|Year : 2015 | Volume
| Issue : 1 | Page : 9-17
Inequity in awareness and utilization of adolescent reproductive and sexual health services in union territory, Chandigarh, North India
Madhu Gupta1, Nidhi Bhatnagar2, Pankaj Bahugana3
1 Associate Professor, Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Haryana and Punjab, India
2 Senior Resident, Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Haryana and Punjab, India
3 Statistician, Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Haryana and Punjab, India
|Date of Web Publication||9-Mar-2015|
Assistant Professor, Room No. 130, School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh - 160 012, Haryana and Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Adolescents are a heterogeneous, vulnerable, and sexually active group. Geographical and educational health disparities exist among urban, rural, and slum adolescents and among out-of-school and school-going adolescents, respectively. Adolescent reproductive and sexual health (ARSH) services should be implemented in a manner to minimize health inequities among them. Objectives: To ascertain the extent of awareness and utilization of ARSH services provided under reproductive and child health(RCH) program among adolescents in Chandigarh. Materials and Methods: A cross-sectional study was conducted among 854 adolescents (402 household, 200 out-of-school, and 252 school-going adolescents) in Chandigarh using pretested validated interview schedule on awareness and utilization of adolescent reproductive and sexual health services from February to April 2011 in North Indian Union Territory of Chandigarh. Ordinal regression analysis was done to study the association of socio-demographic variables with awareness and utilization of ARSH. Results: Awareness about contraception and health services was significantly less among rural (12.7% and 1.1%, respectively) adolescents as compared to slum (17.9% and 4.6%, respectively) and urban adolescents (33.5% and 7.8%, respectively) (P < 0.05). Out-of-school adolescents were utilizing the preventive [odds ratio (OR) 0.39, P < 0.001] and curative services significantly lesser (OR = 0.54, P < 0.001) and had higher substance abuse (OR = 4.26, P= 0.006). Awareness was significantly associated with older age of adolescents (OR = 4.4,P < 0.001), poor education of father (OR = 0.5, P = 0.002), rural area (OR = 0.56, P = 0.001), and out-of-school status (OR = 0.35, P < 0.001). Conclusion: Awareness and utilization of ARSH services was inequitable and was more among urban and school-going adolescents. Educational status was the most important factor affecting it.
Keywords: Adolescent reproductive and sexual health, Adolescents, inequity, Reproductive health, Sexual health
|How to cite this article:|
Gupta M, Bhatnagar N, Bahugana P. Inequity in awareness and utilization of adolescent reproductive and sexual health services in union territory, Chandigarh, North India. Indian J Public Health 2015;59:9-17
|How to cite this URL:|
Gupta M, Bhatnagar N, Bahugana P. Inequity in awareness and utilization of adolescent reproductive and sexual health services in union territory, Chandigarh, North India. Indian J Public Health [serial online] 2015 [cited 2017 Mar 23];59:9-17. Available from: http://www.ijph.in/text.asp?2015/59/1/9/152846
| Introduction|| |
Adolescents aged between 10 and 19 years constitute 18% of the world population, i.e., about 1.2 billion. , About 88% of them live in developing world. India has the largest (243 million) number of adolescents comprising one-fourth of the country's population.  Adolescent health and nutrition status has an intergenerational effect, hence it is one of the important stages of the life cycle in terms of health interventions. , But this period is often ignored.  Nearly two-thirds of premature deaths and one-third of the total disease burden in adults are associated with conditions or behaviors that begin in their adolescence or youth, including tobacco use, lack of physical activity, unprotected sex, exposure to violence leading to unintended pregnancy, early pregnancy and childbirth, human immunodeficiency virus (HIV) and other sexually transmitted diseases, malnutrition, substance abuse, and injuries.  Injuries and communicable diseases are prevalent among adolescents in 10-14 years age group; outcome of sexual behaviors and mental health problems become significant among adolescents in 15-19 years age group. 
