cience

Involving Parents: As Vehicles of Change in Adolescent Sexual and Reproductive Health in Urban and Rural India

Introduction: Adolescence, a period representing transition from childhood to adulthood where experimentation is dominant and the need to challenge authority evident. Adolescent sexual and reproductive health concerns have increasingly been on our national agenda (WHO 2004), driven by high prevalence of HIV/AIDS among young people, which is between 0.5 -1.0 percent for females and between 0.2-0.5 percent for males. (UNICEF, UNAIDS and WHO 2002).

Background: Studies in India highlight that, premarital sexual relations among young people are not rare, but they tend to occur secretly, without full information and without protection (Alexander et al 2006a and 2006b, Awasthi et al, 2000; Abraham & Kumar, 1999).Many factors at individual, family and community level have emerged to influence high-risk behaviour of the adolescents (Gerard & Buehler, 2004). Specifically at family level, discussion of SRH with parents and family connectedness are protective for initiation of sex as well as frequency of sex, number of partners and use of condom and contraception as well as for pregnancy (Kirby et al, 2005; Kristin Mmari et al; 2005; Maria Paz, 2004; Kirby, 2002a; Senderowitz, 2000; Jessor, 2000; Holtzman & Rubinson,1995).

KEMHRC has just completed, one of the first community based studies in India in partnership with Population Council, New Delhi and Ipas which explored sexual partnership formation among youth between 15 to 24 years, both married and unmarried in urban and rural areas, using both qualitative and quantitative tools. Findings from data of about 8000 youth highlight that about 10% males and less than 2% females report premarital sexual relationships. Among boys who are sexually experienced high-risk sexual activity like unprotected sex, multiple sex partners, exists. Qualitative and survey data list parental absence from home leaving children with unsupervised time, lack of communication, inadequate knowledge of parents coupled with reluctance to talk about SRH issues as some of the key factors influencing adolescent risky behaviour.

Study: The DFID (Communication and Advocacy Support Programme) funded intervention research programme by KEM HRC, with a pre and post intervention evaluation design, addressed parent child communication and barriers to communication on SRH issues and was implemented in a sub area of the above mentioned study.

Goal: To address, in the wake of HIV pandemic, key Reproductive and Sexual Health (SRH) issues faced by adolescents in India, in order to facilitate their transition into informed and safe adulthood.

Purpose of the proposed project was to facilitate a supportive family environment by addressing communication barriers between parents and adolescents especially on SRH issues and by empowering parents with knowledge on these issues in rural as well as in urban sites, in order to contribute to the response of the HIV epidemic in India.

Study population and coverage: Around 1000 unmarried adolescents in the age group of 10 to 19 years and about 2000 parents of these adolescents, from two villages and 4 small pockets of urban slums in Pune District, Western Maharashtra having a total population of 5000 at each site, were covered under this intervention.

BASELINE EVALUATION:

One third of available target population was randomly selected and surveyed:

a:]50% of adolescents reported that there was communication however limited between parents and their adolescents, talking to father was even lower, around one in three adolescents spoke to their fathers on school related issues.

b:]Communication on SRH issues was minimal, which was essentially between mothers and daughters and it was confined to talking about pubertal changes in girls (less than 25%) and menstruation (around 50%).

c:]Closeness and interaction was more between mothers and adolescents and mothers spent more time with their adolescents than the fathers.

d:]Many barriers were identified for communication on sexual and reproductive matters, some traditional such as cultural taboo, more contemporary such as lack of time and knowledge.

INTERVENTION:

Community involvement and ownership was ensured by including Community members in Community Advisory Groups. These groups helped in designing survey tools, training package, in conducting sessions in the community, in monitoring and evaluation and in running Resource cum Recreation Centers.

Small Group Interactions:

Adolescents : Sessions of Communication Skills of 90 minutes each for 3 days.

Parents : Sessions of Communication Skills and SRH knowledge of 90 minutes each for 5 days.

Home Based Sessions: Condensed form of the training curriculum was imparted to parents and adolescents at home level for about 90 minutes.

Mass Communication:Folk theatre such as puppet shows, street plays, lavani, etc. were employed to create awareness on the importance of parent child communication in the community.

Recreation cum Resource Centres: Books and indoor as well as outdoor games were made available for the adolescents, so that they could utilize their free time more constructively, since unsupervised free time was highlighted in the previous study, as a risk factor influencing adolescents into high risk activities

Monitoring & Evaluation: The activities of the project were monitored by the project staff, where as the communication process was monitored, door to door, by the CAG members. Qualitative data collection methods were also utilized by the staff to monitor communication process.

ENDLINE EVALUATION:

One third of available target population was randomly selected and surveyed:

a:]Parent child communication had improved in general issues such as peer related issues: 23% of adolescent urban girls in the base line, mentioned that they spoke to their mothers on peer related issues but at end line, 57% reported the same.

b:]Communication on SRH issues improved between mothers and daughters, but mainly on issues such as menstruation and pubertal changes- 53% of rural adolescent girls reported in the base line talking to their mothers about menstruation, where as 62% talked to their mothers on this issue at end line.

c:]Cross gender communication, especially between fathers and daughters, which was limited initially, showed no improvement.

d:]Perception of ability to communicate on personal problems and on growing up issues improved between mothers and adolescents.

e:]Recognition of parents as a source of SRH information improved for the adolescents, from less than 30% at pre intervention survey to about 50% post intervention.

f:]Awareness of parents as well as adolescents on SRH related issues including in depth knowledge of HIV, improved after the intervention- at base line 20% of urban adolescents and 40% of urban parents knew that a girl could get pregnant the first time she has intercourse, which improved to about 45% for the adolescents and 50 to 60% for the parents after the intervention. Similarly, 30% of rural adolescents and parents knew, at base line that HIV status could be confirmed by blood test, which improved to 40 to 60% at end line.

Involving community proved to have a positive role in the intervention in terms of allowing community access for a sensitive issue, calling community for the intervention and receiving continuous feed back for making timely and appropriate modifications to suit community sentiments and needs.

LESSONS LEARNT:

a:]Interventions need to be long term and multi pronged to address adolescents, their parents, family and community at large.

b:]Interventions should have multiple sessions, initially, with gender and generation separated groups but aim to bring them together, towards the end of intervention, on the same platform so that they understand each others’ needs and concerns.

c:]Father’s involvement in creating a supportive environment for the adolescents need to emphasized.

d:]Community involvement in the programme is important for smooth implementation and for sustainability.

IMPLICATIONS:Implemented meticulously, Parent Child Connectedness through communication would add to an already identified and recognized list of supporting factors to help this vulnerable group that is adolescents, to transit into adulthood safely.