A study of the functioning of the adolescent friendly health clinics as well as the awareness and health seeking behaviour of adolescents attending the adolescent friendly health clinics in the Rampurhat health district, West Bengal, India

INTRODUCTION

It is estimated that approximately 253 million adolescents live in India, which makes up 21% of the nation’s population. Adolescents (ages 10-19 years) account for over one-half of the country's population, and one-sixth of the world’s population. The number of adolescents is enormous, but they are also future citizens and the economic drivers of the future as productive workers. Many of them fail to complete school, get married early, work in vulnerable positions, engage in sexual activity, and have health risks. This calls for interventions that are flexible and responsive to their desperate needs. Some of the public health challenges for adolescents are related to early pregnancy, with associated higher risk of maternal and infant mortality, sexually transmitted infections (including HIV) and reproductive tract infections, under-nutrition and anaemia, substance abuse, injuries etc. As adolescents' health will determine India's health, mortality, and morbidity, as well as the pace of population growth in future, it is crucial to give importance to their health.¹ Nearly half of the world’s population is under age 30. 16 million girls (14-19) have babies annually and 95% of them in developing countries. Young women account for nearly half of all unsafe abortion-related deaths each year. Most sexually active adolescents do not have access to modern contraception. 15-24 years old account for nearly half of all Human Immunodeficiency Virus (HIV) infections and 70% of new sexually transmitted infections (STIs).

HIV prevalence among young women aged 15-24 is more than four times higher than among young men of the same age in Southern African hyper-epidemic countries.² A period of transition between childhood and adulthood, adolescence is a time when a person's physical and mental development is in flux. Changes in biology, society, and psychology are all a part of this transformation.³ The common health problems adolescents may face are injuries resulting from accidents or violence; mental health problems, problems resulting from substance use, sexual and reproductive health problems (e.g., too-early pregnancy, mortality and morbidity during pregnancy and childbirth including due to unsafe abortion, sexually transmitted infections including HIV, harmful traditional practices such as female genital mutilation, and sexual coercion), problems resulting from under nutrition and over nutrition and endemic diseases (e.g., tuberculosis and malaria). Some of these health issues manifest in adolescence for the person (e.g., a death caused by suicide or interpersonal violence or from the consequences of an unsafe abortion). Later in life, others have an impact on the person (e.g., lung cancer resulting from tobacco use initiated during adolescence). Adolescent health and well-being are also a key driver of many of the SDGs, including health, nutrition, education, gender equality, and food security. Adolescents are important stakeholders and protagonists in the process of sustainable development because they are the largest group of beneficiaries. Adolescent investments will directly and favourably affect India's health objectives while also boosting economic output, effective social functioning, and population growth as a whole.^2,4 The quality of care or services for adolescents in adolescent-friendly health clinics should be accessible, acceptable, equitable, appropriate, effective, and comprehensive, according to WHO guidelines. To reach out to adolescents in India, the Ministry of Health and Family Welfare (MoHFW) launched a comprehensive programme for adolescents, 'Rashtriya Kishor Swasthya Karyakram' (RKSK), under the National Health Mission (NHM) in 2014. It was a significant step toward implementing the continuum of care approach in the country's health programmes.⁵ According to the NFHS-4 (2015-16) and NFHS-5 (2019-20) reports, 18.3% and 16.4%, respectively, of adolescents in the 15-19 age range have begun childbearing. According to NFHS-4 reports 62.2% and NFHS-5 reports 70.8% of adolescent girls between the ages of 15-19 are anaemic. On the other hand, NFHS-4 reports 31.7% and NFHS-5 reports 38.7% boys between the ages of 15-19 are anaemic.⁶ According to a WHO report, one in every three young men and women aged 15 to 24 years knows about SRH (sexual and reproductive health), including HIV (human immunodeficiency virus). This study represents the results of an assessment conducted among adolescents. Knowing how the adolescence sought out health care and whether the services they sought out at the clinic was helpful to them. It will also give informative feedback on the clinic's operations, any service gaps and potential future development areas.⁷

Aim and objectives

The aim of the study was to assess the awareness and health seeking behaviour among the adolescents girls and boys attending AFHCs as well as functioning of adolescent friendly health clinic services in Rampurhat health district. The objectives of the study were: to assess the functioning of the adolescent Friendly Health Clinic (AFHC) against the guidelines laid down by government programme, to find out the awareness among beneficiaries of AFHCs regarding adolescent friendly health services and their health seeking behaviour.

