training module for peer educators - National Health Mission

facilitator’s guide

training module for peer educators

January 2014

Adolescent Health DivisionMinistry of Health and Family Welfare

Government of India

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Acknowledgements

The Resource Pack for training of Peer Educators under the Rashtriya Kishor Swasthya Karyakram was developed through a consultative process. It would not have been possible to develop this key training material without the valuable contribution of many organizations and individuals.

Additional Secretary and Mission Director (NHM), Ms. Anuradha Gupta’s passion, strong commitment, guidance and support steered this process and was a constant source of encouragement.

Joint Secretary (RCH), Dr. Rakesh Kumar brought in field perspective, based on his wide experience. He provided astute directions and clarity on institutional mechanism, critical for successful implementation of the programme.

List of ContributorsMs. Anuradha Gupta

Additional Secretary & Mission Director, NHM

Dr. Rakesh Kumar Joint Secretary, RCH

Dr. Sushma Dureja Deputy Commissioner, Adolescent Health

Ms. Anshu Mohan Programme Manager, Adolescent Health

Dr. Sheetal Rahi Medical Officer, Adolescent Health

Technical ExpertsDr. Neena Raina, WHO (SEARO) and Dr. Kiran Sharma, WHO (India)

Team MAMTA: Dr. Sunil Mehra, Priyanka Sreenath, Shilpa Jaiswal Bisht and Shikha Sukla

Technical Resource Group for Adolescent Health

Special mention: Dr. Shireen Jeejabhoy, Population Council; Dr. Vartika Saxena, AIIMS, Rishikesh; Dr. Monika Arora, PHFI; Dr. Prabha Nagrajan, TARSHI; Dr. Ravi Verma, ICRW; and Ms. Indu Capoor, (CHETNA).

We would also like to thank Mr. Rajat Ray, UNFPA for facilitating this process and Ms. Marie Joneja, our editor, for ensuring consistency in content and language.

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Contents

Acknowledgements iii

Introduction ix

About the Peer Education Resource Package and Facilitator’s Guide for the Training of Peer Educators xi

Tips and Tools for the Facilitator xiii

introductory module xvii

Welcome and Introduction 1

Logistics 3

Ground Rules 5

Fear and Hopes 7

Training Objectives 9

module I: adolescent peer education programme 11

Session 1: Rashtriya Kishor Swasthya Karyakram and Peer Education 131.1 Health Service for Adolescents – A ‘Friendly’ Approach 14

1.2 Peer Education – Reaching Adolescents through Their Peers 17

Session 2: Peer Educator – A ‘Trusted Friend’ 212.1 Becoming a Good Peer Educator 22

2.2 Your Role as Peer Educator for Adolescent Health and Development 25

2.3 Core Life Skills and Effective Communication 26

2.4 Know Your Coordinators 30

module II: growing up 35

Session 3: Adolescence – Transition to Adulthood 373.1 Pubertal Changes/Process of Growing Up 38

3.2 Male and Female Reproductive Organs and Functions 43

3.3 Managing the Menstrual Cycle 45

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3.4 Managing Nightfall 49

3.5 Personal and Nutritional Care 50

Session 4: Gender and Sexual Identity 574.1 Understanding Sex and Gender 58

4.2 Respecting Diversity 59

4.3 Gender Roles and Adolescent Behaviour 60

module III: health and happiness 65

Session 5: Health Conditions during Adolescence 675.1 Lifestyle Diseases and Risk Factors 75

5.2 Balanced Nutrition and Physical Exercise 81

module IV: healthy mind for healthy behaviours 85

Session 6: Dealing with Peer Pressure 876.1 Assertive Communication 88

6.2 Learning to Say ‘No’ 91

6.3 Substance Misuse and Mental Health 95

Session 7: Managing Emotions and Stress 1007.1 Problem Solving 101

7.2 Peaceful Ways to Resolve Conflict 108

Session 8: Accidents and Injuries 1138.1 Managing Anger 114

8.2 Minimizing Risk Taking 118

module V: adolescent sexual and reproductive health 123

Session 9: Child Marriage 1259.1 Child Marriage – The Legal Framework 126

9.2 Child Marriage – Causes and Consequences 127

9.3 The Appropriate Age for Marriage 129

Session 10: Adolescent Pregnancy 13610.1 Adolescent Pregnancy: Causes and Consequences 137

10.2 Adolescent Pregnancy: Appropriate Age for Planning a Child 143

10.3 Adolescent Pregnancy: Preventing Unwanted Pregnancy 144

10.4 Adolescent Pregnancy: Management of Adolescent Pregnancy 154

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Session 11: Reproductive Tract and Sexually Transmitted Infections and HIV and AIDS 15611.1 Understanding RTIs and STIs: Signs, Symptoms and Prevention 157

11.2 Understanding HIV and AIDS 170

module VI: responding to violence 181

Session 12: Violence against Adolescents 18312.1 Types of Violence and Identification of Perpetrator and Victim 184

Session 13: Gender-Based Violence 19313.1 Gender Roles and Associated Risk of Gender-based Violence 194

13.2 Reducing Risks of Gender-based Violence among Adolescent Girls 196

13.3 Seeking Institutional Support 200

module VII: my rights and entitlements 203

Session 14: Child and Adolescent Rights 20514.1 Understanding Rights and Entitlements 206

14.2 Rights of a Child and an Adolescent (Optional) 207

14.3 Laws that Protect Rights 211

module VIII: health and environment 215

Session 15: Community Sanitation and Hygiene 21715.1 Community Hygiene and Waste Disposal 218

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Introduction

Adolescents (243 million) comprise nearly one-fifth (21.2%) of India’s total population (Census 2011). Of the total adolescent population, 12 per cent belong to the age group 10-14 years and nearly 10 per cent are in the age group 15-19 years. The Government of India recognizes the significance of influencing the health-seeking behaviour of adolescents to support them in realizing their full potential. The health and well-being of the adolescent population is a key determinant of India’s overall population and development scenario. Age-appropriate interventions with this segment of population will help India realize its demographic bonus, as healthy adolescents are an important resource for the economy. The Government of India is committed to provide an enabling environment for adolescents to pursue their dreams and has brought out several policies, programmes, schemes and legal provisions for children and adolescents protecting and promoting their health and well-being. The Rashtriya Kishor Swasthya Karyakram is one such initiative in this direction with six strategic priorities:

1. Sexual and Reproductive Health

2. Mental and Emotional Well-being

3. Healthy Lifestyle

4. Violence free Living

5. Improved Nutritional Status

6. Substance Misuse prevention

Rashtriya Kishor Swasthya Karyakram (RKSK) comes under the National Health Mission (NHM), the flagship programme of the Ministry of Health and Family Welfare, Government of India. This programme has a range of services for adolescents to be delivered through both service delivery points and outreach activities. This means that an adolescent can access these services at a nearby health facility and through the service providers available in the villages. The approach for this programme is different as it is ‘adolescent friendly’. The focus is on building the skills and capacities of adolescent girls and boys to resolve their health concerns through rights-based access to service of choice (information, counselling, preventive, curative and/or referral for legal aid in case of violence).

The RKSK envisages convergence and collaboration with other government and non-government agencies to expand the reach of the programme and its components among all adolescents in the country with special focus on those who are socially and economically marginalized.

Respecting the rights of adolescents to privacy, confidentiality, non-judgemental attitude, non- discrimination and acceptance of their health needs as any other client of health, the programme will follow an ‘adolescent friendly’ approach. In order to reach adolescents irrespective of their age, sex, culture, caste,

Facilitator’s Guide: Training Module for Peer Educators

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religion, marital status or social status, the Government of India has introduced a special programme named ‘Adolescent Peer Education Program’. The programme will facilitate the following:

y Promote learning from trained peers

y Promote support seeking through trained peers

y Help reduce fears or barriers experienced otherwise by adolescents

y Help to establish information and support network among adolescents across the country

y Increase access to scientific and reliable sources

The trained peer educators are young and vibrant adolescents between 15 and 19 years. These peer educators are the most important link between service providers and the adolescents in the community and hence are the key to the success of this programme.

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About the Peer Education Resource Package and Facilitator’s Guide for the Training of Peer Educators

The Peer Educator Resource Package on Adolescent Health comprises the following two documents: (1) Facilitator’s Guide for the Training of Peer Educators and (2) Resource Book for Peer Educators. These documents have been developed through a consultative process. The content is generic in nature and can be adapted to suit the needs of the locale. The documents are available in English and can be translated into the state-specific language.

Peer group educators are adolescents or young adults selected by the community to guide and help adolescents 10–19 years of age to face numerous challenges during the period of growing up and use the opportunities available to them in the best possible way. This package aims to build the capacity of peer educators to create awareness among adolescents about the numerous challenges, risks and vulnerabilities during adolescence, life skills and steps to deal with them and promote utilization of services available to adolescents (such as adolescent-friendly health clinics, menstrual hygiene scheme, weekly iron folic acid supplementation, school health programmes and others) to enhance the health and well-being of adolescents in the country.

This package can be taught to peer educators in six days in the following manner: (a) once a week to be completed in six weeks; (b) twice a week or month to be completed in three weeks or three months; (c) six days at a stretch. The sessions are divided into six days with minimum training period of 7 hours each day. The emphasis in the package is on learning by doing, hence includes group work; role plays; case studies; questions and answers; discussions; brainstorming and forum theatre. The case studies have been built keeping in mind the 10 core life skills that participants get to practise while discussing the cases.

The Facilitator’s GuideThe Facilitator’s Guide is meant for the facilitators to conduct trainings for peer educators. The content of the guide has been developed around the six strategic priorities of the RKSK of the Ministry of Health and Family Welfare, Government of India. The guide has 8 modules and 15 sessions; some of the content is optional though it is suggested that the facilitators complete all. The practice exercises on each topic too have been given in greater numbers so that the facilitator can choose depending on the knowledge of and response received by the participants.


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The flow of each session is as follows:

1. Introduction to the session highlighting the need to transact the content with adolescents and what would be the content of the session

2. Learning objectives, time, materials required and methodologies

3. Activities with participatory exercises, summary of each activity

4. Key messages for the session and role of peer educators

The exercises are based on real-life situations to facilitate learning by doing. Methodologies are participatory including role plays, forum theatres and value exercises. The 10 core life skills by the World Health Organization (WHO) have been interwoven all through the content contributing to the ‘learning through doing’ approach.

The guide also has sessions on peer education and becoming a good peer educator that needs to be reinforced during every session. The package encourages facilitators and peer educators to be creative and innovative to include games, energizers, skits and local songs which could be relevant to the context during the training or sessions in the community. Games and skits would need to be locally developed to effectively cover the content of this package and make it more interesting. However caution needs to be taken to prevent misinterpretation or dilution of the message to be conveyed.

Suggested readings for the facilitator are listed below:

1. Handouts on Orientation Programme for Medical Officers to provide Adolescent-Friendly Reproductive and Sexual Health Services (MOHFW, GOI)

2. Life Skills and Adolescent Education Programme – Teacher’s Workbook and Advocacy Kits (NACO, GOI)

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Tips and Tools for the Facilitator

To develop the art of good facilitation one has to learn to minimize the influence of one’s own values and norms during the training sessions. It is often observed that one tends to carry one’s personal experiences, values and norms into the session. It is therefore important to ask yourself what you are comfortable talking about, and identifying your own strengths and limitations. There are many areas which can be sensitive and difficult; so it is important to find one’s comfort level to facilitate the sessions. However, nobody is perfect the first time; there is need to practice and learn from mistakes. Each step of the training provides an opportunity to the facilitator to overcome his/her hesitation and practise the skills that are required to be a good facilitator.

There are broadly three steps of facilitation listed below to enable the facilitator to prepare accordingly.

Process of Facilitation1. Before the classroom session:Training requires prior study and preparation irrespective of the fact that the facilitator may have organized training on the same issue earlier.

y Get to know your participants

y What are their cultural backgrounds?

y Do they have any previous knowledge on issues that will be addressed through the training programme?

y Which region do they belong to (e.g., which state, rural or urban setting)?

y What are the common myths and misconceptions prevailing among the participants or in their local community related to the training issue?

y Are there any cultural or religious taboos among them which may inhibit discussion on these topics?

y Familiarize yourself with the day’s topic for discussion, the resource material and other essentials such as transparencies, cards, articles, the games to be played, handouts, questionnaires, etc.

y Setting up the room: Try to create some open space for the exercises and role-plays. If feasible, move desks and chairs to form a semi-circular arrangement.

2. During the session: y As far as possible, keep presentations to a minimum. Conduct the skills-based exercises given in the

manual in the workshops. The session should take into account personal beliefs so that it can have an impact on the person’s behaviour. Participatory methods should be used to validate the learners’ experience and to give them confidence, knowledge and skills.

y Introduce the topic of the day and allocate adequate time to various exercises, activities, discussions, question box, reinforcing key messages.


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� Collect ideas on paper, charts, blackboards (individually, without adding your viewpoints or words). Cluster and discuss information.

� Training adolescents and young people about changes during adolescence, human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) requires a sensitive approach to sexuality and concerns of young people. It is important that the facilitator acquire a sense of comfort in dealing with these issues during the training period. If as a facilitator one is convinced that this information is important for protection and there is no choice but to provide the information, then it gives one the strength to overcome biases and misgivings.

y Remember that participants have different experiences; some of them may be into substance use or sexually active, others may not be; some may be victims of sexual abuse; some might have had the opportunity to learn about sexuality with a caring adult or older sibling, others may have only ‘street’ knowledge. As a facilitator your language should not be judgemental: this would make some participants feel excluded, and therefore, uninterested.

y Present topics in positive terms so that participants are prepared to accept the physical and emotional changes and thus have a positive body image and high self-esteem.

y Unless participants are able to be open and honest about their experiences, views and fears it is difficult for them to see how STIs, HIV or substance use affects them, and what they can do about it personally.

y Handling sensitive topics and successfully transacting sessions with participants can be both challenging and rewarding. Rapport with them is critical.

� Participants should not be made uncomfortable. Create opportunities during the session where all are given an equal chance to participate in the activities and discussions. However, do not force them to express their views/opinions on an issue if they do not want to respond.

� Never get personal, never be argumentative, or try to prove that you are right. Most of our statements are based on our values, upbringing and belief systems – on what we perceive to be right or wrong. Tell them that no question is ‘silly’ or ‘stupid’ and that they should feel free to clarify their doubts. Never embarrass them by telling them that their question is silly.

� Encourage all participants to respond and participate.

� Summarize the discussion ensuring all essential points are covered.

� Be very alert to the moods of the participants such as yawning/signs of boredom/sleepiness etc. Take an energizer when spirits are sagging.

y Issues not pertaining to the sessions, however important, should be placed in a ‘Parking Lot’. Ensure that all parking lot issues are discussed before the end of the day/workshop session.

y Any personal questions can be answered at your discretion, but if unanswerable, just calmly say that you cannot answer it.

y Do not say ‘Is it clear, have you understood?’ Instead say, ‘Am I clear?’

y Keep track of time.

y Have the contact phone number of a senior/technical resource person for advice on any issues during the session.

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3. After the session: y The facilitator can use different ways of evaluating if the participants have understood the content

transacted during the session. In case some have not understood, ask them to stay back or talk during lunch time.

y The methodology employed for the training should be extremely interactive, giving the participants space to give their views and opinions. Respond to criticism with a positive attitude.

y Summarize each session and ensure that objectives are realized and topics are covered. Respect the suggestions made by the participants and try to incorporate them, if possible, into future sessions.

y Keep a question box in the training session so that participants can put their queries in the box. This can be taken care of at the end of each session. The presence of the question box will help the shy participants ask their questions.

Characteristics of a good facilitator

y Fluency in language in use

y Well-informed and well-organized for the session

y Ability to listen carefully and patiently

y Non-judgmental, open to different views

y Ability to provide unbiased view on sensitive issues

y Willing to support and guide participants at all times

y Ability to facilitate and stimulate discussion

y Being able to link up session/s and activities with real-life situation/s

y Ability to include and engage all participants during sessions

y Ability to create conducive learning environment

Note for the Facilitator: The activities given in the module are trying to reinforce a message through different ways. If discussions through an activity have covered all the aspects, the facilitator can skip other activities and take up those that bring in new aspects. The facilitator should use his/her creativity in planning the session to avoid duplication during activities. However, if one activity has not been able to raise discussions as required, take up another similar activity.

introductory

module

1

Welcome and Introduction

For a successful training session it is important that participants interact freely, without hesitation and fear. They should all feel at par with each other. In trainings like that of Youth Peer Educators, participants may not have similar educational, economic or social background. At the beginning of a peer education training, icebreakers or warming up exercises are essential to help the participants get to know each other and relieve the initial tension of working with a new group of people.

Learning Objectives:

1. To make participants feel comfortable and relaxed

2. To encourage positive vibrations among participants for each other and hence a sense of comradeship

3. To facilitate introduction between participants and resource persons/facilitators

Time:

1 and 1/2 hours (90 minutes)

Material:

VIPP cards, sketch pens, white board or flip chart, white board marker pens (black, blue, green and red); glass bowl, white (blank) paper chits

Methodology:

Matching Words and Introducing the Partner

Make a list of phrases or words that are always mentioned together. Facilitators should avoid use of culturally or religiously sensitive words. Please see that these are positive matching words and demonstrate the importance of togetherness. (Reinforce what one is without the other while listing the matching words).

For example

1. Tea and sugar (chai; chini)

2. Laila and Majnu

3. Beauty and brains

4. Prince and Princess

5. Basanti and Dhanno

6. Romeo and Juliet

7. Mickey and Donald

8. Tom and Jerry

9. Paint and brush

10. Stars and moon

11. Trees and earth

12. Water and river

13. Coal and diamond

14. Air and environment

15. Paper and pen

16. Jug and glass

Activity 1


2

You may ask participants to suggest more such interesting pairs. Make two slips for each matching pair of words – for example, tea on one slip and sugar on the other – and put them in a bowl. Similarly make more slips for other matches and mix all together in the bowl. Go to the participants with the bowl and ask each to pick up one piece of paper and find their partner according to the match. For example, ‘tea’ will look for ‘sugar’ and ‘Romeo’ for ‘Juliet’. Encourage them to call their partner’s name if they are not able to find. Ask them to sit in pairs. Provide each with a blank sheet of paper and pen. Now ask each to prepare an introduction of their partner as given below (write the following points on the board):

1. Name (with a picture of the participant)

2. Village with one good thing he/she likes about the village and one thing that he/she wants to change or improve

3. Education/work (optional)

4. Favourite colour

5. Favourite sport

6. Favourite movie

7. Favourite story

8. Role model in life and reason (parents; teacher; religious leader; celebrity from cinema or sports or from other areas)

9. Best friend and one quality in that friend that he/she likes the most

If possible all resource persons and facilitators should follow a similar exercise to introduce themselves and be a part of the group. Give the group 5–10 minutes to prepare the introduction. Now call the pairs, one by one, to introduce their partner to the larger group. Once this process is over, facilitators should introduce each other as well. If any participant is left without a partner, the facilitator should pair with him or her.

Key Messages

1. It is important for the workshop that you all talk to each other, work together, have fun and keep smiling.2. We all have some dreams to fulfil – dreams for ourselves, our family, friends, community and village. We should

pursue them; else, what will life be if we don’t have any dreams to pursue?3. We all have someone to look up to and we want to be like them and behave like them. We may or may not

become exactly like them but their good qualities that we admire and try to imbibe will prepare us to become role models ourselves for others to follow.

4. This is what we try to become as a ‘PEER EDUCATOR’.

3

Logistics

Participants need to be informed about important logistics in the beginning of the session itself so that they are aware of arrangements and can attend to their needs without disturbing the training session or the larger group.


1. To inform participants about breakfast, lunch, dinner and tea timings and venue

2. To inform them about location of washrooms and drinking water

3. To inquire whether boarding and travel facilities need any attention and take necessary action to address if required

4. To introduce person responsible for any requirement other than training like medical help, travel etc.

Time:

10 minutes

Material:

Logistic details sheet, contact person/s details and reimbursement forms

Methodology:

Presentation and discussion

Provide the logistics sheet with the contact person’s details and numbers to all participants. Ask them if they have any problem with stay and travel arrangements or with food. Take note of problems or concerns raised and try to address them.

y Hand out the photostat copies of the brief on logistics.

y Review the logistics for the day: training time, tea and lunch breaks and end time.

y Share important details like contact name and address of the person-in-charge of logistics (and also person responsible for taking care of the travel reimbursements etc.). Introduce them to the group for convenience.

Activity 1


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Key Messages

1. Do not hesitate to contact facilitator or other organizer in case of emergency.

2. Ask for medical help if required.

3. Bring issues of harassment and violence to the notice of organizers/facilitators.

5

Ground Rules

Preparing ground rules in a participatory way makes participants more conscious of the rules made and helps maintain the decorum of the training/workshop. Participants, especially young people, are more responsive when they feel that rules are not imposed on them by seniors. This also helps to get volunteers to take charge of upholding the rules during the training among their peers. This session should also be used to prepare a day-wise list of monitors, reporters and evaluators and define their roles and responsibilities.


1. To prepare ground rules in a participatory way

2. To make participants learn the importance of ground rules and encourage self-discipline and sense of responsibility to influence their peers to follow the rules

3. To get day-wise list of monitors, reporters and evaluators

Time:

30 minutes

Material:

Flip chart; white board pens, chart paper

Methodology:

Brainstorming and discussions

Ask participants to think and speak about the rules that they feel are important for smooth functioning of the training. Write suggestions on a flip chart, some of which could be the following:

1. Respect others’ feelings and opinions

2. Be polite

3. Be non-judgemental: don’t impose your opinion of right and wrong on others

4. Maintain confidentiality: avoid sharing with others or making fun of any individual’s opinion that was shared in the context of the training

5. Be on time

Activity 1


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6. Don’t use mobile phones; if there is an emergency, keep ringer on silent mode

7. Don’t talk during presentations

Once the ground rules are ready, tear off the sheet and ask two volunteers to put it up on the wall for reference during the training.

Prepare a day-wise matrix for monitors, reporters and evaluators. Encourage participants to voluntarily take up a role on at least one of the days. Explain the roles and responsibilities of monitors, reporters and evaluators in detail as given below. Put up the chart paper on the wall.

Day Monitor Reporter Evaluator Supervisor

1Anjali

Sohail

Deepak

Babita

Niloufer

RajeevOne facilitator

2

3

Activity 2

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Fear and Hopes

Participants may have some fears and also some expectations from the workshop. It is good to start by saying that the participants have rich experience and valuable information to share and learn from each other. But there might be some fears as well that should be talked about in the beginning itself so that they can be overcome. Do mention that the facilitators too have some fears and expectations.


1. To help participants express their fears and expectations in writing

2. To know about their fears and expectations and make plans to address them appropriately

3. To help participants understand reasons for not including those expectations that are beyond the scope of work in the training plan and provide them appropriate references or time to work on those expectations separately

4. To reorganize the training plan to suit the needs of the larger group

Time:

45 minutes

Material:

VIPP cards in two colours, sketch pens, draw pins/two-side tape/sellotape; pre-test questionnaires

Methodology:

VIPP Cards; pre-test (Pre-training assessment of knowledge level)

Provide each participant with two VIPP cards of different colours: green and pink. Ask them to write one ‘Fear’ on the green card and one ‘Expectation’ on the pink card. Give them 5 minutes. Inform them that they are not required to mention their names on the card. Ask two volunteers to collect the cards and put them up on the wall, greens and pinks separately under heads ‘Fears’ and ‘Expectations’ respectively.

Discuss fears one by one and then expectations. Simultaneously inform the group about those that are going to be addressed during the course of the training. Bring out those expectations that are beyond the scope of the training and explain reasons for not including them in the training plan. If possible provide with appropriate references or assure them of working on those expectations some other time separately.

Activity 1


8

Prepare a Question Box using a cardboard, wooden or steel box with an inlet to put in queries. The box is locked or pasted in a way that no one except the facilitator can open the box. Introduce the Question Box and inform participants that this will be available all through the training for all sessions. The questions will be answered at the end of the day or at the start of the new session.

Question boxQuestion Box is a method to encourage participants to put in their queries regarding the session or their experiences or anything which they want to share with the larger group without their identity being disclosed. The facilitator introduces the box and keeps it in a place accessible to all participants. The box has an inlet like a post box to drop queries. It is locked so that no one else can open it. The facilitator asks participants to write down their concerns or experiences on

a piece of paper without disclosing their identity and put them in the question box. The questions are reviewed at the end of session or day in the presence of the larger group. This method is very useful with young people also.

Activity 2

QUESTIONBOX

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Training Objectives

Now that you have a good understanding of the group’s expectations and fears, you know which sessions need more emphasis. It is good to discuss session-wise objectives of training and relate it to the expectations discussed in the previous session. This would help participants see the training in totality and prepare themselves for each session with better understanding and learning interactions.


1. To make participants understand the objectives of each session

2. To help participants relate their expectations to the planned session during the course of the training

Time:

30 minutes

Material:

Agenda/Session plan sheet

Methodology:

Presentation and discussion

Provide each participant with a session plan. Read out the session plan one by one starting with Day 1. Discuss the objectives of each session. Correlate training objectives with the expectations of the participants. Invite questions from participants and clarify their concerns related to this training.

Note: If the training is planned for six consecutive days, then the introductory module can be taken only once. However, if training is spread across 3–6 months, an hour should be devoted for the following:

1. To reintroduce ground rules2. Introduce any new peer educator3. Recap of last day’s sessions4. Experiences and challenges faced by peer educators5. Introduce question box6. Decide monitor, reporter and evaluator to get the feedback at the end of the day (optional)

Activity 1

module I adolescent peer education programme

13

Session 1Rashtriya Kishor Swasthya Karyakram and Peer Education

IntroductionThe Government of India recognizes adolescence as a distinct age group that has its own perception and concerns regarding health and its pathway to development. Adolescence is a promising but delicate phase of life when a child needs utmost care and support to realize its full potential. But still children’s concerns often go unnoticed. Due to cultural inhibitions an open dialogue/communication between young people and adults on subjects like bodily changes, love, marriage and relationships is often not possible. Due to this, adolescents avoid talking to elders, especially those in family, teachers or doctors and are rather found to be more comfortable with friends of their own age group. During this phase, they experience frequent mood swings and feeling of isolation and the likelihood of being misunderstood by elders and parents is relatively high. It is difficult for a young child to understand how challenging ‘parenting’ is.

Our government recognizes that every adolescent (irrespective of sex, age, caste, religion, marital status), like any adult, has the right to access information and services pertaining to his/her health, safety and opportunities to realize their full potential. Hence, the Rashtriya Kishor Swasthya Karyakram (RKSK) under the National Health Mission Programme of the Ministry of Health and Family Welfare, Government of India, aims to reach out to this special group either through service provision or through their peers. The approach is ‘friendly’ with a focus on building the skills and capacities of adolescents to resolve their health concerns with information, counselling, preventive and curative services from reliable sources only. The RKSK has six strategic priorities:

1. Sexual and reproductive health

2. Mental and emotional well-being

3. Healthy lifestyle

4. Violence-free living

5. Improved nutritional status

6. Substance misuse prevention

Adolescent Peer Education Programme, as the name suggests, is a new programme to establish information and support network among adolescents in a community. This can help them and their friends access scientific and reliable services with regard to health and development.


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1. To know about RKSK

2. To understand the significance of ‘peer education’ in RKSK

3. To understand how health services for adolescents can be ‘friendly’

4. To recognize how much time we give to our friends/friendships in our day-to-day life

5. To understand that peers (friends or people of same age group) influence most of our decisions

6. To understand that peer influence can be negative as well as positive

7. To recognize importance of positive peer influence

Time:

45 minutes

Material:

Chart papers; sketch pens

Methodology:

Brainstorming, group discussion, case study

1.1 Health Service for Adolescents – A ‘Friendly’ Approach

Tell participants that all of us will play a game named ‘Hot Seat’. The facilitator will read out some statements and they will have to tell the facilitator if they agree with the statement or not but without speaking. They can communicate their opinion in the following ways:

y If they do not agree, they should change their seat.

y If they agree with the statements they can remain seated.

y If they are not sure, then too they can remain seated.

After every question, a few participants will be given the chance to speak for their stand, if they wish to. However nobody is forced to speak. Also, when a participant is speaking no one else is allowed to intervene, talk or comment. You must tell participants that all opinions are respected and there is nothing that is right or wrong.

Tell the participants that there will be a vacant chair, so that even if only one participant wishes to change seat, he/she has a vacant seat available.

Activity 1

module I: adolescent peer education programme

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The statements are given below. Start with light statements to help them understand the game.

1. The training room is very cold.

2. Chocolates are better than halwa.

3. I love my family.

4. Honesty is the best policy.

5. Games are good for physical fitness.

6. I am proud to be selected for this training.

7. Jeans and shirt are comfortable.

8. Youth is the best phase of life.

9. Many adolescents in our country do not go to school.

10. For a sexual relationship, consent of both partners is imperative.

11. Child marriage ruins the life of boys and girls.

12. One should have children only after one has some savings.

13. Love marriage is better than arranged marriage.

14. We should always report any incidence of violence to the police.

15. Boys can be a change agent in reducing violence against girls.

16. Having access to information on sexual and reproductive health is the right of an adolescent irrespective of sex, caste, class or marital status.

17. I have a right to choose my partner and plan my children.

18. When girls say ‘No’, it means ‘No’.

19. Doctors and police can be trusted to share our concerns.

After every statement, ask a few participants to provide reasons for their stand if they feel like doing so. Don’t share your opinion at all nor give any kind of inclination that you agree or disagree with any participant’s opinion.

Ask participants if they have ever visited a doctor at the PHC or district hospital. Ask if they are comfortable visiting the PHC and how many are not. Ask some of them to say why. Some of the responses could be as follows:

1. The doctor there is good.

2. The doctor is moody.

3. Got a scolding from the doctor.

4. The receptionist is very inquisitive.

5. People are suspicious if we visit the health centre.

Activity 2


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Narrate the stories given below and ask what the character in the story will do and where he should go.

Story 1: Nagendra has been very uncomfortable the whole day. He has itchiness in his private parts and feels very embarrassed to scratch in front of friends and elders. He didn’t even go to school. He had applied some talcum powder, but it didn’t help him. Nagendra thinks of going to a doctor but is shy to tell this to doctor and fears that the doctor might misunderstand him.

Story 2: Nikhat is a Class 9 student. She wants to become a journalist. Sometimes Nikhat gathers her siblings and friends and acts like a TV anchor posing questions to them. She is very active in co-curricular activities and participates in every competition like debate, dance and quiz in school. But since last few months Nikhat spends more time sitting and chatting. She doesn’t go out to play with friends. When parents and friends ask her, she says she is tired. One day Nikhat’s friends brought her home and informed her parents that she had complained of dizziness. Her parents tell her that this is because she is playing too much and should instead save her energy for studies and house work. Nikhat is feeling low.

Story 3: Roopa has recently got engaged. Her fiancé often asks her to come with him to the cinema. One day when she accompanied him, he took her to a friend’s house and had sex with her. Roopa loves her fiancé very much and hence could not say ‘No’ to him. But now she is scared as her periods have got delayed. She doesn’t know whom to talk to.

Now discuss the situation of Nagendra, Nikhat and Roopa with the following questions:

1. Why can’t Nagendra, Nikhat and Roopa go to the nearest doctor or talk to parents for help?2. Will Nagendra, Nikhat and Roopa face anger and stigma if they discuss it with elders?3. Do they fear that their secrets will get disclosed if they tell elders?4. Who can help Nagendra, Nikhat and Roopa?


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Ask participants, what can be done to assure Nagendra, Nikhat and Roopa so that they can visit the health centre, nearest doctor or health service provider for help. Inform adolescents about the RKSK, explaining the four components.

Summarize with following:

1. Information, counselling and services on adolescent health concerns including sexual and reproductive health issues (both preventive and curative services) are the rights of every adolescent.

2. ‘Friendly’ adolescent health service is the one that

� Respects adolescent clients

� Ensures privacy while discussing problems with the doctor

� Tries to minimize waiting hours

� Maintains strict confidentiality about the concerns of the adolescent client

� Does not stigmatize them

� Does not judge their behaviour

� Promotes adolescent health check-up to lead a healthy future

� Helps adolescent clients identify the root cause and take positive steps to avoid such situations in the future.

Inform adolescents that the adolescent health services are being provided by the Department of Health and Family Welfare at the sub-centres, primary health centres, community health centres and at the district hospitals. Service providers like ASHAs, ANM and counsellors are the key contacts for information and referral services. Inform the participants how they can help their friends and peer adolescents access friendly health services later on.

1.2 Peer Education – Reaching Adolescents through Their PeersPeers are people of your own age group. During adolescence, we make new friends and spend most of our time with our friends. Our likes and dislikes are influenced by our friends and others of our age. However, most of the time, this influence is gradual, and hence it is difficult for young people to assess its impact on their own behaviour and attitude. Peers also exert pressure that could be positive or negative. At times, many young people end up doing things they would not have done on their own. This exercise provides many opportunities for discussion on the pros and cons of peer influence.

Divide all participants and make them sit in pairs as they did during the introduction. Ask participants to choose one day of the week and prepare an hour-wise account of their engagements on the chosen day from the hour they woke up till bed time. Explain that the daily diary should list all those people they met or spent time with (it could be parents, teachers, siblings, friends or anyone else). They should also describe their time spent in school or in field or in a market or in a shop according to their daily engagements.

Activity 1


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Once each pair has prepared their day diary, discuss it in the larger group. Divide the flip chart in two columns. List hours in one column and engagements in the other. Ask participants to help you list out their work on the common chart.

For example the daily diary for boys might be something like this:

6:30 am–7:30 amFreshened up and went for walk. Met friends, sat at the tea corner, had tea with friends.

7:30 am–8:30 amWalked back home with friends. Went to Shyam’s house on the way. Fixed up cricket match for afternoon.

8:30 am–9:30 am

Had bath, breakfast and went to school. Chatted with friends.

Had breakfast, went with father to help him in the fields.

Went to the shop for work (ask whether they have friends of same age group at work)

9:30 am–2:30 pm

Studied with other friends.

Went for games class.

Chatted with friends during recess.

Confirmed plans for match in the afternoon.

Returned home with friends.

2:30 pm–3:30 pm

Had lunch

Went to give father his lunch at the shop/work place.

Went to the market to fetch things required by mother and sisters.

Took sister to her friend’s house.

Went for the cricket match.

3:30 pm–4:30 pm Played cricket.

4:30 pm–5:30 pm Played and went to samosa shop after match as treat from the losing team.

5:30 pm–6:30 pm Chatted with friends and discussed the match.

6:30 pm–7:30 pm Returned home with friends.

7:30 pm–8:30 pmWent to the market/relatives’ house to get something or deliver as instructed by father or mother; met Raju on the way. Went together and cousin of same age group came up to my house when I was returning. We chatted on the way.

8:30 pm–9:30 pm Spent time with siblings. Fought with sister. Studied and had dinner.


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The daily diary for girls may look like this:

6:30 am–7:30 amFreshened up, made tea for family. Prepared breakfast. Spoke to girl next door, a friend, Sushma and her brother Rajeev and their mother.

7:30 am–8:30 am Prepared breakfast, got ready for school and went with friends.

8:30 am–9:30 am Chatted with friends – Rani, Geeta, Hema

9:30 am–02:30 pm

Studied together with friends in the classroom; went for games, played; went for SUPW class (stitching or other socially useful and productive work).

Went home with other friends.

2:30 pm–3:30 pmHelped mother with household work. Shared with her my talk with my friends and other school experiences

3:30 pm–4:30 pm Chatted with friends.

4:30 pm–5:30 pm Chatted with friends; sibling sisters, cousins

5:30 pm–6:30 pm Preparations for dinner

6:30 pm–7:30 pm

Went to Sushma’s house to fetch something required by mother; chatted with her for 15 minutes while her mother was getting the things.

Came home along with Sushma and prepared tea for everyone.

7:30 pm–8:30 pmHelped mother with dinner.

