DOI 10.1515/ijamh-2013-0513 Int J Adolesc Med Health 2014; 26(2): 233–237
Monika Madaan*, Swati Agrawal, Manju Puri, Jyoti Meena, Harvinder Kaur and Shubha Sagar Trivedi
Health profile of urban adolescent girls from India Abstract Context: Adolescents comprise 22.5% of the population, which forms a significant part of the entire population. It is only recently that we have acknowledged the need for a separate specialty to handle adolescent problems and ailments. Aims: The aim of the present study is to study the health profile of the adolescents girls presenting to the tertiary care hospital situated in New Delhi, India. Materials and methods: The study was conducted on 316 adolescent girls who presented to the adolescent clinic at Smt Sucheta Kriplani Hospital, New Delhi. Apart from recording the various health problems to which they presented, a detailed HEADSS assessment was done for each case. Results: Majority of the adolescents (60.74%) presented with menstrual problems, 78.48% discussed their problems with their parents, and 91.77% agreed on common things with them. About 69.62% were attending school or college, while 30.37% had either left or never attended school. Majority of the adolescents (77.84%) had only a few friends, 62.96% watched TV in their free time, and only 7.27% performed regular exercise. In addition, 0.94% adolescents in the study group were married. Among the 313 unmarried adolescents, 3.83% were dating and 4.47% were sexually active. There was a low incidence of teenage pregnancy (0.94%) reported in the unmarried study population. History of contraceptive use was present in only 1.26% cases, and only 5.06% of the adolescents had knowledge of HIV. Conclusions: Adolescent health must be viewed with a comprehensive approach comprising of social, mental, physical and emotional aspects. The active involvement of the entire society, including parents and teachers, must also be encouraged towards the healthy development of adolescents. Keywords: adolescents; HEADSS assessment; contraception, sexuality. *Corresponding author: Monika Madaan, MBBS, MD, Employees’ State Insurance Corporation Hospital, Manesar, Haryana, India, Phone: +09891200166, E-mail: [email protected]
Swati Agrawal, Manju Puri, Jyoti Meena, Harvinder Kaur and Shubha Sagar Trivedi: Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi, India
Introduction Adolescent health is often limited to discussions surrounding malnutrition, sexually transmitted diseases, adolescent pregnancy, cigarette smoking and other drugtaking behaviors. However, the fact is that the spectrum of problems faced by adolescents is very wide, and many other issues require investigation. Adolescence has been defined by the World Health Organization (WHO) as the period of life spanning between 10 and 19 years (1). Following the worldwide interest in child and maternal health in the past decade, improving maternal and child health has been identified as an essential focus of adolescent health discussions. According to Friedman, adolescence can be likened to a crossroad in the human development (2). It is a period of rapid physical, sexual, and psychological changes. Adolescents have diverse problems that lead to morbidity and mortality. In India, approximately 225 million adolescents comprise 22.5% of the population (1). Adolescent health forms an integral part of a government’s health policy, because it has important public health implications. The most prominent health issues in developing countries are malnutrition and anemia, adolescent pregnancy with attendant complications as well as higher maternal and infant mortality, sexually transmitted infections (STIs) including HIV (about 35% new infections of HIV occur in 15–24 years), substance use, depression, suicide, injuries, and violence (1). There are innumerable studies from developed countries that have focused on addressing adolescent issues. In comparison, there is a dearth of such data from the developing world. As the health issues affecting the adolescents are highly influenced by environmental and social factors, it is imperative to have indigenous data in order to facilitate the formulation of policies for this population group. Hence the current study aimed at investigating the health profile of the adolescents girls presenting to the tertiary care hospital situated in Delhi (India). This
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234 Madaan et al.: Health profile of Indian adolescent girls study also aimed to identify the common health problems of adolescents (physical, psychological, and mental) so that preventive measures can be instituted to improve their overall health.
Materials and methods The study was conducted from April 2009 to July 2010 in the adolescent clinic run in the Obstetrics and Gynecology Outpatient Department of Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi. Esthical approval was taken from the ethical committee of the hospital before commencing the study. The study sample comprised of 316 adolescent girls aged between 11 and 19 years, who reported to the adolescent clinic due to various health concerns. At the initial visit, each girl was subjected to a questionnaire, which included a semistructured psychosocial interview based on the Home, Education, Activities, Drugs, Sexuality, Suicide /Depression potential (HEADSS) format. Developed by Cohen et al. HEADSS assessment is an interview instrument that is used to determine issues in adolescents’ lives (3). It was completed by the attending gynecologist and took about 20 min for each adolescent. This was followed by medical evaluation, determination of diagnosis, and institution of the required treatment.