India constitutes 25% of school dropouts globally, as per the World Bank estimation, and about 40% adolescents are school dropouts. , Educational health disparities are observed between school-going and out-of-school adolescents.  Feleke et al. reported that educational status, schooling attendance, distribution of services, type of sexual relationship, and perception of risk were important factors affecting the utilization of family planning and voluntary counseling and testing services among adolescents between 15 and 19 years of age in Gondon town, Northwest Ethiopia. [12 ] District Level Household Surveys (DLHS)-3 in India have reported higher proportion of teenage (15-19 years) pregnancies in rural areas (19.7%) as compared to urban areas (8.6%), reflecting geographical health disparity. 
Promoting the healthy practices during adolescence is critical to the future of a country's health.  Millennium Development Goals (MDGs) five and six are particularly relevant to young people's health, which consider the pregnancy rate among 15-19-year-old girls, and the incidence of HIV/AIDS among young people and the proportion of 15-24 year olds with a comprehensive knowledge of HIV/AIDS.  Providing equitable, comprehensive, accessible adolescent reproductive and sexual health (ARSH) services has been a mandate of reproductive and child health (RCH) program under National Rural Health Mission (NRHM) in India since 2006.  ARSH services include preventive and curative services like counseling on nutrition and sexual problems, immunization, awareness on contraceptives, Reproductive tract infections/Sexually transmitted infection (RTI/STI), and HIV/AIDS, behavioral risk factors, services for pregnancy/abortion, and management at primary, secondary, and tertiary care levels.  The objective of this study was to ascertain the extent of awareness and utilization of ARSH services under RCH program among adolescents in urban areas, rural areas, and slums of Chandigarh, and also among school-going and out-of-school adolescents.
| Materials and Method|| |
A cross-sectional study was conducted in Chandigarh which has a population of 1,054,686 with urban, slum, and rural population constituting 60%, 30%, and 10%, respectively, as per census 2011, from February to April 2011.  Adolescents constitute 22% of the total population. ARSH services were provided in urban, rural, and slum areas in Chandigarh through adolescent-friendly clinics in civil dispensaries by medical officers at the primary level and three tertiary care hospitals served as referrals. Teachers in government schools were especially trained under ARSH strategy for imparting awareness to school children. Out-of-school adolescents were especially planned to be covered under this.
The study population included school-going adolescents, out-of-school adolescents, and the adolescents residing in urban, rural, and slum areas of Chandigarh. For this study, three surveys were planned, including household survey to ascertain geographical differences and school and out-of-school surveys to ascertain educational differences. Sample size was estimated by using the formula n = (1.96) pq/d , wherein n is the sample size, p the prevalence [prevalence of condom awareness among adolescents assumed to be 40% as reported by National Family Health Survey (NFHS)-3], q is 1 − p, and d is precision (assumed to be 5%). , Thus, the sample size was calculated as 384. A total of 402 adolescents were selected from the household survey. For estimating the sample size for school-going and out-of-school adolescents, school enrollment ratio of 60% among 15-19 years age group in schools was taken, as per the NFHS-3.  Thus, 230 (60% of 384) adolescents from schools and 154 (40% of 384) out-of-school adolescents from working places were required. In this study, we selected 252 school-going students and 200 out-of-school adolescents, who covered the minimum required sample size.
Prior consent to interview students in schools was obtained from the Director, Public Institutions, Chandigarh Union Territory. Written informed consent from parents/legal representative of minor adolescents/adolescents (>18 years) directly was taken during household and out-of-school surveys.
Any adolescent of age 10-19 years, whether going to school or was out of school, and was part of the family of the selected household was a household adolescent. For household survey, six urban city sectors, three slum areas, and one rural area were selected randomly from a complete list of urban, rural, and slum areas in Chandigarh by simple random sampling according to probability proportional to size (PPS). Random selection of houses within the selected area was done and 40 adolescents from each area were enrolled in the study.
Any adolescent of age 10-19 years who was not enrolled in school and was working in shops, restaurants, workshops, factories, etc. in Chandigarh or was unemployed was considered as out-of-school adolescent. They were selected from same urban, rural, and slum areas as in the household survey by visiting their various working places like shops, restaurants, shacks on the side of the roads, etc. From each selected area, 20 dropouts were enrolled in the study.
