Client and Provider Perspectives on Adolescent Reproductive and Sexual Health Services in India

The Government of India has opened more than 6,000 adolescent-friendly health clinics across the country to increase services, particularly reproductive health services, for young people. However, few young people have used the services. In the Youth in India study, conducted in 2010 by the International Institute for Population Sciences and Population Council, just seven percent of young men and three percent of young women reported ever receiving information on sexual matters from a health care provider. To understand the reasons for this circumstance, and to assist clinics in meeting the needs of intended clients, the Ministry of Health and Family Welfare asked the Population Council to assess the clinics from the perspectives of young people and health care providers in three states in India (Jharkhand, Maharashtra, and Rajasthan).

"Our goals were to better understand how adolescents in India view their health needs, including the obstacles they face in getting reproductive health information, and their preferences about how and from whom they get this information," explains K.G. Santhya, lead Population Council investigator on these studies. "We also wanted to understand how health care providers view their role in responding to the health needs of young people, and the factors that help or hinder their efforts to provide effective information and services." 

The Adolescent Perspective

The researchers surveyed young people aged 15–24 who lived in villages surrounding selected adolescent-friendly clinics. They reached 736 young people in Jharkhand, 682 in Maharashtra, and 713 in Rajasthan. They found that young women were more likely than young men to seek help, and married women were more likely than unmarried women, but that a pervasive lack of trust in the health system stopped many young people from seeking professional help when they had concerns.

The quality of services received by clients at the adolescent-friendly clinics was mixed. Most clients said they were able to meet with a health care provider without any delay. Most reported that the health care provider paid attention to them when they described their complaint. None were worried that the provider would tell others about their health problems. And most reported that the provider did not shout at or make fun of them.

However, clients also reported that the clinics lacked privacy. Some reported that the consultation time with the providers or the information provided was insufficient and was, at times, moralistic and judgmental. One young woman reported, "There was no privacy; I felt shy to narrate my problem in front of others. The doctor was surrounded by male and female patients." Another young woman said, "The doctor told me that he cannot prescribe an IUD for me since I am unmarried, and that he also cannot explain to me how the condom is used, but would explain it to my boyfriend."

In general, most young people suggested that if they were to seek out help, they would prefer to receive health information from family and friends. When going to a health facility, young people preferred to see a doctor rather than a nurse or other health care provider. These preferences may be tied to a general lack of awareness that other health workers can provide quality services.

The Health Care Provider Perspective

The researchers also surveyed four types of health care providers—accredited social health activists, auxiliary nurse midwives, counselors, and medical officers in Jharkhand, Maharashtra, and Rajasthan. All of these providers asserted that they had received some basic training in adolescent reproductive health issues. However, for many, this training focused on "safer" issues such as nutrition and menstrual hygiene, and ignored the potentially more difficult or controversial areas like sexual relations, contraceptives, and pregnancy. Health care providers receive little, if any, training in non-judgmental communication methods with young people on sensitive topics, especially with opposite-sex adolescents, increasing provider discomfort with these topics.

While not explicitly covered in their trainings, most health care providers believed that young people should learn about pregnancy and contraception before marriage. Yet they also reported that most of the counseling they conduct with unmarried clients is for physical maturation concerns (menstrual hygiene and breast development for girls; growth of facial hair and voice change for boys). Contraception and pregnancy-related counseling is saved for married clients. Providers believe that girls should receive information about reproductive health from their mothers and female providers, while boys should learn from male providers. Indeed, providers reported that most of their interactions with clients break down along gendered lines.

Recommendations for Improving Health Services

Population Council researchers recommend that the Government of India take several steps to improve the quality of sexual and reproductive health services provided to young people in India, including:

  • raising awareness among providers of common health problems experienced in adolescence.
  • expanding the scope of services provided to young people.
  • expanding the health care provider base to serve young people.
  • sensitizing influential others in young people’s lives about their supporting role.
  • improving the awareness and skills of health care providers to respond to the needs of all young people.
  • raising young people’s awareness about the availability of adolescent-friendly clinics.
  • improving the quality of services delivered at the clinics.
  • monitoring and evaluating adolescent-friendly clinics. 

Providers said they would be able to offer higher quality sexual and reproductive health services if they had better training. It would also help if front-line health workers were more aware of adolescent-friendly clinics, so that they could refer adolescents to seek help there, and if parents allowed or encouraged their children to seek care at these clinics.


Sources
Jejeebhoy, S.J., K.G. Santhya, S.K. Singh, et al. 2014. Provision of Adolescent Reproductive and Sexual Health Services in India: Provider Perspectives. New Delhi: Population Council. 

Santhya, K.G., R. Prakash, S.J. Jejeebhoy, and S.K. Singh. 2014. Accessing Adolescent Friendly Health Clinics in India: The Perspectives of Adolescents and Youth. New Delhi: Population Council.

Funding
The John D. and Catherine T. MacArthur Foundation