METHODS

Study design, location, population and duration

It was a Cross-sectional study. All the data were in the form of record review conducted to obtain the explanation of the quantitative findings. Rampurhat health district is an administrative subdivision of Birbhum District in the state of West Bengal, India. The total population of Rampurhat subdivision is 1508506 with the literacy rate of 69.12% as per the census of India 2011. Rampurhat Health District is divided into 8 community development blocks namely Murarai I, Murarai II, Nalhati I, Nalhati II, Rampurhat I, Rampurhat II, Mayureswar I, Mayureswar II. The adolescents belonging to the age group of 15-19 years attending AFHCs during the study period and residents of Rampurhat Health District were considered as the study population. The study period was March 2021 to August 2021. The data collection period for the study was May 2021 and June 2021

Inclusion criteria

Adolescents who are already registered in various AFHCs of Rampurhat health district during data collection period (3 May 2021 to 30 June 2021), and those who were willing to participate in the study were included.

Study sample

There are 10 adolescent friendly health clinics out of which 8 are situated in the different block primary health centers (BPHCs) under Rampurhat Health District; one in the Rampurhat medical college and one in the district hospital. Out of 10 AFHCs 8 were present under Rampurhat Health District which was known as Anwesha clinic, and one was in Rampurhat medical college which was known as SURAKSHA CLINIC. The other one was in District Hospital which was known as Anubhab clinic. Out of 8 AFHCs 4 were RKSK and the other 4 were Non RKSK. The calculated sample size was 96. Assumed the overall awareness of SRH-related problems and satisfaction level regarding Adolescent Friendly Health services among the beneficiaries as 50%, and absolute precision of 10, using the formula,

Where, Z= Value of Z at 95% confidence interval (as per Z-score table) =1.96, P = 50% d = 10 (Absolute Precision).⁸ Considering 10% non-response rate, the required sample size was 106. An arbitrary design effect of 1.5 has been applied to compensate for the clustering effect (beneficiaries under one AFHC form one cluster). Therefore, the final sample size was 159.

Sampling procedure

Complete enumeration was done for selecting the AFHCs for assessing functioning of the clinics and for selection of beneficiaries. So, all ten AFHCs located in Rampurhat Health District were selected for the study. From each clinic 16 beneficiaries of age group 15-19 years have been selected randomly. Therefore, the sample size obtained was 160.

Data collection tools and techniques

Data was collected using a structured, pre-designed checklist to assess the functioning of the AFHCs. Structured pretested self-administered survey questionnaire was used. The questionnaire was developed in English and was translated into local language (Bengali). The AFHC evaluation questionnaire available at the NHM portal was used for the study.

Facilities were assessed regarding AFHS implementation guidelines in terms of infrastructure, equipment, commodities and service provision. The beneficiary satisfaction level on AFH services was measured by the scoring pattern (rating). The questionnaire uses a 5-rating response scale (1 = poor; 5 = good).⁹ A pilot study was conducted in a different block named Md. bazar in suri health district other than the selected ones for main study to test the study schedule and necessary changes were made before starting the main study.

Study variables

Different socio-demographic factors like age of the participants, current educational status, marital status and other factors like awareness about the services, and the reasons behind not seeking the AFHC services were studied. Informed consent was obtained from each participant. Before signing the consent form, detailed information was given to the participants.

Data analysis

Data entry and analysis was done by MS Excel. Descriptive analysis was done to obtain frequency and percentages.

