Actions that protect: Promoting sexual and reproductive health and choice among young people in India

This paper synthesises the evidence on the sexual and reproductive health situation of young people in India, and explores what we know about underlying factors that place them at risk of or protect them from unsafe and unwanted sexual and reproductive health experiences. The picture that emerges suggests that substantial proportions of young people experience risky or unwanted sexual activity, do not receive prompt or appropriate care, and experience adverse reproductive health outcomes. Contextual factors such as poverty, gender imbalances and lack of education or livelihood opportunities clearly increase the vulnerability of youth. Other factors at the family, community and facility level may also exacerbate risk. While young people’s knowledge and awareness about sexual and reproductive health is increasing, much of this knowledge remains superficial and ridden with myths, misperceptions and a sense of invulnerability. Gender power imbalances make risky behaviours acceptable, encourage secrecy and fear of disclosure, and inhibit negotiation among partners. Lack of communication with parents and other trusted adults, similarly, keeps young people ill informed and unlikely to receive parental support or counsel in relation to sexual matters. Sexuality education remains inadequate and irrelevant to young people’s needs, and services remain inaccessible, unacceptable, unaffordable and of indifferent quality. Several encouraging signs are, however, evident. The sexual and reproductive health needs of adolescents and young people are on the national agenda. There is growing recognition that young people themselves must be given a role in articulating, designing, implementing and evaluating such programmes. Finally, experiences of a few programmes already exist that appear to successfully respond to young people’s sexual and reproductive health needs in innovative and acceptable ways. The paper concludes by recommending, on the basis of available evidence, a core set of promising actions that protect

Introducing adolescent livelihoods training in the slums of Allahabad, India

While all adolescents in India face a rapidly changing economic environment, girls’ life choices are very different from boys’. Girls are much less likely to be engaged in economic activities, and when young women do participate in income-generating activities, it is often in unremunerated home-based work. Even when young women are paid for their labor, they may not retain control of their income. The Population Council and its partners are promoting a “livelihoods approach” that aims to expand the decision-making power of young women by building social networks and developing financial and income-generating capacities. This approach attempts to provide technical and life skills and to transform the ways girls view themselves and are perceived by the community. In 2001, the Council teamed with CARE-India to develop a pilot project for adolescent girls in the urban slums of Allahabad, Uttar Pradesh. The pilot integrated livelihoods activities for adolescent girls into CARE’s reproductive health program for slum dwellers. Promoting Healthy, Safe, and Productive Transitions to Adulthood Brief No. 2 details baseline survey results of this project

Unintended pregnancy and abortion in India: Country profile report

A review of literature and analysis of large surveys were carried out with funding from the STEP UP consortium led by Population Council to build a coherent body of robust research-based evidence on the situation in India in the context of unmet need for family planning (FP) and safe abortion services. The study found that there is insufficient training of different cadres of health staff in the public health system on abortion provision, post-abortion care, FP counseling of young couples, emergency contraception, and IUD insertion/removal. Despite service delivery guidelines in India expecting providers to provide FP counseling during antenatal visits, only a fraction of women receive counseling. The report includes recommendations to improve the reach and quality of FP counseling and post-abortion contraception; and to increase adherence of the Medical Termination of Pregnancy and the Preconception and Prenatal Diagnostic Techniques Acts

The effect of a livelihoods intervention in an urban slum in India: Do vocational counseling and training alter the attitudes and behavior of adolescent girls?

This Population Council working paper examines whether an experimental intervention for girls aged 14–19 that provided reproductive health information, vocational counseling and training, and assistance with opening savings accounts in slum areas of Allahabad in Uttar Pradesh, India had an effect on their attitudes and behaviors. Although the livelihoods program was acceptable to parents and feasible to implement, the project had only a minimal impact on the behavior and attitudes of adolescent girls in the experimental slums. The greatest changes between the baseline and the endline surveys were found in those outcomes that most closely reflected the content of the intervention. Girls exposed to the intervention were significantly more likely to have knowledge of safe spaces, be a member of a group, score higher on the social skills index, be informed about reproductive health, and spend time on leisure activities than were the matched control respondents. No effect was found on gender-role attitudes, mobility, self-esteem, work expectations, or on number of hours visiting friends, performing domestic chores, or engaging in labor-market work

Integrating adolescent livelihood activities within a reproductive health programme for urban slum dwellers in India

