IIHMR Working Paper No.

6









Reproductive Health of
Adolescents in Rajasthan:
A SituationaI Analysis






R. S. Goyal
Anoop Khanna



















Indian Institute of Health
Management Research, Jaipur (India)
2005

I. Background

Adolescence is a crucial period in the life of an individual. Between 10 and 19 years of age
many key biological, social, economic, demographic and cultural events occur that set the stage
for adult life. What happens during adolescence determines how boys and girls will live as men
and women not only in the sphere of reproduction, but in the social and economic realm as well.
This makes it imperative to understand adolescents needs, which, surprisingly, have so far been
given little importance in policy and programmes in several countries.

Policy interest in adolescents began to grow only when ICPD (International Conference on
Population and Development) held in Cairo in 1994 called for specific efforts by governments
and civic society to understand and meet their particular reproductive and sexual health needs. It
also observed that the number of adolescents in all the regions of the world is increasing rapidly
although their proportion in total population is declining due to the declining fertility levels.
Against the backdrop of a relatively early maturation of adolescents due to greater exposure to
information, growing complexities of modern life style, tendency to live freely, etc., the
dimensions of the problem have grown in scale, and need urgent attention of all concerned. The
concern for reproductive and sexual health of adolescents has particularly grown because of real
and perceived increase in their sexual activities and associated vulnerability to HIV infection.

Several factors contribute to the adolescents' growth. These factors range from the social,
economic, cultural, geographical and political conditions of wider society to those characterising
the conditions of adolescents including family, education, income, etc. Improving access to
appropriate health services is only a partial solution to their reproductive and sexual health
concerns. Programmes should also focus on assisting adolescents in acquiring education,
building skills, and personality development at Home, school, workplace or community settings.
A logical first step in creating these programmes is the assessment of their needs in the realm of
socio-economic and demographic characteristics, and cultural environmental conditions of
living.


















India has nearly 200 million boys and girls in the adolescent age group of 10-19 years (NFHS-II:
1998-99). They comprise over one-fifth of the total population of the country. From the limited
data available on adolescents, it is apparent that these situations vary widely, by region and
gender (Jejeebhoy: 1996). To plan intervention programmes, these differences need to be taken
into consideration.

This situational analysis presents a review of the available evidence concerning the current
scenario of sexual and reproductive health of adolescents. It also examines policy and
programme response to issues concerning adolescents, and initiates a debate on how best to
design programmes and interventions to address the needs of adolescents in Rajasthan.

II. Socio-demographic Profile of Rajasthan

Rajasthan has a land area of 3.4 lakh sq kilometres and a population of 56 million (Census 2001).
The economy of the state is characterised by a slow growth rate, a wide gap between state and
national per capita income, inadequate infrastructure and low productivity in many sectors. A
large proportion of the population suffers from deprivation in matters of health, safe water
supply and housing. Thirty-one percent of the rural and 11 percent of the urban families live
below the poverty line. Nearly 84000 families in rural areas and 32000 in urban areas have no
house to live in. Also, 62.7 percent of the villages are not connected by pacca roads.

Rajasthan is characterised by sharp differences in terms of geographical terrains, dispersed
pattern of settlements and social identity. Health is strongly influenced by social variables, in a
context of patriarchy where expectant mothers and girl children are neglected, and where women
are more vulnerable to diseases that afflict the population in general. The health status of the
people in the state could be judged from the fact that out of 90 problem districts identified in the
country where the birth rate and the infant mortality rate are significantly high, nearly one-fourth
are in Rajasthan.


















III. Situation of Adolescents

III.1 Size of Adolescent Population

There are nearly 13 million adolescents in Rajasthan, which constitutes around 22.5 percent of
the total population of the state. The sex-ratio of this age group is 927 females per thousand
males that is slightly higher than that of the total population of the state (922).

Table 1: Percent distribution of population in adolescent groups
according to sex and residence

Age Urban Rural Total
Male Female Total Male Female Total Male Female Total
NFHS-I
10-14 12.9 13.5 13.2 14.2 12.6 13.5 14.0 12.7 13.4
15-19 11.0 10.3 10.7 10.5 10.0 10.3 10.6 10.1 10.4
NFHS-II
10-14 13.1 11.6 12.4 12.6 11.6 12.1 12.7 11.6 12.2
15-19 11.0 11.7 11.3 10.2 9.7 9.9 10.4 10.2 10.3
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan, International
Institute of Population Sciences, Mumbai.


The proportion of adolescent population is declining. A comparison between the data of NFHS- I
and NFHS- II indicates that the proportion of adolescent population (10-19 years) has gone down
from 23.8 percent in 1992-93 to 22.5 percent in 1998-99. This decline could be attributed to the
fertility decline that has taken place since mid 1980s. According to Sample Registration System
(SRS), the birth rate of the state was 38.3 per 1000 population in 1981. It came down to 36 in
1991 and reached a level of 32.1 in 1998.
















Importantly, the proportion of population in the age group of 15-19 has shown a negligible
decline (10.4 percent in 1992-93 to 10.3 percent in 1998-99). In comparison, population in the
age group of 10-14 shows a decline from 13.4 percent in 1992-93 to 12.2 percent in 1998-99. A
differential decline in the proportion of adolescents in two age groups reflects the phase at which
fertility is declining.

III.2 Education

Education is one of the most important variables contributing to the development of adolescents.
In India, not all adolescents are able to seek education. In 10-19 years group, 2 out of 3 boys and
2 out of 5 girls are literate (Mamta 2001). The situation could be worse in the states like
Rajasthan, where physical, social and community roadblocks to education are known to be
comparatively stronger.

The data from NFHS-II shows that nearly 86 percent of males and 51 percent of females in the
age group of 15-19 are literate, giving an overall literacy rate of 69 percent. The level of
education among adolescents (15-19) has, however, improved since NFHS I.

Table 2: Education level of adolescents aged 15-19

Education Level Urban Rural Total
Male Female Total Male Female Total Male Female Total
NFHS-I
Illiterate 9.0 27.9 17.5 27.9 73.7 49.0 24.2 64.8 42.8
Literate &
upto middle
23.4 18.8 21.3 30.2 15.6 23.4 28.8 16.1 23.0
Middle & above 67.6 53.2 61.2 41.7 10.7 27.4 48.0 19.0 34.2
NFHS-II
Illiterate 10.5 24.6 17.5 15.5 59.0 36.1 14.2 49.3 31.0
Literate &
upto middle
27.3 21.8 24.1 36.5 23.2 30.3 33.9 22.8 28.6
Middle & above 63.2 53.6 58.4 48.0 17.6 33.7 52.0 27.9 40.4
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan, International
Institute of Population Sciences, Mumbai.




Table 3 shows that the proportion of illiterate girls has gone down from 65 percent in 1992-93 to
49 percent in 1998-99. It is encouraging that a greater improvement in education level is noted in
rural areas and among girls. The table also indicates that the proportion of rural girls qualifying
middle and higher standards was larger.