Results Socio-demographic profile The average age of the adolescent girls attending the clinic was 16.6 years (range: 11–19 years). Of these, 83.9% of the adolescent girls reported attending school or college.
HEADS assessment Home Majority of the population belonged to the lower and lower-middle classes, the average monthly family income was Rs 6474 (range: Rs 1000–25,000). As regards their preference for healthcare or counseling facility, 174 (55.06%) girls preferred government hospitals, 55 (17.40%) private hospitals, 46 (14.55%) family physicians, and 26 (8.22%) preferred indigenous systems, i.e., Ayurvedic or local aids. Meanwhile, 15 (4.74%) responded that they did not visit any health facility. Majority of the adolescents (248 or 78.48%) discussed their problems with their parents, 31 (9.81%) confided in their siblings, 21(6.64%) discussed with friends, 5 (1.58%)
talked with some near relatives, 5 (1.58%) discussed with doctors, and 3 (0.94%) disclosed that they did not reveal their problems to anyone. All the 3 (0.94%) married adolescents girls discussed their problems with their husbands. On being asked whether they discuss everything with their parents, 278 (87.97%) responded positively, 34 (10.75%) gave a negative reply, and 4 (1.26%) could not respond as they either did not live with their parents or their parents were not alive. Their relationships with their parents was graded as excellent in 49 (15.50%) adolescents, very good in 136 (43.03%), good in 123 (38.92%), not good in one adolescent (0.31%), and poor in another (0.31%). The relationships of 2 (0.63%) girls needed improvement, while no information was available in 4 (1.26%) adolescents. Majority of the adolescents (290 or 91.77%) agreed on common things with their parents, while 22 (6.96%) disagreed with them. The parents were not available in 4 (1.26%) cases. As far as parents agreeing with adolescents were concerned, the response was yes for majority (274 or 86.70%) of the respondents, no for 28 (8.86%), and sometimes for 10 (3.16%). Again, the parents were not available in 4 (1.26%) cases. Additionally, adolescents who had a good relationship with their parents had a lower school dropout rate as compared with those who did not (91 out of 310 vs. 5 out of 6), and this difference was statistically significant (p = 0.04). A note was also made of the fact that adolescents who continued with their studies were less likely to indulge in sexual activity compared with those who did not (3 out of 220 vs. 11 out of 96). This difference was found to be statistically significant (p = 0.00), as shown in Figure 1. However, no significant difference was found in the level of sexual activity among adolescents who had a good communication with their parents as compared to those who did not (p = 0.14). Likewise, no significant difference was found in HIV knowledge status between adolescents who were studying and those who were school dropouts (p = 0.11)
Education Out of 316 adolescents, 220 (69.62%) were going to school or college, while 96 (30.37%) had either left or never attended school. The average percentage of marks in their last class among those attending school or college was 60.14% (range, 40%–95%). When asked about the subjects they did not like, among 312 adolescents who were presently attending or had ever attended school or college, 125 (40.06%) adolescents did not respond to the
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Madaan et al.: Health profile of Indian adolescent girls 235
Drugs
Bar chart Sex active Not active Active
250
200
Count
150
Sexuality
100
50
0 Not studying
Studying Study
Figure 1 Relationship of school dropout rate with sexual activity.
question, 42 (13.46%) disliked Math, 24 (7.69%) disliked Social Studies, 18 (5.76%) did not like Science, 17 (5.4%) disliked Sanskrit, 12 (3.84%) disliked English, 8 (2.56%) disliked Hindi, and 7 (2.24%) disliked Commerce. Meanwhile, 58 (18.58%) adolescents did not dislike any subject.
