially social occasions such as marriage, community dining and Christmas celebration the consumption of alcohol especially know as 'zu' made out of rice increased among the youth, the reason may be due to the social acceptance of local drinks made out of rice for such occasions. When the adolescent girls in the town were asked, if substance abuse was a serious problem in the area, all filled-in questionnaire response was positive and they cited peer pressure, lack of self-respect and curiosity to be the main reason for adolescent abusing substance. At the same time, they were also asked to rank the substance in order of abuse, cigarette ranked first among them, alcohol came next and prescription drugs was ranked third, only few of them ranked narcotic drugs vis-a-vis intravenous drugs as one of the substance abused often. Some of the adolescent girls--75 per cent of them also pointed out that tobacco such as dilbag, and raja are some of the heavily abused tobacco by almost the entire adolescent in the town.

(ii) Social occasion and sexual activity

Though all the respondents were asked questioned separately, all of them denied to any such kind of sexual contact among the youth group during social occasions. The reason, as given by most of them was that their village was very less populated and everyone knew everyone hence, indulging in such an activity would not only be known by the whole village but will also lead to bad reputation especially for the girls as they would be branded as 'loose characters'. Apart from the three adolescent girls who are already married in Moldenphai village none of them ever had any sexual experience with the opposite sex. For the ones who were married their age at the first sexual contact were 18 and 19 years. It was surprising to know that out of the three married girls only one of them knew about contraceptive which is condom. However, she is not using it. The remaining girls did not know anything about contraception and were not even inform about it either. In regards to the one who knew about the condom her source of information was her husband who works in the town as a private bus conductor. Of the total adolescents' from the Lamka town who responded, 81 percent of them on being enquired whether social occasions lead to increased sexual activities among the adolescent group mentioned that, when adolescent abuse substance they indulge in sexual activities and this increases more so during social occasions in the town. 39 percent of them reasoned out that when adolescent achieve the high while abusing substance they are not in control of their senses and so end up indulging in such behaviour, 32 percent of them responded that most of the adolescent for the sake of having more fun and enjoyment end up abusing substance while 15 percent of them felt that the absence of parental control during such occasion gives them the guts to try-out substance offered by the friends. The remaining 19 percent of them were not of the opinion that social occasion results in the increase of the abuse of substances among the adolescents.

In regards to the adolescent girls having any sexual experiences, 10 percent of them confidentially responded that they had sexual experiences. Among them, one had her sexual experience at the age of 14 and 2 percent of them had a recent sexual experience with their partners. 5 percent of them mentioned that there sexual experience began at the age of 17 and 18 respectively when they got married.

In response to their knowledge about the contraception of the 85 filled-in questionnaires, 87 percent of them answered yes, while the remaining 1 3 percent of the girls were not aware about any contraception. Majority of them have heard about the condom and pills while the married adolescent girls responded to having knowledge also about the copper-T/IUD and tubectomy. 5 percent of the total responses answered to having knowledge about withdrawal as well. All of them had acquired information from their friends and from the media, while very few of them had got the information from their boyfriends. 1 1 percent of them, who had sexual experiences, had responded to using such contraceptive method as compared to the remaining 89 percent of them have never use any family planning method and they mentioned that they were not yet married and hence, did not use any contraception. 10 percent of the adolescent girls who had sexual experiences mostly use condom and the pills method of family planning. Those who responded to using the family planning method responded that they have not, as yet, had any health problem after using the contraception. When asked if any health or family planning worker had visited them, they all replied in the negative. Some of them even pointed further that they feel embarrass to consult a doctor in regards to family planning methods and as a result, it is their husband's/boyfriends who purchase the same.

Provision of Care and Counseling on Adolescents Reproductive and Sexual Health

Good health is one of the basic needs of human beings and no one should be denied of this right. The adolescent girls in the town when questioned about the ARSH care facilities in the area responded that it was in a very poor state, 65 percent of them blamed the state government for the pathetic condition while 21 percent of them felt that the health personnel were responsible and 14 percent of them thought that the local leaders are not doing their job properly.

Regarding the question whether they feel that there should be a health care provision catering only to the adolescent group only 13 percent of the adolescent girls in Moldenphai village felt the need but the remaining 87 percent felt that there should be as provision for health care for the villagers and not only for the adolescents. It can be concluded that when there is the absence of even the basic health care provision in the village thinking about a health care centre catering to only a section of the population may not be in accordance to their need. However, all of them did not disapprove of the adolescent seeking care for any health related problems. In regards to the question put forward to them regarding the need to bring about the ARSH in their village all the adolescent girls interviewed felt that such an opportunity should be provided to the adolescent group not only the females but the males as well because the rate of ignorance about ARSH is very high and no one not even the elders have any information on such an aspect. All the adolescent girls in Lamka town interviewed responded to having knowledge about the health care services in the town but none of them have any information if the health services included any programme for the ARSH. 75 percent of them thought that such information should be given by the health personnel especially a female health personnel for the girls while 15 percent of them felt that it was the role of the teacher to inform them about ARSH and the remaining 9 percent of them were of the opinion that the social worker in the area should provide such information. When enquired if there was a need to improve ARSH care in the area 83 percent of them responded in the affirmative stating that such an effort will lead to a better ARSH care among the adolescent, check population growth, decrease pre-mature pregnancy and also help in maintaining the health of the adolescent. While the remaining felt there was no need for ARSH care as the health services provided in the district cater to all type of ailments.

