The adolescents comprise one fifth of the population in India (1). People at this age are prone to suffer from the reproductive, sexual, nutritional, mental, and behavioral problems. The health services that exclusively target the needs of the adolescents are scanty and concentrated in few urban areas (2). The government initiated the Reproductive and Child Health (RCH) program with the aim of facilitating good maternal and child health (3). However, some questions are raised in this regard including: Are these schemes equally beneficial to adolescent boys and girls? Do these schemes cover both urban and rural populations? Is enough importance laid on the reproductive health (RH)? And there are still many more questions, which remain unanswered.
The qualitative perspectives of the RH facilities, Adolescent Health Services (AHS), and Adolescent Friendly Health Services (AFHS) are still unexplored among the Indian adolescents. It is essential to furnish the adolescents with proper information as they can easily be misled and engage in unhealthy activities without such trainings. According to the literature, it is during this period that the adolescents are at the high risk of getting misled and having risky behaviours like substance abuse (4), unprotected sex (5), unintended pregnancy (6), and other RH issues. In India, the RH among the adolescents is an under investigated issue. To address the issues related to the unmet needs of this population, a qualitative study approach would be ideal to assess their views since these research methods provide real-life data (7). Additionally, these methods enable the participants to freely express their views. With this background in mind, the aim of the present study was to explore the perceptions and awareness of the RH and its facilities among the adolescents in two districts of India.
Materials and Methods
Prior to the initiation of the study, the researchers obtained the institutional ethical committee clearance. Subsequently, each participant was provided with an explanation of the study objectives, general consent, and time commitment involved in participating in the discussion. Furthermore, they were assured about the confidentiality of their information, and their written informed consents were obtained. The present study was conducted in two coastal districts of Karnataka (i.e., Dakshina Kannada and Udupi) in India during November 2013-April 2015. These districts have a mix of both rural and urban populations. A literacy rate of 86.2% in Udupi, ranks it as one of the most literate districts in the state.
It is hard to obtain quantitative information about the adolescents’ RH or AHS since these issues are sensitive topics to be discussed in the community, and they are confidential. Regarding this, discussions and interviews are the best ways to extract information from the participants about the adolescent RH matters. To this aim, the focus group discussions (FGD) are quite quick and relatively easy to set up. The group dynamics can provide useful information that may be failed to be noticed in the individual data collection. Consequently, the FGD- a qualitative study design- was developed to obtain our study objective (8, 9) of assessing the perceptions and awareness about the RH and its facilities among the adolescents in two districts of India.
The participants (age range: 15-19 years) of the current study were selected through stratified purposeful sampling method. Accordingly, two blocks (taluks) were randomly selected from each district. Subsequently, a rural and an urban area were randomly selected. Out of these areas, an Anganwadi (a community center) was chosen at random, and the in-charge was contacted to obtain the list of the parents who sent their adolescents to these Anganwadis.
To develop trustworthiness for performing the FGDs, first, the parents of each adolescent were contacted individually, and the study objective was explained focusing on its importance. In case of obtaining their agreements to participate in the study, they were given subject information sheet explaining all details of the study. Subsequently, the adolescents were met in person and given a consent form to be filled in. If they agreed to participate; then, they were recruited in the study. Additionally, a pediatric assent form was given to the adolescents under the age of 18 years.
Similarly, a high school was randomly chosen from the selected rural and urban areas. Informed consent was obtained from the school authorities, who agreed to participate in the study. Likewise, the parents and adolescents were contacted and consent/assent was obtained.
Separate FGDs were conducted for school-going adolescents and those who did not attend school. Each FGD had 10-15 participants, which lasted for about 90-120 min (only one session per FGD).
It should be noted that no prior professional-client relationship existed between the participants and the FGD team including a trained male facilitator, a note keeper (to record conversations if permission for audio recording was obtained and to note down body languages during responses), and a person to design the sociogram. A sociogram is a graphical representation that displays the structure of interpersonal relations (lines of communications) in a group, which is considered to be the best way of analyzing a FGD (10).
The FGDs were audio recorded with the participants’ consents. The audio records were transcribed in the local language, translated into English, and then back translated into the local language. To validate the translation, an independent language expert (at local language and English) went through both transcripts. Subsequently, the necessary corrections were made. Additionally, to summarise the participants’ viewpoints, the thematic analysis was performed and codes were generated (i.e., inductive coding). The study panel discussed all the transcripts to reach a common consensus on the coding. Finally, the data were sorted and synthesized according to each theme to be interpreted.