Activity Under this section, adolescents were asked about their close friends, exercise routine, and their activities during their free time. Majority of the adolescents (246 or 77.84%) had only a few friends, 62 (19.62%) had many friends, and 8 (2.53%) did not have any friends. Table 1 shows the various activities the adolescents pursued during their free time. There were only 23 (7.27%) adolescents who exercised regularly, while 60 (18.98%) did so occasionally. Majority of the adolescents (233 or 73.73%) did not exercise at all. Table 1 Activities pursued by adolscents in free time. Activity in free time Watch TV Read books Play Exercise Movies Computer Video game Others
There were no cases of drug addiction except one (0.31%), and the same adolescent had a history of a psychiatric disorder. The history of drug abuse in the form of alcohol, smoking, pan, gutka, and so on, in the family was present in 108 (34.11%) cases.
n (%) n = 316 199 (62.96%) 34 (10.75%) 33 (10.44%) 10 (3.16%) 6 (1.89%) 5 (1.58%) 3 (0.94%) 26 (8.22%)
Menarche was attained in 292 (92.40%) cases, and the average age of menarche was 13.34 years. Out of 292 adolescents who attained menarche, dysmenorrhea was present in 118 (40.41%) adolescents and 45 (15.41%) experienced premenstrual syndrome. There were 3 (0.94%) adolescents in the study group who were married. Among the 313 unmarried adolescents 12 (3.83%) were dating, and 14 (4.47%) were sexually active. In the sexually active unmarried group, only one case gave history of contact with two partners, the rest had contact with only a single partner. The average age of first intercourse was 16 years in the study population. There were 3 (0.94%) cases of teenage pregnancy reported in the unmarried study population, and all presented with amenorrhea. All 3 pregnancies were the results of consensual premarital sexual intercourse, and the parents as well as the girls opted for medical termination of pregnancy. History of contraceptive use was present in only 4 (1.26%) cases, and 16 (5.06%) adolescents had knowledge of HIV.
Presenting complaint Menstrual problems were the most common complaint from 60.74% of the adolescents, followed by abdomen pain in 12.65% of the cases. Table 2 shows the various reasons for the adolescents to visit the health facility.
Discussion In our study, 78.48% adolescents revealed that they discussed everything with their parents, while the rest did not confide in their parents. In addition, 6.96% adolescents and 8.86% parents did not agree on common things with each other. Even in an urban set-up, such as New Delhi, 30.37% adolescents either leave school or never attend it, thereby indicating a scope by which to improve the implementation of various education related programs run by
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236 Madaan et al.: Health profile of Indian adolescent girls Table 2 Reasons for visiting the health facility. Presenting complaints Menstrual disorders Menorrhagia/Polymenorrhea Oligomenorrhea/Hypomenorrhea Secondary amenorrhea Primary amenorrhea Pain abdomen Dysmenorrhea Vaginal discharge Urinary complaints Infertility Galactorrhoea Skin problems Weight changes Vaginal wall cyst Non specific
n (%) n = 316 90 (28.48%) 48 (15.18%) 32 (10.12%) 22 (6.96%) 40 (12.65%) 32 (10.12%) 29 (9.17%) 5 (1.58%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 13 (4.11%)
the government to achieve education for all adolescents. The school dropout rate is also significantly lower in adolescents sharing a good bond with their parents, which highlights the importance of correct parental support and guidance in the life of adolescents. Majority of the adolescents had friends; of these, 42.72% only had a few while 19.62% had many friends. Watching television was the most popular free time activity of 62.02% of the adolescents compared with only 10.44% who spent their time playing. This reflects a need to create more recreational centers, so as to encourage adolescents to socialize and become more involved in healthy activities. In our study population, 73.73% never exercised at all. Hence, there is an urgent need to incorporate physical activities, such as playing, exercises, aerobics or yoga, at the school level. Doing so can help adolescents maintain physical fitness and rejuvenate their mind and body as well. The average age of menarche in our study group was 13.34 years. This is comparable to the mean ages of 13.16 and 13.7 years reported by Jain et al. (4) and Patil et al. (5), respectively. A significant number (40.41%) experienced dysmenorrhea. This is comparable to 53% and 56% of girls in the rural and urban areas, respectively, as reported by other authors (6). Overall, adolescents attended the hospital for information and health problems that were mainly related to general health and menstruation, followed by problems related to vaginal discharge, urinary complaints, and so on. Acne and weight changes were among the less reported problems. Most of the complaints needed only reassurance and counseling. Based on clinical history and examination, it was evident that even vaginal discharge,