Did my school work.

8:30 pm–9:30 pm(Leisure time with family) Sat outside with mother, father, sister and brother and Sushma and Anjana’s family, spent some time with them and listening to our parents’ conversation.

At the end, help participants recognize amount of time spent with friends during the entire day. At the same time, point out the difference between the amount time spent by boys and girls with friends. Highlight that while there may be risks for boys due to unsupervised time spent outside home, there are consequences of girls’ restricted mobility. Confinement to the house prevents girls from engaging in healthy peer group interactions, learning new things, and taking advantage of other opportunities to enhance their knowledge, self-esteem and other skills to lead a healthy life. It is important for both boys and girls to engage in healthy peer interactions.

Explain to them that it is very natural that we are influenced by those with whom we spend maximum time; we see from this exercise that in this age group, we spend maximum time with our friends, or even if we do not, we wish to be with them as much as possible.


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Summarize the activity with following:

1. During adolescence, one spends or likes to spend maximum time with people of own age group.

2. Adolescents make friends fast and in big numbers.

3. There is a bond with friends that becomes much stronger than other relations. Adolescents trust the wisdom of friends more than elders including parents.

4. If one has to seek help, one approaches a friend who may also be uninformed or may have incorrect information which could be dangerous.

5. A friend who is informed and trained is an asset.

6. The Adolescent Peer Education Programme is an effort by the government to train the participants to be friends who will be assets to any adolescent in the community and outside.

7. The participants will be a link between the service providers and adolescents who may require help with regard to health and protection.

Key Messages

1. Adolescent Peer Education Programme is a way to reach out to adolescents to help them resolve their

health concerns.

2. The approach is based on ‘Trust’ and ‘Confidence’ of a friend, peer.

3. The peer educator is the most important link in the programme.

Role of a Peer Educator, A ‘Trusted Friend’

1. Identify and reach out to adolescents (girls and boys) between 10–19 years irrespective of their gender, caste,

religion or marital status.

2. Respect every adolescent and assure him/her that you are a friend.

3. Build rapport in the community and win the trust of peers.

4. Inform and educate adolescents about the Rashtriya Kishor Swasthya Karyakram.

5. Maintain confidentiality and trust with adolescents of all age groups by never disclosing anybody’s concern to

anyone else.

6. Never make fun of any adolescent, try to support or protect those who are being targeted.

Refer to Peer Educator Resource Book to deliver messages

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Session 2Peer Educator – A ‘Trusted Friend’

IntroductionAdolescents are cocooned, for better or worse, in a network of like-minded peers. From best friend duos to a broader circle of close friends, acquaintances and cliques, they are literally surrounded by a world in which adults seem less and less relevant. Many adults view this trend with alarm, especially when it occurs within their own families. ‘Peer pressure’ is the umbrella term used by many parents to describe negative aspects of the world of peers. While peers may indeed influence and steer each other in a dangerous direction, their social interaction also fuels other types of influences – support for each other, modelling of different behaviour, rapport that adults can rarely equal and trust that is more freely given.

Peer education is a process whereby well-trained and motivated young people carry out informal or organized educational activities with their peers (those similar to themselves in age, background or interests) over a period of time aimed at developing their knowledge, attitudes, beliefs and skills and enabling them to be responsible for and protect their own health. Peer education can take place through individual contact or in small groups. It can be conducted at a variety of settings like in schools, playgrounds, friend’s house, tea stall or any place where young people gather for recreation/leisure.

Peer education is an initiative under the Government of India’s RKSK to reach out to adolescents through trained educators of their own age group and socio-cultural background on a range of issues important for their health, safety and overall development.


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1. Learn the qualities of a peer educator and his/her role

2. Learn about 10 core life skills one uses in day-to-day life

3. Practise effective communication

4. Get acquainted with the profile of mentors and how can they reach their mentors

5. Learn about the role of peer educators in community and documentation of their work

Time:

2 hours 30 minutes

Material:


Methodology:


2.1 Becoming a Good Peer Educator

Friends and Friendship Ask all participants to stand in a circle. Give a word ‘Friend or Friendship’ (Dost or Dosti) and tell the participants that they have to make a sentence using that word. Each participant has to take a step forward inside the circle with his/her right hand on the chest as he/she vouches for friend/friendship and speaks the sentence he/she has made. You may initiate the game with your sentence on friend or friendship. For example, Anjali comes forward and says, “My friend is my belief.” Other sentences might be as follows:

y Friendship is the most beautiful feeling in the world.

y A friend in need is a friend indeed.

y Friends are forever.

y To have a friend is like having a god.

y True friends are always supportive and give right suggestions.

y Friends don’t complain.

y My mother is my best friend.

y Friends keep secrets.

Activity 1


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When all participants have presented their sentences, summarize all the good qualities of friend and friendship. Ask them as why they feel that a person (classmate, peer [hum-umr], mother, brother, sister, neighbour, teacher) is their good friend. What qualities do they like in them? Do they know that someone else might have similar thoughts about them as well, that someone might trust them as their true friend? Tell the group that this training will help them to strengthen their qualities of being a ‘Trusted Friend’.

Knowing My Peers Get a plastic ball of medium size. Make the participants stand in a circle. Explain the rule of this game. One of them will start the game by throwing the ball to a co-participant whom she/he knows and call out his/her name at the same time. This game will show who remembers the names of most co-participants. This helps in bringing participants closer to each other and reduces barriers in free interaction. Whosoever has taken more time in throwing the ball or has called out a wrong name should move out of the circle. It has to be played fast. Whoever remains till the end is the winner.

At the end of the game, ask the participants to share their experience and what have they learnt from this game. Ask those whose names were called out wrong how they felt.

Learning

As a peer educator or a true friend one has to increase acquaintance with more and more youth in our community and try to reach most of them with our messages. This can be effective only if we are able to win their trust as true friends. Having a common knowledge about the adolescent/youth, being sensitive to his/her likes and dislikes irrespective of his/her social, educational or economic background helps in bringing people closer. This reinforces trust between two people. As a true peer educator, one should not discriminate against any adolescent and always try to include all those in the larger youth group, who are otherwise excluded in the community. Remembering the names of peers is a step towards this. This shows them that they and their friendship are valued.

Activity 2


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Trust BuildingPlay the Game ‘Blind Car’. Ask the participants to stand in a line according to the starting alphabet of their names. Divide them in pairs in the same order. Ask one in each pair to become a car and the other the driver. The person acting as the car will have both eyes closed but the driver will have both eyes open. The driver will stand at the back of car and will manoeuvre the car with his/her hands. If the driver puts both hands on two shoulders, the car should move straight without any turning. When the driver takes off his/her right hand from the right shoulder, the car turns right. When the driver takes off his/her left hand from the left shoulder, the car turns left. If the driver takes both hands away from the shoulders, the car should stop immediately as there is a risk of crash. The facilitator blows the whistle and the driver starts the car by putting his/her hands on the shoulders. Let the participants enjoy this. After some time ask them to change their roles and repeat the exercise. At the end, ask all of them to stand together and speak about their experiences. Some experiences would be as under:

y It is difficult to trust the driver with closed eyes.

y The driver should be an expert to drive the car well.

y My driver never caused any accident.

y I just followed my driver’s hands and I was safe.

y My driver gave wrong instructions.

Summarize the game and reinforce required qualities of a ‘Friend’ and so for a ‘Peer Educator’ with the following:

y In real life we are (can be) drivers for our friends and manoeuvre our friends in the right direction to bring them out from risky situations and save them from mishaps.

y At times we ourselves may need such drivers.

y We should know that it requires some skill, time and practice to be a consistent and good driver. The same is true about becoming a good friend and a peer educator.

y A good peer educator is a person whom you can trust.

y A good peer educator enjoys the confidence and respect of peers.

y A good peer educator is a person with whom one can share secrets.

y A good peer educator never judges anyone (by saying you are wrong or ‘how could you do this?’)

y A good peer educator helps peers resolve their concerns in a positive way.

y A good peer educator helps peers to overcome fears, guilt, shame and return to normal path of development.

Activity 3


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2.2 Your Role as Peer Educator for Adolescent Health and Development

Ask the participants what in their opinion is their role as peer educators for adolescent health and development. Note down the responses. Add to the list if required and explain that the role of a peer educator in the RKSK would include the following:

1. To prepare a list of all adolescents between 10 and 19 years of age in the village (or in area assigned to you) in phased manner (first 15-20 followed by another 15-20 and so on) with the help of the ASHA, who is the Peer Educator Coordinator.

2. Reach out to all adolescents irrespective of religion, caste, class, gender or marital status. Include adolescents from the most marginalized communities.

3. Select a volunteer to communicate and co-ordinate with each group in your absence, for example, to convey session date to group members; connect adolescent to Peer Educator in case help is required.

4. With the help of the ASHA, talk to village elders like Sarpanch and Mukhiya or the school principal to allot you a space either in the Panchayat Bhawan, school, community centre or even a peer house, to conduct group sessions. Ensure that the space is easily accessible, safe to reach, and is acceptable to the community so that young people don’t face any resistance from parents to visit the place.

5. Build rapport with adolescents, tell adolescents that you are new, but may be of some help to them and you can also put them in touch with the right people if any help or service is required.

6. For each group you have formed, fix a day for holding the sessions and inform group members about the days and your contact details, in case any help is needed.

7. Invite them for sessions or try to establish informal interaction with them.

8. Conduct weekly sessions as given in the Resource Book

9. Help adolescents clarify myths and misconceptions with regard to health and protection issues

10. Put a question box outside the Panchayat Bhawan and in schools for adolescents to put queries. Address the queries, with the help of handbook and the ASHA or ANM.

11. Provide referral service with regard to medical or protection needs of adolescents in crisis with the help of the ASHA or ANM.

12. Maintain confidentiality always.

13. Inform police or child protection officer if you know about any case of violence in the community especially against children and adolescents.

14. Help the victim of violence reach medical care and counselling and get access to legal aid.

Reiterate that peer educators are the most important link in the RKSK.

Activity 1


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2.3 Core Life Skills and Effective Communication

Life SkillsWhat do they know about them? Explain that all of us possess certain skills. For example, writing, painting, cooking, dancing etc.

Distribute two or three flash cards (square or rectangle piece of coloured or white chart paper) to each participant, and ask her/him to write the most important skills she/he possesses. Allow the participants 5 minutes to do this.

Invite the participants to display their flash cards by spreading them out on the floor and then group similar cards. Ask if the cards represent most of the skills required for leading a healthy and productive life. If not, ask them to add more skills.

While the participants are busy doing their work, prepare three flash cards with the following headings:

y All of us have them

y Some of us have them

y None of us have them

Place the three cards next to each other. After the participants have finished the listing, ask them to group the flash cards as per the above headings.

Once this is done, you should be able to draw a matrix of rows and columns on the floor. You should have three columns and as many rows as there are ‘skill’ cards. Ask the participants to start from the first column and put in all cards that fit to the heading “All of us have them”. Do the same with the other two columns.

Once the matrix is complete, invite one or two volunteers to copy it on a chart and put it up on the wall. Ask the participants to discuss the following points:

y Why do we feel that some of the skills are possessed by all of us? Are these essential skills for living life? Why?

y Do you know that many adolescents of your age group such as those who are illiterate or differently abled may not even have the essential skills?

y Do you think you can help them to compensate for the essential skills? What other skills do they have?

y Why is it that not everyone possesses all skills?

y Why are certain skills missing from our group?

y Do we need some skills to deal with daily life situations – say to solve a problem, to help a friend or to communicate our feelings?

Activity 1


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Summarize and close the discussion by using the WHO definition of life skills. Explain to the participants that there are 10 core life skills that we are likely to use in our day-to-day life. Enumerate and explain these life skills.

UNICEF, UNESCO and WHO list the 10 core life skill strategies and techniques thus: Problem solving, critical thinking, effective communication skills, decision making, creative thinking, interpersonal relationship skills, self-awareness building skills, empathy, and coping with stress and emotions. These can be categorized mainly as under:

Thinking Skills

y Self-awareness

y Problem solving

y Decision making

y Critical thinking

y Creative thinking

Social Skills

y Interpersonal relationships

y Effective communication

y Empathy

Negotiation Skills

y Managing feelings/emotions

y Coping with stress


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Divide the participants in groups. Provide each group with a photocopy of some of the situations given below. Ask each group to read it and discuss it and identify one or more of the 10 core life skills required to address the given situation.

Then ask the groups to present their discussions. Encourage the participants to answer and listen without any bias.

Situations

(The hints for appropriate life skills are only to be seen and used by the teachers.)

1. Chon Chon is in Class 9. She wants to be among the top performing students in her class. She is an average student and has been scoring about 60% marks. She decides that she will make every effort to score higher marks. She now studies a few hours every day. (self-awareness, critical and creative thinking)

2. Imtiyaz was a very good student. His father was ill for some time. Imtiyaz failed in the exams. His best friend said that he understood Imtiyaz’s position and was sad about it, but that Imtiyaz should not lose hope and that he should start his studies again. His friend said that he would help Imtiyaz to cover all that he missed during his father’s illness. (empathy, effective communication)

3. Mohit is not very good in studies. He is not able to cope with the curriculum. He needs extra help. He is not able to share his problem with his teachers or his parents for fear of being scolded or ridiculed in front of his friends. (self-awareness, coping with stress, problem solving, effective communication)

4. Josie has lost her father’s expensive watch. She had taken it to school without asking him. She is very scared that if her father gets to know, he will be very angry. She is very depressed and does not know what to do. (coping with stress, conflict resolution)

5. Raghu is very close to Pawan. One day Pawan brought a bottle of alcohol and said they should enjoy themselves. Rajesh believes that drinking is not good for them and they should not drink. Pawan doesn’t like his friend’s response and insists. (critical thinking, assertive communication – learning to say ‘No’, managing interpersonal relationships)

6. Lubna comes to know that one of her close friends is spreading bad rumours about her in the class. She feels betrayed and heartbroken. She doesn’t want to break off her friendship as they are childhood friends. (Decision making, coping with emotions, coping with stress, problem solving)

Tell the participants to remember all these core life skills as they will practise them throughout the training.

Activity 2


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Effective CommunicationTell participants that effective communication is the most important quality of a peer educator as he/she needs to communicate with adolescents between 10–19 years. As peer educators they have a huge responsibility to be clear, honest, sensitive and responsible in communicating with peers and other community stakeholders.

Ask all the participants to stand in a circle. Tell them that you will say something in the ears of one participant and he/she should pass it on by repeating it in the ears of the second, and so on in a clockwise manner, till the last participant reaches the first. Then ask the last in the circle to say the sentence loudly. Ask the first one to inform the group whether the sentence is the same or not.

The sentence may be ‘The doctor asked the ANM and ASHA didi to select active, smart, lively boys and girls from the village to come for the training on Peer Education on Adolescent Health at the PHC, village name, on date’ or ‘Today my brother’s friend told me that his sister’s cow has given birth to a calf and we should go see it in the evening’.

The facilitator can choose a suitable sentence.

By the end, the sentence being said by the last participant may be grossly distorted to something like ‘The doctor will train ANM and ASHA at the PHC’ or ‘My sister gave birth to a baby.’

One notices that when a sentence travels from one person to another, there is loss of information and sometimes the information becomes completely wrong and that could be misleading. Hence, one should be very clear and alert while communicating with other people.

Request two volunteers. Tell them to demonstrate how they as peer educators will contact an unmarried adolescent of 12 years and another married adolescent of 19 years. They have to accomplish the following:

y Establish contact

y Learn their name, age and education

y Ask for their contact details i.e., phone, address

y Introduce themselves

y Introduce the Rashtriya Kishor Swasthya Karyakram of the government

y Inform the adolescents about their work as peer educators

y Enlist their consent to receive invitations for and attend sessions

y Seek consent of the adolescents’ parents

y Convince any community stakeholder who may have objection in their talking to the adolescents

y Tell them who all from the government are with you

y Practise being good listeners; communicating means listening, understanding the other person’s view and talking

Activity 3

Activity 4


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Ask them to enact it as a short role play. Ask some adolescents to act as 10–12-year-old who is busy doing his/her own activities and not interested in the peer educator and some as 19-year-olds who have a lot of work to finish.

While volunteers perform, keep encouraging other willing participants to replace the peer educator if they have different ideas to attract the adolescents. Point out the ‘DOs’ and ‘DON’Ts’ demonstrated through the role play. This is a form of ‘Forum Theatre’ that involves the audience coming up with innovative ways and statements to solve a problem.

Summarize the activities with the following:

1. When one communicates, it is not only words but also the body language of the speaker that counts.

2. While communicating, use simple and straight words that are understood by your audience easily.

3. Be sensitive to the other person’s needs, culture and tradition.

4. Always greet peers and other community stakeholders in age-appropriate ways.

5. Show younger as well older adolescents that you respect their feelings and care for them.

6. Your body language and words should assure them that you will not make fun of them and that you are serious about your work.

7. If you are busy with your friends and a peer or a community stakeholder comes to meet you, make time for them.

8. While communicating, take care not to hurt the sentiments of peers and elders.

9. If you are in situation of conflict, be assertive in communication, but do not let aggression set in.

10. Keep your cool while talking.

11. If you are angry or upset on a personal level, do not go on assignment or take a session.

12. Refrain from making false promises, but do assure that you will try your best to help.

Tell participants that they will learn more about effective communication in other sessions.

2.4 Know Your CoordinatorsTell participants that they are not alone in this task. They will be supported by the selected ASHA didi, ANM and teacher in their village, who have been oriented about the peer educator’s role. Introduce the Peer Educator Coordinators to the peer educators. Provide a village-wise list of peer coordinators and their contact details to the peer educators. Tell them that the Peer Coordinators will contact them at least once in two weeks but they can contact them any time they need any support.


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The role of the peer coordinators is:

1. To facilitate and support peer educators and their activities

2. To help them reach out to adolescents

3. To help them resolve any problems in carrying out their work

4. To ensure quality of messaging

5. To help adolescents clarify myths and misconceptions and answer queries put in the question box set up at the Panchayat Bhawan or school

6. To provide referral to the adolescent clients brought to them by the peer educators

7. To help peer educators maintain a daily diary of their work and submit a report at the end of every month

Give a sample of the Daily Diary format that peer educators need to fill with the help of the mentors. Explain the formats and refer to these formats after every training day to help peer educators understand the format well in the context of ongoing sessions.

A. For one-to-one interactions

Date/Month/Year

S. No. Name of Adolescent/Stakeholder Reached (To be kept confidential)

Sex (M/F)

Age (Years)

Issue/problem Discussed

Referral Slip Issued, if any

1. Sagar M 15 Effects of smoking

No

2. Anil M 17 Only problem. Not diagnosis Pain during urination

Yes

B. For group interactions

Date/Month/Year

S. No. Venue Name of Participants

Sex (M/F)

Age (Years)

Issues discussed

Referrals, if any


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C. Weekly/Monthly Compilation Sheet

Month and Year (May 2014)

Week Days

M T W T F Sa Su Total

Week 1

No. of adolescents reached between 10 and 14 (male)

No. of adolescents reached between 10 and 14 (female)

No. of adolescents reached between 15 and 19 years (male)

No. of adolescents reached between 15 and 19 years (female)

No. of group sessions conducted

No. of adolescents referred for ARSH services (male and female)

No. of cases of GBV reported (male and female)

No. of cases of GBV reported (male and female)

• Child marriage• Sexual abuse• Domestic violence (including

torture for dowry)• Corporal punishment

No. of community awareness and advocacy campaigns organized


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D. Action Plan/Content Check List for Peer Educator (to be maintained for one or more peer groups being facilitated by each peer educator)

Peer Group: (Name of the group to be chosen by group members )

Sessions/Topics to be covered by Peer Educator through Group Sessions (Those covered should be ticked and those not covered can be crossed)

Pubertal changes Menstruation Nightfall Personal hygiene

Gender identity Respecting diversity Under-nutrition and anaemia

Risk factors for health conditions related to life style

Dealing with peer pressure

Preventing substance misuse (alcohol and smoking)

Managing emotion and stress

Minimizing risks to prevent accidents and Injuries

Child marriage Preventing adolescent pregnancy

RTIs and STIs Preventing HIV and AIDS

Responding to violence against children/adolescents

Preventing gender-based violence (violence against adolescent girls and women)

Knowing our rights and entitlements

Community sanitation and hygiene

Pre-and post-session Information :

1. About Rashtriya Kishor Swasthya Karyakram, MoHFW

2. Introducing Peer Educators and Peer Mentors (ASHA, ANM)

3. Informing about providers and service delivery points (including referral service) to seek services and help if required

module II growing up

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Session 3Adolescence – Transition to Adulthood

IntroductionAdolescence is a period of formative and dynamic transitions, when young people take on new roles, responsibilities and identities. It is a period of life changes and young people attempt to achieve autonomy from their parents/guardians. Adolescence also marks cultural transitions through traditions. At the same time, for many it is the transition to work. During this period, health behaviours which will last long into adulthood can be strongly influenced as during adolescence values are firmed and vocational skills are developed. Gender norms, notions about appropriate reproductive and sexual behaviour and awareness of such issues are shaped during adolescence. It is widely acknowledged that adolescents are the most impressionable target for imparting information relating to basic principles of preventive health care. Hence, it is important to educate adolescents on the challenges of growing up and help them enhance their knowledge and skills to manage their concerns positively.


1. To recognize and understand physical changes during adolescence

2. To understand the female reproductive system

3. To understand menstrual cycle and its hygienic management

4. To understand the male reproductive system and facts about nightfall

5. To learn about the personal hygiene and nutritional care needs during growing up

6. To dispel common myths and misconceptions around growing up with scientific information

Time:

90 minutes

Material:

Printed copies of given case study; educational materials like chart with male and female human body with each body part labelled; chart depicting pubertal changes (like apron job aid); blank chart papers; sketch pens.

Methodology:

Brainstorming, group discussion


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3.1 Pubertal Changes/Process of Growing Up Adolescence is the phase of growing up from childhood to adulthood. The process of physical and sexual maturation of boys and girls is referred to as puberty. The major pubertal changes include the growth spurt in which the size and shape of the body changes markedly and the difference between boys and girls are accentuated with appearance/prominence of secondary sexual characteristics. With physical changes, an adolescent also undergoes changes in emotions, cognitive abilities and social behaviours. These changes are normal and together influence the behaviour of an adolescent in any given culture or society.

Divide participants into small groups and ask them to identify a group leader. Give one case study to each group with discussion points. Ask one of the group members to read out the case and discuss the given questions.

Case Study from a Girls’ Perspective:

Sarita is a cheerful 13-year-old girl. She has two brothers, one 15 years and another 12 years old. She is very popular in school and very dear to her brothers. When she plays kabaddi, even boys are not able to match her energy levels. She challenges opponents with ‘Kabaddi, kabaddi, kabaddi…’ for a long time. All the children want to be in her team. But for the past few days, Sarita’s grandmother has started objecting to her playing. One day she told Sarita’s mother, “Why does your daughter always run around, can’t she walk slowly? Can’t you get her a salwar-kameez stitched and also a dupatta?”

One evening, when Sarita’s friends called her to play, her mother refused and asked her to make chapatis and take care of her grandmother. When Sarita insisted, her mother told her that she could only visit the neighbour’s house in her leisure time and that she should start knitting a sweater for her father. However, Sarita’s brothers were not given any such instructions and they continued to go out with friends in their leisure time. Sarita is sad and confused. She is standing in front of the mirror and thinking, “Am I different? How?”

Discussion Points:

1. How does Sarita feel? 2. Why did her grandmother oppose her playing kabaddi and want her to wear a salwar-kameez

and dupatta?3. What would Sarita feel, as her brothers have not been stopped from running, going out with

friends or asked to change their dress?4. Are restrictions (like the ones on outdoor games and choice of dress) imposed by Sarita’s

grandmother and mother unfair? Why?5. Do you think her grandmother and mother should talk to Sarita about onset of puberty and

growing up?

6. What are the other concerns among adolescent girls?

Activity 1

module II: growing up

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Case Study from a Boys’ Perspective:

Dileep and Zahir are close friends and study in Class 9. In the last one year, Zahir has become much taller and has a thin line of moustache as well. His voice has also changed. Dileep who is of the same age is shorter. His classmates often make fun of Dileep’s height. Dileep is upset and stops going out with friends. Zahir tries to console his friend and shares his feelings that even he feels bad having facial hair and rough voice and hates the red boils on face. In fact, he likes the way Dileep is.

Discussion Points:

1. What is the problem and who are suffering?

2. Do you think height and moustache are really a problem? Why?

3. Do you think Zahir is also suffering like Dileep? Why?

4. Is it fair to laugh at anybody’s physical appearance?

5. Do you think Dileep should talk to someone to resolve his issues?

6. What are the other concerns among adolescent boys?

Once discussion in smaller group is complete, invite the group leader to present the case. Pick up discussion points one by one in the larger group. Encourage participants to think about their own experiences and initial reactions. Next ask the participants to think about how an adolescent would feel if he/she does not undergo body changes like their peers. Some of the likely responses are listed below:

Adolescents’ reactions to body changes Adolescents’ reactions to slow or absent body changes as compared to peers

Surprised, anxious, stressed, fearful/afraid, tense, proud, important, happy, uncomfortable, confused as to how to behave; insecure

Anxious, stressed, fearful, inferior, insecure, inadequate, worried about their ‘abnormality’, anxious, socially withdrawn, depressed

Tell the participants that for any adolescent, getting familiar with the changes in his/her physical appearance is a challenging process. Besides, one also has to cope with associated emotions. For many adolescents it is extremely disturbing and stressful. It is accompanied with anxiety due to either early or late onset of puberty in comparison to peers. This is mainly because they are not informed and hence not prepared to deal with such changes and the reactions from elders and friends. Hence, it is important for every adolescent to know the process of growing up to overcome these challenges. However, frequent mood swings and temper are a part of this phase and are normal behaviour.


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Body Mapping Exercise (To be done separately for boys and girls)

Divide participants in two groups. Ask one group to draw an outline of a female human body, clearly depicting the different parts. Ask the second group to draw a male human body and do the same. Give them 10 to 15 minutes to complete the exercise. Invite one group at a time to present the group work and explain it to the others. Help participants to label different body parts (including male and female reproductive organs and secondary sexual characteristics). Explain the functions of different body parts with the help of a chart with male and female human body.

Summarize the activity with following:

y It is very important for every child to know about human body. This helps us to know our own body parts, their vital functions and how to take care of ourselves for improved well-being.

y Many parents do not educate children about sexual and reproductive organs. Some people feel that sexual and reproductive organs are private parts and hence any talk about them is shameful. Others may feel embarrassed as they do not know a comfortable and correct way to talk about our sexual and reproductive organs and related concerns. This may have negative consequences. For example, a child, whether a girl or a boy, may not communicate any ailment related to her/his private parts or may fear to complain or protest if being sexually abused or touched in inappropriate or in unwanted manner. The child may fear being criticised or being misunderstood and may suffer in silence.

y One should learn the correct and scientific terms used for body parts including our private parts like breast and vagina in females, and penis in males and practice using scientific terms to express our concerns clearly and in a respectable way.

Divide participants into small groups and ask them to separately list the changes in boys and girls when they are experiencing puberty. Once the discussion and listing is completed, ask the group to present it. Thank the participants for their inputs. Some of the likely responses are height gain, weight gain, menstruation, acne, facial hair.

Discuss pubertal changes in girls and boys with the help of the chart. Tell the participants that changes during adolescence include physical, emotional and psycho-social changes in adolescents. In this session we focus more on physical changes and will deal with emotional and behavioural changes in a separate session.

Activity 2

Activity 3


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Major Changes in Females

Major Changes in Males

Key Messages

Skin Hormonal changes make skin oily and result in pimples or acne.

Skin becomes oily, sometimes with acne.

Acne usually stops appearing regularly by late adolescence (after 18 years of age). It is not related to eating oily food or fantasizing. Medical treatment is now available.

Hair Hair growth under arms and in pubic area.

Hair growth on legs, chest, face, under arms and in pubic area.

The distribution of body hair is different in boys and girls due to the effects of male and female sex hormones. The age and amount of hair that grows varies for each young man and woman.

Breasts As breasts begin to grow in size and shape, the girl may initially feel some discomfort. Sometimes there can be tenderness in the initial phases.

Sometimes the breasts can become prominent; however this eventually will subside on its own.

In girls, the size of the two breasts may vary but this is normal and not a cause for concern.

Gynecomastia (breasts in males) needs medical treatment.

Extreme obesity can also lead to apparent enlargement of male breast tissue.

Body Size Widening of hips.

Enlargement and development of breasts, weight and height increase.

Shoulders and chest broaden; weight and height increase.

The height of an adolescent is influenced by the height of the parents, nutritional status and many other factors.

Voice Voice starts to crack. This happens due to growth of the larynx (voice box).

Female external genitalia and reproductive organs and physiological changes

Hair appears on external genitalia and becomes pigmented. Internal organs also enlarge.

Menstruation begins, there may be a whitish discharge due to physiological changes; ovum is released.

It shows that hormonal changes lead to maturation of an egg in the ovaries and the girl has the potential to become pregnant (but onset of menstruation does not mean that the girl is physically and mentally ready to carry a pregnancy as the uterus has not matured fully.)

Contd...


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Major Changes in Females

Major Changes in Males

Key Messages

Male external genitalia, repro-ductive organs and physiological changes

Hair appears on external genitalia which enlarge in size and become pigmented.

Semen is a body fluid that carries sperms and seminal fluid. Sperms are formed in huge numbers and flow out through semen. One may experience spontaneous emissions and erections. Sometimes spontaneous emission occurs during the night or when one is sleeping. This is normal. It is commonly known as ‘Wet dreams’ or ‘Nightfall ‘.

Wet dreams and erections are physiological processes and denote sexual maturity in the males. They do not require any medical treatment.

Emotional and psycho-social changes

Level of intelligence and cognitive abilities increase.

Frequent mood swings and temper.

Emotional vulnerability increases.

Level of intelligence and cognitive abilities increase.

Frequent mood swings and temper.

Emotional vulnerability increases.

Adolescents may behave differently and at times their behaviour is not understood by adults. No matter how difficult, they need continued love, guidance and emotional support from peers and elders to get through this tough phase successfully.


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3.2 Male and Female Reproductive Organs and Functions

Tell participants that it is important to be aware about both male and female anatomy and functions especially for older adolescents (15–19 years) as they prepare for adulthood. Divide participants into two groups, boys and girls. Ask the girls to draw and label female reproductive organs and ask the boys to draw and label male reproductive organs. (This exercise should be done with both male and female participants but separately). Once group work is completed, ask each group to present. Thank the presenters. Appreciate if drawings and labels are done correctly: if not, help them correct it through larger group inputs.

Female Reproductive Organs

Vagina

Fallopian Tube

Ovary

Cervix

Uterus

Male Reproductive Organs

Seminal Vesicle

Urinary Bladder

RectumProstate Gland

Vas Deferens

ScrotumTestes

Urethral Opening

Shaft of PenisUrethraHead of Penis

Summarize the activity by presenting the diagram (apron method can be used) on major male and female reproductive organs and their function.


Functions Female Reproductive Organs

Functions

External Reproductive and Sexual Organs

Penis with high nerve endings; 3–4 inches in length and 1.5 inch in diameter when flaccid in an average adult male

It is sensitive to sexual stimulation and is also the conduit for urination. During sexual intercourse, the erect penis enters the vagina (female

Vaginal opening between anus and urethral opening

The menstrual blood flows out through this opening. The urine and menstrual blood flow out through different openings.

Activity 1

Contd...


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Functions

reproductive organ) leading to ejaculation when the semen is released flows from the penis into the vagina introducing sperms into the female body. The sperm is motile and makes its way to the uterus where it may fertilize the ovum leading to pregnancy.

Semen is being secreted continuously in the male body and hence ejaculation of semen has no relation to sexual strength of a person.

The vagina is the opening through which sexual intercourse with the male partner takes place and sperms are released into female body for conception which results in pregnancy.

It is important to know that though thousands of sperms may travel into the female body during a single intercourse only one sperm is needed to fertilize the ovum for pregnancy.

Scrotum Holds and supports testes and vas deferens; temperature lower than body temperature – adequate for sperm formation.

Clitoris with high nerve endings.

Sensitive to sexual stimulation.

Internal Reproductive and Sexual Organs

Testes are two glands located in the scrotum.

Produce male sex hormones; produce and store semen – the fluid containing sperms.

Vagina extends from uterus to vaginal opening.

Sexual intercourse; passage to sperms ejaculated from male penis to the uterus; opening for childbirth.

Vas deferens are tubes or ducts connected to testes and urinary outlet in penis.

Conduit for sperm to travel to penis for ejaculation.

Uterus and cervix It is the site of menstruation, implantation of fertilized ovum and development of foetus during pregnancy. The opening between the uterus and the vagina is called the cervix.

Contd...


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Functions

Seminal vesicle: small glands located behind the urinary bladder

Open into ejaculatory duct. Ovaries are on both sides of the uterus with 3–5 lakh egg cells from the time of birth of the girl.

Every month, one of the two ovaries releases an ovum; the egg/ovum, if fertilized by a sperm, will get implanted in the uterus or else will be discharged through menstruation process.

Fallopian tubes emerge from the top two sides of the uterus, joining ovaries to uterus.

Passage for mature ovum to uterus; fertilization of ovum and sperm takes place in the fallopian tubes; fertilized ovum gets implanted in the uterus for development of the foetus during pregnancy.

Hymen (A membrane partially covering the inner opening of vagina)

Varies in size and shape; has no significance at all, may even be absent in some females from birth; wrongly linked to virginity of female as it may or may not rupture during intercourse or may rupture even during simple physical exercises like skipping or cycling or small accidents.

3.3 Managing the Menstrual CycleThe menstrual cycle and its hygienic management is an issue that every female has to deal with but still is the most difficult subject for many to discuss. The religious and cultural norms associated with it pose barriers for girls to seek the knowledge and skills required for its hygienic management. This results in their low attendance at school, low self-esteem and inactive life at home and outside. Poor hygiene may also lead to inflammation and infections. Hence, it is very important for women and girls to have the knowledge, facilities and cultural environment to manage menstruation hygienically and with dignity.


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Divide participants into small groups. Give them a case study to discuss among themselves and prepare a presentation:

Nagma is a very bright 12-year-old student of Class 6. One day when she was in the classroom she felt a slight wetness in her underwear. She decided to ask the teacher’s permission to go to the washroom. While she was walking to the teacher, a friend hinted her that there were stains on her clothes. All the other students started looking at her. Nagma felt very embarrassed and quickly ran out of the class without even talking to the teacher. Nagma is scared and doesn’t know whom to tell. She doesn’t want to go to school next morning.

Discussion Points:

1. Why do you think Nagma was scared?

2. Was this Nagma’s first menstrual cycle?

3. What could have helped Nagma avoid such embarrassment?

4. Whom should Nagma talk about this?

5. Is our school prepared to take care of our menstrual management needs?

6. What all one need to manage one’s menstruation?

7. Do you think Nagma is responsible for this embarrassment?

8. Can teacher or friends be of some help? How?

Once discussion in small groups is complete, take it in the larger group. Invite the group leaders to present their respective work and then invite others to add or present their opinion. Summarize the activity with the following facts on menstruation:

What is menstruation?Menstruation is a normal physiological process that starts between 12 to 14 years of age in a female and continues till late 40s or 50s. It is commonly referred to as periods or monthly cycle.

Why is the onset of menstruation and the monthly cycle stressful for adolescent girls?Lack of information and knowledge leaves adolescent girls unprepared to manage their menstruation with hygiene and dignity. Social norms related to menstruation are restrictive for girls and mostly surrounded by myths and misconceptions. This leads to unnecessary fear, embarrassment and shame among adolescent girls.

What should adolescent girls do to overcome fear, pain and discomfort? y Adolescent girls should not feel ashamed or guilty of having menstruation; they should follow daily

routine with a bit of extra nutrition and hygiene during these days.

