Reproductive health problems and help seeking behavior among adolescents in Urban India
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《美国医学杂志》
1 Department of Operational Research, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, India
2 Department of Molecular and Immunodiagnostics, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, India
Abstract
Objective. To assess their reproductive health problems and help seeking behaviour among urban school going adolescents. Method. A sample of 300 urban school going adolescents between 11-14 years were chosen at random and assessed using four tools namely, self administered questionnaire : provision of adolescent friendly services; medical screening and focus group discussions. Results. Seventy two percent girls and 56% boys reported health problems during survey with an average of 1.93 complaints per girl and 0.5 complaints per boy. However, only 43% girls and 35% boys reported to the clinic voluntarily to seek help and only one fifth the amount of problems were reported at the clinic in comparison to the quantum of problems reported in survey, which probably reflects a poor health seeking behaviour. A medical checkup with emphasis on assessment of reproductive health and nutritional status helped in detecting almost the same number of reproductive health problems as reported by them in survey. This intervention helped to increase the client attendance in subsequent period of next one year from 43% to 60% among girls and from 35% to 42% among boys. Conclusion. Our study shows that to increase help seeking behaviour of adolescents, apart from health and life skill education, their medical screening with a focus on reproductive health by trained physicians, parental involvement, supported by adolescent friendly centers (AFC) for counseling, referral and follow up are essential.
Keywords: Adolescent Friendly Centers (AFC); Health seeking behavior; Reproductive health; School health checkup
The National Population Policy- 2000 has recognised adolescents as an underserved vulnerable group that need to be served especially by providing reproductive health information and services.[1] Hospital based retrospective studies in India show that primary amennorrhoea, thyroid disorders, genital anomalies,[2] ovarian enlargement,[3] menstrual disorders, leucorrhoea and genital infections[4] are very common among adolescent girls. These studies suggest a need for screening through population-based studies or special health clinics in schools and colleges for early detection and management of common reproductive health ailments.[5] Such an approach is seen in School -based Health Centers in the United States that provide a broad range of reproductive health services either onsite or by referrals, taking care of adolescents at risk who might otherwise not have accessed health care in a timely manner.[6]
Most of the adolescent reproductive health programs focus on the 15-19 year old age group. There is an increasing need to recognize the 10-14 year group that comprises 12% of India's total population.[7] This group is different from the older group as it is difficult for them to understand their problems, the consequences of their behaviour and effects of their actions. Very little is known about their unmet needs making it difficult to mobilize resources and develop program strategies for this group. Recently a number of programs for school going adolescents in India have focused on Information, Education and Communication (IEC) through formal and informal sectors such as the HIV/AIDS Prevention Programs in schools for grade 9 students, with a limited focus on provision of clinical and counseling services. Educational programmes can increase awareness about reproductive health, but in the absence of appropriate health services, this awareness may not always translate into appropriate help seeking by adolescents.
Recognizing the need to pay greater attention to this younger group, which is more likely to accept, adopt and follow positive health measures in later life, a prospective study was undertaken among school going adolescent boys and girls in the city of Mumbai with a special focus on reproductive health. This paper aims to explore the voluntary uptake of school based adolescent friendly services when they are made available, as against their self-reported reproductive health problems.
Materials and Methods
The findings pertain to an ongoing intervention in schools of urban Mumbai during 2003-2004 that is aimed at creating a model for delivery of school-based adolescent friendly services through Adolescent Friendly Center (AFC). Assuming 40 percent (P1=0.40) of adolescents will have one or more nutritional or reproductive health problems at baseline and 30 percent (P2=0.30) after interventions the sample size required to achieve the goals of the study was calculated to be 600 adolescents (99 percent confidence limits (a =0.01) and 90 percent power of the test (b=0.10)). These were further divided into 300 boys and 300 girls with equal numbers belonging to the 11-14 and 15-19 years age group. Data pertaining to 300 adolescent participants in the age group 11-14 years from a secondary school in Mumbai is presented.