as reported by girls, was mainly physiological in 96% of the cases. Only in 4% of the cases was this associated with pruritus vulvae or with poor hygiene. In addition, only 4.47% of the adolescents were sexually active, with a teenage pregnancy rate of 0.94%. The mean age of first intercourse was 16 years, which can be compared with 47.8% high school students having ever had sexual intercourse as reported by US Centers for Disease Control and Prevention in the year 2007, and a teenage pregnancy rate of 3% in 2006 (7). The reason for this glaring disparity may be attributed to the fact that sex before marriage is considered a taboo in our country. It was also possible that the interviewed adolescents hid their true sexual status, because of the stigma associated with it. It is also noteworthy that although the number of sexually active adolescents in the U.S. was 10 times greater than that in our study, the pregnancy rate was only thrice as much. Lack of knowledge about safe sexual practices predisposes the adolescents to hazards such as STIs, HIV, and pregnancy. Meanwhile, sexual activity rates were lower in the adolescents who continued with their studies, indicating the importance of education at this young age. Contraceptive use was present in only 1.26% of cases, which can be compared with a study from North India reporting 21% girls persuaded their partner to practice contraceptive use in premarital sex (8). Surprisingly, only 5.06% of adolescents had knowledge of HIV in our study. In contrast, a study by Sharma et al. in a rural area of Himachal Pradesh found that 93.7% of adolescents were aware of information related to AIDS (9). A study by Parchauri et al. (10) showed that awareness about RTI, STI, and HIV-AIDS among women was very low in Madhya Pradesh; only 24% of women had heard about HIV-AIDS, and 16% and 11% women were aware of RTI and STI, respectively. Chatterjee et al. also found that only 13.5% senior school students in Kolkata had clear knowledge regarding AIDS, including its general aspects, transmission, and prevention (11). In this context the authors would like to emphasize the importance of sex education in the adolescent population. Sex is considered a sensitive topic in the Indian society, and is not discussed openly. This leaves the curious minds of the adolescents at the mercy of insufficient and often incorrect information, from peers and social media, predisposing them to the various hazards of unsafe sex. It is also important to encourage the parents and teachers to improve communication with the adolescents and provide necessary and relevant guidance to them. For this, the authors recommend that certain teachers who are directly interacting with the adolescents in schools be recognized and specially trained to deal with
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Madaan et al.: Health profile of Indian adolescent girls 237
adolescent health issues who, in turn, can serve as counselors for other adolescents as well as their parents.
Conclusion Other than reproductive health, there are many aspects of adolescent health, such as education, promotion of regular physical exercises, sexual health, related issues (e.g., contraception) and so on, which must be addressed and strengthened. Adolescent health is a combined responsibility of the society, parents, and the adolescents themselves. Initiatives should be taken to develop and strengthen adolescent-friendly health services. Parents should also be involved in the reproductive education, and this would require parents to be educated, able to
change their perceptions and attitude about reproductive and sexual health, and willing to initiate age-appropriate dialogues with their children. Many health problems that commonly occur in adolescence can be prevented, with consequent improvement in their quality of life. A basic tenet of effective health provision for both sexes is the need to “identify the conflict between health promotion and cultural values” (12). Increasing the awareness of parents, teachers, and adolescents is necessary to build the healthy future of the adolescents and the country in general. Conflict of interest statement: The authors declare that they have no conflict of interest. Received March 31, 2013; accepted June 16, 2013; previously published online February 17, 2014
References 1. Adolescent Health and Development. WHO May 2008. Available from: http://www.whoindia.org/en/Section6/Section425.htm. Accessed on 6 February, 2013. 2. Friedman HL. Adolescent health and development: investing in the future. A paper prepared for the meeting of the task force on health and development policies. In: Health in Development: prospects for the 21st century: report of the first meeting of the Task Force on Health in Development, 27–30 June 1994, Geneva, Switzerland. Geneva, World Health Organization, 1994. 3. Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health 1991;12:539–44. 4. Jain K, Garg SK, Singh JV, Bhatnagar M, Chopra H, Bajpai SK. Reproductive health of adolescent girls in an urban population of Meerut, Uttar Pradesh. Health and Population: Perspectives And Issues 2009;32:204–9. 5. Patil SN, Wasnik V, Wadke R. Health problems amongst adolescent girls in rural areas of Ratnagiri District of Maharashtra India. J Clin Diagnos Res 2009;3:1784–90.