Activity 1


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y The pain in the lower abdomen and heaviness is common and can be eased by having hot water bath, hot drinks, light exercises like walking, stretching etc. This will help improve blood circulation and lessen pain.

y They should use disposable sanitary napkins to prevent staining of clothes and inflammation /itchiness in private parts. In case sanitary napkins are not available, one can use old soft cotton cloths, washed and dried in the sun. Napkins should be changed at least three times a day.

y Sanitary napkins can be disposed of by dumping into a deep pit, burning or putting them into a waste-bin for waste processing.

y They should have daily bath and clean private parts with water and a mild soap.

Where one can get disposable sanitary napkins? y Ministry of Health and Family Welfare has a scheme promoting menstrual hygiene among adolescent

girls (10–19 years) in rural areas. Under this scheme sanitary napkins are available at a subsidized rate of Rs. 6 per pack (6 pads in each pack) under the brand name ‘Freedays’. These can be bought from the ASHA didi in your village.

y All chemists and general stores keep sanitary napkins. You can choose and purchase from a wide range to suit your need, comfort and budget.

y The ARSH services at sub-centres, PHC and CHC as well as the ANM, ASHA and Anganwadi didis also provide counselling and services on menstrual management.

Small actions at family and community levels that can help girls and women manage their menstrual cycle with hygiene and dignity

y Make cheap/affordable sanitary napkins available.

y Set aside a budget for sanitary napkins for female members of the family or keep properly washed and sun-dried old cotton cloths available.

y Provide soap for washing, allow sun-drying of used cloths and clean and closed space to store them safely.

y Schools should have a female teacher/counsellor to inform and help girls in crisis situations with free sanitary napkins.

y Schools should have separate washrooms for girls with water, soap and disposal facilities.

y Be sensitive to nutritional needs of adolescent girls and give them time and space to rest if they require during menstrual cycle.

y Educate community that menstruation is not ‘unclean’ or a ‘polluting’ event. If managed hygienically, girls can carry out all activities (including daily bath, schooling, outdoor games, cooking and even perform religious duties) with comfort and dignity.

y Explain about safe disposal of sanitary napkins: burying them or burning them in incinerators where available.


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Explain the menstrual cycle in detail with the help of charts/aprons/slides.

Fertile

Time

Bleeding Begins

The Menstrual CycleAbout 28 Days

12

34

5

6

7

8

9

1011

1213141516

1718

19

20

21

22

23

24

2526

2728

The menstrual cycle is about 28 days, varying from 21–35 days from woman to woman.

Cycle begins (1–3 days) Lining of the uterus sheds. The brain begins to produces a hormone (GnRH), which helps the egg to mature in the ovary.

Early days (3–10 days)Within days after menstrual bleeding begins, the endometrial lining begins to rebuild, stimulated by increased production of a hormone secreted from the ovary.

Near mid-cycle (10–16 days)Around mid-cycle, the egg is released from the ovary (ovulation). The inner lining of the uterus becomes thicker and its blood supply increases, preparing the lining to accept an embryo if fertilization and implantation occur. This is also the most fertile period of the cycle.

An unfertilized egg lives only up to 24 hours after ovulation. However, sperm cells can live as long as 3–5 days in the female reproductive tract. If sperms are present as the egg travels from the ovary through the fallopian tube, fertilization can occur.

Activity 2


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Late cycle (21–28 days) If the egg is fertilized, production of hormones continues and the endometrial lining becomes even thicker. The fertilized egg may become implanted in the endometrial lining. The endometrial lining does not shed, and the pregnant woman’s menstrual period does not begin. If fertilization does not occur, hormone levels fall, the endometrial lining sheds and menstrual bleeding begins again.

The duration between two menstrual cycles can vary from 21 days to 35 days, the average being 28 days. The bleeding may last for 3–5 days and the menstrual flow may vary.

Summarize the activity by telling the participants that the onset of menstruation only signifies the ability of girls to become pregnant and not the overall physical maturity to carry the pregnancy and give birth to a child without risks and complications. A woman should not have her first pregnancy before attaining minimum of 20 years of age. Tell the participants that in our society child marriage is so rampant that adolescent girls are at high risk of unplanned and unsafe pregnancies. Tell them that we will discuss the case and consequences of pregnancy in adolescence in another session.

3.4 Managing Nightfall A nocturnal emission, commonly known as nightfall or wet dream is a spontaneous discharge from the sexual organ during sleep. One may wake up with it or simply sleep through it. It is most common during adolescence and early young-adult years. Though girls also experience vaginal discharge, nocturnal emission is more evident among boys. The experience of nightfall among adolescents may vary: some may have it once a week while some may not experience it at all. It is more common during early morning but also occurs during night.

Give participants a case to discuss.

Raju’s exams are approaching but he is not able to concentrate on his studies. One day while returning from school, Raju see an advertisement on treatment for ‘Sawpndosh’ on a wall. Raju wants to visit the Hakim Saheb but does not have enough money to pay for the treatment. He wants to borrow some money from friends but fears that his parents will be very angry if they find out.

Discussion Points:

1. What is Raju’s problem?

2. Why is he tense and why can’t he take money from his parents?

3. Is it a good choice to go for treatment and to the Hakim Saheb?

4. If he doesn’t go to the Hakim Saheb, whom should he contact for advice or help?

Activity 1


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Discuss it in a larger group. Summarize the activity with the following facts on nocturnal emission:

What is nocturnal emission? Formation and discharge of mature sperms can occur during mid-adolescence and manifests as nocturnal emission. It signifies reproductive maturity for an adolescent boy. Nocturnal emission, also known as nightfall, is normal and does not require any form of treatment. Still many adolescent boys are stressed about this and go for treatments that may be extremely harmful to their health.

What causes nocturnal emission /nightfall?There may be several reasons for nightfall that may or may not be linked to sexual fantasy or arousal. Nightfall may occur due to pressure on seminal vesicle by urinary bladder or through involuntary ejaculation.

Is nocturnal emission harmful?It does not represent loss of manhood or sexual weakness; it is essentially harmless and does not require any treatment. Adolescent boys need to be reassured so that it does not become a cause for embarrassment or undue worry. As semen and sperms are continuously produced by the body, the loss through nocturnal emission is replaced. The loss of semen does not lead to weakness.

How and whom to contact to get rid of concerns related to nocturnal emission?Nocturnal emission is a natural process and hence does not require any treatment. Its occurrence /frequency will gradually decrease as one attains maturity. If one still has doubts about it, one should consult the doctor at the nearest Adolescent Clinic/PHC/hospital.

3.5 Personal and Nutritional Care ‘A healthy body is a beautiful body’ and hence to look beautiful one has to cultivate healthy habits. As we grow we need to take care of our body and mind so that we grow healthy. Personal and nutritional care from childhood helps us maintain the fitness and hygiene of our own body including hair, face, skin and private parts.

Ask participants how we should take care of ourselves. List all the answers on a blackboard or a flip chart. Some of the responses may be early to sleep and early to rise; daily bath; eating on time; yoga etc. Thank the participants for their response. Summarize the activity by talking about physical and mental fitness and how adolescents, especially girls, can remain fit.

How to keep an active body and mind?Physical activities like exercises, yoga, dance, martial arts, outdoor games like football, basketball etc. help us build stamina, fight fatigue and obesity and support the growth of bones and muscles. They also add to our confidence level.

One can also explore new games and ways to support our cognitive/learning abilities. One can pursue a hobby like music, poetry, painting or dance, keep up with the latest news by reading daily newspaper and listening to news. These activities stimulate our thinking and learning abilities, keeping us stress-free, confident and happy.

Activity 1


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How can we help girls engage in outdoor games and recreational/fun activities?Many adolescent girls are not allowed to participate in outdoor games and activities. Elders fear that they are not safe outside. This is not good for their physical health, self-esteem and self-confidence which are essential components of healthy growing up. As responsible members of the community, we should ensure that girls are not teased or harassed physically or verbally and take the system’s help to act against perpetrators. This will contribute to the efforts of the community and the government to make the surroundings ‘safe’ and ‘friendly’ for girls to participate in such activities.

Inform the participants that while growing up we need to take special care of ourselves. We will discuss these as ‘personal’ and ‘nutritional’ care.

Discuss the significance of personal hygiene and ways to maintain it with the following facts:

How can we maintain body hygiene?Daily bath is a very important routine of our life. One should have full body bath with gentle soap/cleanser. Bathing includes cleaning of hair and private parts and head bath with soap/shampoo or home-based cleanser at least three times a week to prevent dandruff and other scalp infections. One can also use home-based cleansers available in our kitchen such as wheat flour husk, besan mixed with dahi or plain water with a little turmeric. There are also special kinds of clays (locally known as multani mitti) easily available. These home remedies not only clean our body and hair but also maintain the softness and glow. During daily bath special care should be taken to clean private parts with plain water or gentle cleanser.

Washing the external female genitalia: The genitalia should be washed using normal water; if soap is used, it should be mild (such as a glycerine soap). Vaginal odour is normal and can be checked naturally by maintaining hygiene.

Washing penis and testicle areas: The penis should be washed gently with normal water during daily bath. If soap is applied, it should be a mild one as hard soaps cause soreness. Adolescent boys having foreskin should pull it back gently and wash underneath. If skin under the foreskin is not washed correctly, smegma (a natural lubricant keeping the penis moist) may begin to gather and cause bacterial growth emitting bad odour. In acute cases, the penis head may become red and swollen causing pain, irritation and discomfort. Deodorants or talcum powder should be avoided to prevent its accumulation under the foreskin. For circumcised adolescents care should be taken while cleaning the penis; just washing the penis gently with normal or warm water once a day is sufficient. Also one should not forget to clean the base of the penis and testicles as sweat and dirt may cause irritation.

Why is it important to wash our hands with soap and keep our nails clean?While we take care of our body and looks, it is equally important to wash our hands properly after using the toilet and before handling eatables. Hand washing with soap reduces risk of infections causing diarrhoea, jaundice, typhoid and polio in childhood substantially. Nails should be cut and if one has long nails, they should be cleaned every time during hand wash to remove any dirt or infection underneath.

Activity 2


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Ask participants why growing girls and boys need good nutrition. List their answers on board/flip chart. Some responses may be as under:

y It’s a growing phase of life

y Bones are growing and becoming stronger

y Need more energy as they play, run, study etc.

y To make up for the blood loss during menstruation

Appreciate their response and summarize with the following facts:

y Nutritional need is higher during adolescence than in childhood or adulthood.

y Girls and boys gain up to 50% of their adult weight, more than 20% of their adult height and 50% of their adult skeletal/bone mass during adolescence.

y Ensure calcium levels in bones.

y Girls require additional iron supplementation to make up for the blood loss during menstruation and calcium to strengthen bones.

y Good nutrition supports timely sexual maturation.

y Balanced nutritional habit since adolescence prevents weak/brittle bones, obesity, heart disease and diabetes.

Now ask each participant to mention at least one factor other than the food consumed that may influence nutrition of an adolescent boy or girl. Group similar responses together and list the major factors on the flip chart/black board.

Gender Norms Lack of Knowledge and Misconceptions

• Boys need more food and nutritious food as they do hard work

• Girls need less food as they are more at home• Girls should be happy with whatever they get after

serving male members of family

• Think nutritious food is expensive

• Too much washing of raw material

• Over cooking

• Sour food causes bleeding among girls

Socio-economic Status Cycle of Malnutrition

• Cannot afford nutritious food• Work load is more than affordable food • Forced child labour at home or outside

• Undernourished mother, undernourished infant

Discuss the consequences of each of the factors on the growth of an adolescent, especially a girl child. y Delayed or absence of growth spurt

y Slow pubertal change

Activity 3


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y Stunted body (especially in girls)

y Anaemia, both among girls and boys

y Slow sexual maturation (delayed onset of menstruation in girls)

y Early pregnancy (adolescent pregnancy) is detrimental with more demand for nutrition (for mother and baby)

y Birth of low birthweight babies to adolescent mothers

y Insufficient breast milk to feed newborn baby (who is a weak, low birthweight baby)

y Vicious cycle of stunted mother, stunted baby (baby girls are likely to continue the cycle if necessary interventions are not made to break the cycle by means of additional nutritional support to girls at all stages of life – infancy, childhood, adolescence and adulthood)

Divide participants in a group. Give them a case to discuss.

Rakhi (13), Amar (14) and Amber (15) are siblings. However their food preferences are very different. Their mother is always worried about what to cook for them. One morning when their mother asked them what they wanted for breakfast, Rakhi immediately asked for aloo paratha, Amar suggested noodles and egg, while Amber wanted poori with pickles. Their mother got upset and asked them to decide among themselves and tell her the menu for the whole day covering breakfast, lunch and dinner. She informed them about the vegetables, cereals and other items available at home as nothing could be bought or borrowed at that time. Apart from cooking oil, spices, sugar and salt, wheat flour, rice, pulses, brinjal, cauliflower, onions, green coriander, fish and milk were available. While leaving their mother added that as their father and she would also eat the same food, they should decide on something that would suit all five of them. She also told them that each one would have to help her in cooking at least one item.

Discussion Points:

1. Ask each group to help Rakhi, Amar and Amber suggest a menu for the day. One group can be asked to prepare vegetarian menu and other a non-vegetarian option. After 10 minutes, ask them to present the menu. Discuss the nutritional value of each recipe.

2. Why did mother ask them to suggest menu on foodstuff available at home?

3. Was mother right to ask them to help her in cooking?

4. Of the three, who will help their mother the most and why?

Showcase a table of commonly available foodstuff (cooked or raw or combination of both). Ensure that locally available, seasonal and low-cost food items are not missed out. Also ask the participants to list and draw food items that are used at home during every meal.

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Ask participants their opinion on what makes a particular food nutritious or unhealthy. Help them to name some major nutrients they know about. Write down the responses on a flip chart/blackboard and complete the list if all responses are not received.

Explain major nutrients in food and why growing adolescents need them. Commonly eaten foods can be broadly divided into three groups according to the nutrients they contain and their functions.

Energy-giving nutrients and foods

Growth-promoting/body-building nutrients and food

Protective and supportive nutrients and foods

Carbohydrates: Cereals (wheat, rice, maize), starchy vegetables like potatoes, sugar

Proteins

Animal source: Milk and milk products, eggs, cheese, fish, meat

Natural source: Pulses/ legumes, beans (rajma, soya bean), chana , groundnut

Vitamins: Milk and milk products like paneer, curd; vegetables and fruits of different colours; meat; leafy vegetables (spinach, bathua, methi); raisins, fresh or dried; amla; dates; citrus fruits like orange, lemons, food made with fermented dough like idli and dosa

Fats: Groundnut oil, mustard oil, butter, ghee

Minerals

Iron: Green, leafy vegetables, jaggery, meat

Calcium: Milk and milk products, egg, fish and most of the cereals

Zinc: More in animal protein

Key to nutritious food

• Carefully choose local food that is cheap, fresh and has one or more nutrients.

• Include food of different colours (white, green, saffron, red, yellow).

• Right mix of cereals, vegetables, milk and milk products and fruits (and egg, fish, meat for non-vegetarians) in a day.

• Use a variety of seasonal vegetables and fruits.

• Avoid processed cereals and food.

• Provide your personal help in cooking, so that workload on mother or any other person responsible for cooking is less.

• Everyone should learn cooking irrespective of his/her gender.

• Respect everyone’s choice of food including parents and grandparents.


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Table 1: The Five Food Groups

The Five Food Groups Food Stuff Main Nutrient Contribution

1

MILK

Curds, paneer (cheese), skim milk powder

PULSES

Dried beans & peas, nuts

MEAT

Protein

Calcium

Riboflavin

2

FRUITS

Orange, tomato, mango, papaya, amla, lemon etc.

GREEN LEAFy VEGETABLES

Sag or keerai, cabbage, carrot tops etc.

Carotene (Vitamin A Value)

Vitamin Salts

Iron (in leafy vegetables)

3

OTHER VEGETABLES

Brinjal, gourds, fresh beans, pumpkin, ladies finger, tinda etc.

Vitamins

Minerals

(in small amounts)

4

CEREALS

Rice, wheat, maize, ragi, etc.

Starchy Vegetables

yams, colocasia, tapioca, potatoes

Carbohydrates

‘B’ Vitamins

Protein

(in cereals)

5

FATS AND OILS

Vegetable oil, butter, ghee

SUGAR

Jaggery etc.

Fat (Energy)

Essential fatty acids

Vitamin A (in Animal fats only)

Carbohydrates (in sugars only)


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Summarize the activity with the following:

1. With nutrition, diet also needs to be balanced.

2. A balanced diet is one that provides all nutrients (carbohydrates, proteins, fats, vitamins and minerals) in required amounts and proportions for maintaining health and general well-being and also makes a small provision for extra nutrients to withstand short duration of leanness.

3. As these are present in different types of food items like pulses, chapati, rice, green vegetables and milk, it is important to eat these food items in the right mix every day.

Key Messages

1. Physical and emotional changes during adolescence are normal.

2. In case of onset of pubertal changes before the age of 8 years or their absence till the age of 13 years in a girl

and onset before the age of 9 years or its absence till the age of 14 years in a boy, the adolescent should be

referred for appropriate medical care.

3. Menstruation is a normal body function and girls should follow their daily routine including schooling and

sports, with some extra care for hygiene and nutrition.

4. Nightfall is a normal body function and does not require any treatment.

5. Personal hygiene protects us from infections and embarrassment.

6. Following a daily routine that includes outdoor sports, exercise and a balanced diet helps us to grow fit and

healthy.

7. In case an adolescent still feels that he/she has a problem, he/she should be referred to the ANM didi at the

sub-centre or to the Adolescent Health Centre at the PHC.

Role of a Peer Educator, ‘A Trusted Friend’

1. To educate adolescents between 10–19 years on pubertal changes.

2. To provide support to adolescents to overcome their fear, guilt and embarrassment.

3. To help adolescents deal with emotional stress during the pubertal changes.

4. To help adolescents access health provider and Adolescent Friendly Health Clinics (AFHC) centre at PHC for

counselling and treatment if required.

5. To educate elders and other community people to be sensitive to the needs of adolescents.

6. To maintain confidentiality of peers.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Growing Up

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Session 4Gender and Sexual Identity

IntroductionSex and gender are different but are often used interchangeably in our society, a fact which sends the wrong message to a growing child on his/her expected role in society. Sex generally refers to biology and anatomy. People are often said to be ‘male’ and ‘female’ as determined by three sets of characteristics: external sex organs, internal sex organs and secondary sexual development during puberty. However gender identifies the socially or culturally constructed relationships between women and men, including their roles, privileges, responsibilities and power. Gender relations are context specific and often change in response to altering circumstances. During the growing-up phase, it is common among adolescents to experience uncertainty and confusion because of contradiction in their biological identity as males or females and their expected role in society. Expected gender roles may be restrictive and pose barriers in realizing the full potential of an adolescent. If one’s behaviour does not conform to the socially expected role of a male or a female, it may even stigmatize the individual and increase his/her vulnerabilities to poor health, coercion and violence. Hence, it is important for adolescents to learn about diversity in terms of sexual and gender identities existing in our society and learn to respect diversities.


1. To learn that gender and sex are not the same

2. To recognize and respect diversity in gender and sexual identity

3. To know about socially prescribed gender roles and its impact on adolescent behaviour

Time:

30 minutes

Material:

Coloured cards (equal size cut pieces from chart papers); flip chart/blackboard, LCD or slide projector for presentation

Methodology:

Brainstorming; four corner exercise; presentation, group discussion


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4.1 Understanding Sex and Gender

Initiate this session by conducting a word association exercise on ‘Man’ and ‘Woman’. Take a chart paper and divide it into three columns. Write ‘Man’ in the extreme left column and ‘Woman’ in the extreme right column. The middle column should be left blank.

Now ask female participants to say words they associate with ‘Men’ and write them under the column ‘Man’. Explain that these words may reflect characteristics (good or bad), qualities or even status and value of men in society. Once the female participants have completed, invite the male participants to add to this list.

Then ask the male participants to say words that they associate with women and list them under the column ‘Woman’. Once this is completed, invite the female participants to add to this list. Some of the likely responses are as follows:

Man Woman

Tough Soft

Cruel Beautiful

Smart Shy

Adventurous Giving birth

Anger Affectionate

Moustache Sensitive

Tall Breast-feeding

Father Gossiping

Earns money Mother

Decision maker

Leader

Now interchange the column heads ‘Man’ and ‘Woman’ as shown below. Go through the list once again but review each listed word or expression in the context of the opposite sex and see whether words associated with women are applicable to men and vice versa. For example, you can ask the participants if it is possible for women to be tough, cruel, smart, adventurous, angry etc., and for a man to be emotional, sensitive, shy, quiet, charming etc. You can use examples from real lives (like sports persons, film stars, celebrities, political leaders, freedom fighters and others) to convey this more effectively.

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Man Woman Sex Woman Man

Tough Giving birth Soft

Cruel Moustache Beautiful

Smart Breast-feeding Shy

Adventurous Menstruation Giving birth

Anger Affectionate

Moustache Sensitive

Tall Breast-feeding

Father Gossiping

Earns money Mother

Decision maker Menstruation

Leader Wear frocks, salwar-kameez, sari

Wear trousers Long hair

Short hair

In the central column, help the participants to list the words or phrases that are specific characteristics of either men or women, and are not applicable to both. These could be words like beard, moustache, giving birth, breast-feeding, menstruation, testicles, ovary etc. At the end of the exercise give the central column the heading ‘Sex’.

Explain that the biological difference between a male and a female (described by words in the central column) is defined as ‘sex’ and the other words/phrases/expressions listed in the two columns are the expected roles of a man or woman in society and hence termed as ‘gender’. Emphasize that most of these characteristics or qualities are interchangeable or applicable to both sexes. Hence, ‘gender’ may vary with time and culture. However, gender is so ingrained in our society that it is often mistaken for sex by us and we tend to relate a particular characteristic with only one sex. For example, the thought that men are breadwinners and women are homemakers is changing with time. Today there are many families where both men and women are in employment and both share responsibilities for child care and household chores.

4.2 Respecting Diversity

Tell the participants that in the previous activity there were endless notions about being a man and a woman. Many societies have a clear categorization as male and female. Largely, people identify with their biological sex. Since early childhood (as early as 3–5 years), we start conforming to one of the categories

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through actions and behaviours socially prescribed for a male (masculine) or a female (feminine). Such actions and behaviour are referred as ‘gender roles’. But there are some of us who do not conform to the prescribed role and their biological identity is inconsistent with the gender role they take on. Ask the participants if they know anyone whose behaviour is different from his or her sex/biological identity. Ask them how the community reacts to such people.

Tell the participants that in any given society there could be at least the following types of people (could be more):

1. Biologically male with masculine behaviour

2. Biologically male with feminine behaviour

3. Biologically female with masculine behaviour

4. Biologically female with feminine behaviour

5. Persons with indistinct biological identity with masculine behaviour

6. Persons with indistinct biological identity with feminine behaviour

Many cultures and societies have a third category known as the ‘third gender’ or ‘transgender’ to classify people whose behaviour does not conform to their sex. All such people are as normal as any man or woman. They have the right to talk, walk or act the way they are comfortable. They deserve to be loved and treated with respect and have access to education, entertainment, services, schemes and employment as any other member of society.

Inform the participants that as different people may relate to different gender identity, there are people who have different preferences for partners in love and sexual relationship. Most men partner with women and most women partner with men (heterosexual). How ever there are men who like to partner with only men (homosexual/gay) or with both (bisexual); similarly there are women who like to partner only with women (homosexual/lesbian) or both (bisexual). All such people are as normal as any other member of the society.

4.3 Gender Roles and Adolescent Behaviour

Divide the participants in two groups and give them a set of socially expected gender roles for an adolescent boy and girl such as, boys do not cook or clean at home while girls are expected to do all household chores. Such gender roles are biased and do not promote equal division of labour or sharing responsibilities of household chores. Ask each group to add to the list if they have something new. Tell the participants that though the rules of our society guide us to be good members, some rules like those related to gender roles may be misleading and harmful for adolescent well-being. Ask them to discuss and write down how such expectations can impact the health and well-being of an adolescent. After the group discussion is over, invite each group to present its work. Discuss it in the larger group with reference to the facts given in the chart.

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Draw three columns on a chart paper. Mark the first column as ‘Gender Roles’, the second as ‘Impact on Adolescent Behaviour’ and the third as ‘Facts’.

Gender Roles Impact on Adolescent Behaviour Facts

1. Boys are smarter, know everything.

• May never seek information from right source for fear of being identified as ignorant and inexperienced

• May indulge in high risk activities – sexual initiation at an early age

• May give in to peer pressure for substance abuse or unsafe sexual behaviour

• May approach misleading sources such as quacks, cheap literature, pornography, uninformed peer groups etc.

Girls are also smart and know everything but may not speak for fear of rebuke and strong opposition. In our society girls are not encouraged to speak in public or give their opinions freely. Girls who argue and talk back are often considered ‘tomboyish’ and harassed for these ‘boy-like attributes’.

2. Girls are innocent, shy and simple.

• May shy away from seeking information on health especially related to reproductive health like menstruation, family planning etc.

• May not share their opinion about choice of partner

• May fear seeking help or support in situations of coercion and abuse

• May not try for higher education or vocation

• Those who do not conform to this role may face stigma and discrimination by society

Boys can also be innocent and shy and simple. Very often these boys are rebuked and considered ‘sissy’ or girlish. This is just the opposite of what has been pointed out in point 1 above.

3. Boys never cry.

• Prevents boys/men from expressing their anguish

• May resort to anger and violence to vent their pain

• May not be able to seek support even in coercive and abusive situations and continue with the stress for a long time

• May not concentrate on other work and study

• May even resort to substance abuse

Boys also cry but are not encouraged to do so because crying is considered girl-like behaviour. That is how tough and rough masculinities are formed and socialized. Crying is an emotional outlet and often good for mental health as it allows venting and sharing of feelings.

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Gender Roles Impact on Adolescent Behaviour Facts

4. Men are brave and successful.

• Prevents boys from exploring different learning opportunities in life

• May mislead them on expected parameters of success

• May feign bravery and courage through unfair means like fight, anger, violence, rash driving, unsafe behaviour such as not using condoms, smoking etc.

Girls also are brave and successful.

5. Husbands control wives and wives should be submissive to their husbands.

• This is one of the key reasons behind wife beating.

• This prevents women from resisting unreasonable demands of husbands and in-laws

• Women don’t raise their voice against exploitation and coercion (rape, domestic violence).

• Women have poor control on their reproductive health and may be vulnerable to unwanted pregnancy, sexually transmitted infections like HIV.

Wives can be controlling and husbands may also face violence, but this happens in fewer cases

6. Boys work hard and so need better food.

• Household chores are not recognized as hard work

• Poor nutritional status of women (anaemia)

• Low nutritional intake during pregnancy that results in complications and low birthweight babies

Girls also work hard. In fact they need better nutrition than boys as they to go through the menstrual cycle and later, child bearing.

7. Daughters are the family honour while sons carry forward the family name.

• Son preference and bias

• Girl child faces discrimination

• Load of household chores to prepare her to adjust with husband’s family

• Undue restriction on girl child in the name of family honour

• Early marriage to transfer related responsibility to husband and in-laws

The term ‘honour’ is often used to mean ‘power’ and unfortunately girls and women are ‘used’ to establish power. They are given in marriage irrespective of their choice. Girls/women are raped or subjugated to establish one’s power, reducing them to commodities/objects for establishing power and settling enmities and disputes.

Sons and daughters have responsibilities towards their parents and can make the family proud by their good work and achievements.


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Read out the following job/professions/jobholder and ask the participants to say who does the work – man or a woman. Tick the column based on majority response as given below. Also, ask some of the participants why they think that particular work can be done only by a man or a woman.

Job/Profession Men Women Both Job/Profession Men Women Both

Tailor √ Police

Doctor √ Nurse

Carpenter √ Painter

Priest √ Singer

Henna decorator √ Dancer and actor

Leader (political or social)

√ Cycle mechanic

Astronaut √ Electrician

Engineer Mobile repairing

Teacher Soldier

Car mechanic Housemaid

Cook Fridge mechanic

Cobbler Taxi/Truck driver

Summarize the activity by telling the participants that the gender roles that society expects from us also influence and restrict our choice of profession/job. The majority of work options (whether related to household chores or employment) are possible and permitted for people with different gender identities. One should explore all possible opportunities based on our interests and abilities and not on roles expected by the society. Learning and practising skills whether at home or outside makes us more independent and expands our income opportunities in life. For example a boy or a girl who has interest in cooking may take up ‘cooking’ related professions and become a chef; similarly girls may like to learn driving or household equipment repair work.

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Key Messages

1. Gender is socially constructed while sex is biological/natural.

2. Except for biological characteristics, men and women are alike.

3. The gender-based characteristics and roles for man and woman vary with time and culture.

4. Gender roles may create biases and discrimination.

5. Gender roles may influence our behaviour and restrict our life options.

6. Though majority of the people are born as male or female, there are some whose gender role is not in agreement

with their biological sex. They may be fewer in number but they are normal and valued members of the society.

7. Some people prefer a same sex person for love and sexual relationship. They are normal and have a right to

choose their partner just as anyone else.

8. Irrespective of our biological, gender or sexual (choice of partner) identity, we are equal and deserve the same

love, respect, information, education, services, employment or any other institutional benefits.


1. Inform and educate adolescents between 10 and 19 years on respecting diversity in gender and sexual identity.

2. Identify and reach out to those adolescents who may be different from their peers.

3. Empathize with such adolescents and link them to mainstream society.

4. Reassure such adolescents that they are normal and help them overcome their guilt and fears.

5. Educate other members of the community to be sensitive to the needs of people with different gender and

sexual identities.

6. If concerns on gender or sexual identity remain, link the adolescent to counselling services.

7. Maintain the confidentiality and trust of adolescents who confide in you for help.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Gender and Sexual Identity

module III health and happiness

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Session 5Health Conditions during Adolescence

IntroductionAdolescence is a phase that is largely understood as a very healthy phase of life. However, it has been found that adolescents too have health issues that need immediate attention. Though adolescents may be at a risk for as many infections as any adult like malaria, viral fever, air- and water-borne infections etc., there are factors other than infections that may turn into a health concern for an adolescent. Some of these factors are very specific to adolescence and may impact her/his health lifelong if not addressed as early as possible. The common but serious conditions are those related to malnutrition, obesity and addiction to substance. The factors identified with some of these conditions are linked to poverty, harmful practices and ignorance on the one side while on the other side it is lifestyle that promotes unhealthy eating, sedentary routine, stressful mind and in some cases addiction to alcohol and tobacco in some or the other form.

A diet with low levels of essential nutrients like protein, carbohydrate, fats, vitamins and mineral elements like calcium and iron causes under-nutrition in a child which could be chronic (stunting) or acute (wasting). On the other hand overeating or eating a particular food in a quantity more than required is also a major problem of malnutrition. Often elders in the family ignore childhood obesity or eating patterns, but this is the time when one learns to eat well and eat healthy. Also, if it is not addressed at this stage, it may lead to health conditions and diseases that are more associated with adults like diabetes, cardiovascular problems etc. These diseases are not caused due to any infection but because of unhealthy eating, overeating, sedentary routine and stress. Alcohol and tobacco consumption are the other main causes of lifestyle diseases. Hence these are called ‘lifestyle diseases’. In some of the lifestyle diseases like cancer, stress is considered a reason but confirmed reasons are not yet known.

This session talks about the nutrition-related factors that influence health conditions in adolescents and traditional practices and modern lifestyle that may influence their health.


1. To raise level of self-awareness about nutrition and factors affecting nutrition

2. To understand the cause and consequences of poor nutrition (under-nutrition and anaemia)

3. To understand anaemia, its causes and consequences

4. To understand health conditions due to unhealthy eating and lifestyle

5. To gain knowledge on healthy eating and habits to maintain health and fitness


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Time:

45 minutes

Material:

Chart papers; sketch pens, projector, flip charts

Methodology:

Brainstorming, PowerPoint slides, discussion, case studies

Present the story of Kamala given below:

Kamala Umraon, a 14-year-old student of Class 9, is very popular in her school as a fast runner. Last year she won the 1,000 meters run in the district level inter-school games. Kamala’s teacher tells her that she will become very popular one day and if her performance continues to be good, she will represent her state in the national games. In three months the state-level Annual Games begin in the capital city. The school has high hopes and expects to be in top three on overall performance. Kamala will represent her school for the 1,000 meters and 100 meters relay.

But for the last few months Kamala has been feeling tired and does not want to go for practice after school hours. The sports teacher is very angry with her for not being regular for practice. One day he tells her that she is mature enough to understand her responsibilities and that she is letting her team and school down. He also tells her that he will not listen to any more excuses and will replace her with another more deserving girl.

Kamala doesn’t want to be out of the team, so she comes for practice. She starts running and completes her first round but slows down in the second round. The teacher observes that she is not able to perform as in the past. She is exhausted and gives up after two rounds. Friends and teacher try to build her confidence and ask her to complete the distance. But Kamala cannot complete even half the distance. Her teacher is concerned.

The sports teacher discusses the matter with her class teacher. The class teacher informs him that Kamala’s performance in studies has also deteriorated. The sports teacher feels he should talk to her parents.

Discussion Points:

1. What do you think is the reason for Kamala’s poor performance in games?

2. What did Kamala’s teacher notice?

Activity 1

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3. What should the teacher do to help Kamala?

4. Do you know about others who have complained of tiredness or dizziness like Kamala?

5. What should adolescents do whenever they feel tiredness or dizziness?

Answer

Kamala’s poor performance may be due to not eating well and weakness. She may have an infection if she has fever too. Her tiredness could also be linked to infections like malaria, dengue or conditions related to the menstrual cycle, if she experienced any of these recently. The teacher should have inquired about Kamala’s health even earlier as she has been not well for a few months now. The teacher should talk to Kamala and her parents and refer her for a timely check-up.

Taking Kamala’s story further, narrate the next part of the story:

The teacher visits Kamala’s house and finds that Kamala’s parents work with a local contractor at a factory and that they leave home early in the morning and return only by 5 pm. Some days they also do night shifts. Some days her mother prepares lunch but on other days Kamala has to prepare lunch after returning from school. Kamala also looks after three younger siblings (12-year-old Pinto, 10-year-old Rani who goes to school with her and the youngest one who is 3 and 1/2 years old whom the older ones pick up from the Anganwadi didi while returning from school). She also helps her mother finish other household work in the evening. Her mother says that she is proud of her children especially Kamala and feels bad that on some days, she is so tired that she sleeps early and misses her dinner.

On knowing the schedule followed in the family, the teacher requests Kamala’s parents to get her examined by a doctor. They are scared and cannot understand why their healthy daughter needs to be taken to a doctor but agree. At the health centre, the doctor suggests a blood test. Kamala is found to be anaemic.

Discussion Points:

1. Why did the teacher ask Kamala’s parents to take her for a health check-up? Is there anything wrong with the schedule followed by the family?

2. Do you think Kamala has been eating well? Why?

3. What is anaemia? How many of us may have anaemia? Ask the participants to raise their hands and tell them to get a check-up.

4. Do you feel that Kamala’s siblings may also be suffering from anaemia? Why?

5. Is her workload at home too much for her age?

6. Are Kamala’s parents, especially her mother, aware of their children’s eating habits and nutritional intake? How?

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Answer

The teacher suspects that Kamala is undernourished. Kamala is probably not eating enough in comparison to the physical labour she does. Besides being young and unsupervised most of the time, she is ignorant about her nutritional needs, cooking and nutritional value of food items. Apart from her own studies and practice for games, she has work at home that may prevent her from cooking nutritious food for herself. Anaemia is a condition where the blood level in the body is reduced with inadequate iron folate and vitamin B-12, two essential nutrients for the body at any stage of human life. Tiredness, dizziness and poor concentration are some of the basic signs of anaemia and under-nutrition. In India, anaemia among adolescents is rampant and girls are more affected. However, adolescents and their family rarely think of health check-ups for them, which is a wrong practice. It is possible that Kamala’s siblings too are malnourished. The ages of the first three children also show the mother’s closely spaced pregnancies and it is possible that the children may have been neglected in their infancy too. However, the youngest one visiting the AW centre may have better nutritional level as his/her growth and nutrition is monitored by AW but the child still requires care and frequent feeding at home. It may be difficult for adolescents to take care of a younger sibling.