These observations are further supplemented by a recent study conducted by UNICEF (1999) in
Rajasthan. It reveals that among younger adolescents (10-12 years), 12 percent were illiterate, 66
percent were literate, 16 percent had education upto primary level and 6 percent had education
up to middle and above.

One of the important contributing factors to the growth of education in Rajasthan is the
expansion of schooling facilities. At present, there are more than ten million students receiving
education in 55,360 schools.

Table 3: Educational institutions and students (1998-99)
No. of Schools No. of Students
Boys Girls
Pre-primary and Primary 33716 2534311 1658495
Upper Primary 15944 2300533 1271521
Secondary and Sr. Secondary 5655 1642866 737411
Total 55360 6477710 3667427
Source: Statistical Abstract, Rajasthan, 1999.

.

Regarding the level of schooling, the data from NFHS II shows that in Rajasthan nearly 70
percent children in the age-group of 11-14 years and 46 percent children in the age-group of 15-
17 years attended schools in 1998-99. Schooling of girls, particularly in rural areas, was very
poor. For example, in the age group of 15-17 years, only 19 percent girls in rural areas attended
schools. The corresponding figure for girls in urban areas was 54 percent.




Table 4: Percentage of children (11-14 and 15-17) attending school

Age Urban Rural Total

Male Female Total Male Female Total Male Female Total
NFHS-I
11-14 87.0 75.2 71.2 71.2 28.6 37.7 79.1 54.7 59.3
NFHS-II
11-14 88.9 82.8 84.3 75.5 44.9 52.7 82.8 65.2 69.7
15-17 66.8 60.6 62.2 54.1 19.4 28.6 66.5 40.8 45.9
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan, International
Institute of Population Sciences, Mumbai.


The schooling of children of 11-14 years of age shows improvement between 1992- 93 and
1998-99. The overall attendance rate went up by 10 points, increasing from 59.3 percent in 1992-
93 to 69.7 percent in 1998-99. The change was more prominent in case of rural girls, where it
went up from 29 percent to 45 percent.

Gender discrimination could be one of the major hindrances in the schooling of girls. In the
study conducted by UNICEF (1999), nearly 34 percent girls said that their parents discriminated
between boys and girls in giving education and did not allow girls to go to school. In this study,
of the girls who did not attend schools, 67 percent said that the main reason for their not
attending school was disapproval of parents/elders.

III.3 Exposure to Mass Media

In the studies conducted on adolescents, it has been found that most adolescents tend to be
largely unaware of their reproductive system. A study conducted in 21 districts of the state
revealed that only 23 percent of the girls were aware of the issues related to health, nutrition and
family life (UNICEF, 1999). This study also indicates that one of the reasons for lack of
awareness was poor exposure to mass media or other means of information. The data from
NFHS-I has further supported this observation. It has revealed that 70 percent of teenage married
women did not have regular access to any media. However, the situation showed some
improvement in 1998-99. A little less than half of the women had access to radio or television at
least once a week. The access to television particularly shows improvement between 1992-93
and 1998-99 (Table 15).











Table 5: Percent of married adolescents aged 15-19 by exposure to mass media
Item NFHS - I NFHS - II
Watch television at least once a week 14.4 30.0
Listen to radio at least once a week 26.9 19.2
Visit cinema/theatre at least once a week 5.0 4.0
Not regularly exposed to any media 70.2 62.1
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan,
International Institute of Population Sciences, Mumbai.


The study conducted by UNICEF revealed that the exposure of adolescents to the means of
information and communication is as follows:

Radio: Never listen (29 percent); regularly listen (41 percent)
Television: Never watch (40 percent); regularly watch (21 percent)
Newspaper: Never read (76 percent); regular read (8 percent)
Magazines : Never read (66 percent)
Films: Never watch (69 percent)

Due to poor exposure or access to the effective means of mass communication, especially
television and newspapers, adolescents are most likely to depend on the information obtained
from peer groups. In the cultural context of India, adolescents are not in a position to discuss
sexual and reproductive health issues with parents or other elders. In most cases, peers constitute
the reference group for seeking information about sexuality and reproductive matters. But the
information obtained from peer groups or other such sources may not necessarily be correct, and
can create confusion and misconceptions.

It has been held that to get information on sex and related issues, many times adolescents refer to
sex magazines, pornographic photo albums, adult movies and such other means. The data
obtained in IIHMR (lCMR) studies reveal that a sizeable proportion of adolescents use such
means for obtaining information on sex. Interestingly, the proportion of such adolescents is
significantly high in rural areas.













Table 6 : Adolescents' exposure to sex related literature and films

Media Rural Urban Total
Sex magazines 32.0 25.9 28.3
Pornographic photo albums 25.3 19.3 21.3
Adult Movies 24.9 16.5 19.5
None of the above 42.9 60.9 51.2
Source: Gupta S.D, et al. Report on Study of Reproductive Health and Sexual Behaviour among Adolescents; Institute of
Health Management Research (IIHMR), Jaipur


III.4 Age at Menarche

According to the study conducted by IIHMR in 1998, the average age at menarche among
adolescent girls in Rajasthan was 13.9 years. The results obtained from NFHS-I (1992-93) show
substantial variations in the mean age at menarche in various states, ranging from 12.7 years in
Assam to 14.8 years in Himachal Pradesh. In this survey, the mean age at menarche for
Rajasthan was 14.3 years.

The time-series analysis of NFHS data on mean age at menarche reveals a uniform declining
trend in all the states of India. In case of Rajasthan, the data indicates that the mean age at
menarche for the women below 20 years of age was 14.0, whereas it was 14.3 for the women of
20 years of age and above. Studies have indicated that age at menarche is often inversely
correlated with socio-economic status, showing significant differences between urban and rural
populations and between high and low income groups (Marshall & Tanner, 1986).



















Table 7: Mean age at menarche and marriage

States Mean age at menarche
Women
<20 years
All women
(15-49)
Mean age
at
Marriage
Waiting time
between menarche
and marriage
Andhra Pradesh 13.0 13.1 14.5 1.4
Assam 12.6 12.7 16.8 4.1
Bihar 13.1 13.2 14.1 0.9
Gujarat 13.9 14.3 17.0 2.7
Haryana 13.9 14.2 15.9 1.7
Himachal Pradesh 14.6 14.8 17.7 2.9
Karnataka 13.1 13.5 16.0 2.5
Kerala 13.9 14.3 19.2 4.9
Madhya Pradesh 13.5 13.7 14.2 0.5
Maharashtra 13.3 13.5 15.6 2.1
Orissa 13.0 13.2 16.3 3.1
Punjab 14.0 14.2 18.6 4.4
Rajasthan 14.0 14.3 14.2 -0.1
Tamil Nadu 13.7 14.1 17.6 3.5
Uttar Pradesh 13.8 14.0 14.7 0.7
West Bangal 13.2 13.4 15.5 2.1
India 13.5 13.7 16.0 2.3
Source: Padamdas S. Sabu, Age at Menarche among Indian women: Observations from NFHS, 1992-93;
The Journal of Family Welfare, Vol.45, No.2, Oct. 1999.