A literature review was performed on the adolescents’ perceptions about their RH matters or the related facilities in India. A broad conceptual framework was developed that could guide the empirical studies focusing on improving the modalities of RH service delivery, investigating adolescents’ perceptions about their unfulfilled RH needs, and examining adolescents’ awareness of the existing RH services. An interview guide was developed in the local language (Kannada) and pre-tested on a pilot sample. This guide consisted of open-ended questions related to broader themes such as RH problems, adolescents’ health seeking behaviors, knowledge about available services, and suggestions for improvement of these services. Some of the designed open-ended and probing questions are as follows:
1. With whom do you discuss your adolescent changes? Why only them? Why not other people?
2. What do you know about the RH clinics in your district? Where did you hear about it? What should be done to increase awareness about these clinics?
A total of 197 adolescents, including 102 boys and 95 girls, participated in 16 FGDs. As the results demonstrated, the mean age of the participants was 16±0.89 years.
Reproductive health problems
The RH problems were well discussed by the participants. These discussions gave them a chance to share their views and experiences with one another. The main RH issues among the girls were painful cramps, excessive flow, and myths related to the consumption of food during menstruation. Girls had some information about the menstrual pains and how to maintain personal hygiene during this period. It was also mentioned that in the villages, even today, few families practice untouchability during periods, i.e., no one is even allowed to talk or even look at the females during this time.
“We feel that menstrual cycles are a curse because it just restricts us from doing anything”. (Rural participant–girl)
According to the boys, masturbation was considered as an RH problem. Rural boys even lacked the basic knowledge about the RH during adolescence. They only discussed about masturbation with friends, and neither parents nor doctors. They felt shy to discuss these matters with the elderly, and none of them was aware of wet dreams.
“How that fluid getting ejaculated during masturbation gets generated in our body?” (Rural participant-boy)
There were some counseling services established in few urban schools; however, still the participants had so many queries, which remained had unattended. ‘If masturbation means ejaculation of fluid from our body; then, why should we do it twice a month and not more?’; ‘Should it be done compulsorily?’; ‘Why should that be done?’; ‘Does it happen voluntarily?’ [Group answers and lots of murmurs]
“Counseling was provided at school. It was told that one can masturbate only twice a month”. (Urban participant-boy)
“Excess masturbation causes disc pain and many other problems. Sperm cannot be produced”. (Rural participant-boy)
Adolescents’ health seeking behaviors
In all the FGDs, it was observed that the girls preferred discussing their health problems with their mothers, friends, and teachers. They were close to their mothers to seek guidance for their health issues. However, in terms of the menstrual issues, they discussed it first with their best friends. The majority of the girls were informed about the changes of the reproductive system by their teachers. At Anganwadis, those enrolled under the ‘Kishori Shakti Yojna’ obtained information about puberty changes.
Kishori Shakti Yojana seeks to empower the adolescent girls so as to enable them to take charge of their lives. This scheme is applied in the existing centrally sponsored Integrated Child Development Services. Under this scheme adolescent girls are offered informal trainings in life-related aspects including physical, development, and sex education. The girls are congregated at Anganwadi centers where they can receive basic health supplements such as Iron/Folic Acid and de-worming tablets. Girls can also be given vocational trainings at these centers.
In case of the boys, they agreed unanimously that they did not discuss their RH problems with their fathers. Furthermore, it was found that they consulted their friends for minor health problems. The boys reported that they obtain information on the RH through internet, friends, and social media. Additionally, they argued that the girls have so many RH-related facilities unlike them.
“In some schools, teachers give information about the RH only to girls”. (Rural participant-Boy)
Knowledge about available services
None of the participants had heard anything about the AHS, AFHS, and Adolescent Reproductive and Sexual Health (ARSH) clinics. Consequently, they were poorly aware of related RH services.
The girls were aware of few government schemes, which they utilized, including the Kishori Shakti Yojna, midday meal scheme, and Weekly Iron/Folic acid Scheme (WIFS). On the contrary, none of the boys knew that they could seek help from the ARSH clinics, government hospitals, and Sneha clinic for their teenage problems. Some girls mentioned that boys were deprived of the government facilities.
Boys mentioned that girls have women social welfare organizations, which would protect them from all the problems that they face in the society; however, there are not such organizations for boys. They implied that boys are ignored by the government in this regard and that girls are being given more importance than boys. Therefore, the boys advocated the need of equal distribution of the RH services and other facilities by the government.