Schools with trained teachers in ARSH were included in the study. Private schools (n = 23) did not have teachers trained in ARSH, hence were not included. The list of government schools with trained teachers in ARSH was obtained from District Family Welfare Bureau, Chandigarh. Fifty-nine government schools (46 in urban areas, 10 in rural areas, and 3 in slums) had teachers trained in ARSH, out of which 36 gave consent for the study. These schools had up to middle class only. Two schools in urban area and one each in rural and slum areas were selected randomly among those consented, according to PPS.
Data were collected by four field investigators who were recruited and trained for this purpose. Data collection tool was a pretested, validated, and semi-structured interview schedule. The interview schedule was prepared in English and Hindi languages after reviewing (i) implementation guidelines on RCH-II ARSH strategy by the Department of Health and Family Welfare, Government of India and (ii) adolescent health component of RCH under latest programme implementation plan (PIP) for Chandigarh.  The interview schedule was translated in Hindi and back-translated to English for consistency. It dealt with information on background characteristics, socioeconomic status, awareness, and utilization of ARSH services including nutritional services, reproductive health knowledge, counseling services, self-reported tetanus (TT) immunization, substance abuse among the adolescents, etc. Twenty percent interviews conducted by the field investigator were validated by the supervisor to ensure consistency. The mismatch was less than 1%. There were two modes of data collection, i.e., by self-administration and interview. In household and out-of-school surveys, majority of the data was collected through interview (71% and 78%, respectively), while for the school survey, 52% of the forms were filled by self-administration. All the self-administered forms were cross-checked in the schools on that very day so as to identify any missed entries, which were later got filled up.
Data were entered and analyzed in Statistical Package for Social Science (SPSS) version 16. Outcome variables had four domains, i.e., awareness regarding balanced diet, contraceptives, reproductive health, health services; utilization of preventive and curative health services; access to health services; and practices of adolescents such as substance abuse, reproductive and sexual practices. Differences in proportions were considered significant at 95% confidence interval. Ordinal regression technique was used for performing multivariate analysis. Prior to the multivariate analysis, five variables, including health awareness, preventive health service utilization, curative health service utilization, access to health services, and substance abuse, were created using associated variables in the dataset. Each associated variable had been given equal weightage for calculating the output variable. The continuous output variables thus formed were logically categorized. The criterion for categorization was based on the number of variables used to generate these output variables and the amount of skewness in the distribution of output variables. These five variables were outcome variable input for ordinal regression analysis. The predictors used in the analysis were gender and age of the subject, education of father and mother, monthly income of the family, demographic status, religion, caste, occupation of father and mother, and schooling status of the subject. The link used in the different models was negative log-log link. The choice of using negative log-log link over any other logic link was based on the distribution of categories of dependent variable in which lower categories were more.  Unlike any other logistic regression technique, default beta coefficients generated in ordinal model were combined for all the remaining categories of dependent variable except the reference category, i.e., uppermost category. Odds ratio (OR) was generated manually by experts for better clarity and not as a default part of analysis.
| Results|| |
A total of 854 adolescents (household survey 402, out-of-school survey 200, and school survey 252) were interviewed. The findings in the household survey were as follows: 63% were males; 50% were early adolescents (10-13 years), 23% were middle adolescents (14-15 years), and 27% (16-19 years) were late adolescents; about 90% were enrolled in schools; and 77% were Hindus. Most of the adolescents belonged to upper lower class, except in the urban area where nearly 40% belonged to upper class. In the school survey, the findings were as follows: 54% were males; 42.5% were early adolescents, 51.6% middle adolescents, and 5% were late adolescents; and 68% had completed middle school level and 31% had completed primary education. In the out-of-school survey, the findings were: 92% were males, 68% were late adolescents, 63% had studied till primary level or below, 62% were working as laborers, 16.5% were in jobs, 13.5% were self-employed, 52% had illiterate father working as a laborer, and 44.5% belonged to schedule caste.