This may be true for Indian adolescents also. However, the declining age at menarche is likely to
contribute to increased reproductive health risks for young women, either in the context of early
marriage and child bearing or in the context of high risk sex behaviours.

Table 6 also presents data on mean age at menarche and marriage, and the subsequent waiting
time between menarche and marriage in various states. A girl in Kerala waits for marriage for
almost five years after attaining menarche, whereas a Rajasthani girl gets married before she
attains menarche. Rajasthan is the only state in India where the age at marriage is lower than the
age at menarche.














III.5 Age at Marriage

Despite the Child Marriage Restraint Act, girls continue to be married at an early age in
Rajasthan. These potential mothers and homemakers are destined to face the constraints of lack
of physical development for maternity, nutritional inadequacy and poor health care, leading to
high maternal morbidity and mortality. Child marriages take place particularly in the following
communities: lohar, kumbar, rawat, berwa, regar, balai, khatik, jat, gujar, bishnoi, etc.

According to the RCH-RHS survey, more than 61 percent of the girls in Rajasthan got married
before 18 years of age. The results obtained from NFHS II reveal that more than one-third of
girls in 15-19 age group were currently married. Against this, only 11 percent of boys (15-19
years) were reported to be married. The study conducted by UNICEF (1999) revealed that of the
total adolescent girls covered under the study, 31 percent were married.

Table 8 : Percentage of population aged 15-19 currently married

Urban Rural Total
Male Female Male Female Male Female
NFHS-I 3.9 23.9 12.6 43.4 10.9 39.6
NFHS-II 6.1 22.6 12.6 43.1 10.9 37.3
Source: National Family Health Survey (NFHS-I and 11) 1992-93 and 1998-99, Rajasthan,
International Institute of Population Sciences, Mumbai.


According to NFHS, the proportion of married girls went down slightly between 1992-93 and
1998-99. The data also shows that the changes were more prominent in urban areas than in rural
areas. Though Table 7 also indicates that the proportion of married boys in urban areas increased
substantially from 3.9 in 1992-93 to 6.1 in 1998-99, it could be an empirical paradox also.






Table 9 : Singulate mean age at marriage

Urban Rural Total
Male Female Male Female Male Female
NFHS-I 24.9 20.5 22.2 17.9 22.7 18.4
NFHS-II 24.1 19.9 21.6 17.8 22.3 18.3
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan,
International Institute of Population Sciences, Mumbai.


The singulate mean age at marriage also indicates the tendency of early marriage of girls in
Rajasthan. On an average, a girl in rural areas gets married before she attains 18 years of age.
The comparison between NFHS-I and NFHS-II data indicates that the mean age at marriage had
a slight decline over the years.

III.6 Fertility Level

During the past few years the issue of adolescent pregnancy and childbearing has received the
attention of policy makers. It has been increasingly perceived as a serious health and social
problem. Globally, nearly 15 million adolescent women bear children every year. It results in
high wastage of human resources due to maternal mortality and infant and child mortality. The
most relevant cause behind these problems is ignorance about appropriate maternal health care,
non-availability of quality of health care, inadequate preparation of adolescent girls for
maternity, and various undesirable practices prevalent in society. In Rajasthan, a sizeable
proportion of girls attain motherhood at an early age.

Teenage fertility in Rajasthan is higher than the national level (Table 9). As per NFHS-II, nearly
16.7 percent of the total fertility in Rajasthan could be attributed to teenage women in 15-19 age
group.


















Table 10 : Age specific fertility rates (ASFR) for women aged 15-19 (per 1000)

Rajasthan India
Urban Rural Total Urban Rural Total
1991 (SRS) 65 91 86 46 84 78
1997 (SRS) 35 66 61 32 61 54
NFHS-I 63 124 112 75 131 116
NFHS-II 92 139 126 68 121 107
Source: Sample Registration Bulleting, 1985 and 1991, Registrar General, Government of
India, New Delhi,
National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan,
International Institute of Population Sciences, Mumbai.


A comparison between the pattern of fertility obtained from NFHS and SRS shows some
discrepancy. According to 1991 SRS, the ASFR for teenage women (15-19 years) was 86, but as
per NFHS conducted in 1992-93, it was 112. These differences could partly be due to age
misreporting, which tends to result in the displacement of births further into the past.
Retrospective surveys such as NFHS are subject to such displacement, whereas the SRS, in
which births are recorded during the year in which they occur, is not (as stated in the report of
NFHS-II, Rajasthan).

Further, the NFHS (I & II) indicate that teenage fertility in Rajasthan increased from 112 in
1992-93 to 126 in 1998-99, whereas the SRS figures indicate that teenage fertility declined
between 1991 and 1997. Since the age at marriage shows an increase and the mean number of
children to the teenage mother also went down (Table-10), it could be held that teenage fertility
could have gone down during this period.

More than 38 percent of the currently married teenage women in Rajasthan have become
mothers. Further, eight percent of them have two or more living children. The mean number of
children to the currently married teenage women in Rajasthan is .47 per women, which is lower
than the national average (.63). The data also shows that the proportion of teenage women
becoming mothers as well as the mean number of children they have marginally declined
between 1992-93 and 1998-99. It supports the observation made earlier about the declining
adolescent fertility.











Table 11 : Percent distribution of currently married women (15-19) by mean parity status


Number of children ever born
0 1 2 3+
Mean no. of
children ever born
NFHS-I 63.7 27.2 7.7 1.5 0.48
NFHS-II 61.9 30.2 6.9 1.1 0.47
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan,
International Institute of Population Sciences, Mumbai.


III.7 Nutrition Level

The rapid physical growth that occurs during adolescence requires supplementary nutrition.
More than twenty percent of the total growth in structure and up to fifty percent of adult bone
mass are achieved during this period (WHO 1998). To compensate for the physiological blood
loss during menstruation, adolescent girls have up to fifteen percent additional requirements of
iron. However, the data available from various studies indicates that anaemia is one of the
widely prevalent health problems among adolescent girls. Indian Council for Medical Research
(ICMR) Task Force (1992) and UNICEF (1999) studies have reported low mean haemoglobin
levels among adolescent girls and pregnant women, and have attributed this to low nutritional
intake of proteins, calories and macro/micro- nutrients. In another study conducted in rural areas
of Rajasthan, only 6.5 percent girls were found to have a body mass index (BMI) of more than
18.5 (Chaturvedi et al., 1996). The NFHS-II revealed that nearly 53 percent of the teenaged
currently married women in the state suffered from some degree of anaemia. It also noted that
the prevalence of anaemia was higher among adolescent women than the women of higher age
groups (Table 11).