Addressing the Adolescents Vulnerabilities

Adolescence is a time of heightened vulnerabilities; of opportunities and change, it stands true in the context of all adolescents the world over be it a developed country or an undeveloped one. Married adolescents are neglected when it comes to reproductive health services, we can as well imagine the condition of those adolescents who are unmarried. It is difficult for most of them to obtain contraception, although for different reasons. They are usually excluded from most of family planning or reproductive health services. This is mainly due to the fact that the reproductive and child health services in our country are often barred to adolescents or require them to reach a certain age before they can use them. A comprehensive reproductive health programme should address the adolescent sexual health problems in order to motivate adolescent to play more active and positive roles in reproductive health and family planning.

Health though forming an important component as found from the study is mainly made available to a limited extent in Churachandpur district of Manipur. The health services is restricted to providing treatment for diseases or referral services, the services in regards to spreading awareness is very poor or to say the least non-existent and still needs to be improved. The presence of a number of doctors within the district who at most times do not have patients to treat, proves that the people are often ignorant about their health status and may not seek treatment till their conditions aggravates. The ARSH care for the adolescent especially the girls is, according to the observation made by the researcher during the fieldwork, is practically non-existent and has to be seriously looked into at least by the state government if it really wants to develop the health status of the adolescent population. The adolescents girls in the district, both village and the town, are considered to be vulnerable which definitely is not separated from the facts, but the elders have in some way labeled them as being exposed to the dangers of lives too early and too soon and that they are easy target of moral corruption. The myths of the parents and the social taboo attached to adolescent girls seeking ARSH care, and the inefficient functioning of the health services and the health personnel needs to be intensified if ARSH care in Churachandpur district has to become a reality.

Conclusion and Suggestions

The NRHM undertaken by the government of India is indeed a step towards improving the health status of the rural population which will also result, if not immediately but gradually in the improved health status of the adolescent groups. Evidence shows that withholding information and services from adolescents only increases the likelihood that if and when sexual initiation occurs, it will be unprotected (Kirby, 2001) Young people require not only basic information about their bodies, preventing HIV/STIs, and pregnancy, but also programs that address gender equality, empowerment, rights and responsibilities, and sexual and reproductive negotiation and decision-making. The meaningful participation of adolescents in the design of programs, laws, and policies that affect their sexual and reproductive lives should be guaranteed. However, it must be ensured that the initiative reaches the population for whom the programme has been introduced. Apart from the existing programmes and polices introduced by the government to meet the health needs of the population care should be taken to introduce policies and programmes aiming specifically at the adolescent population. There are certain policies/ programmes that may be introduced to enable the adolescents especially girls to be more aware of their reproductive and sexual health rights. We may strengthen the promotion of the rights of adolescents to reproductive health education, information and appropriate care and involve more youth in the designing and implementing programmes to meet the special needs of adolescents. Such programmes can include support mechanisms for the education and counselling of adolescents and young people in areas of gender relations and equality, responsible sexual behaviour, family life, reproductive health, prevention of STIs and HIV and AIDS and violence against adolescents.

Effort needed to the be made towards sensitizing communities about the information needs of adolescents, including initiatives aimed at parents, religious and political institutions, community leaders, schools, mass media and peer groups and utilizing multi-media, including the Internet, to inform and build support for adolescent sexual and reproductive health programmes and at the same time build a supportive environment for community-based IEC and advocacy programmes. Establishing youth-to-youth peer education programmes and building networks and designing peer education training programmes will be beneficial to the learning needs of the adolescents. In the region and other places sexuality education may not necessarily be included as a separate curriculum and can be integrated across school subjects and at all grade levels.

It can also be added that in regards to the overall sexual and reproductive health situation of the adolescent girls in the district, there is no justification required to say that the vulnerability of the adolescent girls in the district is more on account of lack of information, illiteracy, and emotional problems, social and cultural taboos and to some extent medical problem. In fact, there is a poor fit between existing programs and the needs of adolescent. Thus, planners must build upon existing knowledge about adolescents' needs, preferences, and health-seeking behaviors while taking resource constraints into consideration. There is a demand to consider the need for approaches that can help adolescents to obtain information, skills-building opportunities, counseling, and clinical services in areas such as Churachandpur district.

Notes

(1) For detail sees socialwelfaremanipur.nic.in/icds_schemes.htm.

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Publication:Political Economy Journal of India
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Date:Jan 1, 2017
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