The study was reviewed and approved by the Institute's Scientific Advisory Committee and the Ethics Committee. An information sheet giving all the details of the project was given to the adolescents and their parents and written consent to participate in the study was obtained from both. Quantitative and qualitative data on the reproductive health problems and health seeking behaviour was collected using the following four tools.
Tool 1: Self-administered questionnaire
Pretested self administered questionnaires in local language were filled by 300 adolescents in classrooms, following an anonymous respondent approach after an explanation of its content.
Tool 2: Voluntary attendance in one year to the school based Adolescent Friendly Center
Adolescent Friendly Center (AFC) was established in school premises, which functioned on two days of the week for two hours each day as per the decision of the adolescents themselves and was manned by a medical doctor and two counselors. Services included provision of information, counseling and medical checkup free of cost. A letterbox was also installed near the AFC for dropping anonymous questions by adolescents. The answers to the questions were displayed on a notice board for the benefit of all the students.
Tool 3: Medical screening through health checkup camp
A cross sectional medical checkup of the enrolled 300 adolescents was undertaken after one year of starting the AFC, to identify some unreported or unrecognized health problems and also to help those who could have had problems but did not seek care at the center. A male and a female doctor conducted the medical health checkup separately for boys and girls respectively. Apart from general systemic examination, examination for assessment of reproductive system was also done. Hemoglobin estimation to detect anemia by finger prick was carried out, and for any indicated investigations, adolescents were referred to the collaborating public hospital.
Tool 4: Focus Group Discussion
Qualitative tool of Focus Group Discussion (FGD) was used to explore the adolescent's help seeking behaviour, the type of service facilities they approached, constraints faced by them and the facilitating factors in approaching the school based AFC and the views of elders on their health problems. In all, four FGDs were conducted equally divided among boys and girls.
Results
The mean age of the study participants was 13.17 years. Ninety five percent of them were Hindus and on an average, parents had received secondary level of education (grade 8 to 10). The average family income was approx Rs. 6000/-per month. The mean family size was 5.27 with 57.3 percent belonging to nuclear families and 40 percent staying in joint families. The mean age of menarche among girls was 10.8 years.
Information need
About 17 percent of enrolled adolescents came to seek information on various sexual and reproductive health issues at the AFC. More than 210 questions were put in the letterbox, which were appropriately answered. (List of questions asked through letterbox is summed up in
Psychological problems among adolescents
Adolescent girls and boys (0.6 percent and 2.6 percent respectively) were referred by their teachers to the AFC for behavioral and psychological problems. Some were related to academic performance or abuse of other adolescents. Twelve percent of boys and 3 percent of girls reported problems like depression, low self esteem and interpersonal relationship issues with their peers and parents.
Reproductive health problems amongst girls
As is evident from table2, girls mainly reported problems related to menstruation, excessive vaginal discharge, itching of genitals and urinary complaints. Few girls reported minor problems like acne, height and weight concerns, skin and general health problems. However the help seeking behaviour i.e. voluntary attendance to the AFC for these complaints remained poor and all these problems were better elicited and diagnosed during medical checkup. Figure1 reveals that 93.5 percent of the girls were anemic and mean hemoglobin was 9.6 gms. (S.D ± 1.7). About 14.8 percent of girls were below 5th percentile and 4 percent of girls were above 95th percentile for BMI in comparison to the WHO recommended standards [8] and mean Body Mass Index (BMI) was 19.08 (SD± 4.9).
Reproductive health problems among boys
Help seeking behavior
Forty three percent girls and 35 percent boys reported to the clinic voluntarily in one year, to seek help at the school based AFC compared to 72% girls and 56% boys who reported problems during survey, indicating that many did not visit the center voluntarily in spite of having problems (only one-fifth number of complaints were reported to the center compared to the quantum of problems reported in survey). It seems that only those in whom the awareness of problem was a cause of worry did avail the services of the center.