Table 12 : Percent of women having anaemia

Type of Anaemia Adolescents (15-19 yrs) All women
Percent with any type of anaemia 53.9 48.5
Percent with mild anaemia 35.5 32.3
Percent with moderate anaemia 16.0 14.1
Percent with severe anaemia 2.4 2.1
Source: National Family Health Survey (NFHS-II) 1998-99, Rajasthan, International Institute of Population
Sciences, Mumbai.











These results could be corroborated with the findings of an evaluation of the nutrition
supplements provided to adolescent girls under ICDS programme in Rajasthan, which revealed
that only 3 percent of the girls got IFA (iron folic acid) tablets, and only 4 percent of the girls
took nutritional supplements either in the form of vitamin tablets, syrups, food supplements, etc.
(Kumar, 2000).

III.8 Maternal Care of Adolescent Mothers

Due to lack of knowledge and physiological and social immaturity for childbearing, the health
risks are likely to be more pronounced among adolescents than among older women. Women
attaining motherhood at an early age, therefore, need extra care.

The data from NFHS-II shows that more than half of the teenage mothers did not receive any
antenatal check-ups during pregnancy. Nearly 70 percent of them did not receive iron and folic
supplementation. It was also reported that nearly 53 percent of the currently married teenage
women suffered from some degree of anaemia.

Table 13 : Percentage of mothers below 20 years and all women by status of ANC services

NFHS-I NFHS-II
Adolescents All women Adolescents All women
Percentage of women not receiving any
ANC check-ups during pregnancy
67.8 67.2 52.3 52.5
Percentage of women not receiving any
tetanus toxoid injection
67.3 65.5 37.6 38.1
Percentage of women not receiving any
IFA tablets/syrup
71.8 70.8 59.6 60.7
Percentage of women having their last
delivery at home
89.7 87.4 75.8 77.8
Percentage of deliveries attended to by
untrained persons (including dais)
75.2 76.8 59.3 34.6
Source: National Family Health Survey (NFHS-I and II) 1992-93 and 1998-99, Rajasthan, International
Institute of Population Sciences, Mumbai.








Table 12 also shows that, in spite of having higher obstetric risks in early motherhood, more than
three-fourths of the deliveries of adolescent women are conducted at home and 59 percent of
deliveries are attended to by untrained persons.

A comparative analysis of maternal health indicators obtained in two rounds of NFHS indicates
that there is some improvement during the period in all the indicators. However, the levels are
still very low.

III.9 Awareness for STDs/STIs

Spread of STDs is alarmingly high in India. Some public health reports identify an STD as one
of the three most prevalent communicable diseases in India after malaria and tuberculosis. The
available data indicates that approximately 14 million infections of reproductive tract and
sexually transmitted diseases occur every year. Among them, the number of adolescents is quite
substantial. A review of literature on STDs in India by Ramasubban (1995) suggests that as
many as 25 percent of patients attending government STD clinics in India are below 18 years.
The study also found that a vast majority of the males attending these clinics reported their first
sexual experience before the age of 18 years.

Among adolescents, the level of awareness of sexually transmitted diseases (including HIV) is
also high. The study conducted by IIHMR (ICMR) revealed that a majority (84.7%) of the
adolescents were aware of certain infectious diseases that can spread through sexual intercourse.
More than 75 percent were aware of AIDS (though the respondents were school and college
going adolescents only). Some of the adolescents had misconceptions about the mode of
transmission of AIDS (can spread through: eating unhygienic food - 14%, mosquitoe bite - 14%,
living in a house with an infected person - 21%, wearing used clothes - 22%, kissing - 18%,
sharing utensils with AIDS patients - 19%, etc.). Another study conducted in 21 districts of
Rajasthan revealed that nearly half of the adolescent girls were aware of AIDS. The level of
awareness was significantly higher among literate girls than illiterate girls (Kumar et al., 2000).
However, only 14.9 percent of adolescents were aware that the use of condom could prevent
AIDS.
















III.10 Parents' and Teachers' Perspective on Adolescents' Reproductive and Sexual Health
Information Needs

Parents and teachers both have an equally important role in the socio-cultural and personality
development of adolescents. However, in addressing reproductive and sexual health information
needs and problems, the role of both of them is much below the expected level. Communication
between parents and adolescents on these issues is very low. Several factors can be attributed to
this. Lack of appreciation of reproductive and sexual health problems of adolescents, social
values and norms, parents' lack of understanding or ability to communicate on these issues are
some of them. However, in some recently conducted studies, parents have desired that
adolescents be given education on these issues. For example, the IIHMR (ICMR) study indicates
that a large proportion of parents were in favour of providing information to adolescents on
nutrition, personal hygiene, bodily changes, etc. But a very small proportion of parents were in
favour of giving information on abortion (35.7 percent), masturbation (36.7) and teenage
pregnancy (38.8 percent). Giving information to adolescents on STIs and preventive measures
for STIs was favoured by 52 percent parents, and on contraception by 65 percent parents.

The study also tried to examine the teachers' perspective on these issues. It was found that the
teachers were concerned about the rising incidence of premarital sex among adolescents. The
teachers were unanimous in their views that information on some important reproductive health
issues should be provided to adolescents. However, they had reservations on some sensitive
issues, like masturbation (46.8 percent), teenage pregnancy (53.2 percent), abortion (46 percent)
and contraception (61.3 percent). A similar opinion and attitude of teachers was observed in
some other studies also. A study conducted in Madras revealed that 71 percent of the teachers
felt that sex education would negatively influence their morality (Shirur, 2000). In Rajasthan, it
is interesting to note that only 59.3 percent of the teachers said that education on sexual and
reproductive health issues should be provided though teachers. Nearly one-third of them
suggested that such education should be imparted through external experts or doctors.




IV. Implications of Teenage Motherhood

IV.1 Outcome of Pregnancy

Physiological and social immaturity, lack of knowledge about prenatal care, and lack of access to
services affect the outcome of pregnancy to a great extent. The studies have shown that
adolescents are more likely to experience adverse pregnancy outcomes than older women
(Jejeebhoy, 1998). For instance, ten percent of all adolescent pregnancies in India end in
miscarriage or still birth compared to seven percent in older women (IIPS, 1995). The data
obtained from RCH-RHS reveals that, in Rajasthan, the proportion of still births and abortions
(induced and spontaneous) is higher among pregnancies to adolescent women than to women in
higher age-groups (Table 13).

Table 14 : Outcome of pregnancy of adolescents and women in all ages

Pregnancy Outcome Adolescents (15-19 yrs) All Ages
Live birth 87.6 94.3
Still birth 2.6 1.0
Spontaneous abortion 8.2 4.0
Induced abortion 1.4 0.7
Source: Rapid Household Survey under Reproductive and Child Health Programme, Phase II, 1998,
Institute of Health Management Research, Jaipur; 1999.