Operational definitions

Adolescent: The world health organization (WHO) defines adolescents as individuals in the 10-19 years age group.³ Adolescence is a phase rather than a fixed time period in an individual’s life. This covers both early (10-14 years) and late (15-19 years) adolescents. The target group of this study will be the adolescent between 15 to 19 years of age commonly known as late adolescents. Sexual health: According to WHO, sexual health is “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (WHO, 2006a) Reproductive health: The International Conference on Population and Development (ICPD) 1994 defined reproductive health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies the people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.”(ICPD 1994).

RESULTS

Regarding the physical and environmental features of the AFHC, majority of the clinics (80%) had a dedicated space/room. 40% of adolescent friendly health clinics were located away from the OPD/ Labour Room or any other crowded place. Only 20% of clinics had separate spaces for boys and girls. It was observed that all the AFHCs had an adequately clean environment. IEC materials, signboards with clinic information and policy on confidentiality on display were available in all the AFHCs. 80% clinics had adequately clean and functional toilets available and had separate toilets for girls and boys. All the AFHCs had kept records of adolescent clients under lock and key. Similarly, all the AFHCs had offered SRH services for free, or at affordable rates for adolescents. Only 60% of AFHCs were gone for feedback or grievance redressal systems (Table 1).

All the AFHCs had 100% supplies of the equipment and commodities except sanitary napkins, which were available at 40% of AFHCs (Table 2). It was observed that all the services (for example, provision of free STI/RTI treatment, free condom and contraceptives distribution, outreach and referral services, gender sensitive, IEC materials etc). were available in all the ten centers as per the national guidelines. Adolescent specific indicators are also monitored routinely (quarterly) by all the centers. Hence these are not presented as tables. However, some obstacles in service delivery were observed due to the ongoing COVID-19 pandemic.

Regarding socio-demographic characteristics of the participants more than half of the participants were females (63.1%). Most of the respondents were 15 years old (23.7%) followed by 18 years old (22.5%) and 19 years old (16.2%). The mean and median age was 17 years. 49.3% of participants were Islam and 48.7% were Hindu and remaining 1.8% belonging to the other traditional religion. Majority of the respondents were unmarried (92.5%). In addition, most of the respondents (45%) had secondary education, 42.5% had higher secondary or further education, and 12.5% had primary education but most importantly no one was illiterate. Most of the respondents (88.7%) had heard about adolescent friendly health services (Table 3).

The sexual and reproductive health related problems among boys and girls reveals that majority of the adolescent girls (44.5%) suffered from menstruation related problems. Most of them (36.6%) also suffered from white discharge. On the other side masturbation was the major SRH related issue (27.1%) among adolescent boys followed by nocturnal emission (25.4%). Most of the adolescent boys had genital itching (20.3%) followed by urinary complaints (11.8%). Similarly, 19.8% of adolescent girls suffered from genital itching and followed by urinary complaints (9.9%) (Table 4). The reasons behind not visiting adolescent friendly health clinics indicates that most of the clients (53.1%) were not aware of such types of services pursued in the community which was mostly facility based and moderately community based. 48.5% of clients responded that they didn’t feel the necessity to visit adolescent friendly health centers and 51.2% of clients felt the need to visit AFHCs.

*Multiple responses, #Menstrual problems like including Irregular menses, Heavy menses, Dysmenorrhea, Offensive odour.

However, 17.5% of clients responded that they feel shy to discuss SRH related problems. On the other side 23.7% of clients belonged from some remote areas so, they couldn’t reach the facility whenever they wanted.

*Multiple responses from the beneficiaries.

Another reason was 6.8% of clients were not motivated by the peer educators. Some other reasons were lack of adequate privacy, fear of being stigmatised in the family and the cost of some services. So, these are some factors of less utilisation of services of AFHC (Table 5). Regarding the sources of information, majority of the adolescents had heard about the services from their friends (48.7%), followed by health care staff (41.8%) and from teachers (15%) (Figure 1). It was observed in the present study that health care providers mostly had confidence and non-judgmental approach in dealing with clients although sometimes judgmental behaviour was noted. SRH related health problems which need special attention (treatment) were mostly referred to ‘Suraksha Clinic’. In Rampurhat Health District adolescent girls were getting sanitary napkins (Saathi) which costs Rs.6 per packet.