Focus group discussions with adolescents revealed many underlying factors that influenced the adolescent's visit to the center. Some adolescents went to private practitioners or municipal dispensaries as they always felt better going to these places and many of them preferred home remedies. Very few of them mentioned that they were shy to approach the AFC. Few boys mentioned going to quacks. Most adolescent girls did not consider their problems important enough to seek care. Few said that problems subsided on their own. Mothers or senior female members of the family and neighborhood felt that menstrual problems such as pain and discomfort during menses was very common for girls and they must learn to bear the pain. Thus girls only sought care when the pain was unbearable or during exams or when they had to miss school. Similarly white discharge and itching of genitals was taken on a very casual note. They used home remedies such as applying coconut oil or drinking some herbal remedies for cooling the body as they attributed itching to excess heat in the body. Majority of these girls practiced improper washing technique after defecation.
Improvement in clinic attendance after medical checkup
After the medical checkup, the project staff took efforts to involve parents in understanding the diagnosed problems among adolescents especially with respect to genital anomalies, menstrual and psychological problems, anemia, malnutrition and abnormal vaginal discharge. Constant and rigorous follow up along with counseling was needed to encourage the adolescents to get necessary investigations done, or go to the referral center for necessary treatment, especially amongst girls with regards to compliance in taking treatment for anemia. The clinic attendance in the subsequent period increased from 43% to 60% among girls and from 35% to 42% amongst boys.
Discussion
Overall, we found that adolescents attended the AFC for information and health problems mainly related to general health and menstruation (among girls) followed by problems related to height and weight, vaginal discharge, itching of genitals. Acne, urinary complaints, and psychological complaints were among the less sought services. Most of the complaints needed only reassurance and counselling. Based on clinical history and examination, it was evident that even vaginal discharge as reported by girls was mainly physiological except in 5 percent in whom it was associated with pruritis vulvae or yellowish discharge associated with poor hygiene.
Genital anomalies such as undescended testes were detected during medical examination. It was surprising to note that some of the parents were not aware of this condition, as it was never detected during childhood and those that were aware were not advised properly by the doctors whom they had consulted.
General morbidity such as low BMI and anemia especially among girls were also detected only by an intensive medical check up. The mean age of menarche among girls was much earlier as against the earlier reported age of 12-14 years in India.[9],[10],[11] Anemia amongst the female population is a major public health problem in India. As reported by some studies, anemia probably could be due to an early onset of menarche and poor quality of diet consumed from early childhood[12],[13] resulting in inadequate storage and depletion of iron at a faster rate in adolescent girls. Consequently girls (94%) were found to be more anemic than boys (82%) the mean difference being 1.0801 with p =0.000. The prevalence of anemia among girls was relatively more than that reported in few studies which was around 25-45 percent. [14],[15] This reflects a need to rectify anemia from the age it has manifested as this poses to be a major cause of maternal morbidity in India. Girls had higher bmI0 as compared to boys, the mean difference being 1.1040 with p=0.017, probably due to the earlier growth spurt among girls.
A total of 43% girls and 35% boys among the enrolled 150 adolescents in each group visited the center on their own during the one-year's period after initiation of adolescent friendly services. Almost 17% of them visited the AFC to seek information on general and sexual and reproductive health concerns. However in comparison to the quantum of problems reported by adolescents in the survey, only one-fifth amount of problems were reported voluntarily at the center. This could be considered as a poor health seeking behaviour on the adolescent's part despite our interventions. The reasons derived from the focus group discussions could be further categorized and explained on the factors described in various health seeking behaviour models such as the Health Belief Model (HBM)[16] and Health Care Utilization Model (HCUM).[17]
Taking home remedies for their problems, preference to go to private practitioners because of presumed better services and poor knowledge on reproductive health along with lot of myths and misconceptions could be clubbed under predisposing factors as described in HCUM. Seeking care only when symptoms become unbearable and severe so as to miss school or that the problems are self-limiting fits into the category of the severity or need factor as described in both the models. Lack of support from parents, their casual attitude to adolescent problems, the psychological barriers and health motivation or readiness to be concerned about health matters, feeling shy to approach the health facility fall under the perview of lack of enabling factor or barrier to accessing care as described in both the models. Addressing some of the predisposing factors, actively diagnosing their health problems through medical checkups and informing them about them and creating an enabling environment by parental involvement helped in improving the help seeking behaviour in the subsequent year of the study.