Table 14 shows that the proportion of spontaneous and induced abortions to total pregnancies is
almost double among adolescent women than among women in all ages.

IV.2 Infant and Child Mortality

Children born to adolescent women are at a greater disadvantage than children born to older
women. Morbidity and mortality levels are higher among children born to teenage women.
Infants born to young mothers are more likely to be of low birth weight and suffer from its
sequelae, including neurological problems and mental retardation (Zabin and Kiragu, 1998).














Table 15 : Infant and child mortality among children born to
adolescents and women in all ages

Mothers age at birth
Adolescents (<20 yrs.) All Ages
Neonatal mortality 65.1 54.1
Post-neonatal mortality 44.1 34.0
Infant mortality 109.2 88.1
Child mortality 39.9 40.3
Under-five mortality 144.7 124.9
Source: National Family Health Survey (NFHS-II), 1998-99, Rajasthan, International Institute of Population
Sciences, Mumbai.


The data obtained from NFHS-II (1998-99) reveals that, in Rajasthan, infant mortality both in
neonatal and post-neonatal periods is higher among infants born to teenage mothers. Under-five
mortality is also higher among such children.

V. Reproductive and Sexual Health of Adolescents

V.1 Reproductive Health Problems

Due to early marriage and associated maternity, teenage women are exposed to greater risk of
reproductive health problems. Table 17 shows that more than one-third of the women in 15-19
age group had some reproductive health problem. Nearly 16 percent of these women reported
either pain during intercourse or bleeding after intercourse.

Table 16: Symptoms of reproductive health problems among currently married women

Adolescents Women in all
Ages
Percent of currently married women reporting painful
intercourse
12.6 11.1
Percent of currently married women reporting bleeding
after intercourse
3.0 1.8
Percent of currently married women reporting any
reproductive health problem
34.7 43.2
Source: National Family Health Survey (NFHS-II), 1998-99, Rajasthan, International Institute of Population
Sciences, Mumbai.

Note: Not available in NFHS-I







The comparison between the data on reproductive health problems among adolescents and all
women indicates that painful intercourse and bleeding after intercourse have been reported more
among adolescents, whereas other reproductive health problems are more among women of
higher age groups. In the latter case, it could be associated with a longer period of exposure to
reproductive health hazards.

V.2 Menstruation

The onset of menstruation is an important physiological change occurring in adolescent girls. It
has been held that due to lack of information on this natural phenomenon, many girls get
frightened by the menstrual flow, and are unable to manage it in a safe manner.

In the study conducted by IIHMR (ICMR) it was found that 65.8 percent girls had information
about the onset of menses before it started (this study included only school and college-going
girls, who are likely to have better access to information either from peers in school/college or
from mothers). The study conducted by UNICEF (1999) also found that only 38 percent of the
girls were unaware of menstruation at the time of their first period.

In the Indian cultural context, girls have very limited options to seek information about sexual
and reproductive health issues. Consequently, they discuss these issues either with their mothers
or peers. In the context of Rajasthan, the IIHMR study found that 25 percent of the girls had
learned about menstruation from their mothers and 37 percent from friends.

The IIHMR study also noted many restrictive practices being followed by women during
menstrual period. Restrictions on doing domestic work like cooking, going to temple and
performing pooja, etc. are still being followed strictly in almost all parts of the state.

It is reported that adolescent girls suffer from various reproductive health problems associated
with menstrual irregularity. According to the IIHMR (ICMR) study, a majority of girls (94%)
had menses related problems. Nearly three fourths (75%) had stomach-ache, tiredness and
lethargy. Pain in legs (61%) and body ache (66%) were also reported as common problems. Of
those who had a problem, 60.0 percent had discussed it with their mothers, and 26.6 percent with
friends. But for curative interventions, only 33.3 percent consulted health providers.













V.3 Night Emission

Though night emission is a natural physiological process, due to lack of proper knowledge
several adolescent boys get quite embarrassed or frightened with this. Data from the IIHMR
study shows that, in Rajasthan, only 46 percent of adolescent boys perceived it as a natural
process. It is also evident from Table 18 that boys have several misconceptions regarding night
emission.

Table 17: Perception about seminal discharge

Perceptions Percent reporting
Sign of adulthood 43.3
Natural process 46.0
Hormonal effect 63.3
Due to exertion 15.4
Sign of vigour 23.5
Sign of good health 25.1
Due to excessive heat in body 37.1
Contains sperms which cause pregnancy 44.4
Note: Due to multiple responses, the total does not add to 100. Source: Gupta S.D, et al. Report on
Study of Reproductive Health and Sexual Behaviour among Adolescents; Institute of Health
Management Research (IIHMR), Jaipur:


V.4 Masturbation

Masturbation is a common practice among adolescents. According to a study conducted by
IIHMR (ICMR), more than half of the adolescent boys in Rajasthan reported practising
masturbation, and most of them (54 percent) found it pleasurable. But it is also true that no other
act of sex has been associated with as many myths and misconceptions as masturbation. Table 18
reveals that only 21 percent of boys believe that this act is harmless and natural.


Table 18 : Feelings of boys regarding masturbation

Reported Feeling Percent reporting
Regrettable 43.3
Messy 46.0
Pleasurable 63.3
Harmless 15.4
Unsafe 23.5
Source: Gupta S.D, et al. Report on Study of Reproductive Health and Sexual Behaviour among
Adolescents; Institute of Health Management Research (IIHMR), Jaipur.


V.5 Sexual Relationship

Because of exposure to modern or western values and life styles, adolescents generally have a
greater fondness to experiment with them or adopt them. It invariably results in conflict between
traditional and modern values. In this context, adolescents often find themselves faced with
conflicting definitions of their rights and responsibilities and their sex roles and gender
expectations. For example, though social customs strongly discourage sexual relations before
marriage, available evidences from studies suggest that premarital sex is no longer uncommon,
even in traditional and conservative state like Rajasthan. The study conducted by IIHMR
(ICMR) revealed that more than 15 percent of the adolescents had had sexual intercourse. The
proportion of adolescents having experienced body touching and kissing the opposite sex was 36
percent and 30 percent respectively. Reporting of sexual experiences was found to be
significantly higher among male than female adolescents. Moreover, more premarital sexual
experiences were reported from rural areas than urban areas.




Table 19 : Sexual experiences reported by adolescents

Rural Urban
Male Female Male Female
Total
Body touching 23.7 58.5 13.6 52.4 36.3
Genital organ touching 8.1 34.7 3.4 31.7 19.2
Kissing 14.7 53.3 11.2 41.0 30.1
Masturbation 0.9 21.7 2.3 24.4 13.1
Sexual intercourse 0.9 28.8 2.9 17.8 15.1
Source: Gupta S.D, et al. Report on Study of Reproductive Health and Sexual Behaviour among
Adolescents; Institute of Health Management Research (lIHMR), Jaipur.