Satisfaction of the beneficiaries was measured by the scoring pattern and it was found that the majority of the beneficiaries who visit the clinic were mostly (66%) rated 5 i.e., good. No one rated 1 which is poor and 34% of beneficiaries rated in between 1 to 5 which considered as average. So, the overall experience of the clients on AFH services was satisfied (Figure 2). As IEC materials applicable to adolescent needs must be displayed in AFHCs with provision of pamphlets & posters for communication so according to the guidelines all the AFHCs have displayed a signboard indicating the location and timing of the clinic. All AFHCs were functional all days of the week except Sunday and the timing of the clinics were 9am to 4pm with the presence of Medical Officer. 60% of AFHCs were provided clinical services and 40% of AFHCs were partly provided clinical services. All the commodities like IFA/Albendazole tablets, contraceptives (condoms, OCPs, ECPs), medicines such as paracetamol, anti-spasmodic and first aid, pregnancy testing kits etc were available in the AFHCs.

DISCUSSION

In this present study it was found that all AFHCs were functional all days of the week except Sunday and the timing of the clinics were 9am to 4pm with the presence of Medical Officer. If the opening hours of health services concur with the school hours, college hours or other activities, it might be difficult for the beneficiaries to utilize the AFH services for adolescents. According to the guidelines AFHCs has “outreach activities” twice in a week which means 8 outreach sessions were carried out in a month by the counsellors. In a study in Dang District of Nepal conducted by Giri et al, the similar findings were obtained where adolescents had busy schedule in school, college or other activities so they did not get time to visit clinic and procure healthcare for them.¹⁰ In another study conducted in Ahmedabad Municipal Corporation by Dixit et al it was found that sign boards, basic amenities and a system for data collection on service utilization was present in all AFHS clinics. None of the facilities had training records and information education and communication (IEC) material.¹¹ In the present study all the AFHCs have displayed a signboard indicating the location and timing of the clinic.

This study revealed that all the ten facilities-maintained clients' privacy and confidentiality during the AFHC visit. A study conducted by Kumar et al, in two health facilities of Uttar Pradesh reported that 100% of patients claimed that doctors were friendly. Usually, confidentiality was maintained.¹² The current study showed that none of the clients were illiterate and services provided were friendly but and lack of adequate privacy and fear of being stigmatised in the family, the cost of some services are some factors for less utilisation of services of AFHC. A study in Dang district of Nepal concluded that nearly half (48.7%) of adolescents had utilized adolescent friendly health services. Different socio-demographic factors like age of the participants, current educational status, mother’s education, ethnicity was significantly associated with utilization of adolescent friendly health services. Other factors like awareness about the services, convenient opening days and hours of health facilities and shyness to utilize the services were significantly associated with the utilization of the services.¹⁰ Number of girls visiting AFHCs were more compared to the boys who felt shy to attend the clinic. Another study in Dhading district of Nepal by Pandey et al, reported of 43 female and 47 male participants. The findings are reflecting barriers to accessing SRH services.¹³ To improve menstrual health hygiene in India, Ministry of health and Family Welfare of India supplied subsidized sanitary napkin through the centers. In Rampurhat Health District adolescent girls were getting sanitary napkins (Saathi) which costs Rs.6 per packet. In a study in Puducherry district states that sanitary napkin is given for free to all adolescent girls who attend the AFHC. Provision of Sanitary Napkins for free was the centre of attraction for adolescent girls to attend the clinic.¹⁴ So similar approaches could increase the foot falls in AFHCs. A study in Coimbatore District conducted by Ramasubramaniam et al showed that addressing the menstrual history among 93.67% adolescent girls was a major issue.¹⁵ In the present study it was found that most of them have not visited the AFHCs to access the services relating to sexual and reproductive health. Since majority of the participants are not aware of the services that are available for them in health facilities. In a study in Patna, Bihar conducted by Nivedita Sinha et al, in 2019 indicated that 24.06% are aware about reproductive and sexual health (RSH), and 64.74% about ARSH. Females had significantly more knowledge regarding RSH.¹⁶ In another study in Sindhupalchowk District of Nepal it was found that 47% of adolescents had inadequate knowledge on SRH service and 19% of the adolescents had ever felt the need to access SRH services.¹⁷ Most of the clients of the current study mentioned the reasons behind not seeking services at AFHCs like not accessible, not necessary, not aware of the services, far away etc. and some clients usually visit AFHCs on regular basis even though it is not easily accessible. Similar findings observed in a study conducted by Singhe in Kannada District where majority of the respondents were unaware of the AFH Services.¹⁸ A study in Puducherry also described a huge gap between the awareness and utilization of AFHC services. The reasons for non-utilization were poor awareness and misconceptions about the clinic.¹⁴ Another study by Santhya et al shows similar result where awareness generation was poor.¹⁹ So, lack of awareness is a major drawback to utilize AFH services. In the current study, it was found that the majority of the adolescents (66%) were satisfied with the services. Similarly, Kumar et al found that clients of the AFHC reported overall satisfaction rates of 78.0%, compared to 73.0% for all other respondents, and that 65.0% of AFHC clients were encouraged to recommend these services to a friend.¹² Mehra et al also described in their study that 81.7% clients in Varanasi and 95% clients in Bangalore were satisfied with the services they received from the facility.²⁰

