ARSH 1: Reproductive and sexual health problems of adolescents and young adults: a cross sectional community survey on knowledge, attitude and practice.

OBJECTIVE: To understand the problems faced and the difference in knowledge, attitude and practice of young people across the age group of 10-24 y on reproductive and sexual health issues and to get their suggestions regarding adolescent care services. METHODS: This cross sectional community survey involving three districts in Kerala was conducted among adolescents and young adults of 10-24 y using a population proportion to sample size technique. RESULTS: The main problems faced by the young people between 10 and 24 y of age were financial, substance abuse in family, poor academic performance, difference of opinion, disease in self/family, mental problems, lack of talent, strict parents, difficulty in mingling, love failure, broken family, loneliness and problems at school/office in the descending order. As the age advances higher percentage of both boys (43.4%) and girls (61.7%) discuss reproductive sexual health issues among themselves. There was a statistically significant difference in personal hygiene practices like changing napkins/cloths more than once a day (94.3%), cleaning genital organs with soap every day (71.7%), washing after urination (69.2%), washing from front to back after defecation (62.2%) and washing hands with soap after defecation (73.2%) between 10-14, 15-19, and 20-24 y age group with higher percentages in the older groups. In order to make the service more useful, more of the older group participants suggested giving information on adolescent services to parents, adolescents and society as a whole by creating better societal acceptance and keeping confidentiality in service delivery. CONCLUSIONS: This study has shown an overall inadequacy in reproductive health knowledge in all age groups, but increasing knowledge gain and better attitude and practices on reproductive and sexual health as the age increases. The suggestions made by the group regarding need for adolescent reproductive sexual health (ARSH) and counseling services with privacy and confidentiality ensured, is useful for planning ARSH services under National Rural Health Mission.

ARSH 2: Reproductive and sexual health knowledge, attitude and practices: comparison among boys and girls (10-24 y).

OBJECTIVE: To compare the knowledge, attitude and practice of boys and girls on reproductive sexual health and their perspective on the needs of adolescents on this aspect. METHODS: This comparative study was conducted among boys and girls between 10 and 24 y in three districts of Kerala; through a cross sectional community survey using a pretested structured schedule with additional sexuality related questions for 15-24 y age group. RESULTS: Higher percentage of boys knew about condoms (95.1%, p 0.001) whereas higher percentage of girls (56.5%, p 0.001) knew about copper-T. Girls had a better knowledge on legal age of marriage (91%, p 0.001), that both the partners are equally responsible for the problem of infertility (89.7%, p 0.009) and that the gender of the baby is determined by male sperm (60.4%, p 0.001). Above 90% of boys and girls demanded adolescent care services and facilities for counseling. CONCLUSIONS: This comparative study on knowledge, attitude and practice of boys and girls between 10 and 24 y has shown that greater proportion of girls had correct knowledge on the legal age of marriage, ideal age of pregnancy, preferred an arranged marriage and felt the need for premarital counseling.

ARSH 6: Reproductive health needs assessment of adolescents and young people (15-24 y): a qualitative study on 'perceptions of program managers and health providers'.

OBJECTIVES: To understand the perceptions of program managers and service providers using in depth interview technique, a well-accepted qualitative research that can also offer semi quantitative input. METHODS: Need assessment was done qualitatively using in-depth interviews, among program managers of health care system including District Medical Officers and RCH Officers and program service providers, both in rural and urban areas. RESULTS: In total 34 in-depth interviews were conducted. Nearly half (2+) of the program managers and service providers of adolescent programs opined that the important problems faced by adolescents were issues related to sexuality, psychosocial conflict, identity crisis, adjustment problems and scholastic problems. Approximately half of them thought that improper parenting, negative attitude of parents, separated parents, ignorance of parents, family background, nuclear family setup etc. are the most important factors, which influence adolescent problems and that friends and media are their major source of reproductive sexual health information. Nearly half of them pointed out that pain and psychological disturbances like anxiety, tension and anger were the important menstrual problems faced by adolescents. Again nearly half of them, felt that FLE (Family Life Education) should be given at school and ARSH services at PHCs, but there was little consensus on provision of contraceptive service and abortion services to adolescents. CONCLUSION: All the service providers and program managers are ready to cooperate but they had varied opinions about who should impart adolescent reproductive sexual health education and how the program should be done.

ARSH 4: Parental understanding of adolescent issues: parent-adolescent dyad agreement.

OBJECTIVE: To elicit areas of discordance between the parent-adolescent dyad with regard to reproductive sexual health issues using the same questions to both and to elicit the gender sensitivity of the parents. METHODS: This study was conducted using similar questions for both adolescents and young adults and their parents in three districts of Kerala. Data analysis was done comparing unmarried adolescents and young adults' response to reproductive and sexual health issues and the parental agreement status with their ward's responses. RESULTS: There were a total of 3,625 parent-unmarried young adults dyads. Parental attitudinal difference towards their sons and daughters on selected parenting issues was observed. With regard to the following reproductive and sexual health problems, (i) knew about menstruation before menarche (64.1%), (ii) got information on hygiene practices from home (80.8%), (iii) have menstrual problems (66.4%), agreement with adolescent response was high, whereas with regard to (i) anxious about adolescent physical and mental changes (29.2%), (ii) received information on reproductive sexual health (RSH) from mother (26.7%), (iii) do not have any abnormal vaginal discharge (46.7%), (iv) parents taken precautions to prevent sexual abuse (17.5%), (v) have been sexually abused (15.6%), agreement with unmarried young adults' response was low and all these differences were statistically significant. CONCLUSIONS: The results of 3,625 parent-unmarried adolescents and young adults dyad data showed poor agreement on vital issues like sexual abuse apart from gender inequality favouring sons.