The mother’s own age, education and her health determine the nutritional care of her children. The situation also shows that the father is not much involved in household chores and is equally unaware of the nutritional needs of his children. The parents need to be more careful about their children’s nutrition as they have three adolescents and one who is under 5 years of age.

Cooking three meals a day needs careful planning so that daily intake of nutrition for each family member is met. Cooking is a skill and right from washing, cutting to cooking, utmost care needs to be taken so that food is prepared hygienically and has high nutrient value.

Taking the story further:

After a few months, Kamala’s father decides that Kamala is grown up and he should look for a match for her. He goes to his elder brother’s family and requests them to suggest a good match for her. Kamala’s uncle assures her father that he will find a match soon so that Kamala can be married the following year.

Discussion Points:

1. Is Kamala mature enough for marriage? What is the right age for marriage?

2. What will Kamala lose if she gets married? Refer to Kamala’s potential to be a great sports person.

3. What will happen to Kamala after marriage?

4. Will Kamala’s nutrition level and overall health improve after marriage?

5. What will happen if Kamala gets pregnant before 20 years of age?

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6. Do you think Kamala as a mother will be able to take care of her child’s nutrition?

7. Is there any risk for Kamala’s child or children to be malnourished? How?

Answer

Early marriage, early and frequent pregnancies are key factors leading to malnourishment among adolescent mothers and infants. Large family size worsens the situation and affects health and development of the entire family including young fathers. If Kamala is married as a child, this cycle of early and frequent pregnancy and poor health and nutrition may continue in her family. Under-nutrition in the mother causes under-nutrition in the child from the womb itself. Low birthweight babies are at increased risk of under-nutrition. Ignorance and family practices prevent the newborn being given colostrum (the first milk of mother) and many mothers start feeding water and other milk to babies before 6 months of age. Exclusive breast-feeding up to 6 months is very important for the nutrition and health of the infant. Stunting is rampant among children under 5 years. Hence, it is important to learn, inform and educate all adolescents and their mothers and fathers on the importance of nutrition if this cycle of poor nutrition, poor health, poverty and excessive workload is to be broken.

Cooking at home also needs careful planning. Ask participants to suggest ways to cook ensuring health and nutrition of all of Kamala’s family members. Remind them about the session on personal care and nutritional intake during growing up. Ask them to categorize their responses under three heads:

Selection of food items and the menu of the day

Sharing household work, cooking and food preference

Eating habits

Choose what is available in your local market and in your kitchen garden.

Value food for its qualities and not price.

For nutrition one does not have to choose expensive food items.

Seasonal vegetables and fruits are the best.

Choose Indian traditional sweets as they are made of cereals with high nutrient value (sooji ka halwa, kheer etc.)

Kamala, her parents and two school-going siblings need to share the responsibility of the household chores and the care of the youngest sibling.

The father has an important role in helping the mother cook and teaching the children good ways of cooking nutritious and tasty food.

younger siblings can help with light jobs and in the process learn the value of hygienic management and nutritive value of food.

The family should eat at least one meal together.

Having meals together helps parents monitor children’s diet and teach them the nutritional value of food.

Do not miss any meal. Three meals a day, especially breakfast, are very important and need to be taken on time.

Missing a meal for snacks is a wrong practice. Snacking may also cause acidity and obesity.

Activity 4

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Selection of food items and the menu of the day

Sharing household work, cooking and food preference

Eating habits

Plan your meals to include the five food groups (refer to Session 3).

Plan a few simple recipes that can be prepared easily and in less time on busy days.

Take advice from older members in family and in the community as they have traditional recipes using locally available food items.

Prepare one menu for one meal as too many likes and dislikes about food puts unnecessary pressure on the person cooking.

Always consider suitability of menu to all family members including old people.

Prepare one meal a week which is the choice of one family member or celebrate birthdays or special days of each family member with a meal of that person’s choice.

(This way the family can also have special meals at least once a month and each member’s likes are respected. Birthday celebrations also enhance self-awareness among growing children about their age and related decisions like schooling, learning vocation, career, marriage and family).

Washing hands with soap before handling food items for cooking or eating is the key to good nutrition.

Serve meals according to the requirement of a person. A person doing physical labour requires more food than a person doing sedentary work.

Children and adolescents need extra nutrition as they are growing.

Pregnant women need extra nutrition.

Low intake of nutritious food may also result in intra uterine stunting and wasting of a child and many complications for the mother.

If an adolescent girl gets pregnant, both the adolescent girl as well as the unborn child needs nutrition as mother’s body is also growing.

Harmful Traditional Practices and Norms that are Discriminatory andPerpetuate Malnutrition

Child marriage, adolescent pregnancy, frequent pregnancies (gap of less than three years between two pregnancies), discrimination against girl child in food distribution, restrictions on certain food items and quantity impact the nutritional status of adolescent girls and pregnant women.

Discrimination in food distribution to the poorest and on the basis of caste and religion is another important reason for malnutrition among marginalized communities.

Stand up against such harmful practices and discrimination!


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Discuss under-nutrition and anaemia with the help of PowerPoint slides.

SLIDE 1

Under-nutrition y Under-nutrition is the condition that results from eating a diet in which certain nutrients

are lacking or in the wrong proportions. It includes deficiencies of essential vitamins and minerals (generally known as micro-nutrients).

Signs of under-nutrition y Dizziness y Poor concentration in studies or other work y Fatigue y Dry skin y Weak immune system (fall sick often) y Spongy bleeding gums y Thin and soft nails y Fragile bones that break easily

Consequences y Impaired memory/memory loss/

forgetfulness y Poor school performance

Anaemia: Lack of iron y Anaemia refers to lack of blood or reduced red blood cell (RBC) count.

y A common cause of anaemia is iron deficiency (or low intake of food containing iron like green leafy vegetables – spinach, apple etc.)

y Iron is fundamental for haemoglobin (found in RBC) production that carries oxygen from lungs to the capillaries. Since all human cells depend on oxygen for survival, anaemia may have wide range of consequences.

y The haemoglobin level in adolescents should not be less than 12 gm/dl.

y The body needs more iron when it is growing rapidly and when frequent blood loss occurs (e.g. through menstruation).

SLIDE 2

Activity 5


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SLIDE 3

Causes of anaemia y Insufficient intake of iron, folate and vitamin C rich foods y Hookworm infestation y Low absorption of iron in the body y Loss of blood through menstrual bleeding in adolescent girls y Frequent episodes of malaria

Signs and symptoms y Shortness of breath y Dizziness y Weakness y Fatigue y Cold hands and feets

y Pale skin, nails, etc y Lack of appetite y Women of childbearing age are also at

risk of iron deficiency with continued loss of iron during menstruation

SLIDE 4

How to prevent anaemia y Consume iron-rich foods, green leafy vegetables, jaggery, meat, supplemented with

vitamin C sources like citrus fruits, oranges, lemon and Indian gooseberry (amla). y Take iron and folic acid (IFA) tablets as prescribed by the service provider. y Avoid taking IFA tablet just after the meals. Maintain a gap of at least 30 minutes. y Don’t take tea/coffee with meals or for at least one hour after taking iron tablets and meals. y Maintain personal hygiene and sanitation. y Cook food in iron utensils on some days. y Cooking on slow fire and in covered pan helps reduce nutrient loss (such as cooking in a

pressure cooker). y Wear footwear to prevent worm infestation; take a course of deworming tablets in case

worm infestation is suspected. y Prevent early marriage and early motherhood. y Prevent breeding of mosquitoes to protect from malaria and other mosquito-borne

diseases.


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SLIDE 5

The Five Food Groups

The Five Food Groups Food Stuff Main Nutrient Contribution

1

MILK: Curds, paneer (cheese), skim milk powderPULSES: Dried beans & peas, nuts MEAT

ProteinCalciumRiboflavin

2

FRUITS: Orange, tomato, mango, papaya, amla, lemon etc.GREEN LEAFy VEGETABLES Sag or keerai, cabbage, carrot tops etc.

Carotene(Vitamin A Value)Vitamin Salts Iron (in leafy vegetables)

3OTHER VEGETABLES: Brinjal, gourds, fresh beans, pumpkin, ladies finger, tinda etc.

VitaminsMinerals(in small amounts)

4CEREALS: Rice, wheat, maize, ragi, etc.Starchy Vegetablesyams, colocasia, tapioca, potatoes

Carbohydrates ‘B’ VitaminsProtein(in cereals)

5FATS AND OILS: Vegetable oil, butter, gheeSUGAR: Jaggery etc.

Fat (Energy)Essential fatty acids Vitamin A (in Animal fats only)Carbohydrates (in sugars only)

5.1 Lifestyle Diseases and Risk Factors

Tell the participants that they will do an exercise called ‘four corners’. The rules are that you will narrate a case with a problem and provide them four options to resolve that problem. The four options will be written on separate pieces of paper and put up in four corners. The participants will have to listen to the case carefully and chose the option they find most appropriate and go and stand in that corner. While doing so, no one is allowed to talk to anyone else or say anything about their opinion till you give the next instruction.

Sujoy is a 14-year-old boy. He likes to eat. Sujoy is very fond of packaged snacks like chips and aerated drinks. He also likes sweets a lot. Everyday Sujoy’s mother gives him some pocket money thinking that he will learn to save money to buy something that he likes later on. But Sujoy has been spending that money on eating junk food from the market. His mother has also observed that Sujoy doesn’t eat his meals properly. She finds him a bit lazy and most of the time watching television or on the computer. She tries to talk to him, but Sujoy takes offence and says that it is his pocket money and he should be free to do what he wants with it. His mother gives up.

One day when Sujoy returns from school he complains of heartburn. His mother gives him some cold milk and tells him to rest. While clearing Sujoy’s room his mother sees packets of chips and other fried stuff in his school bag and his reading table. She is very angry and doesn’t know how she can help Sujoy get rid of unhealthy habits.

Activity 1


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Options/Corner 1: Mother needs to be a little more patient with Sujoy while being strict and talk to him on what it means to eat well.

Options/Corner 2: Mother should take Sujoy to a doctor, counsellor or ARSH centre.

Options/Corner 3: Mother should monitor how Sujoy spends pocket money and teach him the importance of saving.

Options/Corner 4: Any other option (participants are free to have opinions other than the three mentioned).

Now ask the participants to choose an option and quietly stand in the corresponding corner. Ask them to share the reason for their choice with the other participants in their own corners but not with the others. In case a corner has only one participant, you should ask the participant to share his reasons with you. Tell the corners/groups that one person from the group will later share the reasons with the larger group. Give 5 minutes for this. You should not give any opinion during the exercise or even later and should avoid appreciating any response by saying ‘good’ or ‘well said’. Such expressions create inhibitions or barriers among participants if they have an opinion different from what is being appreciated or expressed by you.

Then invite each group to present its reasons with the larger group while standing in the corner itself. Also inform others that no one is allowed to speak in between, comment or laugh. Every group will have the opportunity to speak. And while they are speaking they should focus on the reasons behind choosing that option and not on reasons behind not choosing any other option. The smallest group can be invited to speak first.

Once all groups have shared their reasons, ask if any participant wants to change his/her stand and hence the corner. Give 2 minutes for that. There may be some who change or there may be no change. Thank the participants and ask them to go back to their seats.

[These exercises do not aim to establish right or wrong but try to help the participants identify their own values related to the subject and think of a positive solution to the problem. They may be right or wrong, but sharing gives them an opportunity to learn about other opinions that may trigger a change at a later stage.]

Divide the participants into small groups. Give a chart paper to each and ask one group to prepare a list of healthy foods and healthy habits. Ask another group to prepare a list of unhealthy foods and unhealthy habits. Tell them to discuss among themselves the reasons for each food or habit listed as healthy or unhealthy and then paste it on the wall.

Activity 2


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Tell participants that Sujoy’s story is not unique. Ask them if they have experienced something like this. Inform participants that overeating or eating a particular food in excess is also a major problem of malnutrition. Often elders in the family ignore childhood obesity or their eating pattern, but this is the time when one learns to eat well and eat healthy. Also, if it is not addressed at this stage, it may lead to health conditions and diseases that are more associated with adults like diabetes, cardiovascular problems etc. These diseases are not caused due to any infection but because of unhealthy eating, overeating, sedentary routine and stress. Alcohol and tobacco consumption are the other main causes of diseases. Hence these are called ‘lifestyle diseases’ or non-communicable diseases. In some of the lifestyle diseases like cancer, confirmed reasons are not yet known.

Explain lifestyle diseases with the help of PowerPoint slides and help the participants understand better what ‘healthy’ and ‘unhealthy’ mean.

SLIDE 6

Introduction to lifestyle health conditions y Lifestyle health conditions primarily include conditions that may lead to diabetes, hypertension, cardiovascular diseases, chronic respiratory diseases or cancer. These include conditions like obesity, which is observed increasingly among children and adolescents, and are linked to changes in lifestyle with urban and improved economic status and hence termed ‘lifestyle diseases’.

y These can be prevented through adoption of healthy eating behaviour and healthy lifestyle.

Activity 3


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SLIDE 7

Common lifestyle health conditions among adolescents y Overweight/Obesity: Overweight occurs when extra fat is stored in your body. Leading

an unhealthy lifestyle may lead to obesity in young adolescents.

y Diabetes: High blood sugar or diabetes results from a defect in insulin secretion, insulin action or both. Adolescents may suffer from type 1 diabetes (insulin-dependent diabetes mellitus) wherein the body does not make insulin. Insulin helps the body use glucose from food for energy. The other type of diabetes is type 2 (non-insulin-dependent diabetes mellitus) which occurs generally in old age.

y High blood pressure: High blood pressure or hypertension is becoming very common in young adolescents due to increase in stress and unhealthy lifestyle behaviours. High blood pressure may not have any symptoms but causes dizziness, nausea, shortness of breath etc., in some people.

y Heart diseases: Unhealthy lifestyle may predispose a young adolescent to heart diseases in early adulthood.

Explain risk factors associated with lifestyle diseases.

SLIDE 8

Lifestyle diseases and associated risk factors

Hit the roots and trunk, the branches will fall automatically

Overweight

Smoking

Alcohol

Unhealthy Diet

Environmental Pollution

Physical Inactivity

Social Determinants

Diabetes

Chronic Lung DiseaseHypertension

Heart Diseases

Stroke

Cancer


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SLIDE 9

What is an unhealthy diet? y Unhealthy or junk food is a term applied to foods that are perceived to have little or no

nutritional value (i.e. containing ‘empty calories’). y These foods contain ingredients considered unhealthy when regularly eaten, or those

considered unhealthy to consume at all.

SLIDE 10

Why are some foods considered unhealthy? y Foods that provide empty calories – typically all fried and sweetened foods like aerated drinks, soda etc.,

– are harmful and lead to obesity and other related diseases. y Food items having less fibre – all bakery and processed foods made of refined products like pizza,

noodles, cakes, pastries etc., – are harmful and detrimental to health and may lead to problems like constipation, obesity etc.

y Excess fried foods replace healthy meal that has balanced nutrition. y Food items like pakoras, kachoris etc., are generally fried in oils containing hydrogenated fat (such as

vanaspati) which gets converted to transfat and damages the body (fat after being heated to a high temperature or reused is the main culprit for causing obesity, high blood pressure and heart diseases).

y Fast foods (like burgers, hotdogs, noodles, chips etc.) generally lack fresh fruits, vegetables and whole grains and hence are deficient in vitamins and minerals thereby affecting our immunity and endurance to fight lifestyle diseases. Often young people get addicted to fast food.

y Fast food costs relatively less and tastes good, but the negative effects on physical health last much longer than these immediate concerns.

y Alcohol, tobacco and other substance misuse is also responsible for lifestyle conditions and diseases.


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SLIDE 11

Unhealthy habits like tobacco use lead to y Shortness of breath, even when not exercising y Wheezing or gasping y More frequent headaches y Increased phlegm (mucus) y Respiratory illnesses y Worse cold and flu symptoms y Reduced physical fitness y Poor lung growth and function y Addiction to nicotine y Gum disease and tooth loss y Cancer y Chronic lung diseases, like bronchitis, which limit exercise y Hearing loss y Vision problems, such as macular degeneration, which can lead to blindness y Blood vessel disease, which can lead to heart attacks or strokes at a young age

SLIDE 12

Unhealthy habits like alcohol use lead to y Increased risk of heart diseases (coronary heart disease, stroke, hypertension)

y Increased risk of cancer (liver, stomach, colon, pancreas, breast, mouth, throat)

y Impaired immune system

y Malnutrition/obesity

y Reproductive problems

y Accidents/deaths

y Risky behaviour

y Violence

y Poor academic performance


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Divide the participants into four groups. Ask groups 1 and 2 to discuss Case Study 1 and groups 3 and 4 to discuss Case Study 2.

Case Study 1:

Lata is a 16-year-old girl. As summer has arrived, Lata decides to store her winter clothes. She is deciding which clothes to keep and which ones to discard. So she tries on many of the clothes to see if they should be kept. To her surprise, many of the clothes do not fit her any longer. She steps on to a weighing scale to measure her weight. Her weight is 65 kg. Lata is 5 feet tall. She is astonished to realize that she has gained weight over the winter.

y What do you think has happened to Lata? y Will this weight gain be harmful to Lata? How? y What should Lata do? y How can a doctor or nutritionist or you help Lata?

Case Study 2:

Raman, a 15-year-old, has started eating tobacco. It started with pan masala and gutkas and now he smokes too. Raman has lost weight in the past few months and looks very weak and sick. He keeps persuading his friends to buy him tobacco.

y Why is Raman looking sick? Is he eating well? Why? y How can his condition affect the future? y How can you help Raman?


y Lifestyle diseases are caused due to not eating well (overeating, untimely eating and unhealthy eating), sedentary lifestyle and consumption of tobacco or alcohol.

y It is not wise to take up unhealthy habits due to any kind of peer influence or attractive advertisements.

y One needs to practice saying ‘No’ to unhealthy foods and substances like alcohol and tobacco.

y Elders and peers can be of great help in getting rid of such conditions.

y Always remember, you have to live a long and healthy life.

5.2 Balanced Nutrition and Physical Exercise To enjoy a healthy lifestyle, it is important to have a balance of exercise and good diet. Regular physical activity can produce long-term health benefits. Your physical activity should be enough to burn the calories you imbibe in the form of food. If the extra calories are not burnt through physical activity, they accumulate as fat and make you overweight/obese.

Activity 4


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Invite five pairs of volunteers. Assign a health condition to each pair as given below and ask one to act as an adolescent with the given health condition and unhealthy habit and the other as a peer educator. Ask the peer educator to help his/her friend understand his/her condition and help him/her to get rid of this health condition with the facts and tips given in the chart.

Promotion of Healthy Lifestyle

Risk factors Facts you must know Counselling tips for preven-tion of common lifestyle con-ditions among adolescents

High blood pressure

High blood pressure is called the ‘silent killer’.

When your blood pressure is high, your heart works harder than it should to move blood to all parts of the body. If not treated, high blood pressure can lead to stroke (brain attack), heart attack, eye and kidney problems and death.

Blood pressure in adolescents varies with age group and sex.

Advise your friend to get his/her blood pressure checked once a year. Suggest the following:

• Aim for a healthy weight.

• Be active every day.

• Use less salt and sodium.

• Eat more fruits, vegetables and low-fat dairy products.

• Avoid tobacco and alcohol.

Overweight

Overweight occurs when extra fat is stored in your body.

Being overweight increases your risk of developing high blood pressure, high blood cholesterol and diabetes.

• Maintain a healthy weight. Try not to gain extra weight.

• If you are overweight, try to lose weight slowly. Try to lose 1/2–1 kg a month.

Diabetes

When the sugar in the blood is high, your body cannot use the food you eat for energy.

Diabetes is serious; you may not know you have it. It can lead to heart attacks, blindness, amputations and kidney disease.

If you come to know that your friend has high blood sugar, refer him/her to the nearest health facility.

Smoking and alcohol

It is an addiction that puts one’s health at risk and generally starts under peer influence. Unmindful consumption adversely impacts social and family life.

Cigarette smoking is addictive. It harms the heart and lungs. It can raise your blood pressure and blood cholesterol as well as those of others around you.

Alcohol and other substances are addictive.

Person is vulnerable to accidents and injuries.

Help your friend stop smoking or cut back gradually.

• Try convincing your friend about the effects of tobacco and alcohol consumption.

• Take your friend to a nearby health facility for further counselling.

Activity 1

Contd...


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Risk factors Facts you must know Counselling tips for preven-tion of common lifestyle con-ditions among adolescents

Physical inactivity

Physical inactivity can double the chances of heart disease in adulthood.

Physical inactivity increases the risk of high blood pressure, high blood cholesterol and diabetes.

Adolescents should do 60 minutes or more of moderate physical activity each day.

Advise to stay active. you may advise your friends to spare at least 30 minutes each day or one-hour exercise or a walk three times a week.

• Suggest outdoor games to your friends; jogging, yoga, dance, swimming are also popular ways to be physically fit.

• Use of stairs is also a form of physical activity.

Explain good health to participants with the following facts:

y Good health is not about not being ill, it is about adopting a healthy lifestyle and leading a stress-free life, thus being physically, mentally, spiritually and socially fit.

y Being healthy is not anymore just about taking medicines when unwell; it means taking care of ourselves to prevent any illnesses and to change our attitude when we need to heal or get better after the illness.

y Taking care of our health today means doing a lot of things to feel good, from eating the right way, physical exercise, managing anger and stress combined with positive thinking.


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Key Messages

1. Both adolescent boys and girls require good nutrition for optimal growth and development.

2. Intake of inadequate diet can result in severe consequences leading to under-nutrition and anaemia.

3. Girls especially need attention to increase food intake to accommodate ‘growth spurts’ and to establish energy

reserves for pregnancy and lactation.

4. Fight iron deficiencies through consuming foods rich in iron (green leafy vegetables, meat and liver), vitamin A

(papaya, mangoes, carrots, pumpkins, liver).

5. Prevent and treat infections, by timely immunizations, taking IFA tablets and imparting education about under-

nutrition and anaemia.

6. Overeating or unhealthy eating combined with sedentary lifestyle can cause overweight and obesity.

7. Eating well and physical exercise are both important to maintain good health and fitness.


1. To educate adolescents between 10–19 years on importance of under-nutrition and lifestyle conditions.

2. To inform and educate adolescents, their parents and the community on under-nutrition, anaemia and lifestyle

health conditions and diseases.

3. To encourage peers to share the cooking responsibilities with their mothers or the person in charge of cooking

at home.

4. To raise your voice against harmful traditional practices and discrimination against girl child or women that

restricts access to nutritional food.

5. To organize, with the help of Anganwadi worker, educational sessions on nutritional recipes with locally

available food items especially during times of high inflation.

6. To help adolescents go for periodic health check-ups to monitor their health and nutrition.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Health Conditions during Adolescence

module IV healthy mind for healthy behaviours

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Session 6Dealing with Peer Pressure

IntroductionAdolescence is a turning point in one’s life, a period of increased potential but also increased vulnerability. Mental health concerns are rising among adolescents both in urban and rural areas. Youth is the stage in which most mental disorders have their onset. Young people have a high rate of self-harm and suicide which is one of the leading causes of death. Mental health can be strongly correlated with many other health and development concerns for young people, notably with educational achievements, substance misuse (non-medical drugs), violence and reproductive and sexual health outcomes.

Adolescence is also the phase of formative and dynamic transitions when young people take on new roles, responsibilities and identities. As adolescents mature cognitively, their mental process becomes more analytical. They become capable of abstract thinking, better articulation and develop an independent ideology. These are truly the years of creativity, idealism, buoyancy and a spirit of adventure. However, these are also the years of experimentation and risk taking, of giving in to peer pressure, and of making uninformed decisions on crucial issues, especially related to their bodies and their social behaviour. This phase is marked by frequent mood swings and stress compounded by pressure to conform to peer group norms that may conflict with one’s own attitude, values and behaviour. However, peer pressure can also have positive effects when adolescents are influenced positively. The need of the hour is to equip adolescents with the information and skills to manage peer pressure, stress and emotions in constructive ways without harming self, practise responsible sexual behaviour, to make informed decisions and to say ‘no’ to risky behaviour. The session will specifically build practice exercises on some of the core life skills (learnt on day 1) necessary to manage stress, emotions and peer pressure.


1. To learn and practise skills to manage peer pressure

2. To learn about the risks associated with substance abuse, unsafe sexual behaviour and reckless driving

3. To learn the significance of assertive communication and saying ‘No’

4. To practise phrases that help make your response assertive and in saying ‘No’

Time:

30 minutes


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Material:

Printed copies of given case study; chart papers; sketch pens

Methodology:

Brainstorming, group discussion, role plays/forum theatre

6.1 Assertive Communication

Invite the participants to sit in a circle. Explain that communication is about using speech, body language, expression, seeing and listening. This exercise will allow them to practise their communication skills to make them more effective. Invite three pairs of volunteers. Give each pair a role play to prepare in five minutes and enact.

Role Play 1: Shyama is travelling in a bus. A man is standing next to her. He tries to take advantage of the crowd in the bus and tries to touch her deliberately. Shyama is uncomfortable but confused. After sometime, he falls on her. Shyama somehow maintains her balance. He says “Sorry”, pretending again that he was pushed by the crowd. Shyama manages to move away from him. A while later the man again comes near her trying to touch her. Shyama is trying her best to protect herself but doesn’t say anything to the man. The man stretches his other arm to hold the rod where Shyama is moving.

Role Play 2: Shyama is travelling in a bus. A man is standing next to her. He tries to take advantage of the crowd in the bus and tries to touch her deliberately. Shyama looks at him and tells him loud and clear, “Please stand properly as I am being hurt. I can understand there is a crowd but you can hold on to the support so that you don’t fall on others”. The man moves back.

Role Play 3: Shyama is travelling in a bus. A man is standing next to her. He tries to take advantage of the crowd in the bus and tries to touch her deliberately. Shyama pushes him back and shouts, “Can’t you see women are standing, you moron?”. The man answers, “Can’t you see the bus is overcrowded?”

Now write three words on the flip chart/blackboard:

Non-assertive, Assertive and Aggressive

Ask the participants to identify the manner of communication each role play demonstrated. Ask them the reasons for their response and list them in three columns titled Non-assertive, Assertive and Aggressive. Also ask them to tell the advantages and disadvantages of each response. Ask the volunteers how they feel when they are assertive, non-assertive or aggressive. Note down their responses and connect to Activity 2 and Activity 3.

Activity 1

module IV: healthy mind for healthy behaviours

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Explain to the participants the advantages and disadvantages of different ways of communication and the differences between each with the help of the charts given below.

Ways of Communicating: Advantages and Disadvantages

Non-assertive Aggressive Assertive

Disrespectful to oneself Disrespectful to others Respectful to oneself as well as to others

Undervalues knowledge, feelings and rights of self

Undervalues knowledge, feelings and rights of others

Sensitive to self as well as others

Remaining quiet in situations where personal rights, needs and feelings are violated

Only talking and not listening or trying to understand the other person’s situation

Control of the situation and can express opinion after correctly judging the situation

Giving in to external pressure against own wishes and values

Being impolite and rude to others

Being con�dent and polite

Blaming oneself Blaming others Judging the situation without bias and blame

Differences between Non-assertive, Aggressive and Assertive Communication

Non-assertive Aggressive Assertive

Soft, uncertain voice Loud and explosive voice Strong and steady voice

Downcast eyes Intimidating looks Good eye contact

Shifting weight back and forth Intimidating body language Strong body language

Doesn’t feel comfortable talking about how he or she feels

Insensitive (what you want isn’t important)

Aware of others’ feelings (sensitive)

Nervous Demanding Confident

Uncertain Cannot control temper In control

“My thoughts aren’t important” “This is what I want” “This is what I think”

“I guess, maybe” “you’d better, if you don’t, then look out”

“I” statements

“Is everyone else doing it?” “This is what I want” “I would like to hear what you think”

Activity 2


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Invite four volunteers and give them a role play to enact. Tell all the participants to remember the difference explained in Activity 2.

Ajit is stopped by his friends on his way to school.

Friends: Hey, we are going to a movie today. Come with us. You will have fun. Have a smoke with us. (They offer him a cigarette.)

Ajit: Friends, I would have liked to come but today I have to submit my homework to the teacher.

Friends: We will all submit it tomorrow and you can tell the teacher that you were not well. Come, let’s go.

Ajit (a bit nervously): What if we go some other day? I have to take my mother to the doctor this afternoon. (Ajit looks away.)

Friends: Do not worry. We will return by then. If we are late, tell your mother that the teacher gave some work. (A friend holds his hand and pulls him.)

Ajit is confused how to excuse himself from this invitation as he doesn’t want to bunk school. He doesn’t smoke and does not want to try cigarettes at all.

Ask the participants whether Ajit was assertive, non-assertive or aggressive. Invite volunteers to replace Ajit in the role play and ask them how they would respond to get out of that situation. Tell them that each one will get only a few seconds or a minute to make their point. Ask the volunteers how they feel when being assertive or non-assertive or aggressive.

Summarize by saying that assertive communication is an effective way to communicate your feelings. By being assertive you respect your own right to express and practise your opinion and thoughts. You are confident and in control of your environment. It helps you make your point without causing misunderstanding or getting into a heated debate or violence.

Non-assertiveness does not solve your problem and may even increase your risk, while aggressive ways can lead to violence, embarrassment, emotional pain and injuries. It may be humiliating and build a negative image of you as a person who gives into pressure. Aggressive ways can also be humiliating for self and others.

Activity 3


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Adolescents are exposed to situations where it is difficult to communicate effectively. At times it is fear of embarrassment or shame or fear of offending friends and elders. An assertive technique helps make the point without hurting anyone at the same time safeguarding one’s own interests. Never hesitate to be assertive if you are not in agreement with others’ thoughts or pressures.

The second role play on Shyama’s experience of physical harassment demonstrated the assertive response of Shyama. In Ajit’s case, the assertive response could have been, “I don’t want to miss my class/school for a movie. I need to submit my homework on time. If I have to go to a movie, I will go on a holiday or after school with my parents’ permission. That way I will enjoy the outing better and will be safe. Sorry I don’t smoke and do not have any interest in trying.”

6.2 Learning to Say ‘No’

Invite a few volunteers. Tell them that they will do a role play where everyone can participate. Give a role play to the volunteers to prepare in five minutes and enact in front of the group. Inform the participants that in the role play there are two kinds of characters – one a persuader and the second a decision maker (one who has to deal with the persuasion in such a way that he/she does not put himself/herself at risk). The situation is as given below:

Sanjay is invited for a party by a few of his friends. He goes to the party and finds that there are arrangements for smoking and alcoholic drinks. Sanjay is also offered a drink. He says he would like some fruit juice. His friends laugh at him, “Come on, you are a man. You never invite us for parties, but at least keep us company in enjoying drinks.” Atul serves him a large drink. Sanjay doesn’t want to drink or smoke. He says, ”………...”

Ask the volunteers to continue the play with their own dialogues. Let the dialogue between Sanjay and his friends continue for some time and then ask them to ‘STOP’ or ‘FREEZE’.

Ask the remaining participants to identify the persuader and the decision maker. Then ask them if they think that Sanjay has been able to refuse the drinks and cigarettes offered by his friends convincingly. Answers would be ‘No’ or ‘Yes’. Invite them one by one if they want to replace the volunteer for Sanjay’s role to take the position. Start the play again and see how the new volunteer deals with the situation. Try and ensure that many people get the chance to act as Sanjay in the given situation; hence when the play restarts and Sanjay is debating with friends, if anyone feels that he/she has a better way to deal with this pressure, the participant can say ‘STOP’ or ‘FREEZE’ at any point and take the position of Sanjay, with the earlier volunteer returning to the audience. Let this continue for as long as innovative ideas to deal with the situation come.

Activity 1


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Note down some of the interesting ways suggested by the participants through this role play.

Suhani’s Story:Suhani is very happy today and has worn her favourite dress. Today she is attending a college party. Friends say that the party is more fun with Suhani. Suhani is very happy. She is talking to everyone, singing and dancing with friends. After sometime, a boy from a senior class (who is also a friend’s relative), comes to her and invites her to dance. Suhani is not very comfortable but agrees as he is her senior and the relative of one of her friends. Later when the party is over, the boy asks Suhani if he can drop her home. Suhani thanks him and says she can go on her own. The boy starts insisting and then tells Suhani’s friend, who is his relative, to convince Suhani. Now both the boy and his relative are insisting that Suhani goes home with him. Suhani is not prepared to do so. Suhani says, “..............”

Shyama’s Story: Shyama’s friend Anita wants her to accompany her to a cousin brother’s birthday party. She says that her brother has specially invited Shyama for the party. Shyama is not comfortable going with her friend and she knows that her parents will not like this. She is trying to make an excuse but Anita says that she will be upset with her if she doesn’t come. Shyama does not want to hurt her friend but does not want to go to party either. Shyama says, “..............”

Ask peer group members to suggest ways in which Suhani and Shyama can refuse. As in the previous story, this can be also conducted as a role play with participants practicing ways to say ‘No’ by replacing the character of Suhani.

Tell the participants that through the role play, we can understand that saying ‘No’ is not an easy task, especially to friends.

It is not easy to say ’No’ especially to friends, seniors and elders (including those in the family) as we do not want to hurt them. But at times if friends, seniors or elders are forcing you to do something which you are not comfortable with or you feel is not socially accepted and may even be harmful to you, you need to say ‘No’. At times, we may not be directly pressurized but the popular behaviour or practices among people of our age group also create pressure. This is what we call ‘peer pressure’. Peer pressure can be positive as well as negative. When peer pressure is conflicting with our own attitudes, values and behaviours we should learn to say ‘No’. Every adolescent has the right to take decisions in his/her own best interest.

Remember it is alright to say ‘No’ in situations of coercion or pressure. Human relationships are not based on terms and conditions but mutual understanding and consent.

The ways to say ‘No’ could be polite refusal, giving an argument, or being firm and assertive. Being non-assertive or aggressive may increase our vulnerability and hence we should try to communicate in an assertive way. Some ways of being assertive are illustrated in the chart.

Activity 2


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Invite two pairs of volunteers. Give them the chart shown below and ask one participant in each pair to act as persuader and the other as decision maker. Ask the persuader to read his/her line and the decision maker to respond to the persuader. Explain the method used in each response.

Persuader Method Decision maker

Can I get you a drink? Polite refusal No, thank you.

How about a beer? Give reason I don’t like beer.

I am taking medicines and my doctor told me to avoid alcohol.

Here,smoke this cigarette with me.

Come on!

Just try it.

Be firm (Broken-record technique)

No, thanks.

No thanks, I don’t smoke.

No thanks, I said I don’t.

Hey, do you want to buy some tobacco?

Walk away Say ‘No’ and walk away after saying it.

Do you want to smoke? Cold shoulder (No reaction)

Keep going as if you did not hear the person.

(Not the best response to use with friends)

Come, let’s chat. Give an alternative I have housework to finish.

I have some very important work to finish and report to my parents.

Work can wait for 10 minutes, let’s talk for sometime.

Reverse the pressure What did I just tell you? Were you listening?

I will wait for you, please do come.

you will have fun, do come. Other friends are also coming.

Avoid the situation If you know people or situations where you will be pressurized to do things you don’t want to, stay away.

you are not a man. you don’t like teasing girls.

Strength in numbers/groups

Stay with like-minded people who support your decision to not drink, use drugs or misbehave with or tease girls.

Hey, I am going that way and will drop you home on my bike.

Come on, don’t be so formal; allow me to be of some help to you.

Own your feeling Thanks, but I will go with my friends. The house is not that far and I am used to walking this distance.

No, I told you I will walk as I do every day. I like my friend’s company.