An important consequence of a rising age at marriage in association with a decline in age at
menarche is that the gap between menarche and marriage is increasing. This is likely to result in
a large increase in the number of sexually mature but unmarried adolescents. It could result in a
higher number of adolescents becoming sexually active prior to their marriage.

VI. Conceptual Framework, Policy and Programme Response

VI.I Conceptual Framework

Adolescence represents a crossroads in the process of development. Failure to meet the needs of
youths can lead to self-destructive behaviours. Addressing the adolescent sexual and
reproductive health needs is a sensitive as well as complex issue, especially in the socio-cultural
context of Rajasthan. Programmed interventions are required not only to create understanding
but also capacity to take informed decisions.

(a) Relevant Behavioural Theories

The theoretical perspectives that can help in shaping the interventions constitute the cluster of
health risk behaviour and adolescent development theories.














Health risk behaviour theories seek to predict risky behaviour or behavioural change (Auerbach
et al., 1994). It tends to encourage interventions designed to alter an individual's perception of
his or her susceptibility to a health problem and potential personal costs and benefits associated
with a given behaviour. It also emphasises helping the individual acquire motivation and skills
needed to reduce risk (Jughes and McCauley, 1998). However, this theory does not have much
specific significance for an adolescent programme in the present context.

More relevant and specific for adolescents is the Adolescent Development theory. According to
this theory, adolescent development is a complex process of physical, cognitive, social,
emotional and moral maturation (WHO 1993). In order to meet basic personal and social needs,
young people must develop a fundamental set of skills and competencies (Kirby, 1997). The
generic skills emphasised in the theory include planning ahead, seeking help, forming positive
relationships, etc.

The analysis of the health-risk behaviour and adolescent development theories suggests that both
of them share an implicit view that information and services alone are not sufficient to influence
a young person to adopt safe health behaviour, and both stress that an adolescent's acquisition of
skills is also a critical step in the process.

(b) Adolescent Decision-Making

Before designing a programme, there is a need to look into the process by which adolescents
make decisions about various aspects of reproductive life. There appears to be large gaps in our
understanding of many aspects of the decision-making process, particularly the power
dimensions of adolescents' lives, psychological influences, and the relative weights that
adolescents assign to their own attitudes and to the significant reference groups. The relative
importance of various components of the decision-making process might differ depending not
only on the types of decisions, but also on whether the adolescents are in or out of school,
unemployed or working, poor or rich. The programme should, therefore, include differential
strategies to deal with different segments of adolescents in order to bring about a significant
impact.



Moreover, this decision-making process represents a complex interaction of individual, social,
familial and peer factors. These elements act in conjunction with socio-cultural factors, such as
living conditions, job opportunities for women etc., to influence the decisions that young people
make (Anastasia, 1998). It is crucial for the programme managers to understand the relative
importance of these factors in the decision-making process.

VI.2 Policy Response

State governments generally follow Government of India policies, and implement programmes
as per norms/guidelines laid down. Some state governments have, however, undertaken
initiatives to formulate their own state specific policies to address some state issues. A review of
policies of central and state governments reveals that while some of the policies deal with
adolescent health and development related issues explicitly, others, though not addressing the
issue directly, implicitly relate to this important population group (Gupta 2002). The important
policies relevant to adolescent health and development are:

National Policy for Children, 1974
National Health Policy, 1983 (now the Draft National Health Policy, 2000)
National Population Policy, 2000
National Policy for Women
National Nutrition Policy, 1993
National Policy in Education, 1986 (Modified 1992)
National Youth Policy, 1986 and Draft New National Youth Policy, 2000)
National Policy for Child Labour, 1987

In most of the cases, the Government of Rajasthan has followed central policies while preparing
state specific plans of action (Mamta 2001). However, Rajasthan has been among the few states
which have taken initiative to formulate an explicit state specific population policy and women's
policy considering adolescents as a special target group.


The population policy of Rajasthan recognises age at marriage as a crucial issue for policy
intervention and recommends integral and concentrated action by all departments concerned,
such as home, social welfare, women and child department, education, health, etc. In the policy it
has been recognised that the attainment of the objective of population policy will be facilitated
by better understanding and appreciation of health, particularly human reproduction, biology,
contraception, menstrual health among women, and RTIs among adolescents.

"The state will endeavour to educate boys and girls on human reproductive
system, health system, responsible sexual behaviour. For this purpose, proper
reforms will be made in the school curricula. However, for those not receiving
formal education, efforts will be made to share this information through non -
formal education channels or voluntary organisations."

As stated in the Population Policy of Rajasthan (2000)

It also makes certain recommendations for gender equality and emphasises universalization of
elementary education. Specifying the role of the Department of Youth Affairs, the policy
recommends that Nehru Yuwa Kendras be activated for creating awareness among rural youths
of the small family norm and RCH. Reducing prevalence of child labour among children below
14 years has also been mentioned.

Women's Policy of Rajasthan recognises adolescent girls as a specific population group for
programmed interventions. The areas identified for intervention include:

Public awareness campaign on the importance of basic education, guarantee of legal
rights to women, nutritional deficiencies, malnutrition and anaemia among girls, ill
effects of early marriage and early childbearing.

Creating programmes to ensure that adolescent girls have equal opportunity for
education, and health needs, especially for the prevention of malnutrition and anaemia.
This also includes ensuring services for meeting these needs and creating an environment
for effective utilisation of these services.














Within and outside the sphere of formal education, encouraging non- governmental
organisations to undertake programmes for awareness generation regarding health,
education and personality development.

Although Rajasthan does not have any state specific education policy, the state government has
prepared action plans to implement the National Policy on Education. The state's programme
lays emphasis on the achievement of universal elementary education, girls' education, vocational
and adult education, and technical education. Vocational courses are merged with the formal
education system for the development of skill among students. Formal education also gives
emphasis on physical education, health education and other aspects of personality development.

Although the state specific population policy and women's policy have sufficient space for
adolescent issues, their operationalization in terms of effective programmes and schemes is still
to be demonstrated. Inadequacy of infrastructure, lack of inter-sectoral and inter-departmental
co-ordination, inadequate political and administrative commitment, and lack of adequate policy
guidelines and community participation can be listed as some of the major bottlenecks in
designing and implementing agenda to address the reproductive and sexual health needs of
adolescents.

VI.3 Programme Response

It is expected that the commitments shown in the policy statements to address the specific health
and other development needs of adolescents will be incorporated in the programme strategy.
Accordingly, the Reproductive and Child Health Care programme being implemented since 1996
through the network of health care delivery system was expected to address the relevant needs of
adolescents also.

