By Shambhavi Saxena:
Adolescent years can be a pain. The acne, the angst, the aches, and all those changes in your body. When I was a teen, having friends and the internet to turn to for answers made things bearable. Sometimes, a grown-up would ‘break rank’ and tell me what’s what. And that helped. The ages 10 to 19 are not easy, to say the least. But falling headlong into adolescence and adulthood without access to information and adequate healthcare is far, far more difficult.
According to a WHO finding, 3,000 adolescents die each year of preventable or curable diseases. This is directly linked to a lack of access to services and resources. For India’s poor, many of whom live in informal housing (colloquially called slums, and bastis) that dots India’s cities, quality and affordable healthcare is out of reach. Several informal settlements may adjoin a world-class health facility, or a private nursing home, but the communities and families living in these settlements remain on the margins of healthcare services.
Adolescents whose parents have migrated to India’s cities in search of work can bear the brunt of this marginalisation. What does the health-seeking experience of adolescents living in these settlements look like? Whom do they approach when they have questions about their bodies, about sex, and about growing up? Who reaches them faster—a friend with alcohol or a health worker with sound advice against substance abuse? And what role has the State played in meeting their health needs?
A recent survey by PRIA offers a glimpse into the health status and behaviour among adolescents living in five informal settlements in the city of Gurugram. Under the project ‘Our Health, Our Voice’, PRIA trained students of Gurugram University to conduct a participatory mobile-based survey with the adolescents in the settlements of Nathupur, Sikanderpur, Ghata, Chakkarpur, and Harijan Basti. The survey covers seven key components of adolescent health specified under the Rashtriya Kishor Swasthya Karyakram, a national initiative: nutrition, violence and injury, mental health, menstrual health, substance abuse, sexual and reproductive health, and non-communicable diseases. Following community-based research practices, the findings were shared with the adolescents and their care-givers.
A Clean Place Is A Safe Space
PRIA’s survey notes that the informal settlements “are associated with poor-quality construction, and poor sanitation and water supply. Unsanitary physical conditions and living in small rooms with poor ventilation can have long-term adverse effects on the overall health of adolescents.” Trash lying in the streets, swarming with flies, is the perfect breeding ground for disease. Bad air means respiratory illness. Bad water – well, 60% of our body is made of water and that should tell you enough.
A common feature in settlements like these is the shared toilet. The survey found that 80.6% of adolescents only had access to toilets like these. On a regular day, there is high exposure to disease. During the COVID-19 pandemic, it’s downright dangerous. And let’s not forget that toilets like these are linked to higher incidents of sexual violence.
Having a toilet is one thing. Being able to keep it clean is, unfortunately, a whole other ball game, and one that comes with a price. To get their supply of clean water, 6.67% of girls reported using a tanker service. One third of those surveyed had taps inside their homes. But the majority of adolescents had to settle for community taps, just like the shared toilets.
Complications in access (or lack thereof) to clean water is linked to the spread of diseases like cholera, dysentery, hepatitis A, and typhoid. That’s not all. Imagine dealing with your periods without water.
A ‘Growing Pain’: Sexual And Reproductive Health
Menstruation is widely considered a turning point in an adolescent’s growth. It’s a wild ride. Suddenly, you’re losing blood and need more calcium- and iron-rich food. The cramps drive you up the wall. You have cravings and nausea at the same time. And that’s on a good day. Some people live with severe and debilitating conditions like Premenstrual Dysphoric Disorder (PMDD). For a 10-year-old, all of this can be disquieting. But the right health information and guidance is immensely beneficial.
One of the first things any person is taught about periods is hygiene and disposal. Among the 149 participants who had begun menstruating, branded sanitary napkins were the most popular menstrual hygiene product. While the usage of sanitary pads in urban areas, nationally, is 59.2%, PRIA’s survey found it’s much higher in these settlements, at 73.15%. Of course, the second thing that a majority of menstruating persons are taught is shame. Unsurprisingly, the survey revealed period stigma existed in all five settlements.