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Ask the participants if they have experienced or know about pressure statements used by friends which they can share with the group. Inform them that pressure may influence people into taking risks that may lead to unsafe sexual practices, sexual abuse, substance misuse or criminal acts. Sometimes it is accompanied by threats or emotional blackmail. In any circumstance, or for any friend, no matter how close he/she may be, pressure is harmful for an adolescent and hence adolescents should learn to communicate assertively and say ‘No’ so that they don’t give in. They should use their judgement based on their own knowledge, attitudes and values. It is best to avoid situations or the company of people that could be risky.

List the responses from the participants. Go through some of the pressure lines given below and suggest some assertive ways to deny the pressure:

Pressure line Assertive response

You cannot get pregnant the first time. Let’s just do it once.

Unprotected sex is unsafe anytime. I don’t want this risk at all.

You don’t think I have a disease, do you? No, I don’t think so. I want both of us to be safe.

Come on, you are not a kid anymore! I am smart and I know why I don’t want to.

I know you want to, you are just feeling shy. My ‘no’ means ‘no’. If I was interested, I would have said yes but I am not.

We are more than friends. I love you so much. For me you are only a friend/If you love me don’t force me to do things I am not comfortable with.

Come on, just have one drink. It will relax you. No, thanks. I have other ways to relax.

Smoke this and you will be in paradise. Smoking is injurious to health. Do you think a hospital bed is paradise?

No one will know about it, it’s just you and me. I don’t want to do anything that will embarrass me later.

You may not get another chance like this. That is fine with me. I don’t want any such risk.

Why can’t we do it when everyone else is doing it? I know what I should do and what I should not. I don’t have to learn now.

Do it or goodbye. Okay then, goodbye.

Nothing will happen, it is all right. No, I am not prepared and I don’t want to do it.

Do you think I will hurt you? You are my love. If you love me, don’t force me.

I can hurt you if you don’t. You are threatening me. That is wrong. I don’t care for your threats.

If you really loved me, you would do it. You are using emotional blackmail. If you really love me you will not force me.

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Summarize by saying that learning to say ‘No’ is a skill that will get better with practice. It helps a person to be able to prevent risky situations by dealing with pressures confidently and assertively. Assertive communication helps prevent situations that may cause unnecessary stress and emotional disturbance.

6.3 Substance Misuse and Mental Health

Divide the participants into two groups and give a case study to each to discuss and present their response to the larger group.

Group 1: Suhani is very happy today and has worn her favourite dress. She is attending a college party. At the party she is offered a drink. Friends say that the party is more fun with her. She is happy and flattered and takes a few glasses. She starts dancing and shouting. Friends also join her. She loses control, falls and passes out. When she wakes up she finds herself in her room. She finds her mother crying and her father shouting at her.

y What went wrong with Suhani? y Why did Suhani faint? Is Suhani habituated to alcohol? y How did Suhani get home? y Why was her father shouting and her mother crying? y Do you think Suhani put herself at risk? How? y What could have happened to Suhani that day? y What should parents do?

Group 2: Neeraj is very popular among his friends. He is also good in studies. But for some time now, classmates find him behaving differently. Neeraj also looks very weak and his eyes are red most of the time. His performance has also deteriorated and his teacher is worried. The teacher informs the principal and Neeraj’s parents are called. The parents inform the teacher that they too have felt that he is not eating well and most days he sleeps without dinner. He has also been asking for money every week and his mother feels that he has stolen money from her box. His parents are worried and on the verge of tears. The teacher suggests they take Neeraj to a doctor, who informs them that he suspects that Neeraj is using drugs.

y What do they understand by the term ‘drug use’? y What are the symptoms of a drug user? y How do they think Neeraj has taken to drugs? y How will drug use harm Neeraj? y How can Neeraj overcome this challenge

and get back to normal life? y What should his parents and teachers do?

After listening to the participants’ responses, thank the groups.

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Write the phrase ‘substance misuse’ on the board. Ask the participants what they understand by this. Have they ever heard about drugs? Explain about drugs/substance misuse, users and addiction with the help of the information given in the box below.

A drug is a chemical substance which, when consumed, alters the body’s function physically and/or psychologically. (This excludes food and water.) It could be a pharmaceutical preparation or a naturally occurring substance (like opium) used primarily to alter the physical and mental functioning of an individual. Thus drug sare chemically prepared or naturally available substances that change the way the body works.

There are two types of users:Experimenters: Begin using drugs largely because of peer pressure and curiosity and usually confine their use to recreational/party settings.

Compulsive users: Devote considerable time and energy to getting high, talk incessantly about drug use and become experts on street drugs.

Substance abuse: It refers to the overindulgence in and dependence on a stimulant, depressant, chemical substance, herb (plant) leading to effects that are detrimental to the individual’s physical health and/or mental health or the welfare of others. Addiction to a substance is a compulsion to repeat behaviour regardless of its consequences. The addicted person is called an addict.

Addiction: Repeated use of substance to the extent that the user (addict) is periodically or chronically intoxicated, shows a compulsion to take the preferred substance/s, has great difficulty in modifying his/her behaviour and exhibits determination to obtain the substance by almost any means.

Refer to the case of Suhani and Neeraj. Tell them that Suhani and Neeraj are examples of young people taking to drugs and alcohol due to peer pressure. Drugs not only alter physical functions but also mental abilities. Their use has many associated risks like sexual abuse, unprotected sex leading to unwanted pregnancy and/or HIV, reckless driving, delinquency, unsocial behaviour etc. Adolescents who are more popular with friends are at increased risk to give in to peer pressure. Such adolescents are more worried about their social image among friends and fear losing that kind of popularity. Therefore at times popular students are not always the best performers in studies or any other constructive field. Suhani may or may not be habitual, but drinks at such parties also have the risk of being mixed with drugs that impair thinking and self-control temporarily. These are often used in cases of date rapes.

Neeraj on the other hand shows signs of addiction as he is trying all means, including stealing money, to get drugs. Suhani and Neeraj have a good chance to overcome these challenges but they need support from their family, friends and most importantly, teachers and mentors. It is natural for parents and mentors to lose control and become angry but such reactions will only worsen the situation and not help their children in any way. They have to be patient, strict and at the same time supportive to help their children overcome this. They should also seek help from doctors and counsellors, as well as from relatives, children and the community they live in to be supportive in helping their children fight drugs and addiction.

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Some common characteristics/signs in adolescents who are misusing substances

If someone is misusing substances, you might notice changes in how the person looks or acts. The most obvious sign of an addiction is the compulsion to have a particular drug or substance. The adolescent user may

y Lose interest in studies and school

y Change friends (to spend time with people who use drugs)

y Have an unexplained change in personality or attitude such as sudden mood swings, irritability, anger, etc.

y Want to be alone most of the time

y Have trouble concentrating on work or studies

y Sleep a lot (maybe even in class), be depressed

y Show change in eating habits, including weight loss or weight gain

y Have unexplained need for money and start stealing or selling belongings

y Frequently get into trouble.

y Have unusual odour in breath, body or clothing

y Appear fearful, anxious or paranoid for no reason

y Have red or puffy eyes; pupils are larger or smaller than usual

y Cough a lot and show deterioration in physical appearance, personal grooming habits

y Have tremors, slurred speech or impaired coordination.

Summarize with the following facts:

1. Substances such as depressants, stimulants and hallucinogens are harmful, having serious consequences on one’s health and well-being.

2. These substances affect personal, physical and psychological abilities and the growth of an individual.

3. Life skills like assertive communication, learning to say ‘No’, coping with stress, managing emotions help protect against such risky habits and situations.

4. Help your friends, family and community to get rid of all forms of substance abuse. You have the strength to do that.

5. Long- and short-term effects of some drugs/substances are given in the chart below:

Substance Short-Term Effects Long-Term Effects

TobaccoDescriptionIt consists of the crushed and dried leaves of the tobacco plant.

It is one of the most commonly used drugs.

The user’s pulse rate and blood pressure increases. The amount of acid in the stomach and urine production increases. Activity in the person’s brain and nervous system initially speeds up but then slows down. The appetite decreases.

Blood vessels in the heart and brain are narrowed; person develops shortness of breath and cough. Infections in the lungs, such as pneumonia, are more likely.

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Substance Short-Term Effects Long-Term Effects

The nicotine in tobacco is largely responsible for the short-term effects of smoking and its addictive nature.

Other Names (forms of tobacco)

Cigarettes, smokes, sticks, butts, gutka, beedi

Cancer of the lungs, mouth, larynx, oesophagus, bladder, kidney or pancreas is more likely. Stomach ulcers may develop.

The skin ages prematurely. A pregnant woman who smokes is more likely to have a premature baby, or one with a lower birthweight.

A woman smoker who takes birth control pills is more likely to develop blood clots and also increase her risk for heart attack and stroke.

AlcoholDescriptionIt is one of the most commonly used drugs made through fermentation of fruits and or grains.

It is a depressant that slows down the activity of the central nervous system.

Other Names

Beer, brew, suds, wine, spirits, booze, grog, hooch, moonshine.

At first, the person feels relaxed and less inhibited but s/he actually loses the reflection and ability for clear thinking, judgement and decision making. The person’s reflexes will become slower; s/he will have trouble working and doing anything that requires any physical and mental co-ordination.

The person’s mood may change; s/he may become angry or take more risks.

If the person drinks a large amount of alcohol on a single occasion (binge drinking), the respiratory system may slow down seriously or even stop, causing death (alcohol poisoning). The effects of alcohol may increase if combined with certain other drugs.

Short-term effects are intensified with binge drinking. Hangover may occur. (Discomfort occurs the next day due to rebound excitation of an alcohol-depressed nervous system. Symptoms include headache, low blood sugar levels, dehydration and irritation of the lining of the digestive system).

A person who drinks heavily on a regular basis may develop:

• Inflamed stomach or pancreas

• Cirrhosis of the liver

• Certain cancers of the gastrointestinal tract

• Heart disease, high blood pressure

• Brain and nerve damage

In men, especially, the production of sex hormones will decrease

In pregnant women, prenatal exposure to alcohol can cause Foetal Alcohol Syndrome (FAS) or Foetal Alcohol Effects (FAE) (facial abnormalities, growth deficiencies and damage to the central nervous system which can result in developmental delays, learning disabilities, and hyperactivity and memory deficits).


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Key Messages

1. Mental health is a growing concern among adolescents.

2. Unnecessary stress, emotional swings and taking to substance use impact mental health during adolescence.

3. It is important to communicate assertively and develop the skill to say ‘No’ to deal with negative peer pressure

or any negative influence.

4. By giving in to negative peer pressure you are disrespecting yourself and undervaluing your own knowledge

and decision-making skills.

5. Respect your own rights while using your judgement to act upon a pressure.

6. Practise saying ‘No’ to drugs in any form be it alcohol, tobacco in the form of gutka, cigarette or beedi, opium

and other drugs.

7. Substance abuse has many associated risks like unsafe sexual behaviour leading to unwanted pregnancy and/

or HIV, sexual abuse, cancer, lung and liver diseases, reckless driving leading to accidents and deaths.

8. Addiction not only ruins the life of the addict but poses a heavy economic burden and social stigma on the

entire family and community at large.

9. Manufacturing, cultivation, import, export, storage, sale, purchase or consumption of substances like cocaine,

morphine and heroin are serious offences and have penalties like rigorous imprisonment, fine and even death

in some cases of repeat offence.

10. Help those who have given in to such habits to overcome these challenges.


1. To educate adolescents between 10–19 years on mental health issues and factors triggering such conditions

in adolescents.

2. To help adolescents recognize peer influence in their life and teach them ways to deal with peer pressure.

3. To educate adolescents and the community at large about consequences of substance misuse.

4. To provide support to adolescents who have given in to negative peer pressure to overcome their fears, guilt

and embarrassment.

5. To support adolescents to deal with emotions and stress.

6. To help adolescents access health provider at Adolescent Friendly Health Services/Clinics (AFHCs) at PHC for

counselling and treatment, if required.

7. To educate elders and other community people to be sensitive to the needs of adolescents who have taken to

substance abuse.

8. To maintain confidentiality and trust of peers.

Refer Peer Educator Resource Book to deliver messages andclarify doubts related to Dealing with Peer Pressure

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Session 7Managing Emotions and Stress

IntroductionWe are almost constantly stressed during the adolescent phase. The reasons could be many: fear of exams, concerns about physical changes, falling in love, getting admission in a good school/college, pressure by employers if employed, pressure by friends, discriminatory behaviour of elders, risk of violence etc., and trying to maintain good relations with everyone during this process. Any of these can cause a susceptible person to break down and slip into depression. However stress alone does not disturb the mental health of an adolescent. The individual’s personality, environment and ability to cope with stress and manage emotions contribute to his/her mental health. Hence it is important for adolescents to learn and practise skills to solve their problems, resolve conflicts and manage stress and emotions.


1. To learn and practise skills to manage emotions and stress

2. To learn to identify the root cause of stress and emotional disturbance

3. To learn how to solve problems and resolve conflict peacefully

Time:

30 minutes

Material:


Methodology:



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7.1 Problem Solving

Tell the participants that all of us face numerous problems in our day-to-day life. If we do not solve our problems as and when they appear, they might get bigger and create difficult situations in our lifestyle and in the future.

The session will help you identify the problems and highlight the ways to find solutions to problems. Thus, it is first important to understand the reasons for the problem(s). Usually we fail to identify the root cause of problems and therefore we are not able to find solutions for them.

Divide the participants into four groups and provide them case studies for discussion.

Case Study 1:

Ravi likes to spend his time with friends. He leaves home around 3:30 pm and returns only after 6:30 pm, at times even after 7:00 pm. Sometimes his friends come over and spend hours chatting. Ravi’s parents are not happy and they often send somebody to bringhim home. If they are not able to find him, his mother also calls the houses of his friends to enquire about him. Ravi is upset with his mother’s behaviour as he thinks he is grown up enough to decide when to return home. Ravi often has heated arguments with parents. He tells them that he hates to be with them.

1. Who is right, his mother or Ravi?

2. Who is stressed more, his mother or Ravi?

3. Why is Ravi stressed?

4. How can Ravi solve this problem?

Case Study 2:

Ramesh is studying in Class 9. His parents are very poor and find it difficult to bear his schooling expenses. Ramesh is a good student. One day, the teacher announces in the class that the school fees have been hiked. Ramesh is very sad and doesn’t know whom to talk to about his problem. He is well aware that it will be very difficult for his parents to pay the fees and that he might have to leave school.

1. What do you think Ramesh should do in this situation?

2. How would you handle this problem?

3. Do you think there could be a possible solution to this problem?

Activity 1


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Case Study 3:

Safina is a student of Class 9 who likes a boy called Nitesh. Nitesh starts dating her and asks to have sex with her. Safina refuses and tells him that if her parents get to know about it, they will scold her. Nitesh leaves Safina and starts dating another girl. Safina consults an astrologer and asks for a solution to get Nitesh back in her life. The astrologer fools her and tells her to pay him Rs. 5,000/- for that. Safina shares this with her childhood friend, Meenakshi, and also her plan to steal money from her house. Meenakshi tells Safina that the astrologer is fooling her but Safina refuses to listen to her.

1. What is the root cause of Safina’s stress?

2. Is it wise to chase someone like Nitesh?

3. What would you do in Safina’s place?

4. How can Meenakshi help?

5. Is there a solution to this problem? If yes, explain.

Case Study 4:

Sakshi is a blind girl who stays with her brother Sanjay. Her parents died in an accident and so there is no one to take care of Sakshi at home. Sanjay goes to college and locks the door while going. He gives the keys to a neighbour. The neighbour assures Sanjay that he will take care of Sakshi but then starts assaulting Sakshi in his absence. Sakshi becomes very depressed and irritable. She shares with Sanjay that somebody comes to the house and assaults her in his absence but Sanjay feels that Sakshi is lying to him as she wants him to stay with her all the time. On Sakshi’s request, Sanjay stays with her all the time and does not go to college regularly. He starts feeling frustrated as his college friends make fun of him. He wants to get rid of Sakshi.

1. Why is Sakshi depressed?

2. Is Sanjay also going through mental and emotional stress?

3. How can Sanjay get rid of Sakshi? Is it right for him to do that?

4. What could be the possible alternatives for Sanjay?

5. How would you deal with this situation?

6. How would you counsel Sanjay?

Explain to the participants that in the beginning simple problems that can be easily solved should be identified. For solving more difficult problems, they can approach someone for help. Explain that as peer educators, they should remember that after they have completed their training, they will be able to solve at least some of the common and simple problems. As they become more skilled and competent they will be


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able to identify more complex problems and solve them with expert help. However, the key is to discuss the problem with as many people as possible without revealing the identity of the person with the problem. Seek the help of community elders, doctors and social workers as required. Discussion brings informed and innovative solutions to a problem, just as we practise in this training.

Discuss the case studies in detail with the participants and make sure that they are able to identify the problem and suggest possible solutions.

Explain some ways to solve problems.

Problem solving enables a person to deal constructively with problems in his/her life. Problems left unresolved can cause mental stress and give rise to physical strain.

At times problems do not have easy solutions. Give some time to yourself. In such situations it is better to look for what best can be done rather than coming under wrong influence that will harm you as well as others. In such cases talking to different people like peer educators, parents, relatives, doctor, teacher, social worker or an older member of the community helps.

Steps to solve problems:

1. It is important to recognize the problem/s.

2. Identify the root cause to be addressed.

3. Once you decide to solve the problem/s, give importance to solving it.

4. Select the problems one by one instead of trying to solve all of them at one go. Trying to solve multiple problems at the same time only creates confusion.

5. Try to think of various solutions. Identifying more than one solution to a problem can result in selecting the best solution.

6. You can discuss the various options with someone you trust, and choose the most appropriate solution which can be implemented without too much difficulty.

7. Commit yourself to solving the problem.

8. Implement the solution. This should be done as soon as possible since any delay might lead to decrease in the priority given to solve the problem.


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Contd...

Explain the case of Ravi with the help of the matrix given below.

Steps How to do it Example

Describe the problem. Use ‘I’ messages.

Don’t accuse, blame or criticize.

Ravi: “I don’t like it when you tell me I have to come home early. When I leave early, I feel like I’m missing the best part of time spent with my friends.”

The other person listens and then reflects on what he/she has heard.

Listen quietly without interrupting, and then summarize the other person’s thoughts and feelings without advising, criticizing or judging.

Parent: “you don’t like it when I tell you to be home early. When you have to leave early, you feel like you are missing the best time of the day with friends.”

Ask the other person for his or her thoughts and feelings about the problem.

Listen quietly without interrupting, asking questions or commenting.

Ravi: “What do you think about the problem?”

Parent: “I get upset when you stay out late and I have noticed you are awake till midnight. I worry that you won’t get enough sleep or that something bad might happen.”

Reflect on what you hear. Summarize the other person’s thoughts and feelings without advising, criticizing or judging.

Ravi: “you get upset when I stay out or when I am awake till midnight because you worry that I won’t get enough sleep or that something bad might happen.”

Summarize the problem, including both people’s needs and feelings.

Avoid judging, criticizing and blaming.

Ravi: ”Seems like the problem is that you want me to come home early, and I don’t want to miss out on conversation with my friends.”

Invite the other person to solve the problem with you.

Each person comes up with several possible solutions. Some will be workable, some will not.

Ravi: “Let’s each try to come up with some ideas to work this out.”

List the ideas. Be respectful of each other’s ideas even if you don’t agree with them.

Ravi: “Well, just don’t worry about me.”

Parent: “Come home on time and we will stop worrying.”


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Steps How to do it Example

Ravi: “How about if I call you if I’m going to be late?”

Parent: “That’s good. But how about fixing a time for your friends and calling and telling me exactly where you are? We will call only if you don’t reach home at the decided time.”

Comment on each idea. Avoid judging or criticizing. Ravi: “Sometimes I want to hang out with my friends and not be home so early.”

Parent: “Until you’re old enough to handle your life, we will keep worrying about you.”

Parent: “I like it when you call me, but when you call to say you’re staying out till 8:00 or 9:00 pm, it doesn’t solve the problem.”

Ravi: “OK, I can try that. But 6:00 pm seems kind of early.”

Make a plan on how the solution will work.

Include details and what each person needs to do.

Parent: “Let’s try this for a week. you’ll come home by 6:00 pm and by 7:00 pm on the weekends. If it works well we can stay with it.”

Ravi: “So if I come home on time for a week, you won’t ask me when I’m coming home every time I go out.”

Write the plan down and put it somewhere you both can see every day.

Parent: “Let’s write out our agreement and put it on the wall so that we both can see it.”

In Ramesh’s case, he should discuss it with his teacher and other members in the community. Someone can suggest a scholarship or government schools where there is free education up to 14 years. Someone in the village can also sponsor his education. To get help, one has to ask for help.


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In Safina’s case, it is good that she discussed the issue with her friend. She needs to be educated that Nitesh is not in love with her or else he would have not asked her for such favours. Also, if he can leave her on such an excuse he doesn’t deserve her at all. In fact she is lucky she came to know his true character. She should concentrate on her studies and work and look for true friends rather than wasting time, energy and money on the astrologer. She should also not do anything wrong like stealing money, as this will not help her in any way and she will only lose the trust of her family and friends.

In Sakshi and Sanjay’s case, they should seek the help of the village head, teachers, social workers or relatives to find a school for the blind for Sakshi, where she will have the opportunity to grow to her full potential. This will empower her and help her become self-sufficient. If there is no such school nearby, Sakshi should be allowed to attend regular school and listen to the lectures. She should spend time with her friends and co-learners rather than being locked up at home. Sanjay could seek help from her co-learners or friends to help Sakshi reach the learning centre and return home safely.

Explain to the participants that positive thinking and constructive solution seeking helps one cope with stress.

Healthy ways to manage stress

1. Avoid unnecessary stress by managing your time, identifying your strengths and limitations, saying no to pressures and avoiding hot-button topics.

2. Alter a stressful situation by being assertive, expressing your feelings rather than bottling them up and take control of the situation.

3. Adapt to the needs of the stressful situation: maybe by changing your ways to suit the demands, by being more active and considerate and focussing on the positives of the situation.

4. Accept things that you cannot change; let go of bitter experiences, forgive, seek a compromise where you neither win nor lose too much.

5. Engage in recreational activity and fun; take up music, sports, dance, yoga etc. These help immensely.

6. Adopt a healthy lifestyle that maintains nutritional balance, keeps your weight in control, aids immunity and thus helps you have a disease-free body.

7. Take help from friends, parents, teachers or other elders. If you present your case properly, they will understand your situation and help you.

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Discuss some examples of stress builders and stress busters. Ask the participants to add from their experience.

Stress Builder Stress Buster

I am always late in submitting my home work. I will fail this time also.

If I stay focused, I will improve. I will not be the best but I will improve on my earlier performance. I should also take help from the teacher or someone who knows the subject well.

My teacher did not respond to my greetings. She doesn’t like me as I don’t get good marks.

I am jumping to conclusions. Whether I get good marks or not, the teacher will always respond to me as it is basic courtesy. She must have not noticed or been absorbed with something else. Even if she did ignore my greeting, I will continue to be respectful. I am right in doing that.

Ritesh doesn’t love me. What should I do so that he starts loving me?

Maybe I am not his choice. I should not change myself just to attract Ritesh. I will get someone who likes me the way I am.

Summarize with the following:

1. Stress is a combination of physical, mental and emotional feelings that result from pressure, worry and anxiety.

2. Too much or too frequent change in one’s life can cause stress.

3. Stress may be caused due to pleasant or unpleasant events.

4. Stress is a result of related and unrelated reasons and many times is more apparent to others than to one.

5. Mild stress and anxiety can enhance performance and life but if it is of high degree it may be disruptive.

6. Positive ways of thinking can help us cope with stress.

Activity 3


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7.2 Peaceful Ways to Resolve Conflict

Divide the participants into two groups and give a case to each one to discuss and present.

Case Study 1:

Anmol, Raghav and Noosarat are good friends and lead their class in planning for Teacher’s Day celebrations. They have been allowed to prepare a one-hour programme. Noosarat says that she will prepare a folk dance with other girls and boys, a play and some speeches. Raghav says that they should have some snacks and flowers for the teacher and give her a nice present from the class. Anmol does not agree with either of them and wants to take the teacher out for a picnic as she is always working and never seems to have any leisure time. While discussing this, none of them wants to give up his/her idea and suddenly their voices are raised and Noosarat is in tears while Anmol and Raghav are angry with each other.

1. What is the cause of conflict?2. Who is suffering and who is happy?

3. Can this conflict be resolved? How?

The group can give as many solutions as they want but solutions should be practical and peaceful.

Case Study 2:

Manju, Prabhakar, Jose and Neekhat are friends. They are in the same school and try to spend time together. For some days Manju and Neekhat observe that Prabhakar and Jose are not spending enough time with them. Even during recess they have lunch with other boys and not with them. Neekhat is very close to Jose and feels that he shares everything with her. One day another classmate came to her and said, “Neekhat where were you yesterday? We had a party after games practice. Manju, Prabhakar and Jose were also there.” Neekhat is upset that she was not informed by her friends and even Jose didn’t bother to tell her. When she asks Manju, Manju teases her a bit and then says that it was just unplanned. Neekhat feels depressed and at the same time angry with her friends, especially Jose. She stops talking to them. Prabhakar, Manju and Jose are sad. Neekhat does not listen to Manju at all.

1. What is the cause of conflict? Who is suffering and who is happy?

2. Can this conflict be resolved? How?

The group can give as many solutions as they want but solutions should be practical and peaceful.

Once the group discussions are over ask each group to present their case. Explain the following:

Activity 1


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Healthy interpersonal relationships are the heart and soul of human experience. Friendship and relationships are a crucial part of adolescence. As children grow into adolescents, they become increasingly reliant on peers for friendship, intimacy and validation. However, conflicts due to external or internal factors do arise. At times they are due to differences in opinion, views and attitude with our near ones or others and sometimes due to our own conflicting choices like choosing between a new dress or a new game; choice of career; one-sided liking for someone etc. For girls it is even more difficult as there are social norms that restrict them from expressing their feelings and opinions. Unresolved conflicts may lead to risky situations like being taken advantage of by others who may not be true well-wishers or slipping into self-harming or delinquent behaviour. Resolving conflict is difficult but not impossible and that too through peaceful means of effective communication.

Conflicts and Why They Occur

y Conflict is a natural part of our lives and is very common during adolescence as adolescents think differently and have different perspectives.

y Conflict is an inevitable part of relationships.

y Conflict refers to some form of disagreement arising within a group when the beliefs or actions of one or more members of the group are either resisted or unacceptable to other members of the group.

y Conflict reflects the complex and sometimes inconsistent wants, values and expectations of individuals and groups.

y Conflict can occur on different levels. Interpersonal conflicts occur between strangers, acquaintances, friends, parents and children. Intrapersonal conflicts occur within oneself.

y Although conflict often is perceived as negative, it has the potential to positively contribute to both relationship quality and personal development.

Show the slides given below and explain different ways of conflict resolution.

SLIDE 1

Competition:Win-Lose

Giving In/Accommodating:Lose-Win

“I satisfy your needs at my expense.”“I satisfy my needs at your expense”


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SLIDE 2

Co-operation: Win-Win

“Neither you norI satisfy our needs.”

“We have discovered new and creative ways to satisfy our needs.”

“I give up some of my needs to satisfy you and you give up some of your

needs to satisfy me.”

Avoidance Compromise: Both win a bit/both lose a bit

Some peaceful ways of resolving conflict are listed below:

1. Stop the argument when you feel you are getting angry and may say something that you will regret later.

2. Walk away when the discussion is getting heated.

3. Stay calm and take deep breaths.

4. Tell the person what is bothering you, but do it nicely. Use ‘I’ statements while describing your feelings and how the other person’s behaviour is hurting you.

5. Listen to the other person’s point of view.

6. Try to understand how the other person is feeling.

7. Look for a compromise; think of possible solutions that can satisfy both sides. Remember compromise is not a win-win situation always.

8. Do not indulge in name calling or insults.

9. Do not yell or raise your voice.

10. Agree to disagree.

11. Ask someone else to help (teacher, parents, other friends, etc.).

There are six ways to handle conflict. Each of them is appropriate in some situations and inappropriate in others.

1. Directing/Controlling: We’re doing it my way and that’s that.

2. Collaborating: Let’s sit down and work this out.

3. Compromising: Let’s both give a little.

4. Accommodating: Whatever you want is fine.


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5. Avoiding: Let’s skip it.

6. Appealing to a third party: Let’s get some help.

The key to successful conflict resolution is knowing when to use which style and not getting stuck in one or two styles or using them inappropriately. Conflict resolution is about expanding our options and increasing our skill for achieving non-violent outcomes.

Invite four volunteers for a role play/forum theatre. Give them a situation to prepare.

Rijwan, Mahendra, Rosy and Shireen are decorating the walls of a small space at Panchayat Bhavan, from where Mahendra was able to convince the sarpanch/village head to allow them to run a youth club. Shireen’s mother is a doctor in the PHC and she said that she will get some first-aid items and condoms and will also invite ANM didi at least once a month to talk to the youth on health and safe sexual behaviour. Mahendra and Shireen are very excited about this club. Rosy and Rijwan plan to paint the room with bright colours and put up some paintings to attract young people. Mahendra wants it to be painted white while Shireen finds it a waste of money as they can get this space painted whenever the Panchayat Bhavan is painted. All four are arguing. Suddenly Mahendra shouts that he would decide as he was the one who got this space. Shireen shouts back, “Keep it to yourself, I will start a new one.” Rijwan says he is fine with whatever they decide and he will not be part of this team. Rosy is furious, “This club belongs to all youth and is not Mahendra’s personal property.” Mahendra gets abusive on hearing that. All four friends are angry and sad and are not able to concentrate on anything else.

Now ask the volunteers to enact the situation. Once the situation has been enacted ask them to ‘STOP’ or ‘FREEZE’. Ask others to replace anyone they want in the play by saying ‘STOP’ or ‘FREEZE’ and try to calm the situation. Continue this for some time and allow as many as possible to try peaceful ways to resolve this issue.


1. Conflict resolution is solving the problems created by the conflict. Positive conflict resolution has three qualities:

� It is non-violent.

� It meets some important need or needs of each person involved.

� It maintains - and can even improve - the relationships of the people involved.

2. Conflict is a normal and natural part of life. Without conflict there is stagnation. The goal of conflict resolution is to use conflict for its constructive and positive aspects, rather than its destructive ones.

3. Conflict is not a contest. In a contest, only one person is the winner; everyone else loses. In conflict resolution we aim for what is called the win-win resolution, where both parties get what they want or need. Lastly, there is no one right way to handle all conflicts.

Activity 2


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Key Messages

1. It is important to manage your emotions and stress in constructive ways for mental and physical health.

2. One should try to identify the root cause of stress and plan to solve it through small steps.

3. Stress can be managed in constructive and positive ways.

4. Mild stress can be a source of motivation to do well while higher levels may be disruptive.

5. Conflicts are normal and a natural part of life. However if left unresolved they may cause unnecessary stress

and emotional disturbance.

6. Conflicts are not contests where one has to win and the other has to lose.

7. Conflict resolution should aim at win-win situation for all involved parties.

8. Violence and abusive language are the most dangerous methods of conflict resolution.

9. Effective communication helps resolve conflicts peacefully.

10. If unable to resolve, take the help of a third party.

11. Unnecessary stress and conflicts take away our time and energy that could have been used positively.



in adolescents.

2. To help adolescents recognize situations that may cause stress.

3. To educate adolescents on how to identify the root cause and plan to resolve problems and conflicts peacefully.

4. To educate adolescents about constructive ways to manage stress.

5. To promote sports, music, dance, painting, yoga and other recreational activities among adolescents to reduce

stress and engage them in constructive activities.

6. To always maintain the confidentiality and trust of peers who seek your help.

7. To seek the help of elders in the community like parents, teachers, social worker, doctor, ANM didi, ASHA didi

etc., in crisis situations.

Refer Peer Educator Resource Book to deliver messages andclarify doubts related to Managing Emotions and Stress

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Session 8Accidents and Injuries

IntroductionAdolescence is full of potential but also has an increased risk-taking tendency and vulnerability to acts that may lead to accidents and injuries. While risk taking in this age group is more of a physiological drive, negative peer influence increases vulnerabilities. Peer pressure and substance misuse (especially alcohol) are common influences in the life of some adolescents and are highly associated with aggressive behaviour and delinquency. Reckless driving and unnecessary confrontations with parents or friends or anyone in the community are some of the unwanted effects. Such behaviour may lead to accidents and physical injuries to self and/or others. The 10 core life skills teach us in different ways to manage our emotions, control our anger and differentiate between safe and unsafe behaviour. It is important to learn that risk taking, violence and being insensitive to feelings of other people is not ‘macho’. Risk-taking behaviour can be addressed by channelizing the drive to positive mediums like sports and games. Vulnerabilities can be reduced by replacing negative peer influence with positive peer influence in the communities.


1. To understand some of the causes of accidents and injuries associated with adolescent behaviour

2. To learn and practise anger management skills

3. To learn how to prevent accidents and injuries

Time:

30 minutes

Material:


Methodology:



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8.1 Managing Anger

Introduce the session to the participants. Tell them that adolescence is the phase when one is most vulnerable to accidents and injuries. Most of these accidents and injuries can be prevented by working on the factors leading to such situations. Some of the factors associated with accidents and injuries among adolescents are anger leading to aggression, peer pressure and the influence of alcohol and drugs. As adolescents we do not realize how often we get into unnecessary confrontations with friends and family, including parents. At times in our anger we also get physically violent and end up harming ourselves or others. Sometimes, due to peer pressure, adolescents adopt risky behaviours, like taking alcohol and drugs, reckless driving or driving without a helmet, unprotected sexual intercourse etc. Hence, it is important for us to learn to manage anger and resist peer pressure in such a way that we minimize our risks and vulnerabilities to accidents and injuries. We have learnt about resisting negative peer pressure in earlier sessions. In this session we discuss managing anger and minimizing risks.

Divide participants in to two groups. Give each group a situation and ask them to discuss and present their response.

Case Study: Story of Rahul and Vijendra

Rahul and Vijendra are standing at a chai shop. They hear two men criticizing a political leader from that area. Rahul is a big fan of the leader and gets agitated when he hears anything negative about him; he turns violent and tries to defend the leader by beating others. Rahul is very angry but Vijendra holds him back and says, “This is not the right platform for a political debate. Everyone has the right to express his or her opinion and the best way is through exercising one’s right to vote. Let’s go from here.”

Discussion Points:

1. What do you think has happened in this situation?

2. Is it right for Rahul to get so angry? Why?

3. Can such situations be harmful not only for Rahul but for others as well? How?

4. What would you do in Rahul’s place?

5. How would you help Rahul to manage his anger?

Activity 1


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Case Study: Story of Neetu and Raunak

Neetu is a 13-year-old girl who likes to watch films and listen to film songs. She sings as well. Family and friends appreciate Neetu’s singing. Neetu wants to pursue singing as a career. One summer, Neetu’s grandparents come to visit Neetu and her parents and stay with them for a month. They disapprove of Neetu’s fondness for films and songs. One day, when Neetu and her friend Raunak are singing together and noting down the lyrics of one of their favourite songs, Neetu’s grandfather scolds her for singing so loudly and also tells her parents to be strict with Neetu and teach her how to behave. Her grandparents believe that singing film songs, that too loudly, is not culturally appropriate for a girl like Neetu. Seeing her grandparents so upset, Neetu’s parents ask Neetu to do house work and not waste her time singing.

Neetu is embarrassed. She is very angry not only with her grandparents but also with her parents. In anger, she starts singing even louder. Neetu’s parents try to stop her but she doesn’t listen to them. Her grandmother gets so angry that she throws a glass of water on Neetu. Neetu is very angry and emotionally hurt. She feels no one likes her and her hobby. Raunak tries to console her. She tears up the diary in which she has written lyrics of hundreds of songs and starts breaking all the cassettes and CDs. While doing so she hurts her hand badly and is bleeding profusely. Raunak calls Neetu’s parents for help and makes Neetu sit down. He tells her, “By doing this you are only harming yourself. Our grandparents belong to the old school of thought and we should try to make them understand our views rather behaving like this.”