Geographical differences in ARSH awareness, utilization of ARSH services, and practices of adolescents in urban, rural, and slum areas of Chandigarh, as per the household survey, are given in [Table 1]. Significantly more number of adolescents in rural area (90%) were aware of balanced diet, as compared to those in urban (85.8%) and slum (53.7%) areas (P = 0.000). Awareness of all types of contraception [except emergency contraception pill (ECP)] was significantly more in urban area as compared to rural and slum areas (P < 0.05). Significantly more number of adolescents in urban area were aware about availability of health services (9.5%, P = 0.025) and had information of HIV testing centers (37.7%, P = 0.020). Among preventive health service utilization, significant differences across areas were found in nutritional counseling (P = 0.000) and immunization for TT (P = 0.003). About 2% adolescents indulged in substance abuse (drugs, tobacco, alcohol) in urban area and 5% indulged in alcohol consumption in rural area.
|Table 1: Area wise distribution of adolescent reproductive and sexual health service awareness and utilization among adolescents in urban, rural, and slum areas of Chandigarh, 2011|
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Gender differences in ARSH awareness, utilization of ARSH services, and practices of adolescents, as per the household survey, are given in [Table 2]. Significantly more females (93.2%) as compared to males (66.7%) were aware of balanced diet [P = 0.00]. Awareness of contraception and contraceptive methods was significantly more among females as compared to males, except condom (P < 0.05). Awareness of RTI/STI and HIV was also more among females. Availability of health services was reported more by females (8.7%) compared to males (6.3%). Only males reported substance abuse (n = 7) and sexual activity (n = 1). Awareness and utilization of preventive and curative ARSH services increased with increasing age of adolescents.
|Table 2: Gender wise distribution of adolescent reproductive and sexual health service awareness and utilization among adolescents in Chandigarh, 2011|
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Differences between school-going and out-of-school adolescents regarding ARSH awareness, utilization, and practice, as per school and out-of-school surveys, are given in [Table 3]. Total number of school-going adolescents [n = 641 (389 + 252)] and out-of-school adolescents [n = 213 (200 + 13)] included those recruited from household, school, and out-of-school survey, respectively. School-going adolescents were significantly more aware of the health camps (20%), ARSH services (7.5%), and integrated counseling and testing centers (35%), as compared to out-of-school adolescents (10%, 2%, and 23%, respectively; P = 0.005, 0.017, 0.000, respectively). Awareness of condoms was significantly higher among out-of-school adolescents (P < 0.01). Utilization rates of preventive health care services like nutritional counseling (60%) and TT immunization (52%) were significantly higher among school-going adolescents as compared to out-of-school adolescents (22% and 25.5%, respectively; P = 0.000). Significantly more school-going adolescents utilized curative services like treatment for anemia (36%) and worm infestations (26%), as compared to out-of-school adolescents (18% and 19.5%, respectively; P = 0.00 and 0.005, respectively) Substance abuse was observed to be significantly higher among out-of-school adolescents (28.5%) as compared to the school-going adolescents (1.3%; P = 0.00) [Table 3].
|Table 3: Educational status wise distribution of adolescent reproductive and sexual health service awareness and utilization among school-going and out-of-school adolescents in Chandigarh, 2011|
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As per multi-ordinal regression analysis, health awareness about ARSH services was significantly more among older adolescents (OR = 4.4) and less among adolescents with poor educational status of father (OR = 0.4), family income less than Rs. 5000 per month (OR = 0.7), those belonging to rural (OR = 0.5) and slum areas (OR = 0.7), and school dropouts (OR = 0.36, P < 0.001). Utilization of preventive health services was worse among school dropouts (OR = 0.4, P < 0.001). School dropouts were also less significantly utilizing the curative ARSH services (OR = 0.54, P < 0.001). Substance abuse was significantly more among adolescents between 16 and 19 years of age (OR 18.8, P = 0.007) and school dropouts (OR = 4.5, P = 0.006) [Table 4].
|Table 4: Ordinal regression to study the predictors of adolescent reproductive and sexual health awareness and utilization in adolescents|
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| Discussion|| |
Geographical and educational differences in awareness and utilization of services among urban, rural, and slum adolescents and school-going adolescents versus dropouts, as observed in this study, reflect inequity in service delivery mechanism in spite of provision of ARSH services under RCH-II program in Chandigarh. Predictors observed to be significant for awareness of ARSH services were age of adolescents, education of father, family income, geographical area and educational status of adolescents; for utilization of preventive services were education of mother and school-going status; for utilization of curative services was school-going status; and for substance abuse were older adolescents and out-of-school status.