Suggestions for improvement
“No one knows about the existence of the Sneha clinic. It should be made known to everyone”. (Rural participant-girl)
“It’s good if it is kept on Saturday afternoon”. (Rural participant-girl)
“We have never heard about 104 helpline*”. (Rural participant-boy)
*104 - a helpline exclusively meant to resolve the adolescent issues
“Schools should provide information; advertisements must be made about 104 helpline and its benefits. Health education camps s should be conducted on the weekends”. (Urban participant-girl)
“First, if we want to know about the schemes, somebody should use it. Then, others will know about it. In the beginning, we would not know about it. So advertisements must be given”. (Urban participant-boy)
“Government facilities should be made available equally to everyone”. (Rural participant-girl) [Group shouts girls deserve the best]
It was also reported that government has established some schemes, under which iron tablets are only distributed in the government schools and not private ones. The participants believed that the awareness programs targeting adolescents to use the RH facilities should be conducted in the places where it is easily accessible for them. In terms of the services provided to girls, they reported that the food quality under Kishori Shakti Yojna was good; nevertheless, some improvements were required in terms of timely supply of commodities since a delay in this issue would lead to their abandonments. This scheme should also be provided for the boys. One of the government facilities is distribution of sanitary pads in the government schools once a year; however, they believed that it is not enough, and these pads should be issued monthly.
Reproductive/sexual health means a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity in all the matters relating to the reproductive system functions and processes (11). However, this issue is poorly attended to among the Indian adolescents. Accordingly, few studies carried out in India have supported this assumption (2, 12, 13). To the extent of the researchers’ knowledge, no studies have employed qualitative study designs to examine this issue. Likewise, the RH services of India, especially those in the South, have not been investigated.
Consequently, the current study is the first attempt to address the adolescents’ perceptions and utilization of the RH services. Parents, friends, and school play a pivotal role in an adolescent’s upbringing. The first barrier that adolescents need to surpass is the communication gap existing between them and their parents. Rural and urban settings play their own roles in forming an adolescent’s attitude. To identify the issues that inhibit this population to discuss the RH-related issues, first, their mindset needs to be addressed.
As the findings indicated, the boys were unaware about their RH; accordingly, they had misconceptions about masturbation and were totally unaware of wet dreams. The perceptions of the rural and urban boys did not differ in this regard. They had many questions about the RH issues and did not know who they can refer to for such quarries. They felt shy to discuss these matters with parents; as a result, the friends were the only people they talked to about these issues. These findings were consistent with those of other studies (14-16).
In case of the girls, the findings demonstrated that they were aware of their RH matters since they were close to their mothers who would properly guide them about the puberty changes. They discussed the health problems they faced during their menstrual cycles. They also shared their concerns regarding the menstrual hygiene and practices. The rural girls pointed to still prevailing myths that they are forced to follow. Our study is the first attempt that has reported the practices that are being followed by the adolescent girls and the myths that exist among the boys about masturbation in South India. Our findings about the adolescent girls were similar to those of the previous studies conducted to address the menstrual hygiene and practices (17-19).
Unlike the current study, the majority of the previous studies addressing the RH and its services for adolescents have been carried out in the northern parts of India. It was highlighted that in only few schools, teachers provide the students with some information about the RH. Accordingly, few urban boys reported that they were provided with counseling facilities and health education discussions at school.
Regarding the knowledge and experiences of the adolescents about the RH services, a poor awareness was reported. The participants had never heard of the AFHS, ARSH, and Sneha clinics. The government schemes like Kishori Shakti Yojna and WIFS have been introduced for the improvement of the RH among adolescent girls (20, 21). However, the adolescent boys were deprived of such RH schemes. Additionally, the government has provided facilities for better menstrual hygiene (22). The boys argued that the parents and government have arranged the RH facilities just for the girls.
Furthermore, neither boys nor girls were aware of the RH services that were provided by the government. The participants gave lots of suggestions for improving these services. They all highlighted the importance of proper advertisements of the services. Furthermore, they believed that these programs should be held on the weekends to be easily accessible. According to the subjects, friendly staff and confidentiality at the RH clinics were the prime requisites. Receiving counseling from the health care experts are of fundamental importance for the adolescents in terms of the mental and RH issues. Considering the government schemes, girls offered some suggestions to improve the quality and timely delivery of food commodities. Furthermore, these schemes were administered only in the government schools, and not the private ones. Our study reported the adolescents’ viewpoints that would be helpful in the utilization of the RH services.
Our study gave an impression of the RH services among the adolescents of two districts in South India. The findings should not be taken as the representation of all adolescents in the state. Based on the participants’ viewpoints, it was concluded that the RH of the adolescent boys is neglected in the government schemes. Furthermore, the adolescent boys were observed to be unaware of the RH issues and have some misconceptions in this regard. Additionally, girls were found to receive much better guidance pertaining to the puberty changes. To spread knowledge about the RH services, more advertisements or awareness programs must be performed. Further studies are needed to focus on improving the RH status among this population.
We would like to acknowledge all the participants of our study. We would like to thank Indian Council of Medical Research and Manipal University who had provided us the research infrastructure.
Conflicts of Interest
The authors declare no conflicts of interest.