Conclusion
Our short experience with the study indicates that a comprehensive package of health and life skill education, medical screening with a focus on reproductive health by trained physicians, increased parental involvement supported by AFC for counselling, referral and follow up are essential to improve help seeking behaviour of adolescents. However, newer outreach innovative interventions may be needed to create a sustained demand for services.
Acknowledgements
We would like to acknowledge the support and encouragement received from Indian Council of Medical Research (No. NIRRH/MS/35/2004), Dr. Chander Puri Director, NIRRH and the Principal, Staff, Parents and Students of participating school, Parel, Mumbai for cooperating with us during the entire process. We acknowledge the inputs of Dr. Kamal Hazari (Deputy Director, NIRRH) and Dr. Perveen Meherji (Deputy Director SG, NIRRH) in managing the referral cases , Ms. Nazia A. Khan (Lab Technician, NIRRH) who helped us with hemoglobin testing and Dr. Mohan Ghule (Health Educator, NIRRH) who helped us in data collection and in conducting IEC activities.
References
1. National Population Policy 2000. Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government of India 2000
2. Patki S, Pandit S.N, Niyogi G.M, Patkar V.D. Amenorhea and genital anomalies in adolescents. Journal of Obstetrics and Gynecology of India 1993; 234-240.
3. Kumar A, Verma A, Mittal S. Gynecological disorders in girls less than 20 years of age. Journal of Obstetrics and Gynecology India 1998; 48(1): 61-63.
4. Bhalchandra G, Soundra S, Rajaram P. Gynaecological problems in adolescents. Journal of Obstetrics and Gynecology India 1993; 43 : 599-604.
5. Gandhi A.B, Kakodkar P.C, Raval M.Y. Role of audiovisual in creating awareness. Journal of Obstetrics and Gynecology India 1993; 251-261.
6. John S, Nystrom R, Brindis C et al. Reproductive Health in School based Health Centers: Findings from the 1998-99 Census of School based Health Centers. Journal of Adolescent Health 2003; 32: 443-451.
7. A summary of selected DHS data on very young adolescents India 1998/99. www. populationcouncil (online cited Dec 29th 2004)
8. WHO Technical Report, Physical Status: The Use and Interpretation of Anthropometry 1995; 854: 445.
9. Majumdar R, Ganguli S.K. A study of adolescent girls in Pune. Health and Population perspectives and Issues 2000; 23(2): 95-104.
10. Hegde K, Desai P, Hazra M. Adolescent menstrual patterns. Journal of Obstetrics and Gynecology India 1990; 40: 269-274.
11. Vaidya R. A, Shringi M. S, Bhatt M. A. Menstrual pattern and growth of schoolgirls in Mumbai. Journal of Family Welfare 1998; 44(1): 66-72.
12. Bhargava S.K, Duggal S, Ramanujacharyulu T.K.T.S, Chaudhary P. Pubertal changes and their interrelationships in Indian girls. Indian Pediatrics 1980; 17: 657-665.
13. Narasinga Rao BS. Studies on iron deficiency anemia. Indian Journal of Medical Research 1978; 5: 58-69.
14. Jeejibhoy SJ. Adolescent Sexual and Reproductive Behavior-A Review of Evidence from India. 1996; 5: 35 ICRW Working Paper No. 3.
15. Thavaraj VK, Reddy V. Serum ferritin in healthy school children. Indian Pediatrics 1985; 22: 409-410.
16. Conner M, Norman P 1996. Predicting Health Behaviour Search and Practice with Social Cognition Models. Open University Press. Buckingham, 1996.