ARSH 5: Reproductive health needs assessment of adolescents and young people (15-24 y): a qualitative study on 'perceptions of community stakeholders'.

OBJECTIVE: To explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among adolescents in order to improve reproductive health services for adolescents. METHODS: The study was conducted in three districts of Kerala and need assessment was done qualitatively using focus group discussions (FGDs), five each from all the three districts among junior public health nurses (JPHNs), anganwadi workers (AWWs), non-government organizations (NGOs), community leaders and adolescents. RESULTS: Majority of community stakeholders expressed that adolescents get knowledge regarding personal hygiene from their family itself and that they have poor knowledge about genital hygiene. Pain and associated problems are the most important difficulties faced by adolescent girls during menstrual periods. Most of the adolescents believed that excessive masturbation is a very dangerous practice. Most of the community stakeholders pointed out that though our adolescents know about HIV, they have very poor knowledge about other STIs and that parental ignorance increases vulnerability for sexual abuse among adolescents. They also suggested family life education sessions at schools and colleges for younger ones and premarital counseling for older ones, apart from counseling services and adolescent clinics. The important barriers in the utilization of services for adolescents are lack of awareness of parents, stigma to utilize services, economic factors, facility available at faraway places, and non-availability of services. CONCLUSIONS: The need for adolescent friendly health services and premarital counseling services in the community attached to health facilities, has been highlighted.

ARSH 3: Reproductive and sexual health knowledge: a comparison among married male and female young adults (15-24 y).

OBJECTIVE: To examine reproductive and sexual knowledge of young married men and women between (15-24 y) in Kerala and to compare the reproductive health knowledge and sexual health knowledge among young married men and women of 20-24 y. METHODS: This cross sectional community survey was conducted in three districts in Kerala. The married young adults were stratified into age groups of 15-19 y and 20-24 y. Data was collected using separate pretested structured interview schedule. RESULTS: There were no married males below the age of 20 y and only 24 females below the age of 20 y. More proportion of males had statistically significant knowledge about masturbation (72.3%), night emission in boys as an indicator of adolescence (92.6%), the fact that there is no relation between size of penis and sexual performance (78.8%) and condom prevents pregnancy and HIV/AIDS. Among the married 20-24 y group higher proportion of males had knowledge on safe period (47.9%) and condom use (97.9%) whereas higher proportion of females had knowledge on copper-T. With regard to sexual health higher percentage females talked about satisfactory sexual life (83.5%) and good sexual hygiene practices (81.5%). CONCLUSIONS: This study on reproductive sexual health knowledge of married men and women between 15 and 24 y, conducted in three districts of Kerala suggests a gap in knowledge level of reproductive health between married men and women. However, with regard to sexual health the opinion expressed are more open in content but not necessarily healthy, suggesting the need for both premarital and newlywed counseling.

Attitude of parents and teachers towards adolescent reproductive and sexual health education.

OBJECTIVE: To assess parents' and teachers' attitude towards Adolescent Reproductive Sexual Health Education (ARSHE). METHODS: The study group consisted of a random sample of 795 parents and 115 teachers belonging to three urban schools (one boys only, one girls only and one co-education) and one co-education rural school at Thiruvananthapuram district, Kerala, where an ICMR supported ARSHE intervention programme was done subsequently. A self-administered questionnaire for parents and teachers developed by an ICMR taskforce for ARSHE programme was used to assess their opinion on the need, content and the appropriate person to provide adolescent reproductive sexual health education in a school setting. RESULTS: 65.2% of parents and 40.9% teachers have not discussed growth and development issues with their adolescents. Only 5.2% teachers and 1.1% parents discussed sexual aspects with adolescents. 44% of parents agreed that information on HIV/AIDS/STD should be provided. More than 50% of parents were not sure whether information on topics like masturbation, dating, safe sex, contraceptives, pregnancy, abortion and childcare should be provided to adolescents. CONCLUSIONS: Results pointed out the need for introducing reproductive and sexual education in the school setting. Only 1.1% of parents and 5.2% teachers actually discussed sexual aspects with adolescents which highlights the need for parent and teacher awareness programs before ARSHE is introduced in the schools.

Effectiveness of a reproductive sexual health education package among school going adolescents.

OBJECTIVE: To assess the effectiveness of a school based "Adolescent Reproductive Sexual Health Education (ARSHE) Package" in improving students' knowledge on reproductive sexual health matters. METHODS: An ARSHE package originally developed at Child Development Centre, Kerala, modified and approved by ICMR taskforce group was administered in three urban schools (One boys only, one girls only and one co-education) and one co-education rural school at Thiruvananthapuram district, Kerala. The study sample consisted of 1,586 adolescents including 996 boys and 560 girls of class IX and XI. Pre and post intervention knowledge regarding reproductive sexual health matters was assessed using a self-administered questionnaire. RESULTS: In the pre-intervention period, it was observed that majority of adolescents were poorly informed about reproductive sexual health matters, particularly about contraceptives. As compared to boys, girls had much poorer knowledge about prevention of pregnancy and after intervention; there was a statistically significant increase in the knowledge in both boys and girls. Among girls percentage of poor knowledge had reduced significantly from 64.1% to 8.3% and among boys from 37.7% to 3.5%. Similarly, increase in knowledge level was also observed in various other aspects of reproductive and sexual health including, STI, HIV/AIDS and perceptions about premarital sex. CONCLUSIONS: The study results revealed the feasibility and effectiveness of school based reproductive and sexual health education intervention programs for adolescents.