Discussion Points:

1. What do you think has happened in this situation?

2. Is it right for Neetu to get so angry? Why?

3. Who is the loser? Neetu or her grandparents? How could Neetu have dealt with this situation?

4. How would you help Neetu manage her anger?

Explain

Anger is a human emotion that is expressed in many different ways. The common methods used to deal with anger are either to express it openly and honestly or to release it in a passive-aggressive manner. The most common recipients of misdirected anger are younger siblings, peers, mothers and teachers– basically those whom we perceive as less powerful than us.

y Expressing anger is a need for every individual but expressing it in a socially acceptable and harmless way needs to be learnt.

y Uncontrolled anger can lead to violence and physical harm. At times in anger we harm ourselves or we harm others or we may get harmed by others. Hence one should learn how to manage our anger and practice it in such situations.

y Most of the time our anger is misdirected at people who have nothing to do with the situation.


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y It is important to be aware of our emotions and our reactions to different situations so that we can control our emotions.

y All emotions are neither good nor bad, but how we express them is important.

y Adolescents may get into situations of confrontation but if they know how to communicate their views assertively, negotiate in the best interests of the person affected (self or others), provide reasonable arguments and manage their emotions and anger, they can overcome such situations in a way that does not cause any physical harm or hard feelings.

y In some situations one may find the opponent unrelenting but still one should continue communicating one’s views assertively rather reacting in ways that can be socially unacceptable such as physical violence, verbal abuse, threatening etc. If the other person gets violent and your reasoning is not being listened to it is better to leave the place or move away from the person. One can resolve the matter calmly later with the help of others.

With help of the information given above explain ‘Anger’ and ‘Steps to Control Anger’

What is anger?

y If conflict is left unresolved it causes anger.

y Anger is a negative emotion that is managed in one of the two ways: keeping it inside or letting it out.

y It is important to acknowledge, accept, manage and appropriately express feelings rather than being overwhelmed by their strength.

y Anger, which comes out, can harm oneself, damage friendships, interfere with learning, disturb family relationships and limit participation in group activities/team work.

Steps to control anger

STEP 1: Prepare for the provocation

If possible, get yourself ready for a potential conflict. Make statements such as these:

y I can handle this.

y I know how to control my temper.

y This could get ugly, but I know how to handle myself. Let me take deep breaths.

y If it is not going well, I need to calmly excuse myself and address it later.

STEP 2: Confront the provocation

While the conflict or problem is going on or after it has happened and you are going to address it, make statements such as these:

y Keep calm. Be cool. This is not that big a deal.

y I will control the situation if I stay in control.

y Yelling and screaming are not going to solve anything.

y This person is really acting poorly, he must really be upset. I can help this person if I remain calm. I am not going to let him upset me.


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STEP 3: Coping with arousal and distress

When you start to notice that you are getting upset and losing your cool, make statements such as these:

y I can feel my heart pounding, let me take a few breaths.

y My head is pounding, let me take a break and talk about it later.

y I have a reason to be annoyed, but I am going to stay in control.

y He can probably see that I am getting upset, but my voice and words will be calm.

y Even though I am steaming, I am going to try to work this problem out.

y I am way too upset to confront her; I will talk to her later.

STEP 4: Self-evaluation

After the episode is over, make statements such as these:

y That was not so bad. I got a little peeved, but I stayed in control.

y I did a good job breathing. It helped me.

y I can see that keeping cool turned out to be better in that situation.

Ask Participants: What could be other ways to deal with our anger? Listen to all the answers. With the help of a volunteer, note down all the responses. Summarize the responses and highlight those that were non-violent and healthy. With the help of the points given below suggest few alternative ways to deal with anger.

Alternative ways to deal with anger

y Write out and log recent episodes of anger. Explore what happened, what the issues were, how you felt and what resulted. Then think of times in the past when you were able to control your anger, probably at work: how did you control it? What did you do or say? What did you tell yourself in order to calm down?

y Learn to take time-outs immediately. You can walk away from situations/people that trigger your anger. Give yourself time to cool off: 10–20 minutes. Take a run, pray and think about what it is that you are really upset about. What is the real issue and what are the feelings underlying your anger? What do you want to request from the person?

y How can you negotiate or compromise some conflict you are having?

y Avoid too much caffeine. Completely avoid alcohol and drugs, unless you are taking a prescription medication. Caffeine increases the metabolism, heart rate and blood pressure and causes irritability.

y You may be dealing with a lot of stress or loss. Begin an exercise programme so that you can work off some of the stress in your life physically.

y Learning to communicate assertively is one of the most important tools for expressing your anger in a healthy way. Begin to share more openly and lovingly your needs, requests and opinions with others.

y Learn to forgive. Bitterness plays a big part in anger and rage. When you hold on to resentments from the past, when someone does or says anything hurtful or disappointing, you perceive it as more hurtful or disappointing. Your perception of events is skewed at that time.


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8.2 Minimizing Risk Taking

A. Write the words ‘RISK TAKING’ on the board and ask the participants what they understand by this. Ask them if they can or would like to share any event in their lives wherein they have taken some risk and the consequence thereof.

Listen to responses patiently and avoid using words like ‘good’, ‘very good’, ‘very bad’, ‘oh’, etc. It will unnecessarily influence the adolescents and they may not share their experiences freely.

Make a chart and list the consequences as positive or negative after discussing with the group.

B. Explain factors leading to risk-taking behaviour in boys and girls with the help of the information given below.

Risk Taking among Adolescents

During adolescence we all tend to take risks for various reasons. Both boys and girls engage in risk- taking behaviour. Research also shows that boys take more risks and are injured more often than girls. This is more because, from childhood, boys face fewer restrictions than girls. For example, few parents stop their son from running or spending unsupervised time out of the house. On the other hand, most parents teach daughters to walk slowly and spend more time at home. If daughters go out, their movements are supervised. Different ways of socialization bring different risks and vulnerabilities Boys take more risks due to overconfidence while girls may take risks due to poor self-esteem and poor self-confidence. For example, boys often drive motor vehicles without a driving license, drive a bike without a helmet or indulge in unprotected and unsafe sexual behaviour. On the other hand, girls do not have the confidence and skills to resist sexual coercion or pressure, physical violence like beating or may give in to other forms of exploitation. Hence, the type of risks that boys take may be different from the ones that girls take but both are equally vulnerable to accidents and injuries that could be physical, sexual or emotional.

Reasons for Adolescent Risk-Taking Behaviour

y Desire to have autonomy from parents and elders and establish one’s identity

y Desire to be popular and to conform to peer norms

y To prove masculinity – In some cultures risk taking is associated with ‘Macho’ behaviour

y To conform to gender norms, especially where girls are expected to be shy, polite, submissive

y Negative peer influence

y Curiosity with regard to sex, friendship and attraction

y Experimenting, especially with unprotected sex, substance abuse including alcohol and cigarettes

y Anger and impulsiveness

y Lack of self-control,critical and creative thinking abilities

y Desire to be ‘powerful’: Bullying, physical violence like beating, slapping, kicking; sexual harassment and violence, that includes verbal abuse and eve teasing are some aggressive behaviours demonstrated against those whom perpetrator thinks of as powerless or weak. Such violent behaviours can cause serious injuries to victims but can have serious consequences for the perpetrator as well

Activity 2

Contd...


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Some Common Risks Taken by Adolescents

y Impulsive decisions resulting in dangerous situations may happen more if one is overconfident or emotionally unstable.

y Reckless driving; driving without helmets, racing in busy streets, stunts without expert supervision

y Provoking, arguing and testing limits with peers and adults. Confrontation with parents and teachers.

y Experimentation with substances like alcohol, tobacco and others

y Multiple sexual partners

y Sex without condoms

y Giving in to sexual coercion, peer pressure

y Not resisting or protesting against physical violence like slapping, beating, kicking etc.

C. Tell participants that one should try to analyze the risks being taken and how will it affect one, one’s family and other community members in the long run. Sometimes a risk perceived by us as small, can cause serious injuries. For example, being careless with crackers has often caused severe injuries like burns, damage to eyes. Similarly, unprotected sexual intercourse – even for the first time – may cause an unwanted pregnancy and/or sexually transmitted infection. Hence, it is always advisable to be a little careful and follow the rules rather than be overconfident and lose out on a healthy and satisfying life. Discuss with participants how one can minimize risk-taking behaviour with the help of the following points.

Minimizing Risk Taking

y Do not drive a vehicle if you are less than 18 years of age.

y Do not drink alcohol if you are below 25 years of age. (Alcohol drinking affects young people differently from adults as it increases risk taking).

y Do not drive a vehicle in drunken state. Also, do not sit in a vehicle that is driven by a person who is drunk.

y While riding a motorcycle, scooter or bicycle, always wear a helmet. Do not exceed the speed limit.

y Be extra careful in case of bad weather or when driving conditions are challenging.

y When you are tired or sleepy do not work with a machine or with fire (for example, a stove).

y Do not meddle with any equipment or try to repair it if you do not have adequate knowledge about it. Do not try to use any equipment if you do not know how to use it. Be very careful with electrical equipment and wiring. They can be dangerous.

y Learn to swim whenever you get the opportunity. If you do not know how to swim, do not try to save a drowning person. Do not get into deep water unless you are fully confident. Seek help immediately from a counsellor, healthcare worker or a doctor if the adolescent is depressed and talks about committing suicide, taking poison or running away from home.

y Observe safety at farms and at workplace as well as in the school at all times.

y Protest against situations of coercion like sexual violence, physical violence like beating, slapping, kicking etc. and seek help to stop it.

y Never have sex without using condom and be faithful to your partner.


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D. Discuss with peers how to handle injuries with the help of basic first aid tips

Try to prevent injuries as far as possible. Educate your peers about safe behaviours. You can also spot/identify boys and girls who seem to be more violent in their daily behaviour. Try to talk to them and suggest activities which can help to divert their attention towards productive work.

A person who has been injured should be given first aid immediately. A peer educator should provide assistance to transfer the injured to the hospital immediately and safely.

Some Basic First Aid Tips

Bleeding y Pressure should be applied with a towel or gauze until bleeding stops.

y Minor cuts and scrapes should be treated with hydrogen peroxide.

y Sealing the wound with a ‘Band-Aid’ and antibiotic ointment can reduce the chance of infection.

If bleeding is profuse, seek medical help immediately.

Burns y Minor burns can be treated with cool running water or a cold compress.

y Seek the help of a medical professional if blistering occurs.

y An antiseptic spray can provide temporarily relief from sunburn or minor burns.

Sprains y Apply a cold compress or ice immediately to help reduce swelling.

y Talk to a medical professional as soon as possible to prevent further damage.

y Elevate arms or legs to help reduce swelling.

If fracture in any part of the body is suspected, seek medical/expert help to transfer patient

Bites and Stings y Ice or cold compress should be applied immediately.

y Remove the sting if at all possible.

y Elevate the location of the bite or sting.

y Seek the help of a medical professional for treatment for any side‐effects such as shortness of breath or swelling.

Other Precautions

y In case an adolescent is bleeding, it is essential to stop the bleeding immediately. The peer educator should know the correct method to stop the bleeding. This can also be learnt through first-aid training.

y In case there is a head or neck injury, lay the injured person with the head low and feet raised. This should be done with as little movement of the injured person as possible.

y Keep the injured person warm. Cover with a blanket. If s/he is awake, give her/him clear fluids to drink but do not give anything to eat.

y If you suspect that there is a broken bone then the affected area should be given some kind of support.


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Key Messages

1. Anger is natural but its management is a skill and needs practice.

2. Anger and risk taking are seen among both boys and girls.

3. Anger and risk taking are two major causes of accidents and injuries among adolescents.

4. Anger is one of the causes of delinquency among adolescents.

5. It is not ‘Macho’ to be angry, show aggression, or be physically violent (beating, slapping, kicking etc.).

6. It is not a good practice to give in to pressures and coercion. One should protest against physical and sexual

violence and avoid any kind of exploitative situation.

7. Substance use like alcohol affects our decision making abilities and leads to risk taking behaviours.

8. It is important to be informed and knowledgeable about the consequences of risky behaviour.

9. Unprotected sex, multiple partners, reckless driving, bullying, sexual violence, eve teasing, violence against

those perceived as powerless are some forms of such behaviour.

10. It is important to manage anger and minimize risk taking in life to prevent accidents and injuries.



in adolescents.

2. To help adolescents recognize situations that cause anger and help them manage it with life skills like conflict

resolution, negotiation, assertive communication, managing emotions.

3. To educate adolescents about risk-taking behaviours. Tell them that it is not ‘macho’ for boys to take risks nor is

it ‘feminine’ for girls to be submissive and take risks.

4. To make peers aware that to be popular one doesn’t need to take risks. One must try to be a responsible human

being and follow the rules as per the State law.

5. To help adolescents with risk-taking behaviour by taking them to counsellors.

6. To create a positive peer influence in the community to discourage such behaviour.

7. To encourage adolescents to engage in recreational activities like sports, yoga, meditation, regular exercise

etc., to channelize energy in constructive ways.

Refer Peer Educator Resource Book to deliver messages andclarify doubts related to Accidents and Injuries

module V

adolescent sexual and reproductive health

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Session 9Child Marriage

IntroductionGlobally, more than 60 million girls under the age of 18 are married, many to men twice their age or older. Half of those are in Asia, with a significant proportion from India, where almost half the women are married by the age of 18 years. Child marriage is the most harmful practice prevalent in our country cutting across the boundaries of region, religion and cultures. It often occurs in the shadow of poverty and gender inequality, impeding efforts to empower girls and boys to achieve long-term sustainable development. Though child marriage happens among both women and men, it has lasting and damaging consequences to the health, development and well-being of young women and compromises their right to take part in informed decision making. It is a critical human rights violation, particularly to ‘consent to marriage’ and at its worst, can be tantamount to bonded labour or enslavement as it denies basic rights to health, nutrition, education, freedom from violence, abuse, exploitation and deprives the child of his/her childhood. It increases vulnerability to frequent domestic and/or sexual violence. The right to ‘free and full’ consent to a marriage is recognized in the Universal Declaration of Human Rights – with the recognition that consent cannot be ‘free and full’ when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. Consent to marriage means every individual has the right to decide whether to marry or not, whom to marry and when to marry and to give consent based on his/her choices.


1. To understand child marriage as per the legal framework in the country

2. To understand the right age for marriage

3. To understand the consequences of child marriage

4. To practise and enhance life skills to prevent child marriage

5. To learn about the Prohibition of Child Marriage Act, 2006

Time:

40 minutes

Material:


Methodology:

Brainstorming, group discussion, exercises like goal setting


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9.1 Child Marriage – The Legal Framework

Write the words ‘Child Marriage’ on a flip chart or the blackboard. Ask the participants whether they understand the term and ask some of them to explain. Some of the responses could be

y A marriage that takes place during childhood

y When a child is married

Then ask the participants, “Who is a ‘child’?”

Some of the responses could be

y A newborn baby or an infant

y All those up to 5 years of age

y All those up to 10 years of age

y An adolescent girl is a child

y Adolescent girl or boy is a child

Thank all the participants. Ask them if they have heard of ‘Prohibition of Child Marriage Act, 2006’ (PCMA, 2006). Inform them about the salient points of the Act and explain the definition of a ‘child’ as per the Act with the help of the slide given below.

SLIDE 1

1. In India the legal definition of a child in the context of marriage is

� For girls: all those below 18 years of age � For boys: all those below 21 years of age

2. The PCMA, 2006 is the legal framework under which all marriages below the defined age (i.e., 18 for girls and 21 for boys) are illegal.

3. A child being forced into marriage or anybody else who has information of such marriages to take place has a legal obligation to inform the Child Marriage Prohibition Officer (CMPO) (please give the name and designation of all officials in charge as CMPO in your area) or the local police station.

4. The CMPO has the power to request for issuing injunction (stay) on the reported marriage and is required to counsel the child, parents and families involved to cancel or delay the marriage.

5. Any person promoting or supporting or involved in any way in solemnization of such marriage is liable for punishment (imprisonment or fine or both).

6. In case of the victim of child marriage, the CMPO needs to ensure the safety of the victim and realization of his/her basic rights like the right to live with own parents and siblings with the same love and respect, enrolment in school/college, access to counselling on health and his/her rights as per the PCMA 2006, health services and medico-legal aid if required.

7. If a child marriage has happened due to ignorance, it stands as legal till its nullification is requested.

8. A victim of child marriage has the right to request for the marriage to be declared null and void (meaning the marriage does not have any legal standing and the victim is free of that marriage) up to 2 years of reaching the age of majority (i.e., up to 20 years for girls and up to 23 years for boys).

Activity 1

module V: adolescent sexual and reproductive health

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9.2 Child Marriage – Causes and Consequences

Divide the participants into two groups. Ask one group to list the causes of child marriage and the second group to list the consequences of child marriage. The causes and consequences can be listed under the following heads:

y Educational

y Socio-cultural (including gender-based situations)

y Economic

y Health related

Allow 15–20 minutes to the group to discuss and prepare ‘Causes’ or ‘Consequences’ on a chart paper. Invite each group to present it to the larger group. The group responses might be as follows:

Causes of Child Marriage

Educational Socio-cultural (including gender-based situations)

• Illiteracy• Leaving school in between (school dropout)• No school nearby• High cost in travel to school and overall expenditure

on education• No toilet in school• No drinking water in school• Poor quality of education• Teacher very strict/rude• Teacher always absent• Punishment (corporal)• Not interested in studies

• Girl child as burden• Girl child as a responsibility• Discrimination against girls denying right to

education and vocational opportunity• Exercising control on girls and women • Safety and security a concern• To make young boys responsible from early age• Early marriage ensures longer reproductive years• To have children early in life• Limited choice for a match because of region,

religion and caste restrictions• young girls and boys may marry someone on their

own or from another caste

Economic Health related

• Cost of marriage to be borne by girl’s parents• Expectation of high dowry • Poor financial status• Low income • Exchange of young brides for money• Kidnapping and trafficking of young girls for money

(forced to marry or engage in commercial sex)

• Poor health and nutritional status

• Adolescent mothers tend to marry their children early (practice continues for generations in the absence of information and education)

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The other group may have more or less similar responses as consequences.

Consequences of Child Marriage

Educational Socio-cultural (including gender-based situations)

• Leaving school in between (school dropout)• Poor information and knowledge• Poor skills to manage responsibilities of self and

family well• Poor professional skills to earn good living

• Vulnerable to discrimination and violence

• Separation from parental care

• Expected to behave as adults when still children

• Risk of early and frequent pregnancies, abortions

• Become parents when they themselves are children

• If the child born is a girl, double discrimination

• Denied right to education and vocational opportunities

• Exploitative situations

• Vulnerable to physical and sexual abuse and torture

• Boy as the bread earner forced to work and earn for his family

Economic Health related

• Burden of poor health due to adolescent pregnancy

• Increased expenditure due to family size but low income

• Poor earning

• May get into exploitative situations

• Exchange of young brides for money

• Kidnapping and trafficking of young girls for money (forced to engage in commercial sex)

• Poor health and nutritional status of both boy and girl

• Early initiation of sexual activity

• Increased risk of sexually transmitted infections (STIs) like HIV

• Adolescent pregnancy

• Grave nutritional status of adolescent mother as her own body and the child in the womb compete for nutrition for growth (adolescence is the phase of physical, mental and emotional maturity)

• Low birthweight babies

• Illness among mothers and babies

• In some situations may lead to the death of adolescent mother and/or baby


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Inform the participants that from the charts prepared by each group a vicious cycle of poverty, poor education, poor health and harmful socio-cultural norms and practices is evident.

Cultural norms

Increased risk of infantmortality/morbidity

Increased risk ofmaternal mortality

and morbidity

Female infant survives

Education isprematurely ended

Decreased economicautonomy or contribution

Early child-bearing

Early marriage

9.3 The Appropriate Age for Marriage

Setting Goals for Life Ask the participants to think about what they aspire to be in life or what their dreams are for themselves, their family, village or country. Ask them to then write it down in their notebook. Give them 5–10 minutes to do this.

Tell them that now that they have reflected upon their aspirations and know the legal age for marriage in our country, they need to prepare a plan for their own lives for a period of 10–15 years from now in a way that will help them achieve or realize their aspirations and dreams. The plan should highlight major events/or milestones in life like compulsory education, marriage, children etc. They have to do an age-wise goal setting for life as given below:

y 15 years: Complete higher secondary school

y 18 years: Admission in college with (subject of interest)

y 22 years: Graduation in (area of interest – arts, science, commerce), marriage

y 24 years:

y 26 years:

y 28 years:

y 30 years:

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Similarly they need to list other events that could be related to education, personal life, relationship, profession, philanthropic or charitable work etc. (such as to be a successful business person; have own shop; be a doctor, an engineer, a Panchayat leader; select a life partner; love, marriage, first child, second child, son or daughter’s marriage etc.)

As most of the participants are between 15 and 19 years, the life plan can start from the age of 15 years and go up to 25–30 years. Those who are older than 15 can list events in their life that took place after the age of 15 years for reference.

Give a blank sheet and a sketch pen to each participant and ask him/her to prepare an age-specific goal to be achieved individually. Give them 15 minutes for this. Invite a few volunteers to present their work to a larger group. Ask them to keep it safely for reference later. Do not comment at this point.

Divide the participants into three groups and give the case study of Meena given below to each group with a different set of questions.

Case Study:

Meena is a 14-year-old girl living with her parents and two younger siblings in a village in Bihar. She left school after Class 7 as her mother was not keeping well. She helps her mother with the household chores and looks after the younger siblings. Meena’s mother is worried about her marriage and wants to see her settled before anything happens to her. She has shared this with other relatives and requested them to suggest a suitable match for Meena. One day an aunt who lives in the neighbouring village visits Meena’s house and informs her parents that she has spoken to a family in her village about a match for Meena’s. The family has a good-looking 19-year-old son. He is the youngest of four siblings. All the other siblings are married and have families of their own. The family has good farm land and has more than enough wealth. And the good news is that the family liked Meena’s photo and is agreeable to the marriage. Her aunt tells Meena’s parents that if they agree she can invite the family to meet them and fix the details for the wedding. Meena’s parents are very happy and agree to invite them home. Meena is disturbed and sad.

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Discussion Points:

1. Do you think Meena’s case is common?

2. Do we know anyone who has left school for any reason, maybe even for marriage?

3. Is her mother right in planning Meena’s marriage early? Why?

4. Is her being aunt nice to Meena and her parents? Why?

5. Do you think Meena’s parents should accept this proposal? Why?

6. Why is Meena disturbed and sad?

7. How can Meena convince her parents to delay the marriage?

8. What would you have done to help Meena?

Meena’s story is common and many girls in our country go through such situations. Many girls are forced to leave school for marriage or other reasons like safety, cost of travel to school or distance from home as in Meena’s case. These girls get married early. Meena’s parents are ignorant about the consequences of early marriage and do not understand that their daughter will be safe and competent only if she completes her education and becomes self-dependent. They also do not understand that Meena at this age is not physically and mentally prepared to take on the responsibility of marriage and family.

Meena is disturbed and sad for she may not be interested in marriage at that age and would probably be expecting to return to school some day. She may also be sad or confused with the sudden proposal and may have queries about her future husband and in-laws. She may be feeling scared at the thought of living with people whom she doesn’t know at all. Meena, her parents and her aunt need to be counselled and informed on her rights and the legal age for marriage. They need to be educated on the negative consequences of child marriage and need to be convinced to postpone the marriage at least till Meena is 18 years of age. Meena can take the help of ASHA didi, ANM didi, teacher, PRI member, any other respected member of the community or peer educators to convince her parents. If her parents do not agree, she should also approach the CMPO to prevent her marriage.

Meena should have an alternative plan for self-development and skill enhancement and not merely wait for a suitable match. Till she is ready for marriage, she should be allowed to attend school or take vocational classes so that she has scope for a livelihood and employment in future.


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Invite a few volunteers and give them a role play to prepare and enact. Conduct this as a forum theatre (process explained below).

Role PlayRaghav lives in a joint family and is the youngest of four siblings. One day he returns home to find his parents talking to a lady from the village about his marriage. His father shows him a photo and informs him that he is going to fix his marriage with this girl in a week’s time. They also want the marriage to be solemnized this winter itself. Raghav is upset and tells them that he is not ready for marriage. On hearing this, his parents get angry and accuse him of being rude and disrespectful to his elders. They say that their decision is final. Raghav is trying to convince his parents but they seem unrelenting.

The interaction between Raghav and parents will continue with each arguing his/her stand. While arguing, Raghav has to be polite and respectful to his parents and can seek help from others like teacher, PRI member, ASHA didi, ANM didi, peer educator or CMPO to convince and counsel his parents.

Option: Meena’s story can also be used for role play and forum theatre.

Allow the role play to continue for as long as the volunteer playing the role of Raghav is able to give convincing arguments. When you feel that Raghav’s character has no fresh argument to make, ask the volunteers to ‘STOP’ or FREEZE’. Now ask the others if they find Raghav’s arguments convincing. Ask them if anyone wants to replace the volunteer playing Raghav and start the interaction with his parents afresh. Allow as many participants as are willing to play the role of Raghav with fresh arguments. They have to follow the same rule of ‘STOP’ and ‘FREEZE’ to stop the volunteer and replace him/her. At the end, thank all the participants and summarize the activity by pointing out arguments that were legally correct and convincing (e.g., the legal age for marriage; that saying no to early marriage is not being disrespectful to elders; you don’t love and care for me if you force me to marry; I want to become a responsible son, husband and father; alternative plan for life; career plan, to complete education and get a job; to be financially stable; early marriage may be harmful for self and spouse; children born of early pregnancy may be low birthweight and not healthy) and some that were impolite or incorrect or leading to any form of abuse or violence (e.g. If you don’t agree I will leave home; or physical violence or use of abusive language).

Now ask all the participants to take out the sheet on which they noted the plan for their life in the coming 10–15 years. Ask them to review their plan and see if they are satisfied with it or need to change the sequence of some life events. Tell them that from the above activities, we know that it is very important to be physically and emotionally mature and financially stable before we marry and plan for children. Education and financial independence help us and our family to live and carry out our responsibilities with respect and dignity.

Activity 3

Activity 4


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Work out a general plan for a youth on a blackboard or flip chart.

Plan for Life

(A general plan based on realistic targets for education and employment and possible situations with regard to relationship and marriage)

15 years or above: Complete matriculation; may or may not like to have a boyfriend or a girlfriend

18 years and above: Complete senior secondary/intermediate; may or may not have a love affair

20 years and above: Pursue graduation in subject of interest/pursue a vocational skill; may or may not have made a choice for marriage

22 years and above: Complete graduation and go for higher studies/apply for jobs/complete vocational training and join internship; may or may not have a steady love relationship

24 years and above: Have a source of livelihood and some savings; may have or may not have a steady love relationship

26 years and above: Have a decent job/stable employment/own business/shop and good savings; may think of marriage or a new love relationship

28 years and above: Look for new avenues in professional life; promotions; maybe marriage for some; or a decision to have a child for some

Some youngsters may decide on marriage and children even later in life depending on personal dreams and aspirations.

Remember:It is your right to decide when to marry and whom to marry. Your consent is important for your marriage. It is your right to decide when to have children and how many. One should always take an informed decision about such important events in life.

Ask them at what age they would like to place events like marriage, first child and second child. Tell them to assume that they get married between 15 and 21 years of age or even younger and see how their life plans may change. It may be as follows:

15 years: Out of school and marriage/huge age gap with spouse/poor negotiation skills and communication gap with spouse

18–20 years: One or two abortions/children/poor health/no time and finances for vocational opportunities; spouse not able to share responsibilities well

21–24 years: Responsibilities of family and children; low-paying jobs/poor savings

24 years and above: Increased financial pressure and large loans


1. One should plan marriage and children after ensuring a certain level of education and financial stability.

2. Chances of a good marriage and life partner after completing education and becoming financially secure are more with fewer risks.


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3. If both husband and wife are educated and have vocational and professional skills, they can complement each other and share responsibilities equally.

4. It is important to have some personal savings before you plan marriage and children so that you carry out responsibilities with respect and dignity.

5. An educated couple also understands the significance of family planning and how to take care of health and nutrition of self and family.

6. Each individual, whether a man or a woman, has a ‘right age’ and ‘right time’ for marriage and children. Hence, one should not give in to unfair social pressures.

Note for Facilitator

Child marriage is a common and serious problem, and the person most affected is the girl child. In India, under Prohibition of Child Marriage Act, 2006, the legally accepted age for marriage is 18 for girls and 21 for boys. If a girl is married at an early age, she is likely to face many problems. Early marriage is usually followed by early childbearing and this is dangerous for both the mother and the baby. Girls who marry young are more likely to be victims of violence and abuse. They have little or no decision-making power and negotiation skills to safeguard their interests.

The minimum legal age for marriage tries to safeguard the interest of a child so that children are able to achieve a minimum level of physical, sexual, and emotional maturity before they marry, which otherwise would be detrimental to his/her physical, sexual and mental health. However, the ‘right age for marriage’ is an individual decision depending on the dreams and aspirations of that individual.

The factors for deciding the ‘right age for marriage’ may include the following: y Completion of education as desired

y Acquiring skills for a job/employment

y Getting employment or have potential to exploit some earning opportunities

y Have the information and life skills to make informed decisions and protect oneself and partner from risky situations

y Have financial stability/some savings

y Have knowledge and life skills to plan a family

y Ability to take care of spouse, children and parents in a better way and bring harmony to relationships

Possible health risks and consequences of child/early marriage and pregnancy are: y Poor nutritional status

y Injuries and depression due to physical, sexual violence and verbal abuse/torture

y Frequent pregnancies and abortions

y Complications in pregnancy and delivery like obstructed labour, fistula, poor health outcomes such as anaemia

y Death of mother in some cases

y Poor outcomes of pregnancy such as low birthweight children, pre-term birth and death of infant etc.

y Fertility outcomes (high fertility, low fertility control and poor fertility, no use of contraceptives, unwanted pregnancy, pregnancy termination, stillbirths, miscarriages or abortions).

y Violence (domestic violence and abuse, increased economic dependence, denial of decision-making power, inequality at home)

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Child or forced marriages undermine a number of rights guaranteed to a child or a person as per the Constitution of India and the UN Convention on the Rights of the Child:

y Right to education

y Right to health and nutrition

y Right to live with own parents

y Right to rest and leisure

y Right to economic enablement

y Right to be protected from all forms of physical or mental violence, injury or abuse, including sexual abuse, and from all forms of sexual exploitation

y Right to the enjoyment of the highest attainable standard of health

...and many more

Key Messages

1. Legal age for marriage is 18 years for girls and 21 years for boys.

2. The law that provides protection from child marriage is the Prohibition of Child Marriage Act, 2006.

3. Child marriage is a violation of child rights and basic human rights.

4. It is a harmful traditional practice that has long-lasting impact on health and development of the victim,

especially girls.

5. It leads to discontinuation of education, poor opportunities for skill enhancement, separation from parental

care (especially for girls who have to move to husband’s house) and increased risk of physical, mental and

sexual violence.

6. Early marriage results in early initiation of sexual activity.

7. A child bride is highly vulnerable to closely spaced and numerous pregnancies and STIs like HIV.


1. To talk to young people between 10–21 years of age about the legal age for marriage.

2. To educate community on consequences of early marriage.

3. To help young girls and boys and the community to decide an appropriate age for marriage through a goal-

setting exercise.

4. To help friends and peers delay their marriage.

5. To inform village elders or the CMPO if you have information on possible child marriage.

6. To enlist the help of ASHA didi, ANM didi, AWW didi, teachers, doctors and other workers in village to counsel

parents and families to stop or postpone the child marriage.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Child Marriage

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Session 10Adolescent Pregnancy

IntroductionChild marriage is one of the major factors contributing to early, closely spaced and too many pregnancies among women. Early marriage leads to early initiation of sexual activity and the risk of unplanned and unwanted pregnancy is high. Biased social norms expect a young bride to prove her fertility by bearing a child in the very first year of marriage. Any failure to conform to such a norm draws undue criticism, stigma and discrimination to the bride and her parental family. A woman is subjected to enormous pressure with regard to her child bearing ability. An adolescent girl has poor information, knowledge and skills to decide and negotiate for safe sexual practices that protect her from unwanted pregnancy and risk of STIs. Unwanted pregnancy may also result due to sexual abuse and gender based violence against girls. An unplanned and unwanted pregnancy is a huge risk to the physical and mental health of a mother, especially adolescent mothers who themselves are children.

[Note: It is suggested that information pertaining to this session be discussed preferably with married adolescents or those above 15 years of age.]


1. To understand the factors leading to pregnancy among adolescent girls

2. To understand the consequences of adolescent/early pregnancy

3. To understand the concept and benefits of a small family

4. To learn about modern ways to prevent unwanted and unplanned pregnancies

5. To decide the right age for planning the first child and gap between two children

6. To practise and enhance life skills to negotiate for safe sex

Time:

40 minutes

Material:


Methodology:

Brainstorming; group discussion; exercises like goal setting, case studies


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10.1 Adolescent Pregnancy: Causes and Consequences


This activity is a value exercise. Value exercises help participants identify their own values about an issue, know the opinion of other participants, learn to respect other opinions and know that a person’s value or opinion about an issue may change. This activity is to help participants learn about different values related to sex and contraception from the point of view of adolescents. It will also help them practice a ‘non-judgmental’ approach so as to be a good peer educator.

As a facilitator, you are not supposed to comment on the stand taken by participants. You will respect the decision or choice of all participants. You should try your best to avoid changing your facial expression, nodding or using words like ‘Good’ or ‘Okay’ as these may create misunderstanding among participants and may influence their decision. The objective of the exercise is to help participants make their own decisions without being influenced by anyone.

Ask participants to stand in a row in the middle of the hall. Tell them that they will be playing a game. In this game, the facilitator will read out a few statements. The participants need to decide on their own (without any discussion) whether they agree with the statement or not. If they agree they will move a step forward and if they do not agree, they will move a step back. Each participant has to decide on his/her own.

Read out following statements one by one. Repeat the statement if it is not understood by the participants. After each statement ask some of them to explain the reason for agreeing or disagreeing. Then tell them that if anyone wants to change their position they can, without saying anything. Give them a few seconds to do so and do not make any comment. Then move to the second statement. Follow the process till you finish reading out all the statements. (The rule of the game is that no one is allowed to convince, comment or interrupt any participant sharing his/her reasons for agreeing or disagreeing).

Statements for the exercise: y Not many adolescents are exposed to sexual activity.

y Adolescents should delay sex till they reach adulthood.

y Adolescents have the right to sexual and reproductive health.

y All adolescents need to be educated on risky situations that may impact their sexual and reproductive health.

y Contraceptive methods are available for both males and females.

y Adolescents need to be informed about the causes and consequences of adolescent pregnancy.

y Older adolescents (those above 15 years of age) need to be informed about safe sex and contraceptive methods so that they can protect themselves from the risks of STI and unwanted pregnancy.

y Adopting or using a suitable contraceptive method is the responsibility of both partners.

y The condom is the best contraceptive method for young people.

y Adolescents should access information and services on contraception.

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At the end of the exercise thank participants and say, “As we saw in the exercise, there was no right or wrong decision. Everyone agreed or disagreed based on their own values, the information and knowledge that they had on the issue.” Tell participants that they will learn how adolescent girls are vulnerable to unwanted or unplanned pregnancy. Different activities in this session may also inform our opinion about many other situations or issues related to adolescent or teenage pregnancy.

Divide the participants into three groups and provide them with a printout of the case studies given below to discuss.

Case Study 1: Nilofer and Shahid’s story

Nilofer got married at the age of 16. Her husband Shahid works in a tannery. After marriage, guests and elders bless them and express the wish to see the couple with a baby soon. However, Nilofer and Shahid have decided to postpone the first pregnancy for some years. They want to spend some time getting to know each other well. Nilofer wants to do something in life and was very sad when she had to drop out of school to get married.