17. Anderson R, Neuman J.F. Societal and Individual Determinants of Medical Care Utilization in United States. Milbank Memorial Fund Quarterly/Health and Society. 1975; 51:95-124.(Joshi Beena N, Chauhan SL)
2 Department of Molecular and Immunodiagnostics, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, India
Abstract
Objective. To assess their reproductive health problems and help seeking behaviour among urban school going adolescents. Method. A sample of 300 urban school going adolescents between 11-14 years were chosen at random and assessed using four tools namely, self administered questionnaire : provision of adolescent friendly services; medical screening and focus group discussions. Results. Seventy two percent girls and 56% boys reported health problems during survey with an average of 1.93 complaints per girl and 0.5 complaints per boy. However, only 43% girls and 35% boys reported to the clinic voluntarily to seek help and only one fifth the amount of problems were reported at the clinic in comparison to the quantum of problems reported in survey, which probably reflects a poor health seeking behaviour. A medical checkup with emphasis on assessment of reproductive health and nutritional status helped in detecting almost the same number of reproductive health problems as reported by them in survey. This intervention helped to increase the client attendance in subsequent period of next one year from 43% to 60% among girls and from 35% to 42% among boys. Conclusion. Our study shows that to increase help seeking behaviour of adolescents, apart from health and life skill education, their medical screening with a focus on reproductive health by trained physicians, parental involvement, supported by adolescent friendly centers (AFC) for counseling, referral and follow up are essential.
Keywords: Adolescent Friendly Centers (AFC); Health seeking behavior; Reproductive health; School health checkup
The National Population Policy- 2000 has recognised adolescents as an underserved vulnerable group that need to be served especially by providing reproductive health information and services.[1] Hospital based retrospective studies in India show that primary amennorrhoea, thyroid disorders, genital anomalies,[2] ovarian enlargement,[3] menstrual disorders, leucorrhoea and genital infections[4] are very common among adolescent girls. These studies suggest a need for screening through population-based studies or special health clinics in schools and colleges for early detection and management of common reproductive health ailments.[5] Such an approach is seen in School -based Health Centers in the United States that provide a broad range of reproductive health services either onsite or by referrals, taking care of adolescents at risk who might otherwise not have accessed health care in a timely manner.[6]
Most of the adolescent reproductive health programs focus on the 15-19 year old age group. There is an increasing need to recognize the 10-14 year group that comprises 12% of India's total population.[7] This group is different from the older group as it is difficult for them to understand their problems, the consequences of their behaviour and effects of their actions. Very little is known about their unmet needs making it difficult to mobilize resources and develop program strategies for this group. Recently a number of programs for school going adolescents in India have focused on Information, Education and Communication (IEC) through formal and informal sectors such as the HIV/AIDS Prevention Programs in schools for grade 9 students, with a limited focus on provision of clinical and counseling services. Educational programmes can increase awareness about reproductive health, but in the absence of appropriate health services, this awareness may not always translate into appropriate help seeking by adolescents.
Recognizing the need to pay greater attention to this younger group, which is more likely to accept, adopt and follow positive health measures in later life, a prospective study was undertaken among school going adolescent boys and girls in the city of Mumbai with a special focus on reproductive health. This paper aims to explore the voluntary uptake of school based adolescent friendly services when they are made available, as against their self-reported reproductive health problems.
Materials and Methods
The findings pertain to an ongoing intervention in schools of urban Mumbai during 2003-2004 that is aimed at creating a model for delivery of school-based adolescent friendly services through Adolescent Friendly Center (AFC). Assuming 40 percent (P1=0.40) of adolescents will have one or more nutritional or reproductive health problems at baseline and 30 percent (P2=0.30) after interventions the sample size required to achieve the goals of the study was calculated to be 600 adolescents (99 percent confidence limits (a =0.01) and 90 percent power of the test (b=0.10)). These were further divided into 300 boys and 300 girls with equal numbers belonging to the 11-14 and 15-19 years age group. Data pertaining to 300 adolescent participants in the age group 11-14 years from a secondary school in Mumbai is presented.