The National Population Education Programme (NPEP) has been making efforts since 1980 to
institutionalise population education in the existing education system. Recently, the programme
has been given nomenclature of Population and Development Education in order to focus on new
thrust areas and strategies emerged since ICPD. To facilitate the introduction of sensitive issues
of adolescent reproductive health in school education, it has been conceptualised as Adolescent
Education. Its conceptual framework covers three major components: process of growling up,
HIV/AIDS, and drug abuse.












Population education has also been incorporated in the post-literacy and continuing education
programmes as well as vocational training programmes. District Primary Education Programme
makes it a point to achieve universalization of primary education, and recommends special
efforts to enhance girls' access, enrolment and retention in the school system. National Service
Scheme and Bharat Scouts and Guides aim at personality development of the students through
community service.

The ICDS is implementing Adolescent Girl Child Scheme in the selected districts of the state.
The scheme aims to reach girls in 11 to 18 years age-group so as to improve their nutritional and
health status, and to upgrade their home-based skills, to promote awareness of health, hygiene,
home management and child care. A special focus is on enabling adolescent girls to understand
their reproductive roles and the importance of delaying age at marriage.

Some NGOs are also carrying out adolescent health programmes in certain pockets of the state.
Institute of Health Management Research is carrying out a project in Ajmer district to meet the
sexual and reproductive health information needs of adolescent boys and girls. The project will
be based on the situational analysis of the unmet needs of adolescents on sexual and reproductive
health issues and will undertake interventions to meet these needs.

Chetna, an Ahmedabad based NGO, is also working in Rajasthan to build local capacity to
address the needs of adolescents. The organization conducts health camps in collaboration with
local organizations to provide health services to adolescent girls. It also works in the area of
capacity building of local organizations and advocacy for adolescent issues. However, the work
is mostly targeted on girls. UNICEF is also implementing an action research project in selected
areas of the state.






















VII. Critical Issues

The analysis of the information available through secondary sources on the issues related to
adolescent health and the review of the relevant policies and programmes raises several critical
issues. Some of the issues identified during this exercise are:

Although there has been a notable improvement in education during the last decade, the
educational attainments of adolescents are still at a low level. A notable feature of
schooling is a substantial gap between the proportion of enrollment of boys and girls.
Urban girls are better placed than their rural counterparts or girls living in tribal and
desert areas. In the socio-cultural context of Rajasthan, gender discrimination prevailing
in the area is also a major impediment in the education of girls.

The available data shows a decline in the age at menarche during the last two decades.
Keeping in view the trends in the socio-economic development in the state, the age at
menarche is likely to further decline in future in the areas where nutrition levels are
improving. The declining age at menarche is likely to contribute to increased
reproductive health risks for young women, whether in the context of early marriage and
child bearing or in the context of high risk sexual behaviour.

Despite the fact that perinatal complications are common among teenage mothers, and
despite the Child Marriage Restraint Act, a Rajasthani girl gets married before she attains
menarche. The comparison of data of 1992- 93 and 1998-99 reveals no significant change
in the age at marriage.

A sizeable proportion of girls enter motherhood without adequate preparation,
physiologically and socially. It results in high wastage of human resources, increasing
rate of maternal, infant and child mortality and morbidity. The longitudinal analysis of
data on fertility levels indicates that the teenage fertility in Rajasthan has not declined.

Low nutritional status of adolescent girls has emerged as a serious cause of concern.
Nearly half of the teenage women suffer from some degree of malnutrition. The
nutritional supplementation provided under government programmes (like ICDS) is still
not reaching the target group.














Women marrying in adolescent age generally have a poor access to maternal health care
services. It has been noted that half of the teenage mothers do not receive antenatal
checkups.

A large proportion of girls in Rajasthan have access to prior information on body
changes, particularly about the onset of menstruation.

Although social values strongly discourage sexual relations before marriage, available
evidences suggest that premarital sex is not uncommon among adolescent boys and girls
both in urban and rural areas.

Adolescents' awareness level of the issues related to health, nutrition and family life is
low. The efforts made through mass media during the last one decade have been able to
generate some awareness of HIV/AIDS. But the understanding of the causes, modes of
transmission and preventive measures of HIV/AIDS is still low.

Adolescents in Rajasthan have a limited exposure to the means of mass communication.
The information on health related matters is generally acquired from peer groups. Due to
lack of scientific validity, this may lead to the development of myths and confusion.

In recent years, efforts are being made to incorporate various issues affecting adolescents
in the policies and programmes of different departments. For example, the State
Population Policy and Women's Policy of Rajasthan have specific space for adolescent
issues, but its operationalization in terms of effective programmes and schemes is still to
be demonstrated.

The issue of adolescent sexuality and sexual health remains largely ignored under
programmes and policies related to adolescents. Although a part of the issue has been
taken up in the reproductive health programme, serious efforts are needed to incorporate
the entire issue of sexuality and sexual health.

Most of the efforts, whether by the government or by NGOs, are made to increase the
level of awareness and knowledge. However, the issue of sexuality and reproductive
health requires to go beyond that. Appropriate, interventions at the institutional (schools
and colleges) and community level should be designed keeping in view the socio-cultural
context.








IX. Forging Ahead

This situational analysis clearly indicates that there is no appropriate fit between the current
programmes and the needs of adolescents. The major challenge is to design a programme that
could address the needs of adolescents in the present social and cultural environment. A relevant
response to their need-equipping them with the knowledge, skills, values, support and
opportunities for self-advancement - can set the stage for their healthy development and growth.

Due to socio-cultural complexities and barriers of traditional thinking, very little is known about
what will work and what will not. A few experiments have been done in the state by the
government and NGOs. However, guidelines can be evolved to carry out assessment of needs,
experiments and innovations on the basis of insights from behavioural change theories, review of
the decision-making process, and research findings. On the basis of situational analysis and
conceptual understanding of issues, the following guidelines may help design and strengthen the
programme interventions for adolescents:

Provide Fundamental Skills: Programmes for adolescents need to provide, overall
negotiation on life skills training that can be applied to various facets of their lives. They
should rather provide tools necessary for responsible sexual behaviour than narrowly
focussing on sex education or the slightly broader family life education, which deals with
only one dimension of adolescents' lives.
























Address Social Norms and Practices: Although the changes associated with
urbanisation, increase in formal education and greater reach to media have a large impact
on life style, in matters of sexuality, reproduction and marriage, the most important forces
shaping adolescence are the particular cultural values and institutions, which, to a
considerable degree, remain intact. The studies provide clear evidence that
communication about sex and birth control is strongly influenced by adolescents'
perception of how socially acceptable their knowledge about sex is. The studies suggest
that a programme for adolescents should target not only adolescents and health service
providers but also consider communities' social norms and practices, if significant
sustained behavioural change has to be effected (Magnani et al., 2001).