Still, it pales in comparison to attitudes towards sex. Though 141 adolescents in PRIA’s survey said their mothers were their primary source of information, followed by teachers and friends, it wasn’t exactly dinner-table conversation. When asked if they could discuss sex-related matters with their parents, a sizeable 68.03% of adolescents made no bones about it when they said ‘No’. They were also least likely to consult a doctor who is actually an authority on sexual health. It’s no wonder that 89% of adolescents surveyed by PRIA could not identify even one symptom of a sexually transmitted infection.
This lack of information does not bode well when you consider the stats on infections or teen pregnancies. A 2018 Lancet study revealed that half of all pregnancies in India are unintended. Can we chalk it down to limited or missing access to sexual and reproductive health and rights?
And that brings us to the next concern – nutrition. Just as it’s important to get the right kind of food while menstruating, nutrition plays a huge role in healthy development during adolescence.
What’s On My Plate?
Mothers from Sikanderpur, who participated in PRIA’s research, said that, unlike nutrition during pregnancy, nutrition during adolescence did not figure in the government’s outreach to them. While they cannot rattle off factsheets and figures of recommended daily intakes, each mother has a basic understanding of what kind of nutrient-rich food her adolescent children need. But the higher the nutritional value, the higher the price. And no matter how much they wanted to better their children’s diet, they couldn’t.
A city like Gurugram boasts of many shops emblazoned with words like ‘organic’, ‘natural’, ‘vegan’, or ‘whole foods’. Frequented by the city’s health-conscious elite, you’ll find them a stone’s throw away from any informal settlements. The disparity is jarring.
What are the repercussions of not getting a balanced diet? According to UNICEF, 1 in 2 children “suffer from deficiencies in essential vitamins and nutrients such as vitamin A and iron.” It also found that 40% of girls and 18% of boys in India are anaemic.
Malnutrition is a persistent and silent crisis in India, but news from the urban informal settlements surveyed by PRIA isn’t as bleak.
Over 70% of the adolescents consumed a healthy amount of vegetables per week. A majority (30.91%) reported having fruits at least twice a week. And interestingly, more girls (30.91%) than boys (25.1%) reported consuming non-vegetarian food like meat and fish.
But there is still much room for improvement.
And that’s where the State needs to play a major role.
A Clinic, Just For Us
In 2014, the Ministry of Health and Family Welfare launched the Rashtriya Kishor Swasthya Karyakram (RKSK) to promote the “holistic development” of India’s adolescent population. Under it, Adolescent-Friendly Health Clinics (AFHCs) have been set up to provide “preventive, promotive, curative and counselling services, routine check-ups at primary, secondary and tertiary levels of care […] to adolescents, married and unmarried, girls and boys during the clinic sessions.”
A place just for adolescents and their health needs. Isn’t that grand? Well…
“I don’t know about such clinics,” said one adolescent girl from the Sikanderpur settlement. Like her, the other adolescents that PRIA spoke with said it was the first time they had even heard about the RKSK. An initiative of this scale should have, by now, reached Gurugram’s informal settlements. If, after six years, the scheme is still struggling with information dissemination, we’ve got a problem on our hands, it would appear?
Adolescent friendly health services are, in effect, missing from these settlements. And that leaves an entire population vulnerable. Even before COVID-19 hit, numerous challenges existed for these young Indians. A visit to the doctor is rare. Why wouldn’t it be when your only two choices are an expensive private clinic or a ramshackle government hospital?
The adolescents’ answers indicate that local-, state-, and national-level authorities need to ramp up efforts to connect them to the AFHCs and other services under the RKSK. As stakeholders, as beneficiaries, the voice of adolescents needs to be supported to influence health service delivery and enable them to access adolescent-friendly health care. Can adolescents from Sikanderpur, Ghata, Harijan Basti, Chakkarpur, and Nathupur show the way?
Read the findings of the survey here.