The study was reviewed and approved by the Institute's Scientific Advisory Committee and the Ethics Committee. An information sheet giving all the details of the project was given to the adolescents and their parents and written consent to participate in the study was obtained from both. Quantitative and qualitative data on the reproductive health problems and health seeking behaviour was collected using the following four tools.
Tool 1: Self-administered questionnaire
Pretested self administered questionnaires in local language were filled by 300 adolescents in classrooms, following an anonymous respondent approach after an explanation of its content.
Tool 2: Voluntary attendance in one year to the school based Adolescent Friendly Center
Adolescent Friendly Center (AFC) was established in school premises, which functioned on two days of the week for two hours each day as per the decision of the adolescents themselves and was manned by a medical doctor and two counselors. Services included provision of information, counseling and medical checkup free of cost. A letterbox was also installed near the AFC for dropping anonymous questions by adolescents. The answers to the questions were displayed on a notice board for the benefit of all the students.
Tool 3: Medical screening through health checkup camp
A cross sectional medical checkup of the enrolled 300 adolescents was undertaken after one year of starting the AFC, to identify some unreported or unrecognized health problems and also to help those who could have had problems but did not seek care at the center. A male and a female doctor conducted the medical health checkup separately for boys and girls respectively. Apart from general systemic examination, examination for assessment of reproductive system was also done. Hemoglobin estimation to detect anemia by finger prick was carried out, and for any indicated investigations, adolescents were referred to the collaborating public hospital.
Tool 4: Focus Group Discussion
Qualitative tool of Focus Group Discussion (FGD) was used to explore the adolescent's help seeking behaviour, the type of service facilities they approached, constraints faced by them and the facilitating factors in approaching the school based AFC and the views of elders on their health problems. In all, four FGDs were conducted equally divided among boys and girls.
Results
The mean age of the study participants was 13.17 years. Ninety five percent of them were Hindus and on an average, parents had received secondary level of education (grade 8 to 10). The average family income was approx Rs. 6000/-per month. The mean family size was 5.27 with 57.3 percent belonging to nuclear families and 40 percent staying in joint families. The mean age of menarche among girls was 10.8 years.
Information need
About 17 percent of enrolled adolescents came to seek information on various sexual and reproductive health issues at the AFC. More than 210 questions were put in the letterbox, which were appropriately answered. (List of questions asked through letterbox is summed up in
Psychological problems among adolescents
Adolescent girls and boys (0.6 percent and 2.6 percent respectively) were referred by their teachers to the AFC for behavioral and psychological problems. Some were related to academic performance or abuse of other adolescents. Twelve percent of boys and 3 percent of girls reported problems like depression, low self esteem and interpersonal relationship issues with their peers and parents.
Reproductive health problems amongst girls
As is evident from table2, girls mainly reported problems related to menstruation, excessive vaginal discharge, itching of genitals and urinary complaints. Few girls reported minor problems like acne, height and weight concerns, skin and general health problems. However the help seeking behaviour i.e. voluntary attendance to the AFC for these complaints remained poor and all these problems were better elicited and diagnosed during medical checkup. Figure1 reveals that 93.5 percent of the girls were anemic and mean hemoglobin was 9.6 gms. (S.D ± 1.7). About 14.8 percent of girls were below 5th percentile and 4 percent of girls were above 95th percentile for BMI in comparison to the WHO recommended standards [8] and mean Body Mass Index (BMI) was 19.08 (SD± 4.9).
Reproductive health problems among boys
Help seeking behavior
Forty three percent girls and 35 percent boys reported to the clinic voluntarily in one year, to seek help at the school based AFC compared to 72% girls and 56% boys who reported problems during survey, indicating that many did not visit the center voluntarily in spite of having problems (only one-fifth number of complaints were reported to the center compared to the quantum of problems reported in survey). It seems that only those in whom the awareness of problem was a cause of worry did avail the services of the center.