Exploit Peer Pressure to Promote Desirable Behaviour: Adolescents are particularly
susceptible to peer pressure. Perceptions about what is accepted in their peer group and
what their peers are doing have a considerable influence on their sexual behaviour. It is
evident through several studies that the responsibility of transmitting sexual information
to adolescents primarily lies not with parents or other elders, but with peers. While peer
pressure can lead them to an irresponsible behaviour, it can just as easily be a resource to
be exploited for promoting desirable behaviour. Hence, the dissemination of information
and behavioural change intervention may be routed though peer groups in a systematic
manner in order to increase the pace and quantum of change.

Impart Necessary Skills to Teachers and Health Providers: In the present context,
teachers and health care providers are also not prepared and willing to discuss sexuality
and reproductive issues with adolescents mostly because they feel uncomfortable while
discussing such issues. The education system is also ambivalent about imparting sex
education. Teachers, by and large, find the topic embarrassing and avoid it (Jejeebhoy
1998). Orientation and skill-building of teachers and health providers on adolescent
sexuality and reproductive health are urgently needed.
















Build Environment of Family and Parent Support: That family acceptance and support
is an important component of the success of programmes for adolescents is undisputed
because adolescents, especially girls, often need to be provided with adult permission and
support to receive information on sexual and reproductive health issues. Family
influences are manifested not only through family structure and control of finances, but
also through elders' power over marriage and childbearing decisions (Goyal, 1998). The
experience of work done by Chetna suggests that the role of parents is critical in effecting
and sustaining change. Efforts are needed to develop this component and to make it an
integrated part of the strategy.

Develop Community Based Programmes: School based programmes are not very
productive because of low enrolment and high dropout rates. Studies have demonstrated
that education in these matters can best be imparted to young people in a community
setting. However, their acceptance will depend on the extent to which they are introduced
in an appropriate manner by educators who address cultural as well as medical concerns
(Awasthi et al., 2000).

Promote Programmes for Boys Also: Presently, most of the adolescent programmes are
targeted on girls. Although the importance of interventions for addressing the needs of
adolescent girls is undisputed, programmes for adolescent boys are also crucial in order
to initiate change in gender relations.

Implement in a Phased Manner: Looking to the resource constraints and the sensitivity
of the issue, it is not possible to cover all the issues at one go. It is, therefore, suggested
that the agenda for adolescents should be implemented in a phased manner through well-
defined strategies. Obviously, the partnership of the government, NGOs and community
is crucial to the success of a programme.
.


References

1. Anastasia J.Gage. Sexual Activity and Contraceptive Use: The Components of the
Decision making Process. Studies in Family Planning, Volume 29, No. 2, June 1998.

2. Auerbach, Judith D. et al. AIDS and Behaviour: An Integrated Approach. National
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3. Awasthi et at. Developing an interactive STD Prevention Programme for Youth: Lessons
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8. Gupta S.D, et al. Report on Study of Reproductive Health and Sexual behaviour among
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11. Human Development Report, Rajasthan. Society for International Development,
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12. Kirby, Douglas. No Easy Answers. The National Campaign to Prevent Teen Age
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15. MAMTA. Adolescent Health and Development in India: An Action Approach; MAMTA -
Health Institute for Mother and Child. New Delhi, January 2001.

16. Mangnai et al. Impact of an Integrated adolescent Reproductive Health Programme in
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Chetna, Gujrat and Rajasthan. Population Council, 1999.

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About the Authors

Professor R. S. Goyal is an eminent social scientist and presently a Professor at Indian Institute
of Health Management Research. Before joining IIHMR he was Deputy Director, Population
Research Centre, Punjab University, Chandigarh. He has been associated in various capacities
with several national and international research and academic organizations. He is a leading
expert on operations research in adolescent reproductive and sexual health as well as HIV/AIDS
prevention and care programme management. He is also an accomplished trainer, especially in
the area of HIV/AIDS and reproductive health, and organized a large number of capacity
building programmes with various national and international organizations. He has two and half
decades of experience in management information systems (MIS) and programme evaluation,
monitoring and surveillance, policy analysis, strategic planning, advocacy, networking and
resource mobilization for research and capacity building programmes for reproductive and
sexual health. He has published several papers in various international and national journals. He
has association in different capacities with various professional bodies, including Carolina
Consulting Group, University of North Carolina at Chapel Hill, USA, International Editorial
Advisory Committee of John Hopkins University, Baltimore, USA, Population Action Council,
Washington DC, International Union for Health Promotion and Education, Paris and Society for
International Development, Rome.

Anoop Khanna has a background in Social Work and is presently Lecturer at Institute of Health
Management Research. He is an accomplished trainer as well as a well-known researcher. He
specialises in programme planning, management and implementation, especially in the area of
reproductive health. He has a long experience of working in health system management and
other development areas. With a research experience of more than 10 years, he possesses
excellent understanding of reproductive health and population programme management issues.
He has led several projects and programmes supported and commissioned by WHO, World
Bank, UNAIDS, UNFPA, UNICEF, Ford Foundation, CRS, NORAD, DFID, PATH, PLAN as
well as Central and State Governments. He has presented and published several research papers
in many acclaimed national and international journals.


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Prashanta Pathak and K K Gaur. A Composite Index-based Approach for
Analysis of the Health System in the Indian Context (No.2) 1997
US $ 3/ Rs. 50.00
Devendra Kothari and S. Krishnaswamy. Breaking the Vicious Circle of Poverty
and Fertility through Streamlining Supply Management: A Case Study in
India (No.3) 1998
US $ 3/ Rs. 50.00
Devendra Kothari. Population Projections for Rajasthan and District: 2002-
2001, No.3, 2002


POLICY BRIEFS

Devendra Kothari et at. Operationalising the Concept of Unmet Need for Family
Planning Services: A Case Study (No.1) 1997

Dhirendra Kumar and Rahul Bhawsar. Quality of Care . Infrastructure, Human
Resources and Services Utilisation: Findings from Concurrent Evaluation of
Reproductive and Child Health in Rajasthan, India (No.2) 1997

Suneeta Sharma. Effective Financing and Management Autonomy in Public
Health Facilities: Rajasthan's Model (No.3) 1998

Hitesh Gupta et at. Should Salt Testing Kits be Used for Monitoring the
Universal Salt Iodisation Programme in India? (No.4) 1998

P. R. Sodani et al. Willingness to Join Health Insurance: Results from
Rajasthan Pilot Study for Informal Sector (No.5) 2002


Research Briefs

Ch. Satish Kumar, S. D. Gupta, Shachi Bhatt, Abraham George and Aruna
Bhattacharya. Men. Masculinity and DomesticVoilence against Women,
January, 2005


P. D. AGARWAL MEMORIAL LECTURE SERIES

Saroj Pachauri. Reproductive Health in India: Conceptual Issues and
Implementation Challenges 1997.

D. A. Henderson. The Looming Threat of Bioterrorism