This project, whose collaborators included CARE, the Centre for Operations Research and Training, and the Population Council, tested the impact of economic skills training among girls in a slum in Allahabad, India. Recognizing the relative disadvantage of adolescent girls, the study aimed to build an evidence base for adolescent livelihoods programs. Participating girls and their parents welcomed the program, and the baseline survey clearly indicated the appropriateness of an intervention that addresses the capabilities and opportunities available to adolescent girls—including both vocational training and savings schemes. However, few girls turned their new skills into economic gain, in part because of social barriers that impede girls\u27 access to economic markets. The report recommends that vocational training programs combine family and community sensitization with training to enhance adolescent girls\u27 economic participation

Promoting healthy timing and spacing of births in India through a community-based approach

The Indian Family Welfare Program, though successful in increasing contraceptive use among couples who have achieved their desired family size, has failed in educating people about the importance and need of using contraceptive methods for spacing births. With its Indian collaborators, the Population Council’s Frontiers in Reproductive Health (FRONTIERS) program undertook a study to test a model to increase use of postpartum contraception among young pregnant women with a parity of 0 or 1. The study showed that the Behavior Change Communication (BCC) model developed to promote Healthy Timing and Spacing of Pregnancy (HTSP) was effective in promoting the lactational amenorrhea method and postpartum contraception and could be rolled out easily; misconceptions about the return of fertility and its links to the biological marker of the menstrual cycle are the main barriers in a timely beginning of postpartum contraception; and acceptance of community workers (CWs) in a family increases if counseling focuses on HTSP and its benefits to mother, child, and family. The report concludes that the complementing effort by CWs of two Ministries to achieve similar objectives is feasible and provides a synergistic effect. The BCC materials, counseling aids, and messages developed for the projects are ready to use in scaling up the program

High HIV incidence among male injection drug users in Delhi, India

India has a large injection drug user (IDU) population estimated at 177,000. The overall national HIV prevalence is around 7.2 percent in this group, the highest among all key populations in the country. There is limited HIV incidence data among IDUs in India. In collaboration with Arise—Enhancing HIV Prevention Programs for At-Risk Populations, the Population Council initiated a prospective cohort study at five centers in Delhi to examine HIV incidence and behavior change both pre-introduction and post-introduction of HIV prevention services among IDUs. HIV transmission risk remains high among IDUs in Delhi despite targeted prevention interventions. Despite the widespread availability of free sterile needles and syringes from needle exchange programs and targeted interventions with harm-reduction messages, HIV risk is primarily associated with risky drug injection practices. Targeted intervention programs must find ways to increase regular access to harm-reduction services and ensure that use of services translates to changed behaviors. This study demonstrates that a large number of IDUs can be enrolled into a prevention study with reasonable rate of follow-up. Thus, this population should be considered for future HIV prevention trials

Prevalence of HIV, hepatitis B and C, and co-infection in a cohort of male injection drug users in Delhi

India has a large injection drug user (IDU) population estimated at 177,000 nationally with an HIV prevalence of 7.2 percent. Historically, the presence of IDU populations and associated HIV infection was concentrated in the northeastern states of the country. Recent evidence documents IDU populations in other parts of the country. Delhi has an estimated 17,000 IDUs and the second highest HIV prevalence in India at 18.3 percent. The probability of becoming infected with HIV after using an infected syringe ranges from 0.34 percent to 1.4 percent. By comparison, the risk for hepatitis C (HCV) ranges from 1.5 percent to 5 percent. Several studies have documented high prevalence of HIV-HCV co-infection among IDUs in the high HIV prevalence states of India, but there is little evidence from the low HIV prevalence states in the country. The Population Council and partners implemented a project to avert HIV infections among IDUs and their sexual partners in Delhi. As part of the project evaluation, an assessment of the prevalence of HIV, hepatitis B, and HCV infection was conducted in a cohort of male IDUs in Delhi. This document presents a research update

Manual for Building Capacity of Trainers and Program Managers in Emergency Contraception

This manual equips trainers with appropriate knowledge on emergency contraceptive pills (ECPs). Emergency contraception (EC) refers to any method of contraception that can be used by a woman to prevent an unwanted pregnancy within three days of unprotected intercourse or a contraceptive accident such as condom leakage. This manual discusses ECPs and the provision of related services. After a day’s training, trainers have the knowledge and skills necessary to train service providers and workers on ECPs. The manual is divided into four sessions. The first provides an overview of the demographic and reproductive health (RH) situation in South and South East Asia and briefly discusses the role of EC as an RH intervention. The second defines EC, and discusses when and how ECPs should be taken. Service delivery guidelines are covered in the third session, particularly what users should do in case of method failure. The fourth session covers counseling on ECPs and frequently asked questions on EC