Focus group discussions with adolescents revealed many underlying factors that influenced the adolescent's visit to the center. Some adolescents went to private practitioners or municipal dispensaries as they always felt better going to these places and many of them preferred home remedies. Very few of them mentioned that they were shy to approach the AFC. Few boys mentioned going to quacks. Most adolescent girls did not consider their problems important enough to seek care. Few said that problems subsided on their own. Mothers or senior female members of the family and neighborhood felt that menstrual problems such as pain and discomfort during menses was very common for girls and they must learn to bear the pain. Thus girls only sought care when the pain was unbearable or during exams or when they had to miss school. Similarly white discharge and itching of genitals was taken on a very casual note. They used home remedies such as applying coconut oil or drinking some herbal remedies for cooling the body as they attributed itching to excess heat in the body. Majority of these girls practiced improper washing technique after defecation.
Improvement in clinic attendance after medical checkup
After the medical checkup, the project staff took efforts to involve parents in understanding the diagnosed problems among adolescents especially with respect to genital anomalies, menstrual and psychological problems, anemia, malnutrition and abnormal vaginal discharge. Constant and rigorous follow up along with counseling was needed to encourage the adolescents to get necessary investigations done, or go to the referral center for necessary treatment, especially amongst girls with regards to compliance in taking treatment for anemia. The clinic attendance in the subsequent period increased from 43% to 60% among girls and from 35% to 42% amongst boys.
Discussion
Overall, we found that adolescents attended the AFC for information and health problems mainly related to general health and menstruation (among girls) followed by problems related to height and weight, vaginal discharge, itching of genitals. Acne, urinary complaints, and psychological complaints were among the less sought services. Most of the complaints needed only reassurance and counselling. Based on clinical history and examination, it was evident that even vaginal discharge as reported by girls was mainly physiological except in 5 percent in whom it was associated with pruritis vulvae or yellowish discharge associated with poor hygiene.
Genital anomalies such as undescended testes were detected during medical examination. It was surprising to note that some of the parents were not aware of this condition, as it was never detected during childhood and those that were aware were not advised properly by the doctors whom they had consulted.
General morbidity such as low BMI and anemia especially among girls were also detected only by an intensive medical check up. The mean age of menarche among girls was much earlier as against the earlier reported age of 12-14 years in India.[9],[10],[11] Anemia amongst the female population is a major public health problem in India. As reported by some studies, anemia probably could be due to an early onset of menarche and poor quality of diet consumed from early childhood[12],[13] resulting in inadequate storage and depletion of iron at a faster rate in adolescent girls. Consequently girls (94%) were found to be more anemic than boys (82%) the mean difference being 1.0801 with p =0.000. The prevalence of anemia among girls was relatively more than that reported in few studies which was around 25-45 percent. [14],[15] This reflects a need to rectify anemia from the age it has manifested as this poses to be a major cause of maternal morbidity in India. Girls had higher bmI0 as compared to boys, the mean difference being 1.1040 with p=0.017, probably due to the earlier growth spurt among girls.
A total of 43% girls and 35% boys among the enrolled 150 adolescents in each group visited the center on their own during the one-year's period after initiation of adolescent friendly services. Almost 17% of them visited the AFC to seek information on general and sexual and reproductive health concerns. However in comparison to the quantum of problems reported by adolescents in the survey, only one-fifth amount of problems were reported voluntarily at the center. This could be considered as a poor health seeking behaviour on the adolescent's part despite our interventions. The reasons derived from the focus group discussions could be further categorized and explained on the factors described in various health seeking behaviour models such as the Health Belief Model (HBM)[16] and Health Care Utilization Model (HCUM).[17]
Taking home remedies for their problems, preference to go to private practitioners because of presumed better services and poor knowledge on reproductive health along with lot of myths and misconceptions could be clubbed under predisposing factors as described in HCUM. Seeking care only when symptoms become unbearable and severe so as to miss school or that the problems are self-limiting fits into the category of the severity or need factor as described in both the models. Lack of support from parents, their casual attitude to adolescent problems, the psychological barriers and health motivation or readiness to be concerned about health matters, feeling shy to approach the health facility fall under the perview of lack of enabling factor or barrier to accessing care as described in both the models. Addressing some of the predisposing factors, actively diagnosing their health problems through medical checkups and informing them about them and creating an enabling environment by parental involvement helped in improving the help seeking behaviour in the subsequent year of the study.