It is now a few months since the marriage. One day a neighbour tells Nilofer, “Are you going to give us ‘good news’ soon?” Nilofer has to face such questions quite frequently and this is making her uncomfortable. Her in-laws and her own mother have also started pressurizing her to become pregnant. One day her mother-in-law suggests that Nilofer go for a medical check-up, to see if she has any problem in getting pregnant. Nilofer is very disturbed and does not feel like talking to anyone. She avoids meeting relatives or guests visiting their house to escape any discussion about pregnancy. Shahid has also started avoiding friends and family.

Nilofer and Shahid are tense and now they have started blaming each other. Nilofer feels helpless and wants to run away from everyone.

Discussion Points:

1. What does everyone, including her mother and mother-in-law expect from Nilofer?

2. Is their expectation unreasonable? Why?

3. Is the decision to not have a child soon by Nilofer and Shahid right? Why?

4. Why are Nilofer and Shahid tense?

5. How can you help Nilofer and Shahid deal with this situation?

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Case Study 2: Radha and Jatin’s Story

Radha (18 years) and Jatin (20 years) are in love with each other and have decided to marry after a few years so that they can complete their studies and have good jobs by that time. Both of them are in college in different cities pursuing graduation. They visit each other during holidays. On one such visit, the couple have sex with each other. They think there is no risk since it is the first time and they do not have sex on a regular basis. Jatin returns to his city at the end of the holiday. After a couple of months, Radha is unwell and has nausea. She takes a tablet and decides to rest. But the tablet and rest are of no help. She visits a doctor. After the initial check-up, doctor asks her if she has had her menstrual periods on time. Radha recollects that she has not had periods for the last couple of months. The doctor asks her about her marital status and sexual relations and then suggests a urine test. The test confirms pregnancy. Radha is shocked. She informs Jatin. Jatin is tense and asks her to come to his place soon. Radha does not know how to cope or what to do and is in tears.

Discussion Points:

1. Is Radha’s pregnancy an unplanned and unwanted pregnancy? Why?

2. Where did Jatin and Radha go wrong? Why?

3. Is first time sex free of risks? Why?

4. Why are Radha and Jatin shocked and tense?

5. What should Radha and Jatin do now?

6. Is it difficult for Radha and Jatin to visit a clinic or a hospital for an abortion? Why?

7. Should the doctor help them with counselling, referral service for abortion and information on contraception? Why?

8. Is abortion a legal way to terminate an unwanted pregnancy?

9. How can Jatin console Radha and share the responsibility?

10. What precautions should they take in future?

Case Study 3: Bindiya’s Story

Bindiya is a 15-year-old girl who lost her parents in early childhood. She was brought up in the family of a poor and distant relative. Sometimes, Bindiya is forced to have sex with some village goons. She is scared of them and gives in to their pressure. For some days, Bindiya has not been well. She approaches ASHA didi for medicine. After a month or so, ASHA didi visits Bindiya’s house. On seeing her, ASHA didi has some doubts and takes Bindiya along with her for a medical check-up. After some tests, the doctor confirms that Bindiya is pregnant and her pregnancy could be around three months now. The doctor, ASHA didi and ANM didi are disturbed and tense. Bindiya is in tears and pleads with them to help her.


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Discussion Points:

1. Was Bindiya going through a situation of sexual violence?

2. What has happened to Bindiya?

3. Why are the doctor, ANM didi and ASHA didi tense and disturbed?

4. Can pregnancy of more than three months be terminated? How?

5. How will the doctor, ANM didi and ASHA didi help Bindiya in such a situation?

6. Who else can help Bindiya in this situation?

7. How can such situations of violence be averted?

Invite each group to present its discussion summary one by one. Help the participants understand the context and possible solutions.


1. There can be numerous situations that may pose risks for forced and/or unsafe sex and which may result in an unwanted pregnancy for an adolescent girl like child or early marriage, love relationships, influence of alcohol or drugs, prostitution in exchange for money or other favours; in the name of religious or cultural practices; sexual abuse (physically and/or mentally challenged girls are more vulnerable) and so on.

2. In situations like that of poverty, social inequality and discrimination, loss of parents, lack of parental care and support, young girls and women are forced to engage in sex work. Forced sex also occurs in some harmful practices that are considered as ‘tradition’ in some communities.

3. A sexual act with anyone without the consent of the person or in situations where consent has been taken in deceitful ways (like luring, making false promises, cheating etc.) is violence and a criminal offence.

4. Most young girls and women subjected to sexual abuse face social and cultural barriers and threats to keep them from accessing protection from such violence.

5. In some cases adolescent girls may not be able to relate their discomfort or illness to pregnancy and so are unable to seek timely help. This is also because adolescent girls have poor information and negotiation skills and are unable to protect themselves from forced sex and unwanted pregnancy; cannot identify the signs and symptoms of possible pregnancy (like missed menstrual cycle etc.) and so do not seek medical or legal help as per the need of the situation.

6. Sexual intercourse can be risky any time if it happens without adopting any modern contraceptive method.

7. A pregnancy is not the sole responsibility of an adolescent girl but also that of her partner/husband.

8. The male partner should share the responsibility of pregnancy equally with the pregnant woman.

9. Every individual has the right to decide when to marry and whom to marry.

10. Every individual (including an adolescent) has right to access information, knowledge and services to make an informed decision related to marriage and children.

11. The services provided to help an adolescent prevent, manage or terminate an unwanted pregnancy have to ensure privacy, confidentiality, and respect without judging the adolescent client.


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12. The doctor, ASHA didi, ANM didi and the peer educator are required to help such adolescents and youth with correct information and referral services (both medical and legal as required).

In India, medical termination of pregnancy is legal up to 20 weeks of pregnancy under the Medical Termination of Pregnancy Act, 1972, but the opinion of a second doctor is necessary between weeks 12 and 20 weeks. It is advisable to undergo an abortion in the early weeks to avoid health complications. There are various procedures for inducing medical abortion, depending on the period of gestation of the pregnancy. (For more on medical termination of pregnancy or safe abortion refer to the table ‘Understanding pregnancy and contraception’.)

Divide the participants into two groups. Give a chart paper and sketch pens to each. Ask them to prepare a list of causes and consequences of adolescent pregnancy as done in the earlier session on child marriage. Help the groups to add factors and explain the risks associated with each. Also explain terms like fistula, obstructed labour, eclampsia, pre-term baby and low birthweight baby.

Causes of Adolescent Pregnancy

Educational Social (including unfair gender and social norms)

• Poor information on safe sex• No knowledge about contraceptive methods• Surrounded by myths and misconceptions

• To prove fertility in first year of marriage

• A woman is complete only when she has a child

• A couple cannot be happy without a child

• Preference for sons

• Control over women’s sexuality; forced sex; violence

• Sex without the consent of female partner

Economic Health

• Poverty• Contraceptive services not affordable• Sex for money or favours• Prostitution

• Substance abuse

• Abortion or pre-term or death of first or earlier children

• Couple blackmailed on grounds of poor health of older people in family – they would like to see the grandchild before they die.

• Mental illness of mother/woman who cannot assess risky situations

• Failure of contraceptive method adopted

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Consequences of Adolescent Pregnancy

Educational Social (including gender norms)

• Forced to leave school• Poor opportunity for knowledge or skill

enhancement• Poor vocational or professional skills for good

employment

• One gets trapped in a vicious cycle

• Uneducated mother may bring up children with biased norms

• Discriminated against for giving birth to a girl child

• Girl child faces discrimination

• Social stigma and isolation if unmarried or out of marriage

• Judgemental attitude of service providers and other members of society

Economic Health

• More mouths to feed, fewer hands to work• Increased burden of health expenditure• No financial stability• Poor income; no savings• Large debt and loans• Poor quality of life

• Poor nutritional status of mother (a situation created because the adolescent mother’s body and the child in her womb compete for nutrition to grow at the same time)

• Anaemia in adolescent mothers

• Abortion or pre-term babies

• Prolonged and obstructed labour causing health risk to mother and child (Explain.)

• Damage to reproductive tract of expectant mother; fistula (Explain.)

• Low birthweight babies

• Maternal and/or infant death

• Lifelong illness/health complications

• Poor health and nutrition of father due to Increased burden of work and not enough food

• May result in mental illness, depression for some mothers and fathers

• High risk of closely spaced pregnancies and abortions

• High risk of STIs like HIV


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10.2 Adolescent Pregnancy: Appropriate Age for Planning a Child

Note for the facilitator: This activity has a ‘Goal-setting exercise’. This exercise will help participants take informed decisions to plan for a child.

Give the case study to each group of participants and ask them to discuss and prepare a plan.

David and Shelly’s Story:

David (20 years) is a very hardworking boy. His father is a great fisherman and they have a shop in the town from where they supply fresh fish to other vendors. David has two younger brothers and two sisters. The two sisters are married with children and live with David’s father as one big happy family. As the size of the family is increasing, David’s father wants to expand the business but they need a new and better boat that can take them to the deep sea where they will get more and bigger fish. They also need bigger fishing nets. David wants to help his father in his business and have a boat of his own. David doesn’t have any personal savings and has been dependent on his father so far. David has also got married recently. He and his wife Shelly (18 years) are often teased by friends and relatives to plan their first child.

Discussion Points:

Help David and Shelly plan their first child.

1. At what age they should have their first child?

2. Can they plan for a second child or not?

3. If they plan for a second child, when should they have it?

Now give a chart paper to each group and ask them to refer to the goal-setting exercise in the earlier session about child marriage. Ask them to prepare a similar plan for David and Shelly together for the next 10 years at least. The plan should help them have a boat for themselves; some skill enhancement course; some work for Shelly; some savings; a first child; a second child, if they wish; any contraceptive method to be adopted etc. The chart should look like this:

David (20 years) and Shelly (18 years):




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1. Medically, the right age for the first pregnancy is after the woman completes 20 years. The appropriate age may differ for couples depending on the health and nutritional status of the woman, educational and livelihood aspirations of the partners etc.

2. The recommended gap between the first and second child is a minimum of 3 years (more if the mother is an adolescent). This helps the mother regain her health and at the same time take good care of her first child as the years of infancy need utmost care.

3. Just as one has the right to free choice in decisions related to marriage, one also has the right to make an informed decision about planning pregnancy and children (when and how many) along with one’s partner.

4. It is beneficial if one achieves at least basic (compulsory) level of education to understand the needs and responsibilities of parenthood before planning a child.

5. It is always better to have a steady source of employment/income and some personal savings before planning the first or second child.

6. Better financial standing helps one carry out one’s parental responsibilities with respect and dignity.

7. Parenthood means providing the best possible care and support to your child to grow into an educated, healthy and socially responsible person.

10.3 Adolescent Pregnancy: Preventing Unwanted Pregnancy

Divide the participants into four new groups and give each a case study to discuss and prepare their response.

Case Study 1:

Raji (18 years) and Surendra (24 years) have a 1-year-old son. Raji got pregnant in the first year of marriage and they don’t know anything about contraception. They fear that Raji may get pregnant again. They have not adopted any method of contraception. One day ASHA didi visits Raji and enquires about her and her son’s health. Raji is debating whether she should share her fears with ASHA didi or not.

Discussion Points:

1. What is Raji and Surendra’s problem?

2. Should Raji and Surendra share their fears with ASHA didi?

3. How can ASHA didi help them?

4. What are the different contraceptive methods available and suitable for the couple?

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Case Study 2:

Gyanendra and Nandini met each other at a wedding. It was love at first sight. They decide to marry soon. After a few months Gyanendra visits Nandini’s town and they meet at a friend’s house. During that meeting they have sex. Gyanendra leaves that evening and Nandini returns home happy. She calls her best friend and shares her experience. The friend tells her that she understands her feelings and is happy that they have decided to marry but that she needs to be careful. Her friend asks if they used a condom. Nandini says, “No”. The friend explains that she is at risk for pregnancy which could be devastating for her and Gyanendra at this stage of their relationship. The friend, who is a trained peer educator, helps Nandini understand the seriousness of the situation and suggests that she visit a doctor to get an emergency contraceptive pill immediately.

Discussion Points:

1. Do you think Gyanendra and Nandini could have been a bit more careful?

2. Was it responsible behaviour on the part of Gyanendra to have sex without a condom?

3. Was it responsible behaviour on Nandini’s part to have sex without a condom?

4. Is Nandini’s friend right to tell her about the risk associated with unprotected sex?

5. Why does her friend want Nandini to visit the doctor and get an emergency contraceptive pill immediately?

6. What is an emergency contraceptive pill and how can it help Nandini now?

7. What is the most suitable contraceptive for such couples?

Case Study 3:

Suhail and Ameena are newly married. During intercourse Ameena wants Suhail to use a condom but Suhail says, “Condoms are used by people who are not faithful to their partners. You don’t trust me”. Ameena replies, “It is not about trust, it is about being safe and we don’t want a child so early in our life together”. Suhail is upset as he does not want to use a condom but he too does not want a child so early. Ameena is firm in her decision and says, “If you love me and trust my love for you, please use a condom always, except when we plan for a child”.


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Discussion Points:

1. Is Suhail right in pressurizing Ameena to have sex without a condom? Why?

2. Is Ameena right to persuade Suhail to use a condom? Why?

3. Is a condom the most suitable method for young couples? Why?

4. What could be other methods of contraception for Suhail and Ameena?

5. Is it a wise decision to not have unprotected sex till both partners get to know and understand each other?


Case Study 4:

Pramila (20 years) finds out that she is pregnant. She informs her husband, Ravindra, who is surprised as he too is not prepared for a child. Pramila is very disturbed as she feels that she is not mentally prepared for this pregnancy. She also had severe typhoid a few months back and has still not regained her health. She wants to go for an abortion. Ravindra informs his parents. His parents are angry with them about this decision. Pramila and Ravindra are confused and feeling helpless.

Discussion Points:

1. What do you think Pramila and Ravindra should do? Go for an abortion or not?

2. Will this pregnancy harm Pramila’s physical and mental health?

3. Can this pregnancy be risky for the foetus/unborn child?

4. Is abortion of unwanted pregnancy legal in such cases? Why?


Give a chart paper to each group and ask them to list the names of the contraceptive methods they know and start with those that are best suited for an adolescent or young couple. Give 15 minutes for the exercise. Invite each group to present their case study, summary of discussions and list of contraceptives suitable for an adolescent and young couple.

If possible show various contraceptives or pictures of contraceptive methods available in our public health system. Explain each method and its advantage and suitability to young couples. Put the contraceptives on display so that the participants can see and discuss them during the break. But before discussing contraceptives, conception must be explained to the participants.

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Understanding Pregnancy and Contraception

How does pregnancy happen?

Pregnancy happens when a male and female have sexual intercourse. The male sex organ (penis) penetrates the female vagina and ejaculates semen (white male sexual fluid) into the vagina. The semen carries sperms (male reproductive cells) in large numbers. Sperms travel through the vagina to the fallopian tubes; only one sperm fertilizes the ovum (female egg) in the fallopian tube. Ova are released every month from the ovary in the female body (refer to process of menstrual cycle). The fertilized egg gets implanted in the uterus (where inner lining thickens to receive the fertilized egg) to grow and take birth as a child. This is conception.

How conception takes place

If fertilization does not happen, the thickened inner lining of the uterus bleeds. This is known as menstruation or monthly period. When pregnancy happens, a woman’s menstruation stops as the uterus has the implanted fertilized egg.

What is contraception?

Contraception is a method by which pregnancy/conception may be prevented, or a method by which the fertilization of sperm and egg is prevented.

Why should couples adopt contraception?

To prevent unwanted pregnancies.

Who should be responsible for practising contraception – husband or wife?

Both the partners need to mutually decide on the method of contraception considering the suitability, advantages, risks associated and convenience for the user. Contraception is not the sole responsibility of the female partner.


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A couple may use two methods simultaneously, say a condom by the man and an oral contraceptive pill (OCP) by the woman to ensure protection.

What are contraceptive methods for men?

Condoms

What are contraceptive methods for women?

Female condom, OCPs, intra-uterine device (IUD) like Copper-T (only for those with one or more children).

What is emergency contraception?

Emergency contraception is a way to prevent pregnancy within 72 hours of unprotected sex. Unprotected sex may happen due to non-use of condom, incorrect use of condom, tearing of condom, no contraception adopted, sex under the influence of alcohol and drugs and in cases of forced sex, sexual violence/assault (date rape, sexual abuse etc.). This contraceptive is available in the form of a pill on a doctor’s prescription. One has to access a doctor as soon as possible after unprotected sex so as to take the pill within 72 hours. If consuming this pill within 72 hours does not prevent pregnancy, the person should go for a pregnancy confirmation test and consult a certified doctor for medical termination of pregnancy.

Note: The emergency contraceptive pill is not to be consumed on a regular basis or as an OCP.

Most Suitable Contraceptive Methods for Adolescents and Young Couples

Condom: Condoms are available for both men and women but more commonly and at cheaper rates for men. A male condom is a sheath or covering made to fit over a man’s erect penis. The most commonly available brand in the public health system is ‘Nirodh’. The condom prevents the semen carrying sperms from entering the vagina and hence prevents fertilization of ova by the sperm. The female condom is closed at one end and is inserted inside the vagina with the help of fingers with the open end outside the vagina. This creates a physical barrier for the semen ejaculated into the vagina from coming in contact with the ovum.

Both male and female condoms provide protection against STIs including HIV and hence serve a dual purpose. This makes condoms the most suitable contraceptive for adolescents and young couples. But condoms need to be used correctly and consistently.


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Hormonal contraceptive pills: The OCP which is a combination of hormones can be taken every day to prevent ovulation in women. Some of the commonly available oral pills are Mala-D, Saheli and Pearl.

Emergency contraceptive pill or the ‘72-hour pill’: ECP is indicated for the prevention of pregnancy within 72 hours of unprotected or unsafe sex. It is most suitable in situations of contraceptive failure, unprotected sexual intercourse, forced sex, sexual abuse and violence such as rape, sex under the influence of alcohol and drugs like those in the case of date rape.

Other methods (only for those with a child)

Intra-uterine device: This is a device which can be placed inside the uterus of a woman that prevents the fertilization of egg. This method is not recommended for unmarried women or those without any children.

Some other methods (not recommended for adolescent mothers)

Lactational Amenorrhea Method (LAM), a traditional method, is the use of breast feeding as a temporary family planning method. This method is effective for about 6 months following childbirth, provided the mother practices exclusive breastfeeding (with no substitutes for breast milk) and the interval between feeds is less than 6 hours. Further, the menstrual period should not have returned after childbirth. For all post-partum women, especially adolescent mothers, use of one of the modern contraceptives (like condoms, oral pills or intra-uterine device) is recommended, as all the criteria for LAM may be difficult to follow.

Permanent methods of contraception (to be adopted only in later adulthood and by couples who have completed their family): Permanent methods are those which provide permanent contraception, also called ‘sterilization’. This is a simple surgical process, and can be performed on both males (vasectomy) and females (tubectomy). Permanent methods only block the passage of semen that carries sperms (if performed on males) and block the passage of ova (if performed on females) to protect a couple from pregnancy and in no way affect sexual strength of the male or female who has undergone the surgery. However, it is recommended only for those who have completed their family as, unlike temporary methods, it is non-reversible. Temporary methods allow a couple to discontinue with the method when they plan a pregnancy.

Safe Abortion or Medical Termination of Pregnancy

In India, medical termination of pregnancy (MTP) has been legalized through the MTP Act that came into effect in 1972. Any woman above 18 years of age, irrespective of marital status, can opt for an abortion. In the case of minors (below 18 years of age), written consent from a parent or guardian is necessary.

Safe Abortion

Safe abortion is the medical termination of pregnancy performed by certified doctors in a certified clinical setting. It is legal in India on well-specified grounds that include failure of contraceptive method, risk to physical health and mental trauma to mother, risk of congenital defects in foetus/child to be born.

Abortion in India can be done till 20 weeks of pregnancy, but the opinion of a second doctor is necessary between 12 and 20 weeks.


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When is abortion unsafe?

Unsafe abortion (that is, abortion at home or at non-certified clinics or hospitals and by non-certified person/doctor) has serious risks like partial abortion, damage to internal organs, puncturing, tearing etc. This may lead to excessive bleeding and may also prove fatal.

When is abortion illegal?

Abortion can be illegal if

y Performed by untrained person,

y Performed in an uncertified clinic or hospital. The Government of India has certified select clinics and hospitals based on availability of necessary infrastructure like facility for blood transfusion etc. to provide safe abortion services.

y Duration of pregnancy is above permitted weeks of gestation

y The necessary procedures (like approval of two or more doctors) have not been followed in cases of pregnancies beyond 20 weeks.

y It is conducted based on the sex of foetus (like female foeticide)

Note: Termination of pregnancy after determining the sex of child is a criminal offence by both the doctor performing it and the couple and family going in for the heinous act.

When can a woman plan the next pregnancy after a miscarriage or induced abortion?

The recommended minimum interval for the next pregnancy is at least six months. This will help reduce risks of adverse conditions for mother and the unborn child.

Write each statement given below on a different card. Tape two chart papers on the wall and write a heading on one as ‘Myth’ and the other as ‘Fact’. Explain to the participants that you have some cards with statements written on each. You do not know whether the statement on the card is a myth or a fact. Ask them to help you paste the card under the right heading on the two chart papers. Read out the statements one by one. After each is read out, discuss with the participants whether the statement is a myth or a fact and with their help put it up on the chart paper. The statements are listed below.

1. There are other contraceptive methods like ‘safe period’ and ‘withdrawal of penis’ that are effective and risk free.

2. Taking birth control pills makes you fat.

3. Wearing two condoms will provide extra protection.

4. Using emergency contraceptive pill is the same as performing abortion.

5. Usage of contraceptive pills by mother may have harmful effect on the health of the child she has subsequently.

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Statements Answers

Withdrawal method and safe period methods for contraception

Myth: The withdrawal method is not effective as there may be ejaculation before orgasm which may have sperms that could travel into the female body through the vagina. This can cause pregnancy or even infection. Often men, especially young men, have trouble ‘pulling out’ in time.

The safe-period method for girls is not safe at all as (i) the duration of the menstrual cycle may not be same in all months; (ii) the calculations are cumbersome and it is difficult for an adolescent girl to keep track of her menstrual cycle for six months; (iii) no period is completely safe and no sexual activity is safe without using appropriate contraceptive method. Hence, this is not at all effective or risk free.

These methods are not at all recommended for adolescents and young people.

Taking birth control pills makes you fat

Myth: There is no evidence of a causal relationship between taking birth control pills and weight gain. Some women may experience minor weight gain depending on their physiology and the pill taken. A good exercise regime and a healthy nutritious diet can prevent or minimize weight gain.

Wearing two condoms will provide extra protection

Myth: Wearing two condoms at the same time, one on top of the other, is often referred to as ‘double bagging’. This does not reduce the chances of pregnancy or STI. In fact, double bagging may actually cause problems due to slippage or breakage. (Using more than one condom creates friction and can cause the condoms to rip.)

The ‘emergency pill’ is same as the ’abortion pill’

Myth: The emergency contraception pill when taken within 72 hours of unprotected intercourse prevents fertilization inside the fallopian tube. When fertilization is prevented, pregnancy does not happen. Hence it is not the same as an abortion. The ‘abortion pill’ is used for medical abortion, a method of safe abortion done only under the supervision of a certified doctor.

Usage of contraceptive pills by mother may have harmful effects on the health of the child she has subsequently

Myth: This myth persists because of the mild side effects (nausea, dizziness, vomiting and irregular periods) of oral pills in many women. Contraceptive pills only contain synthetic female hormones (progesterone and oestrogen or derivatives), and no other chemical or pharmaceutical substance that can affect the baby in the long run. They contain such a low dose of hormones that, fertility returns as soon as it is stopped. They have no relation to or effect on the health of the child to be born.


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Optional: If required, you can discuss myths associated with other contraceptives and provide correct information based on information given below.

Some Basic Facts

Condoms • Do not make men sterile, impotent or weak• Do not decrease men’s sex drive• Cannot get lost in the woman’s body• Prevent STIs

Oral Contraceptive Pills

(MALA-D, MALA-N)

• Do not build up in a woman’s body• Women do not need a ‘rest’ after taking oral contraceptive pills• Do not make women infertile• Do not cause birth defects or multiple births• Do not change a woman’s sexual behaviour• Do not collect in the stomach. Instead, the pill dissolves each day• Do not disrupt an existing pregnancy• Must be taken every day, whether or not a woman has sex that day

Intra-uterine Device (Copper-T) • Does not cause infection of uterus or genital tract• Does not make women infertile• Does not cause birth defects• Does not cause cancer• Does not move to the heart or brain • Does not cause discomfort or pain for the woman during sex

Lactational Amenorrhoea Method (LAM)

• Highly effective when a woman meets all three LAM criteria• Just as effective among overweight or thin women• Can be used by women with normal nutrition. No special foods are

required• Can be used for a full six months following childbirth without the

need for supplementary foods

Emergency Contraceptive Pills (ECPs)

• Not effective if taken before sex• ECPs may have some temporary side effects like nausea, dizziness or

tiredness• ECPs do not protect from STIs/HIV and AIDS• ECPs cannot cause abortion, they only prevent pregnancy• ECPs should not be taken frequently


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(It is suggested that this session be held separately for girls and boys)

Write the terms ‘Unsafe Sex’ and ‘Unprotected Sex’ on the flip chart or blackboard. Ask the participants to say what they understand about these terms. Note down their responses and explain the terms to them and about ‘Safe Sexual Practices’.

Safe Sexual Practices(for those who have an active sexual life)

The term stands for sexual activities that are protected and safe. That means there is no or minimum risk of unwanted pregnancy or transmission of sexually transmitted infections. This includes the following:

y Masturbation

� Commonly understood as self-stimulation of sexual organ with hands for sexual pleasure � It may be practised alone or with a partner � There is no evidence about its negative effect on health, loss of sperms, fertility etc. � However among adolescents and young people, preoccupation with masturbation may impede other

activities like study, play, social interaction etc.

y Holding hands, touching, kissing, cuddling are some safe ways to show affection and love

y Avoiding sexual intercourse

y Correct and consistent use of condom (condom provides triple protection)

y Using a suitable contraceptive method (only protection from unwanted pregnancy but not from STIs and HIV)

y Being faithful to partner (not engaging in sex with multiple partners)

y Abstaining from sex (delaying sexual debut till adulthood)

Note: you must explain and emphasize delaying sexual initiation till adulthood, having a single partner and being faithful to that partner and correct and consistent use of condoms to protect oneself from associated risks.


1. Unwanted pregnancies can be prevented by seeking information and services on contraception and safe sexual practices.

2. It is beneficial to have knowledge on methods of contraception before planning marriage and sexual initiation.

3. One should not hesitate to consult ASHA didi, ANM didi or the local doctor to get information regarding risks associated with unsafe or unprotected sex (sex without using condom and other contraceptive method) and safe sexual practices.

4. Unwanted pregnancies can be prevented by not giving in to any undue pressure through good decision making and negotiation skills.

5. Convince partner to adopt safe practices which will be beneficial to both.

6. Untimely and unplanned pregnancy may be a risk to both mother and child and timely abortion may prevent such harm.

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7. Unplanned pregnancy may cause mental trauma to mother and hence the mother has the right to decide to have a safe abortion.

8. For an adolescent couple, the condom is the most suitable contraceptive method as it provides double protection – from unwanted pregnancy and STIs like HIV.

9. Use of condom reflects how responsible and caring a partner is.

10. Other suitable methods are ECPs, OCPs and IUDs like Copper-T for those with one or more children.

11. A couple has the option to undergo sterilization later in adult life and/or on completion of family.

10.4 Adolescent Pregnancy: Management of Adolescent Pregnancy

Discuss care to be taken in the case of an adolescent pregnancy (if pregnancy is wanted) with the participants.

All adolescent pregnant girls should be counselled on the option of safe abortion and should be helped in accessing a medical facility to decide whether they want to continue with the pregnancy or not. In case of wanted pregnancy:

y The adolescent pregnant girl needs to be registered with the ANM didi for compulsory antenatal and post-natal care and institutional delivery. She should be taken for antenatal check-ups (at least four times during pregnancy).

y She should be administered two TT injections and 100 iron and folic acid (IFA) tablets.

y She should sleep for eight hours each night.

y She must rest or sleep for two hours during the day.

y She should maintain personal hygiene.

y She can undertake light exercise, for example walking for half an hour every day.

y She should wear loose, comfortable clothing and low-heeled shoes that support her feet.

y She should drink plenty of fluids and eat healthy, hygienically prepared and served nutritious food.

y She should go for institutional delivery.

y She and her husband need to be counselled on post-natal care, child care and contraceptive methods to avoid pregnancy for 3 to 5 years.

y Support from the husband and family is crucial during these days. She should be kept happy and not face any physical, verbal or emotional abuse.

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Key Messages

1. Adolescent pregnancies can be prevented. Child marriage is a major cause of adolescent pregnancies in

our country.

2. If married early or as a child, postponing ‘Gauna’, a practice in some regions where bride is sent to her husband’s

house after a few months or years. This is to delay consummation of marriage.

3. It is advisable to have the first child only after completing 20 years or later.

4. There should be a minimum of three and preferably five years’ gap between two children.

5. Gap between two children not only ensures health of mother and child but also increases opportunities for

parents to enhance their skills and knowledge.

6. Condom is the most suitable contraceptive for adolescents and young couples.

7. Emergency contraceptive pills are available for emergency situations, to be taken within 72 hours of

unprotected sex.

8. An unintended/unwanted pregnancy can be terminated through safe abortion. Safe abortion is abortion by

legally certified doctors and in government certified clinical or hospital settings. The duration of pregnancy

should be below 20 weeks.

9. In case of adolescent pregnancy, thorough care should be taken including antenatal care, institutional delivery

and post-natal care.


1. To be careful and selective in discussing topics with adolescents between 10–14 years and those who are

unmarried: discuss as appropriate to age and situation.

2. To inform peers about advantages of delaying sexual initiation and risky situations.

3. To inform peers about sharing responsibility of adolescent pregnancy and parenthood with partner.

4. To educate adolescents and the community on causes and consequences of adolescent pregnancy.

5. To educate peers about most suitable methods of contraception.

6. To counsel newly married peers on contraception and safe sexual practices.

7. To report cases of adolescent pregnancy to ASHA didi or ANM didi.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Adolescent Pregnancy

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Session 11Reproductive Tract and Sexually Transmitted Infections and HIV and AIDS

IntroductionReproductive tract infections (RTIs) including sexually transmitted infections (STIs) are the second largest cause of poor health among women of reproductive age, after maternal morbidity and mortality. Reproductive tract infections are common among young men and women. These may occur either due to poor personal hygiene or through unsafe and unprotected sexual contact. Although not all RTIs are due to sexual contact, vulnerability to STIs increases with pre-existing RTIs that may have caused lesions on the skin. Adolescents suffering from RTIs avoid talking about them for fear of stigma and discrimination and unnecessarily suffer in silence. If left untreated, RTIs may cause discomfort and embarrassment in social life, impede other activities such as studies, play and social interactions and may lead to serious health complications. Any form of inflammation in the reproductive tract needs to be treated medically. Also, medical test helps in early diagnosis of any other infection that could be sexually transmitted as well such as the human immunodeficiency virus (HIV).

Timely diagnosis of such conditions is very important to initiate early treatment. STIs, if left untreated, may lead to complications such as infertility, ectopic pregnancy and cervical cancer. Pelvic inflammatory disease (PID) is another condition that is the result of untreated RTIs/STIs. HIV has sexual transmission as one of its transmission routes and causes AIDS in the later stage. Globally, nations have experienced loss of generations due to HIV and AIDS. In India, half the new infections were reported from young people between 15 and 24 years. As our country is moving towards reversing the spread of HIV, all adolescents and youth need to enhance their knowledge and skills to be able to identify risky situations, have protected sex, seek medical care and support and fight stigma and discrimination against people living with HIV or other STIs.


1. To understand modes of transmission and prevention of RTIs, STIs

2. To understand common signs and symptoms of RTIs and STIs

3. To understand prevention and management of RTIs and STIs

4. To learn about HIV and AIDS, modes of transmission and ways to prevent transmission

5. To examine common myths related to RTIs, STIs, HIV and AIDS

6. To understand the importance of seeking timely help from a qualified doctor

7. To practise some core life skills in situations related to the topic


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Time:

60 minutes

Material:

Chart papers; flip chart; sketch and marker pens, copies of case studies, blank paper slips

Methodology:

Brainstorming, group discussion, case studies, quiz, participatory games

Part I Reproductive Tract and Sexually Transmitted Infections

11.1 Understanding RTIs and STIs: Signs, Symptoms and Prevention

A. Ask participants if they have heard of infections of the reproductive tract. If yes, ask them to name some. Also ask them if they have heard about HIV and AIDS.

Tell participants that today you will inform them about infections of the reproductive tract and also about HIV and AIDS.

B. Write on the blackboard or flip chart as given below and inform participants about different terms associated with infections of or through the reproductive system and how they are different.

y RTI: R – Reproductive T – Tract I – Infections (are defined as any infections of the reproductive system)

y STI: S – Sexually T – Transmitted I – Infections (infections of the reproductive tract transmitted by infected person to another person through unprotected sexual intercourse)

y HIV: H – Human (only found in humans) I – Immunodeficiency (weakens the immune system) V – Virus (a type of germ)

y AIDS: A – Acquired (to get something that you are not born with) I – Immuno- (the body’s defence system, which provides protection from infections) D – Deficiency (a defect or weakness, lack of something) S – Syndrome (a group of signs and symptoms in a disease)

Explain that:

� Reproductive tract infections may occur either due to poor sanitation and personal hygiene or through unprotected sexual contact with an infected person. Hence, not all infections of reproductive tract are sexually transmitted.

� Sexually transmitted infections are transmitted through unprotected sexual contact. HIV has four modes of transmission and one of them is through unprotected sexual contact.

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� HIV is also transmitted through transfusion of infected blood, use of infected needle and from mother living with HIV to her unborn child. Though HIV can be transmitted through the reproductive tract (unprotected sexual contact), the infection affects the entire immune system and not the reproductive tract alone. Hence, in case of HIV infection, there are no symptoms like itching, pain in genitals or difficulty in urination etc.

� AIDS is the advanced stage in a person living with HIV. AIDS can be delayed through timely treatment and management of HIV in an infected person (including good nutrition, healthy lifestyle and having a positive attitude)

Addressing Myths and Facts 1. Give each participant two or three cards or half-sheets of paper and ask them to write two or three main

things they know or have heard in the community (true or untrue) about RTIs/STIs and HIV. They should write only one statement on one card or piece of paper.

2. In the meantime, draw a line down the centre of the flip chart. Label one side ‘Myths’ and the other side ‘Facts’. As the participants finish writing, collect the papers.

3. Read what is written on the first paper. Ask the participants to decide whether it is a myth or fact. On the basis of the response of the majority, tape the paper under the chosen heading and proceed to the next one. Anything that cannot be decided should be taped in the middle. Some of the statements could be (the facts are also given below to be discussed later):

� A person can always tell if she or he has an STI

� All infections of the reproductive tract are caused due to sex

� With proper medical treatment, all STIs except HIV can be cured

� The organisms that cause STIs can only enter the body through the woman’s vagina or the man’s penis

� You cannot contract STIs by holding hands, talking, walking or dancing with a partner

� Many curable STIs, if left untreated, can cause severe complications

� RTIs occur because of unclean toilets

� Foul smelling discharge from the vagina is not a cause for worry

4. The facilitator should not provide correct information at this time and tell participants that they will revisit this at the end of the session to see if the responses are correct or not.

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Statements Answers

A person can always tell if she or he has an STI

Myth

People can have STIs without having any symptoms. Symptoms of HIV are not specific as in case of RTIs or STIs and hence one may not associate his/her illness like cold, sneezing etc with HIV.

All infections of the reproductive tract are caused due to sex

Myth

Not all infections of the reproductive tract are sexually transmitted. RTIs also occur due to poor sanitation and personal hygiene, like using unclean sanitary napkins or cloths during menstruation, improper washing of genitals during daily bath. It is common among both adolescent girls and boys.