6. Avasarala AK, Panchangam S. Dysmenorrhoea in different settings: are the rural and urban adolescent girls perceiving and managing the dysmenorrhoea problem differently? Indian J Comm Med 2008;33:246–9. 7. Adolescent sexuality. In: Wikepedia, the free encyclopedia. Available from: http://en.wikepedia.org/wiki/Adolescent sexuality. Accessed on 6 February, 2013. 8. Trikha S. Abortion scenario of adolescents in a North India cityevidence from a recent study. Indian J Comm Med 2001;269:48. 9. Sharma S, Nagar S, Chopra G. Health awareness of rural adolescent girls: an intervention study. J Soc Sci 2009;21:99–104. 10. Parchauri N, Warvadekar J. Awareness of RTI, STI and HIV-AIDS in Madhya Pradesh. In: Sharma KK, editor. Reproductive and child health problems in India. Delhi: academic Excellence, 2005:458–80. 11. Chatterjee C, Baur B, Ram R, Dhar G, Sandhukan S, Dan A. A study on awareness of AIDS among school students and teachers of higher secondary schools in North Calcutta. Indian J Public Health 2001;45:27–30. 12. Friedman HL. Culture and adolescent development. J Adolesc Health 1999;25:1–6.
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Monika Madaan*, Swati Agrawal, Manju Puri, Jyoti Meena, Harvinder Kaur and Shubha Sagar Trivedi
Health profile of urban adolescent girls from India Abstract Context: Adolescents comprise 22.5% of the population, which forms a significant part of the entire population. It is only recently that we have acknowledged the need for a separate specialty to handle adolescent problems and ailments. Aims: The aim of the present study is to study the health profile of the adolescents girls presenting to the tertiary care hospital situated in New Delhi, India. Materials and methods: The study was conducted on 316 adolescent girls who presented to the adolescent clinic at Smt Sucheta Kriplani Hospital, New Delhi. Apart from recording the various health problems to which they presented, a detailed HEADSS assessment was done for each case. Results: Majority of the adolescents (60.74%) presented with menstrual problems, 78.48% discussed their problems with their parents, and 91.77% agreed on common things with them. About 69.62% were attending school or college, while 30.37% had either left or never attended school. Majority of the adolescents (77.84%) had only a few friends, 62.96% watched TV in their free time, and only 7.27% performed regular exercise. In addition, 0.94% adolescents in the study group were married. Among the 313 unmarried adolescents, 3.83% were dating and 4.47% were sexually active. There was a low incidence of teenage pregnancy (0.94%) reported in the unmarried study population. History of contraceptive use was present in only 1.26% cases, and only 5.06% of the adolescents had knowledge of HIV. Conclusions: Adolescent health must be viewed with a comprehensive approach comprising of social, mental, physical and emotional aspects. The active involvement of the entire society, including parents and teachers, must also be encouraged towards the healthy development of adolescents. Keywords: adolescents; HEADSS assessment; contraception, sexuality. *Corresponding author: Monika Madaan, MBBS, MD, Employees’ State Insurance Corporation Hospital, Manesar, Haryana, India, Phone: +09891200166, E-mail: [email protected]
Swati Agrawal, Manju Puri, Jyoti Meena, Harvinder Kaur and Shubha Sagar Trivedi: Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi, India
Introduction Adolescent health is often limited to discussions surrounding malnutrition, sexually transmitted diseases, adolescent pregnancy, cigarette smoking and other drugtaking behaviors. However, the fact is that the spectrum of problems faced by adolescents is very wide, and many other issues require investigation. Adolescence has been defined by the World Health Organization (WHO) as the period of life spanning between 10 and 19 years (1). Following the worldwide interest in child and maternal health in the past decade, improving maternal and child health has been identified as an essential focus of adolescent health discussions. According to Friedman, adolescence can be likened to a crossroad in the human development (2). It is a period of rapid physical, sexual, and psychological changes. Adolescents have diverse problems that lead to morbidity and mortality. In India, approximately 225 million adolescents comprise 22.5% of the population (1). Adolescent health forms an integral part of a government’s health policy, because it has important public health implications. The most prominent health issues in developing countries are malnutrition and anemia, adolescent pregnancy with attendant complications as well as higher maternal and infant mortality, sexually transmitted infections (STIs) including HIV (about 35% new infections of HIV occur in 15–24 years), substance use, depression, suicide, injuries, and violence (1). There are innumerable studies from developed countries that have focused on addressing adolescent issues. In comparison, there is a dearth of such data from the developing world. As the health issues affecting the adolescents are highly influenced by environmental and social factors, it is imperative to have indigenous data in order to facilitate the formulation of policies for this population group. Hence the current study aimed at investigating the health profile of the adolescents girls presenting to the tertiary care hospital situated in Delhi (India). This
Brought to you by | University of Connecticut Authenticated Download Date | 6/21/15 3:20 PM
234 Madaan et al.: Health profile of Indian adolescent girls study also aimed to identify the common health problems of adolescents (physical, psychological, and mental) so that preventive measures can be instituted to improve their overall health.