Conclusion
Our short experience with the study indicates that a comprehensive package of health and life skill education, medical screening with a focus on reproductive health by trained physicians, increased parental involvement supported by AFC for counselling, referral and follow up are essential to improve help seeking behaviour of adolescents. However, newer outreach innovative interventions may be needed to create a sustained demand for services.
Acknowledgements
We would like to acknowledge the support and encouragement received from Indian Council of Medical Research (No. NIRRH/MS/35/2004), Dr. Chander Puri Director, NIRRH and the Principal, Staff, Parents and Students of participating school, Parel, Mumbai for cooperating with us during the entire process. We acknowledge the inputs of Dr. Kamal Hazari (Deputy Director, NIRRH) and Dr. Perveen Meherji (Deputy Director SG, NIRRH) in managing the referral cases , Ms. Nazia A. Khan (Lab Technician, NIRRH) who helped us with hemoglobin testing and Dr. Mohan Ghule (Health Educator, NIRRH) who helped us in data collection and in conducting IEC activities.
References
1. National Population Policy 2000. Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government of India 2000
2. Patki S, Pandit S.N, Niyogi G.M, Patkar V.D. Amenorhea and genital anomalies in adolescents. Journal of Obstetrics and Gynecology of India 1993; 234-240.
3. Kumar A, Verma A, Mittal S. Gynecological disorders in girls less than 20 years of age. Journal of Obstetrics and Gynecology India 1998; 48(1): 61-63.
4. Bhalchandra G, Soundra S, Rajaram P. Gynaecological problems in adolescents. Journal of Obstetrics and Gynecology India 1993; 43 : 599-604.
5. Gandhi A.B, Kakodkar P.C, Raval M.Y. Role of audiovisual in creating awareness. Journal of Obstetrics and Gynecology India 1993; 251-261.
6. John S, Nystrom R, Brindis C et al. Reproductive Health in School based Health Centers: Findings from the 1998-99 Census of School based Health Centers. Journal of Adolescent Health 2003; 32: 443-451.
7. A summary of selected DHS data on very young adolescents India 1998/99. www. populationcouncil (online cited Dec 29th 2004)
8. WHO Technical Report, Physical Status: The Use and Interpretation of Anthropometry 1995; 854: 445.
9. Majumdar R, Ganguli S.K. A study of adolescent girls in Pune. Health and Population perspectives and Issues 2000; 23(2): 95-104.
10. Hegde K, Desai P, Hazra M. Adolescent menstrual patterns. Journal of Obstetrics and Gynecology India 1990; 40: 269-274.
11. Vaidya R. A, Shringi M. S, Bhatt M. A. Menstrual pattern and growth of schoolgirls in Mumbai. Journal of Family Welfare 1998; 44(1): 66-72.
12. Bhargava S.K, Duggal S, Ramanujacharyulu T.K.T.S, Chaudhary P. Pubertal changes and their interrelationships in Indian girls. Indian Pediatrics 1980; 17: 657-665.
13. Narasinga Rao BS. Studies on iron deficiency anemia. Indian Journal of Medical Research 1978; 5: 58-69.
14. Jeejibhoy SJ. Adolescent Sexual and Reproductive Behavior-A Review of Evidence from India. 1996; 5: 35 ICRW Working Paper No. 3.
15. Thavaraj VK, Reddy V. Serum ferritin in healthy school children. Indian Pediatrics 1985; 22: 409-410.
16. Conner M, Norman P 1996. Predicting Health Behaviour Search and Practice with Social Cognition Models. Open University Press. Buckingham, 1996.
17. Anderson R, Neuman J.F. Societal and Individual Determinants of Medical Care Utilization in United States. Milbank Memorial Fund Quarterly/Health and Society. 1975; 51:95-124.(Joshi Beena N, Chauhan SL)