Limitations

This study may shed light on how adolescents in West Bengal's Rampurhat Health District approach their sexual and reproductive health as well as AFH services.

Although unintentional, some forms of selection bias and social desirability bias could not be ruled out. The ongoing COVID-19 pandemic, as well as the resulting changes in service delivery, lockdown, or movement restrictions, have resulted in some form of time limitation as well as accessibility issues.

CONCLUSION

The current study explored that all the AFHCs were functioning maintaining necessary guidelines laid down by the Govt. But utilization of AFHCs services by the beneficiaries is quite inappropriate. Lack of awareness is one of the main reasons for less utilizing of available SRH related services. Thus, promoting and extending awareness about AFHC services is the corner stone of success of adolescent sexual & reproductive health program. Additionally, prevention of adolescent well-being problems demands a multi-sartorial approach where it includes the effective or productive participation of many partners like the adolescents, schools, the parents or household members, the society, the government and most importantly, the duty of health care providers in providing health management services to the beneficiaries. The study also indicates a need for age-appropriate information and adolescent friendly services.

Recommendations

Raising awareness about AFHS service among health care providers will improve the quality of services and thereby increase the utilisation of services. Regular training and refresher courses are necessary for health care workers. It is also necessary to assess female adolescents' knowledge and practises in order to change their menstrual hygiene behaviour and thereby improving their sexual and reproductive health. The active participation of adolescents and adult community members in the planning and delivery of AFHS is needed in order to make the services more responsive to community needs and user friendly. Provision of necessary equipment and commodities, as well as regular monitoring and supervision, were required to ensure the smooth operation of the AFHCs. Frequent high-quality communication skills refresher training to improve ASHA and ANM knowledge of adolescent health care is needed so that they can encourage the adolescents about the nondisclosure and confidentiality policy. Increase awareness among beneficiaries is also needed for proper utilisation of services which is necessary for achieving future objectives and goals (SDH) related to adolescent health.

ACKNOWLEDGEMENTS

Authors would like to thank Dr. Kajari Bandyopadhyay, Dr. Asit Kumar Biswas, Dr. Gautam Joardar, Dr. Samir Dasgupta, Professor Dr. Kunal Kanti Majumder, Dr. Rabindranath Pradhan, all the district officials, health department employees, and staff members of all those departments of the Rampurhat Health District who offered their support and cooperation throughout the research project.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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