Materials and methods The study was conducted from April 2009 to July 2010 in the adolescent clinic run in the Obstetrics and Gynecology Outpatient Department of Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi. Esthical approval was taken from the ethical committee of the hospital before commencing the study. The study sample comprised of 316 adolescent girls aged between 11 and 19 years, who reported to the adolescent clinic due to various health concerns. At the initial visit, each girl was subjected to a questionnaire, which included a semistructured psychosocial interview based on the Home, Education, Activities, Drugs, Sexuality, Suicide /Depression potential (HEADSS) format. Developed by Cohen et al. HEADSS assessment is an interview instrument that is used to determine issues in adolescents’ lives (3). It was completed by the attending gynecologist and took about 20 min for each adolescent. This was followed by medical evaluation, determination of diagnosis, and institution of the required treatment.
Results Socio-demographic profile The average age of the adolescent girls attending the clinic was 16.6 years (range: 11–19 years). Of these, 83.9% of the adolescent girls reported attending school or college.
HEADS assessment Home Majority of the population belonged to the lower and lower-middle classes, the average monthly family income was Rs 6474 (range: Rs 1000–25,000). As regards their preference for healthcare or counseling facility, 174 (55.06%) girls preferred government hospitals, 55 (17.40%) private hospitals, 46 (14.55%) family physicians, and 26 (8.22%) preferred indigenous systems, i.e., Ayurvedic or local aids. Meanwhile, 15 (4.74%) responded that they did not visit any health facility. Majority of the adolescents (248 or 78.48%) discussed their problems with their parents, 31 (9.81%) confided in their siblings, 21(6.64%) discussed with friends, 5 (1.58%)
talked with some near relatives, 5 (1.58%) discussed with doctors, and 3 (0.94%) disclosed that they did not reveal their problems to anyone. All the 3 (0.94%) married adolescents girls discussed their problems with their husbands. On being asked whether they discuss everything with their parents, 278 (87.97%) responded positively, 34 (10.75%) gave a negative reply, and 4 (1.26%) could not respond as they either did not live with their parents or their parents were not alive. Their relationships with their parents was graded as excellent in 49 (15.50%) adolescents, very good in 136 (43.03%), good in 123 (38.92%), not good in one adolescent (0.31%), and poor in another (0.31%). The relationships of 2 (0.63%) girls needed improvement, while no information was available in 4 (1.26%) adolescents. Majority of the adolescents (290 or 91.77%) agreed on common things with their parents, while 22 (6.96%) disagreed with them. The parents were not available in 4 (1.26%) cases. As far as parents agreeing with adolescents were concerned, the response was yes for majority (274 or 86.70%) of the respondents, no for 28 (8.86%), and sometimes for 10 (3.16%). Again, the parents were not available in 4 (1.26%) cases. Additionally, adolescents who had a good relationship with their parents had a lower school dropout rate as compared with those who did not (91 out of 310 vs. 5 out of 6), and this difference was statistically significant (p = 0.04). A note was also made of the fact that adolescents who continued with their studies were less likely to indulge in sexual activity compared with those who did not (3 out of 220 vs. 11 out of 96). This difference was found to be statistically significant (p = 0.00), as shown in Figure 1. However, no significant difference was found in the level of sexual activity among adolescents who had a good communication with their parents as compared to those who did not (p = 0.14). Likewise, no significant difference was found in HIV knowledge status between adolescents who were studying and those who were school dropouts (p = 0.11)
Education Out of 316 adolescents, 220 (69.62%) were going to school or college, while 96 (30.37%) had either left or never attended school. The average percentage of marks in their last class among those attending school or college was 60.14% (range, 40%–95%). When asked about the subjects they did not like, among 312 adolescents who were presently attending or had ever attended school or college, 125 (40.06%) adolescents did not respond to the
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Madaan et al.: Health profile of Indian adolescent girls 235
Drugs
Bar chart Sex active Not active Active
250
200
Count
150
Sexuality
100
50
0 Not studying
Studying Study
Figure 1 Relationship of school dropout rate with sexual activity.