Participation of higher number of males in this study could be because of less migration of girls for employment to urban areas like Chandigarh in the out-of-school survey, lower enrollment ratio in selected government schools in the school survey, and lower sex ratio in Chandigarh (818/1000 males) as per census 2011 in the household survey. ,
Geographical differences in awareness and utilization of ARSH services suggested poor penetration of ARSH services in the rural and slum areas. Overall low awareness of ARSH services (7.2%) and health camps (25.6%) in this study was similar to the study conducted in Gujarat, where out of 28 focus group discussions (FGDs) on ARSH services, only 3 FGDs (1 among boys and 2 among girls) reported awareness.  Awareness about health services influences utilization of services. Kotecha et al. observed that 70% adolescents were ready to use adolescent-friendly services if they knew about these.  Yadav et al. observed similar rates of utilization of ARSH services as in our study, with a higher rate observed in urban areas (67%) as compared to in rural areas (33.3%) and slums (16.7%) in Chandigarh.  Gupta et al. also observed reproductive and child health inequities in Chandigarh, with higher teenage pregnancy rates in rural (4.5%) compared to urban (2.2%) and slum (0.5%) areas.  Higher rate of utilization for nutritional counseling, TT immunization, Iron Folic Acid (IFA) tablets, and deworming treatment as compared to reproductive and sexual health services, observed in this study is similar to the finding of Berhane et al.'s study. 
More awareness and utilization of ARSH services found among female adolescents in the ho educators for addressing the reproductive and sexual health of dropouts is a good step in this direction taken by the ministry in India, but usehold survey is similar to the findings by Nair et al.  Schooling is an important determinant influencing ARSH awareness and utilization in adolescents. School-going adolescents were more aware of nutritional counseling, ARSH services, health camps, and utilization of curative services, while awareness regarding contraception, HIV testing, ready access to ECP, high-risk behavior, counseling for sex, contraception, and about HIV and RTI/STI was more in out-of-school adolescents. It indirectly suggests that ARSH-trained teachers imparted knowledge regarding nutrition and ARSH service availability, but were not comfortable in imparting information on topics related to reproductive and sexual health, as these adolescents were mainly early and middle adolescents. Similar differences in awareness were observed by Kotwal et al. between school-going and out-of-school adolescent girls in a rural area in Jammu.  Awareness of RTI/STI was more (29%) among youths aged 15-24 years in a study conducted by National AIDS Control Organization (NACO) compared to this study (9.9%) because of the inclusion of later age groups in that study.  Similarly, awareness of condoms, contraception services, HIV/AIDS, and HIV/AIDS testing centers was more in DLHS-3, Chandigarh because of inclusion of unmarried women aged 15-24 years.  Alarmingly, high substance abuse rate (drugs 12%, smoking 8%, alcohol 8.5%) was found among out-of-school adolescents in this study. This finding is similar to a study where dropping out of school was a predisposing factor for substance abuse among Manipuri dropouts in urban slums.  A systematic review of literature published between 1990 and 2006 suggested a consistent relationship between dropping out of high school and substance use. 
Poor awareness and utilization of ARSH services signal change required in the way program is being implemented and monitored by the program managers. More emphasis on generating awareness of ARSH services among adolescents is required so that the utilization pattern, especially for reproductive and sexual health services, is improved. Efforts to strengthen ARSH services in rural and slum areas are required. At a policy level, there is a need to address the problem of substance abuse especially among out-of-school adolescents. Involvement of peer group educators for addressing the reproductive and sexual health of dropouts is a good step in this direction taken by the ministry in India, but needs constant follow-up and monitoring. 
The limitation of the study is that private schools could not be included because they did not give the consent. Distribution of out-of-school adolescents in different regions of Chandigarh and the reasons of dropping out of school and poor utilization of ARSH services need to be explored further.
Authors would like to acknowledge the contributions by Dr. Navpreet and Dr. Jeyashree, Senior Residents in School of Public Health, PGIMER Chandigarh, for planning and conducting the survey. They are also thankful to Dr. Soma Rani, District Family Welfare Officer, Chandigarh for her kind cooperation in the project.
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[Table 1], [Table 2], [Table 3], [Table 4]