question, 42 (13.46%) disliked Math, 24 (7.69%) disliked Social Studies, 18 (5.76%) did not like Science, 17 (5.4%) disliked Sanskrit, 12 (3.84%) disliked English, 8 (2.56%) disliked Hindi, and 7 (2.24%) disliked Commerce. Meanwhile, 58 (18.58%) adolescents did not dislike any subject.
Activity Under this section, adolescents were asked about their close friends, exercise routine, and their activities during their free time. Majority of the adolescents (246 or 77.84%) had only a few friends, 62 (19.62%) had many friends, and 8 (2.53%) did not have any friends. Table 1 shows the various activities the adolescents pursued during their free time. There were only 23 (7.27%) adolescents who exercised regularly, while 60 (18.98%) did so occasionally. Majority of the adolescents (233 or 73.73%) did not exercise at all. Table 1 Activities pursued by adolscents in free time. Activity in free time Watch TV Read books Play Exercise Movies Computer Video game Others
There were no cases of drug addiction except one (0.31%), and the same adolescent had a history of a psychiatric disorder. The history of drug abuse in the form of alcohol, smoking, pan, gutka, and so on, in the family was present in 108 (34.11%) cases.
n (%) n = 316 199 (62.96%) 34 (10.75%) 33 (10.44%) 10 (3.16%) 6 (1.89%) 5 (1.58%) 3 (0.94%) 26 (8.22%)
Menarche was attained in 292 (92.40%) cases, and the average age of menarche was 13.34 years. Out of 292 adolescents who attained menarche, dysmenorrhea was present in 118 (40.41%) adolescents and 45 (15.41%) experienced premenstrual syndrome. There were 3 (0.94%) adolescents in the study group who were married. Among the 313 unmarried adolescents 12 (3.83%) were dating, and 14 (4.47%) were sexually active. In the sexually active unmarried group, only one case gave history of contact with two partners, the rest had contact with only a single partner. The average age of first intercourse was 16 years in the study population. There were 3 (0.94%) cases of teenage pregnancy reported in the unmarried study population, and all presented with amenorrhea. All 3 pregnancies were the results of consensual premarital sexual intercourse, and the parents as well as the girls opted for medical termination of pregnancy. History of contraceptive use was present in only 4 (1.26%) cases, and 16 (5.06%) adolescents had knowledge of HIV.
Presenting complaint Menstrual problems were the most common complaint from 60.74% of the adolescents, followed by abdomen pain in 12.65% of the cases. Table 2 shows the various reasons for the adolescents to visit the health facility.
Discussion In our study, 78.48% adolescents revealed that they discussed everything with their parents, while the rest did not confide in their parents. In addition, 6.96% adolescents and 8.86% parents did not agree on common things with each other. Even in an urban set-up, such as New Delhi, 30.37% adolescents either leave school or never attend it, thereby indicating a scope by which to improve the implementation of various education related programs run by
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236 Madaan et al.: Health profile of Indian adolescent girls Table 2 Reasons for visiting the health facility. Presenting complaints Menstrual disorders Menorrhagia/Polymenorrhea Oligomenorrhea/Hypomenorrhea Secondary amenorrhea Primary amenorrhea Pain abdomen Dysmenorrhea Vaginal discharge Urinary complaints Infertility Galactorrhoea Skin problems Weight changes Vaginal wall cyst Non specific
n (%) n = 316 90 (28.48%) 48 (15.18%) 32 (10.12%) 22 (6.96%) 40 (12.65%) 32 (10.12%) 29 (9.17%) 5 (1.58%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 1 (0.32%) 13 (4.11%)
the government to achieve education for all adolescents. The school dropout rate is also significantly lower in adolescents sharing a good bond with their parents, which highlights the importance of correct parental support and guidance in the life of adolescents. Majority of the adolescents had friends; of these, 42.72% only had a few while 19.62% had many friends. Watching television was the most popular free time activity of 62.02% of the adolescents compared with only 10.44% who spent their time playing. This reflects a need to create more recreational centers, so as to encourage adolescents to socialize and become more involved in healthy activities. In our study population, 73.73% never exercised at all. Hence, there is an urgent need to incorporate physical activities, such as playing, exercises, aerobics or yoga, at the school level. Doing so can help adolescents maintain physical fitness and rejuvenate their mind and body as well. The average age of menarche in our study group was 13.34 years. This is comparable to the mean ages of 13.16 and 13.7 years reported by Jain et al. (4) and Patil et al. (5), respectively. A significant number (40.41%) experienced dysmenorrhea. This is comparable to 53% and 56% of girls in the rural and urban areas, respectively, as reported by other authors (6). Overall, adolescents attended the hospital for information and health problems that were mainly related to general health and menstruation, followed by problems related to vaginal discharge, urinary complaints, and so on. Acne and weight changes were among the less reported problems. Most of the complaints needed only reassurance and counseling. Based on clinical history and examination, it was evident that even vaginal discharge,
as reported by girls, was mainly physiological in 96% of the cases. Only in 4% of the cases was this associated with pruritus vulvae or with poor hygiene. In addition, only 4.47% of the adolescents were sexually active, with a teenage pregnancy rate of 0.94%. The mean age of first intercourse was 16 years, which can be compared with 47.8% high school students having ever had sexual intercourse as reported by US Centers for Disease Control and Prevention in the year 2007, and a teenage pregnancy rate of 3% in 2006 (7). The reason for this glaring disparity may be attributed to the fact that sex before marriage is considered a taboo in our country. It was also possible that the interviewed adolescents hid their true sexual status, because of the stigma associated with it. It is also noteworthy that although the number of sexually active adolescents in the U.S. was 10 times greater than that in our study, the pregnancy rate was only thrice as much. Lack of knowledge about safe sexual practices predisposes the adolescents to hazards such as STIs, HIV, and pregnancy. Meanwhile, sexual activity rates were lower in the adolescents who continued with their studies, indicating the importance of education at this young age. Contraceptive use was present in only 1.26% of cases, which can be compared with a study from North India reporting 21% girls persuaded their partner to practice contraceptive use in premarital sex (8). Surprisingly, only 5.06% of adolescents had knowledge of HIV in our study. In contrast, a study by Sharma et al. in a rural area of Himachal Pradesh found that 93.7% of adolescents were aware of information related to AIDS (9). A study by Parchauri et al. (10) showed that awareness about RTI, STI, and HIV-AIDS among women was very low in Madhya Pradesh; only 24% of women had heard about HIV-AIDS, and 16% and 11% women were aware of RTI and STI, respectively. Chatterjee et al. also found that only 13.5% senior school students in Kolkata had clear knowledge regarding AIDS, including its general aspects, transmission, and prevention (11). In this context the authors would like to emphasize the importance of sex education in the adolescent population. Sex is considered a sensitive topic in the Indian society, and is not discussed openly. This leaves the curious minds of the adolescents at the mercy of insufficient and often incorrect information, from peers and social media, predisposing them to the various hazards of unsafe sex. It is also important to encourage the parents and teachers to improve communication with the adolescents and provide necessary and relevant guidance to them. For this, the authors recommend that certain teachers who are directly interacting with the adolescents in schools be recognized and specially trained to deal with
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Madaan et al.: Health profile of Indian adolescent girls 237
adolescent health issues who, in turn, can serve as counselors for other adolescents as well as their parents.
Conclusion Other than reproductive health, there are many aspects of adolescent health, such as education, promotion of regular physical exercises, sexual health, related issues (e.g., contraception) and so on, which must be addressed and strengthened. Adolescent health is a combined responsibility of the society, parents, and the adolescents themselves. Initiatives should be taken to develop and strengthen adolescent-friendly health services. Parents should also be involved in the reproductive education, and this would require parents to be educated, able to
change their perceptions and attitude about reproductive and sexual health, and willing to initiate age-appropriate dialogues with their children. Many health problems that commonly occur in adolescence can be prevented, with consequent improvement in their quality of life. A basic tenet of effective health provision for both sexes is the need to “identify the conflict between health promotion and cultural values” (12). Increasing the awareness of parents, teachers, and adolescents is necessary to build the healthy future of the adolescents and the country in general. Conflict of interest statement: The authors declare that they have no conflict of interest. Received March 31, 2013; accepted June 16, 2013; previously published online February 17, 2014
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