With proper medical treatment, all STIs except HIV can be cured

Myth

Herpes, an STI caused by a virus, cannot be cured at the present time. However most of the other STIs can be cured and it is important that the sexual partner of the infected person is also treated.

yes, HIV cannot be cured. Treatment is for management of HIV to help maintain the body’s immunity.

The organisms that cause STIs can only enter the body through sexual contact

Myth

Bacteria and viruses causing infections that are mostly sexually transmitted can also enter the body through cuts and lesions, wherein the body fluid of the person comes in contact with the body fluid of an infected person as in the case of HIV. HIV has other modes of transmission as well, like use of infected needles and transfusion of infected blood. Infection with HIV may also happen through tears and lesions on the skin, exposing the person to body fluids of an infected person (blood, semen, saliva). However such cases are rare.

You cannot contract STIs by holding hands, talking, walking or dancing with a partner

Fact

STIs are transmitted through unprotected sexual contact with an infected person

Many curable STIs, if left untreated, can cause severe complications

Fact

Some complications can lead to infertility in women. Other complications can lead to heart failure or even damage to the brain

RTIs occur as a result of use of unclean toilets

Myth

RTIs can also occur due to personal poor hygiene that includes use of unclean pads, improper washing of genitals and transmission of infections through unprotected sexual contact

Foul smelling discharge from the vagina is not a cause for worry

Myth

This is a sign of an RTI that could also be an STI. One should seek medical help as soon as possible.


160

Divide the participants into three or four groups. Give each group a photocopy of the case studies given below. Ask the groups to discuss the cases with help of the discussion points given with each case.

Reena’s Story:

Reena, a 14-year-old girl, uses cloth as sanitary pads. Her mother has given her 4-5 pieces of cloth that she has to wash and use during her menstrual cycle every month. During one cycle, due to heavy rains, Reena is not able to dry the cloths properly. Since she has no other option, she has to use the cloths that are not well dried. She stores her sanitary cloths in a small store-room in the courtyard and most of the time she has to dry the cloths in that room as well. For the last few days Reena has been having itching in her private parts and pain while passing urine. She finds it unbearable but hesitates to talk to mother or anyone about it.

Discussion Points:

1. What is Reena’s problem?

2. Why and how did she get this problem?

3. What she should do for treatment?

Ajmal’s Story:

Ajmal is a 16-year-old boy working at a transport company. He lives in a city, far away from his parents. Ajmal is sexually active. He never uses a condom as he is ashamed of buying it from the shop.

Of late Ajmal has been a having burning sensation while urinating and itching in the genital area. He has been ignoring it but now sees that there are rashes around his genital area and a foul smelling discharge from his genital organs. Ajmal is scared and don’t know what to do. He discusses his problem with one of his friends who works in same company. The friend tells him that he had similar problem and advises him to go to a hakim who will keep the matter confidential and will not even do a physical check-up.

Ajmal is grateful to his friend and is preparing to go to the hakim.

Discussion Points:

1. What is Ajmal’s problem?

2. What do you think the reason for this problem can be?

3. Is his decision to approach the hakim for treatment right?

4. What should he do for treatment?

Activity 3


161

Payal and Raja’s Story:

Payal and Raja have been married for two years. Payal is pregnant and she has registered for antenatal care at the primary health centre. A few days after the first antenatal check up, Payal is informed that she is HIV positive.

Discussion Points:

1. How may Payal have got HIV? Should Raja also go for HIV testing?

2. What are different modes of transmission of HIV?

3. Will their HIV status affect the child? What can be done to prevent the child from being infected?

4. Can Payal and Raja lead a normal life?

Once the group discussion is over, invite each group to present their story and help participants understand the case with the analysis for each story given below.

1. Reena is probably having an infection of the reproductive tract due to poor sanitation and personal hygiene. She has been using cloths as sanitary pads without drying them in the sun. In fact, at times she has used damp cloths as well. Also, the place where she keeps her sanitary cloths is not clean and hygienic. Such infections are common among adolescent girls and women. Reena need not hesitate or feel shy and immediately contact a health service provider or visit the nearest health facility. If left untreated, RTIs may have serious health implications. They also increase vulnerability to sexually transmitted infections and HIV.

2. Ajmal has been sexually active and may also have been sexually abused as he is away from parental care and guidance. Ajmal may be having unprotected sexual encounters (sex without condom). His friend’s advice to visit the hakim is wrong as any infection needs to be treated by a medically trained person and physical examination of the private parts is an important procedure for the doctor to provide appropriate treatment. Further, visiting the hakim will not confirm whether Ajmal has also been infected with HIV. HIV testing can be done only at HIV testing centres.

Note: It is also important to know that HIV does not have any symptoms and even the first unprotected sexual encounter can lead to infection with HIV. Hence, it is advisable to go for HIV counselling and testing at the Integrated Counselling and Testing Centre (ICTC) at the nearest government hospital after any unprotected sex encounter.

3. Payal and Raja may both have been infected with HIV if they were ever exposed to any of the following four modes of HIV transmission:

� Sexual intercourse with HIV infected person without a condom

� Transfusion of HIV infected blood

� Use of HIV infected needle like in administration of intravenous drugs

� Infection from the mother if any one of them or both are living with HIV (HIV can be transmitted from HIV infected mother to the unborn child)


162

When one partner is detected with HIV or any STI, the other partner should also get tested. As HIV can only be prevented and not cured, timely knowledge of HIV status helps treatment and management in a better way. Payal and Raja, with the help of testing and counselling centre and staff (that keeps their information confidential), can lead a normal life that includes good nutrition, physical exercise, healthy lifestyle and positive attitude.

The unborn child has a risk of being infected with HIV but now there are medical interventions that can prevent it if the pregnant mother gets timely medication. This facility is known as prevention of parent to child transmission and is available at all district hospitals.

With the help of the chart given below discuss how adolescents have increased risks and vulnerabilities to RTI infections including those transmitted through unprotected sexual contact and HIV.

Adolescents’ Risks and Vulnerabilities to RTIs, STIs and HIV

y Adolescents have inadequate information and facilities to maintain personal hygiene including management of menstruation.

y Adolescents have poor information on safe and protected sexual behaviour, have no access to condoms, and poor skills to seek support.

y During adolescence, there is increased risk-taking behaviour that also includes experimenting with sex.

y During adolescence, sexual encounters are often spontaneous and unplanned.

y Adolescents may give in to pressure to have unprotected sex under peer influence or poor skills to say ‘No’.

y Young people often confuse sex with love and engage in sexual relations before they know and understand their partner well.

y Communication with spouse or partner on safe sex is limited.

y Adolescents are also vulnerable to situations of sexual abuse and violence (sexual coercion).

y Child marriage leads to early initiation of sexual activity though the couple is poorly informed on safe and protected sexual behaviours.

y Young women may have their first sexual experiences with older men (marriage to older man). This causes barriers in negotiating safe sex even if the girl is informed and knowledgeable.

y Adolescent girls are biologically more susceptible than older women to STIs because of immature vaginal linings.

y Adolescents may engage in unsafe and unprotected sex under the influence of alcohol and drugs.

y Adolescents have poor access to information, counselling and services on ways to prevent such infections, as well as to testing and counselling and medical treatment due to social and cultural norms that make it inappropriate for adolescents to seek such information and service. The stigma with regard to adolescent sexual behaviour is very high.

Activity 4


163

Inform participants about signs and symptoms of RTIs (including those transmitted sexually) and long- term consequences of RTIs and STIs

Inform participants that many individuals infected with STIs will have no symptoms. Hence, the only way to know for sure is to see a health care provider and get tested. Also, there is no way to tell if the person with whom sexual contact has been made has an STI or not if the person himself/herself does not disclose it.

Signs and Symptoms in Males Signs and Symptoms in Females

• Discharge from penis (green, yellow, pus-like)

• Pain or burning during urination

• Swollen and painful glands/lymph nodes in the groin

• Blisters and open sores (ulcers) on the genitals which may or may not be painful

• Nodules under the skin

• Warts in the genital area

• Non-itchy rash on limbs

• Itching or tingling sensation in the genital area

• Flu-like symptoms (headache, malaise, nausea, vomiting)

• Fever or chills

• Sores in the mouth

• Heaviness and discomfort in the testicles

• Irregular bleeding

• Lower abdominal/pelvic pain

• Abnormal vaginal discharge (white yellow, green, frothy, bubbly, curd-like, pus-like, and foul-smelling)

• Swelling and/or itching of the vagina; swelling of the cervix

• Burning during urination

• Sores on genitals

• Painful or difficult intercourse

Long-term Consequences of RTIs/STIs on Adolescents

RTIs (including those transmitted sexually) if left untreated can lead to serious health consequences including pelvic inflammatory disease (PID), infertility, and certain kinds of cancer. Untreated STIs can also lead to complications during pregnancy and in newborns. Some STIs, such as HIV and syphilis, can lead to death.

Activity 5


164

Long-term Consequences of RTIs/STIs on Adolescents

Social Health(The long-term health consequences of RTIs/STIs are more serious among women)

• Discrimination and exclusion from mainstream and social groups

� Loss of friendship � Diminished income potential � Possible eviction from community/school � Stigmatized and treated as a “bad person”

• Difficulty in finding marriage partner

• Inability to participate fully in community activities/education due to ill health

• Infertility and loss of credibility in the community

• Possible judgment and/or rejection by service providers

• Women and girls are less likely to experience symptoms, so many STIs go undiagnosed until a serious health problem develops

• Adolescents who contract STIs are also at risk of chronic health problems, including permanent infertility, chronic pain from PID, and cancer of the cervix

• Adolescents who contract syphilis may develop heart and brain damage if the disease is left untreated

• STIs are a risk factor for HIV transmission and for contracting HIV, which leads to chronic illness and death

• STIs can be transmitted from an adolescent mother to her infant during pregnancy and delivery

• Infants of mothers with STIs may have lower birth weights, be born prematurely, and have increased risk of other diseases, infection, and blindness from ophthalmia neonatorum

Discuss with participants how vulnerabilities and risks to RTIs, STIs and HIV can be minimized among adolescents. Note down responses on a chart paper and summarize at the end.

Minimizing risks and vulnerabilities to RTIs, STIs and HIV

1. Maintain personal hygiene, especially of genitals.

2. Proper management of menstruation that includes using washed and sundried cotton cloths or disposable sanitary pads, washing genitals, changing underwear, daily bath.

3. Delay marriage till physically and emotionally mature. This will help delay early initiation of sexual activity and prevent STIs.

4. Delay sexual debut. Enhance life skills to negotiate for safe sex, resist peer pressure and say ‘No’ to coercion.

Activity 6


165

5. Inform parents, teachers or service providers about situations of sexual coercion/abuse so as to access timely help.

6. Be informed on safe sexual behaviour that includes masturbation and other ways to demonstrate love and affection like kissing, holding hands, hugging etc.

7. Abstain from unprotected sexual intercourse if the partner indulges in risky behaviour (including addiction to alcohol or drugs) or has signs of RTI until medical diagnosis and treatment is complete.

8. Use condoms ‘Correctly’ and ‘Consistently’ (if possible facilitator can demonstrate condom use). The male condom is the most effective way to prevent STIs and transmission of HIV through sexual intercourse.

9. Getting oneself tested after any unprotected sexual encounter (be it the first encounter or at a later age).If one has signs of RTI contact trained medical professional (at primary health centre, district hospital or private clinic) at the earliest.


What are reproductive tract infections? y Reproductive tract infections (RTIs) are defined as any infection of the reproductive system. They include

sexually transmitted infections (STIs) and other infections of the reproductive system that are not caused by sexual contact.

y RTIs can happen to both men and women. These are caused by bacteria, viruses or protozoa. The infection affects the genital tract and can affect female or male reproductive organs. RTIs can be present without producing any symptoms.

y RTIs include all infections of the reproductive tract whether transmitted sexually or not.

y The infection may come from the use of unhygienic toilets or faulty genital hygiene.

y RTIs may even occur due to imbalance of the normal bacteria in the reproductive tract.

y Practice of proper genital hygiene in males and females and menstrual hygiene in females can prevent RTIs.

y For cure of RTIs, patient should seek advice and treatment from qualified doctors.

y RTIs may lead to serious complications, especially in women, if they are left untreated. In addition, RTIs increase the risk of acquiring or transmitting HIV, the virus that causes AIDS.

y RTIs occur following miscarriage and pregnancy or with the use of contaminated instruments during surgery.

What are sexually transmitted infections? y Sexually transmitted infections (STIs) – also known as sexually transmitted diseases (STDs) – are infections

primarily passed from an infected person to another person through unprotected sexual contact (sex without condom).

y Infections transmitted during unprotected sexual activity with an infected partner are called STIs. The infections are transmitted via the mucous membranes and secretions of the genital organs, throat and rectum.

y Not only do they affect genital organs but they are also harmful for overall health.

y There is strong evidence that STIs put a person at greater risk of getting and transmitting HIV. This may occur because of sores and breaks in the skin or mucous membranes that often occur with STIs. There are various types of STDs.

y Most STIs are easy to treat if they are detected and treated early. If not, the infection may spread and cause various complications.

Contd...


166

Transmission y Different STIs spread in different ways. Some are passed through infected body fluids including blood, semen,

vaginal fluids and breast milk. Others are passed through skin-to-skin contact. All STIs can be transmitted during oral, vaginal or anal sex with an infected partner. STIs that are present in body fluids can be passed from one person to another if they share needles, such as for using drugs. Also, some STIs can be passed from mother to child during pregnancy, childbirth or breastfeeding.

y In general, a woman’s risk of infection is higher than a man’s. The vagina and rectum are more easily infected than the penis. Women also generally have fewer symptoms than men. As a result, they are less likely to know if they are infected.

y STIs are not transmitted through hugging, shaking hands, sharing food, using the same utensils, drinking from the same glass, sitting on public toilet seats or touching doorknobs.

Testing and Treatment y Individuals who have any symptoms should see a health care provider immediately or visit an ARSH clinic.

y The most common ways that health care providers test for STIs include collecting urine, taking blood and/or swabbing the mouth, throat, penis or cervix.

y Because many STIs show no symptoms, all sexually active individuals should consider being tested for STIs regularly.

y If tests come back positive, health care providers help individuals decide what to do. If the infection is curable then they will be prescribed medication, which the individual has to take for the prescribed amount of time even if the symptoms subside before the course of medication is over.

y If STIs cannot be cured, health care providers can help individuals treat the symptoms and advise on management.

HIV and AIDS are discussed in detail in the latter part of the session.


167

Not

e fo

r the

Fac

ilita

tor (

Som

e Co

mm

on S

exua

lly T

rans

mitt

ed In

fect

ions

)

Dis

- ea

seA

bout

Tran

smis

sion

Sym

ptom

sTe

stin

g/tr

eatm

ent

Long

term

hea

lth

conc

erns

Chlamydia

Infe

ctio

n is

caus

ed b

y ba

cter

ia.

In m

en a

nd w

omen

, ch

lam

ydia

can

infe

ct

the

uret

hra,

anu

s or

thro

at.

In w

omen

, chl

amyd

ia

can

also

infe

ct th

e ce

rvix

, ute

rus o

r fa

llopi

an tu

bes.

Chla

myd

ia is

pa

ssed

from

an

infe

cted

per

son

thro

ugh

sem

en

or d

isch

arge

from

th

e va

gina

or

cerv

ix.

Mos

t peo

ple

infe

cted

with

ch

lam

ydia

don

’t ha

ve a

ny

sym

ptom

s.

Men

who

hav

e sy

mpt

oms m

ay

feel

hea

vine

ss a

nd d

isco

mfo

rt

in th

eir t

estic

les,

pain

or b

urni

ng

durin

g ur

inat

ion

or p

us co

min

g ou

t of t

heir

peni

s.

Sym

ptom

s in

wom

en m

ay in

clud

e itc

hing

, vag

inal

dis

char

ge o

r bu

rnin

g du

ring

urin

atio

n.

Hea

lth ca

re p

rovi

ders

che

ck fo

r ch

lam

ydia

by

test

ing

urin

e or

swab

bing

th

e pe

nis,

cerv

ix o

r thr

oat.

Chla

myd

ia ca

n be

cur

ed w

ith

antib

iotic

s.

If le

ft u

ntre

ated

, ch

lam

ydia

can

caus

e sc

ar ti

ssue

in

the

uret

hra,

ute

rus

or fa

llopi

an tu

bes.

This

can

mak

e it

very

diffi

cult

to g

et

preg

nant

.

Gonorrhoea

Infe

ctio

n is

caus

ed b

y ba

cter

ia.

In m

en a

nd w

omen

go

norr

hoea

can

infe

ct

the

uret

hra,

anu

s, ey

es

or th

roat

.

In w

omen

, gon

orrh

oea

can

also

infe

ct th

e ce

rvix

, ute

rus o

r fa

llopi

an tu

bes.

Gon

orrh

oea

is

pass

ed fr

om a

n in

fect

ed p

erso

n th

roug

h se

men

or

dis

char

ge fr

om

the

vagi

na o

r ce

rvix

.

Mos

t peo

ple

infe

cted

with

go

norr

hoea

don

’t ha

ve a

ny

sym

ptom

s.

Men

who

hav

e sy

mpt

oms m

ay

have

a y

ello

wis

h di

scha

rge

from

th

eir p

enis,

bur

ning

or p

ain

durin

g ur

inat

ion,

freq

uent

urin

atio

n an

d pa

in o

r sw

ellin

g in

thei

r tes

ticle

s.

Sym

ptom

s in

wom

en m

ay in

clud

e a

yello

w o

r blo

ody

disc

harg

e fro

m

the

vagi

na a

nd p

ain

or b

urni

ng

durin

g ur

inat

ion.

Hea

lth ca

re p

rovi

ders

che

ck fo

r go

norr

hoea

by

test

ing

urin

e or

sw

abbi

ng th

e pe

nis,

cerv

ix o

r thr

oat.

Gon

orrh

oea

can

be c

ured

with

an

tibio

tics.

If le

ft u

ntre

ated

, go

norr

hoea

can

caus

e sc

ar ti

ssue

in

the

uret

hra,

ute

rus

or fa

llopi

an tu

bes.

This

can

mak

e it

very

diffi

cult

to g

et

preg

nant

.

Cont

d...


168

Dis

- ea

seA

bout

Tran

smis

sion

Sym

ptom

sTe

stin

g/tr

eatm

ent

Long

term

hea

lth

conc

erns

Trichomoniasis or “trich,”

Gen

ital i

nflam

mat

ion

is

caus

ed b

y th

e pr

otoz

oa

tric

hom

onas

vag

inal

is.

Tric

hom

onia

sis

is tr

ansm

itted

th

roug

h sk

in-t

o-sk

in co

ntac

t.

Mos

t men

with

tric

hom

onia

sis

do n

ot h

ave

sign

s or s

ympt

oms;

how

ever

som

e m

en m

ay

tem

pora

rily

have

an

irrita

tion

insi

de th

e pe

nis,

mild

dis

char

ge o

r sl

ight

bur

ning

afte

r urin

atio

n or

ej

acul

atio

n.

Sym

ptom

s in

wom

en m

ay in

clud

e a

froth

y, y

ello

w-g

reen

vag

inal

di

scha

rge

with

a st

rong

odo

ur.

Wom

en m

ay a

lso

expe

rienc

e di

scom

fort

dur

ing

inte

rcou

rse

and

urin

atio

n, a

s wel

l as i

rrita

tion

and

itchi

ng o

f the

gen

ital a

rea.

Hea

lth ca

re p

rovi

ders

test

for

tric

hom

onia

sis b

y sw

abbi

ng th

e ur

ethr

a or

vag

ina.

In w

omen

, hea

lth ca

re p

rovi

ders

may

al

so b

e ab

le to

see

sore

s tha

t ind

icat

e tr

icho

mon

iasi

s dur

ing

a ph

ysic

al e

xam

.

Tric

hom

onia

sis i

s cur

able

with

an

tibio

tics.

Both

par

tner

s mus

t und

ergo

trea

tmen

t at

the

sam

e tim

e to

pre

vent

pas

sing

the

infe

ctio

n ba

ck a

nd fo

rth.

The

y sh

ould

be

sure

to fi

nish

the

full

cour

se o

f an

tibio

tics e

ven

if sy

mpt

oms s

ubsi

de.

Infe

ctio

n w

ith

tric

hom

onia

sis

mak

es in

divi

dual

s, w

omen

in

part

icul

ar, m

ore

susc

eptib

le to

oth

er

STIs,

incl

udin

g H

IV.

HPV

HPV

stan

ds fo

r hum

an

papi

llom

aviru

s.

The

viru

s can

caus

e w

arts

to g

row

on

the

cerv

ix, v

agin

a, v

ulva

, pe

nis,

scro

tum

, ure

thra

or

anu

s.

Ther

e is

no

cure

for

HPV

.

HPV

is p

asse

d fro

m a

n in

fect

ed

pers

on th

roug

h di

rect

skin

-to-

skin

cont

act.

War

ts a

re sm

all,

rais

ed b

umps

th

at d

o no

t itc

h or

hur

t. M

ost

war

ts a

re h

ard

for i

ndiv

idua

ls to

se

e be

caus

e of

thei

r sm

all s

ize

and

thei

r loc

atio

n.

Man

y pe

ople

infe

cted

with

HPV

w

ill n

ever

kno

w th

ey h

ave

it.

Hea

lth ca

re p

rovi

ders

may

see

war

ts

durin

g an

exa

m.

In w

omen

, the

viru

s mig

ht b

e de

tect

ed

durin

g a

gyna

ecol

ogic

al te

st ca

lled

a Pa

p sm

ear.

The

war

ts m

ay d

isap

pear

on

thei

r ow

n,

or th

ere

are

a nu

mbe

r of p

roce

dure

s an

d m

edica

tions

that

can

rem

ove t

hem

.

HPV

, how

ever

, sta

ys in

the

body

and

the

war

ts co

uld

com

e ba

ck.

Mos

t HPV

infe

ctio

ns

that

caus

e w

arts

do

not c

ause

long

-te

rm h

arm

in e

ither

w

omen

or m

en.

Som

e H

PV

infe

ctio

ns ca

n le

ad to

canc

er o

f th

e ce

rvix

, vul

va,

vagi

na, a

nus,

thro

at

or p

enis.

Cont

d...


169

Dis

- ea

seA

bout

Tran

smis

sion

Sym

ptom

sTe

stin

g/tr

eatm

ent

Long

term

hea

lth

conc

erns

Genital herpes

This

recu

rrin

g sk

in

cond

ition

is ca

used

by

a vi

rus.

The

viru

s cau

ses s

ores

on

the

mou

th, v

ulva

, pe

nis,

scro

tum

, anu

s, bu

ttoc

ks o

r thi

ghs.

Ther

e is

no

cure

for

herp

es b

ut so

me

med

icat

ions

can

help

indi

vidu

als h

eal

fast

er a

nd h

ave

few

er

outb

reak

s.

Gen

ital h

erpe

s is

pass

ed fr

om a

n in

fect

ed p

erso

n th

roug

h di

rect

sk

in-t

o-sk

in

cont

act.

Man

y pe

ople

with

gen

ital h

erpe

s m

ay e

xper

ienc

e ve

ry m

ild o

r no

sym

ptom

s and

not

real

ize

that

th

ey h

ave

the

viru

s.

Oth

er p

eopl

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170

Part II HIV and AIDS

11.2 Understanding HIV and AIDS

Elephant Game Ask for one volunteer, this volunteer will be a baby elephant. Ask him/her to stand in the front of the room.

1. Ask for six more volunteers. These volunteers are the adult elephants. Their job is to protect the baby elephant. They should form a circle around the baby elephant and join hands.

2. To show them the importance of their job, you should try to hit the baby elephant with a paper roll. In response to the attack, the adult elephants will quickly close ranks to ward off the attack. The adult elephants should stand very close to the baby elephant.

3. Now, request four or five more volunteers to join the game. These volunteers will pose as lions. Their job will be to attack the baby elephant. The lions will try to touch the baby elephant (if they manage to touch the baby elephant, it counts as an attack).

4. When you say ‘Go!’ the lions should try to touch the baby elephant. Let this continue for about 30 seconds or 1 minute – until the baby elephant has at least one contact from the lions – but the baby elephant should not be hurt.

5. After a few attempts stop the activity and ask the following questions (the volunteers should stay where they are):

� What is the baby elephant? What does the baby elephant represent? The baby elephant is the human body.

� What are the adult elephants? The adult elephants are the immune system. Their job is to protect the body from invading diseases.

� What are the lions? The lion represents diseases, illnesses and infections that attack a human body. (There may be a few people who say that the lions are HIV. That is not so; ask another participant to tell you the meaning of the lion.)

6. Now go to each of the lion volunteers and say, “These diseases, such as tuberculosis (touch the first volunteer), malaria (touch the second), diarrhoea (touch the third) and cholera (touch the fourth) may attack the human body, but are they usually able to kill the human body?”The answer should be ‘No’. Diseases or germs attack the human body every day, but the immune system (point to the adult elephants) manages to fight them off and protect the body. The human body might get sick (such as the hit or kick that the baby elephant suffered) but it does not die, because the immune system is strong.

7. You continue, “But suppose I am HIV. I come to this body (the baby elephant) and I attack and kill the immune system.” At this point, you should touch all but two of the adult elephant volunteers and ask

Activity 1


171

them to sit down. Touch each person (adult elephant) as you remove them, acting as if HIV is killing the immune system. Then say, “Now, will the baby elephant be protected? Will the human body be safe with the immune system gone?”

8. Again tell the lions to attack (touch only) on the word ‘Go!’ The lions are able to easily get to the baby elephant this time! After a while stop all volunteers and thank them.

Summarize the activity by informing how HIV destroys the immune system in the human body. HIV infection makes the infected person easy prey to different infections and in some cases with very poor immunity, such infections are fatal.

Ask someone to tell the group the differences between HIV and AIDS.

HIV AIDS

HIV stands for human immunodeficiency virus (HIV) that causes AIDS. HIV attacks and gradually destroys the body’s immune system that helps it fight off infections and other diseases. This makes people more susceptible to other infections like tuberculosis and diarrhoea

H = Human (only found in humans)

I = Immunodeficiency (weakens the immune system)

V = Virus (a type of germ)

Acquired immune deficiency syndrome (AIDS) is the stage wherein HIV infection has brought the immunity of the body to a very low level, when an infected person becomes susceptible to different minor and serious infections that may also cause death.

A = Acquired (to get something that you are not born with)

I = Immune (the body’s defence system which provides protection from infections)

D = Deficiency (a defect or weakness, lack of something)

S = Syndrome (a group of signs and symptoms constituting a disease)

To be sure participants have understood the effect of HIV infection on a human body, ask the participants, “Does HIV kill a person?” Whether the response is ‘Yes’ or ‘No’ ask why they think so.

Inform the participants that HIV does not kill a person but leads to a condition wherein the body’s immunity becomes extremely low and in such conditions the body is not able to fight any infection. This condition is called AIDS. Tell them that with medication (known as anti-retroviral therapy or ART), good nutrition, physical exercise, healthy lifestyle and a positive attitude one can delay the onset of AIDS.

Activity 2


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Modes of Transmission of HIV and PreventionHIV transmission game

Explain to the participants that they are now going to play a game that will help them to better understand how HIV is transmitted from one person to another. Tell them that for this exercise, they must assume that they live in a community where the HIV virus is present. Prepare slips of paper marked ‘X’ and ‘C’. Ensure that at least 5 per cent of the slips are marked ’X’, 10 per cent are marked ‘C’ and the remaining 85 per cent are blank. You can also consider being a participant in this game as it will reassure the participants and allay their fears.

Place the folded slips in a box or container. Invite the participants to pick up one slip each from the box but not to read it. Invite them to walk around the room and greet their friends or someone they would like to know better. (The participants should be given 3–5 minutes for this; each participant should try to meet as many people as possible and remember whom they have met, ask them their names and shake hands with them.

Stop the activity after a few minutes. Ask everyone to look at his or her slip of paper. Ask all those who have ‘X’ on their slip to come forward to the middle of the room and make a circle. It is assumed that those participants with ‘X’ on their slips are HIV positive. (Make sure that the participants understand that this is only a game and not a reflection of reality.)

Ask the participants who shook hands with these ‘positive people’ (with ‘X’ slip) to come forward. Explain that the handshake here represents having a sexual contact and as these participants have come in contact with those with the ‘X’ slip (people with HIV), they are at risk of being infected with HIV. Once again emphasize that this is a game and HIV does not spread through handshakes.

Now ask those participants with ‘C’ on their slips to come forward. These participants are instructed to sit down. Explain that they represent people who use condoms and hence they are safe as condoms reduce the risk of HIV transmission.

a. Discuss the following points with the participants:

� How many people were originally infected with the virus?

� How many others are now at risk of being infected?

� How many remain uninfected and why?

� What does this tell us about the spread of HIV in our community?

b. Ask the group how they could have avoided infection in this game, other than using condoms. (Possible answers can be as given below. Reinforce the method of prevention.)

� They could have refused to shake hands (abstinence from sex).

� They could have insisted on knowing their partner’s HIV status (HIV testing of partner before getting into a relationship).

Activity 3


173

� They could have only greeted one partner (risk reduction – being faithful).

� Remind the group that they must check the card before being faithful with that partner (testing).

c. Ask the participants for other modes of transmission of HIV.

Transmission of HIV

Modes of transmission

Unprotected vaginal and/or anal sex with an

infected partner

Transfusion of infected blood and blood

products

Use of infected needles, like sharing needles

with infected drug users

From parents living with HIV to their

unborn child

HIV is NOT transmitted through

Hugging Sneezing Being bitten by a mosquito

Shaking hands Using public toilets

Sharing or eating food in same utensils, or using objects handled by people with HIV

Spending time in the same house, school or public place with a person who has HIV.

It is very unlikely that HIV is transmitted during kissing. It could only happen if the partners were bleeding from their gums or had other sores in their mouths.


174

d. Ask the how HIV can be prevented.

HIV can be prevented by

y Correct and consistent use of condoms (male or female or both)

y Being faithful to partner

y Abstinence from sexual intercourse

y Transfusion of uninfected blood and blood products

y Use of disposable syringe

y Not sharing injecting equipment even during drug use

y Preventing parent to child transmission (PPTCT) by registering pregnancy for institutional delivery and PPTCT care and support

e. Ask the participants if they have heard about testing for HIV infection and the treatment available. Explain the testing and treatment with the help of information given below.

Signs and Symptoms of HIV

Generally a person does not know that he or she has HIV without getting tested for it as symptoms of illness post HIV infection will be similar to an infection the person has caught, say diarrhoea or tuberculosis, and one may be misled and continue treatment only for the other infection and not HIV.

Testing HIV Status and Treatment

Any person who has ever been exposed to at least one of the above mentioned four modes of transmission of HIV should contact an Integrated Counselling and Testing Centre (ICTC). The HIV testing is confidential and free treatment is provided if required. The most important part of ICTC is counselling that helps one inculcate healthy practices. There are two kinds of diagnostic tests for HIV:

a. Screening test (enzyme-linked immune sorbent assay – ELISA)

b. Confirmatory test (western blot test)

There is no cure for HIV or AIDS; however treatment helps the affected person manage the infection well so that he/she lives with less risk of other infections. Antiretroviral drugs are the most effective intervention to date in managing HIV infection. These drugs have the potential to dramatically improve the health and extend the lives of many people living with HIV/AIDS.

Window Period

The most frequently used HIV tests detect the presence of antibodies to HIV, not the actual virus itself. A positive HIV antibody test indicates the presence of antibodies to the virus. A negative test result indicates either no antibodies or an undetectable level of antibodies to the virus. It is possible that these tests can miss infection in a person who was recently infected with HIV and has not yet developed enough antibodies to show a positive result.


175

The period of time from infection with HIV till the body has developed detectable antibody levels is called the window period. The window period is approximately three months on an average. A person who feels that he or she may be exposed to infection is encouraged to seek HIV testing. If the test is negative, it needs to be repeated after three months to confirm the result thus taking care of the possible window period (when a person may not test positive even if he/she may be infected with HIV).

Addressing common myths

Refer to Section 11.1 Activity 2 on Myths and Facts and tell the participants that the group will now work together on myths and replace them with facts.

Take out the sheet which was used in Section 11.1 Activity 2. Read out each statement again and ask the participants whether it is a myth or a fact. Add information wherever necessary. You can add some statements and have a discussion. Some statements and responses are as follows:

Statements Response

It is possible to have an STI and not even know about it

Fact

Some STIs have easily recognizable symptoms; others may have no symptoms at all. Not everyone who has an STI has signs and/or symptoms. Sometimes these don’t appear for weeks or months and sometimes they go away, but you can still have the infection and pass it on to someone else.

Having sex with a virgin can cure STIs/HIV

Myth

STIs cannot be cured by having sex with virgin. In fact, it will put the girl at risk of contracting an STI including HIV. Putting a person at risk of STI and HIV by hiding one’s status and not using a condom is violation of the rights of the other person and a serious offence.

HIV can only be prevented by correct use of condom every time one has sex. It is not curable and can be managed with treatment and positive living (that includes good nutrition, physical exercise and healthy lifestyle).

Safe Sexual Practices

Refer to the session on safe sexual practices during the session on adolescent pregnancy. Tell them that with safe practices, though risk of STIs may still be present (for example due to incorrect use or tearing of condom), it is reduced substantially. Some safe sexual practices are given in the box under Section 10.3 Activity 4.

Activity 4

Activity 5


176

A. If possible demonstrate condom use (optional). A condom needs to be used for every sexual contact/intercourse. The male condom is used on the erect penis.

Inform participants that condoms provide triple protection:

1. From unwanted pregnancy

2. From sexually transmitted infections

3. HIV (that has other modes of transmission as well)

B. Ask participants what prevents people from using condoms. If there are some responses, note them on the flip-chart and thank participants. Invite three pairs of volunteers. It is advisable to pair girls together and boys together as the exercise may cause inhibitions.

Give each pair a copy of the list of excuses and options as given below. If possible, provide a copy to all participants. Ask one member of each pair to read the excuse and the other member to read the most appropriate option from the options given in order to counter the excuse. Though appropriateness of the option or answer depends on the situation of the person being pressurized and his/her relation with the partner, a better choice will be the one which is assertive, firm, polite, and nails the excuse appropriately.

This will help participants learn and practice some assertive statements to deal with pressures for unsafe and unprotected sex.

At the end ask participants to share their feedback. Do they think that some of the excuses are used by adolescents as well? If yes, ask them to inform the larger group which the commonly used excuses among adolescents are.

Excuse Option

You think I have a disease. 1. I don’t want either of us to take a chance of getting HIV.

2. Many people infected with HIV have no symptoms at all.

3. Probably neither of us has a disease, but isn’t it better to be sure?

But condoms don’t work. 1. They’re okay if we use them the right way.

2. Condoms may even be fun.

3. I have never had a condom break.

They spoil the mood. 1. It will be okay once we get used to them.

2. Why don’t you try condoms a few times and see?

3. But it would make me feel more relaxed if I felt safe.

Activity 6

Contd...


177

Excuse Option

They don’t feel good. 1. But we know condoms can protect us.

2. I know you don’t like the idea but condoms are so important now.

3. Think about the fun we are going to have and not the condom.

They make me feel cheap and dirty.

1. These days condoms have become a way of life for everyone. you would be surprised how many people use them.

2. you know I care for you and respect you. That is what is important.

3. I want to use condoms because I don’t want you to get pregnant before we both plan for it. Also it will protect both of us from infections.

4. There is nothing cheap and dirty about that.

I’m already using pills for birth control.

1. We have to use condoms as well because the pill doesn’t stop infections.

2. That doesn’t help against HIV and STI.

3. Too bad – no condoms, no sex.

I’d be embarrassed. 1. It won’t be so awkward after the first time.

2. I’ll buy them, so we’ll have them next time.

3. Embarrassment never killed anyone.

They cost too much. 1. When it comes to our health we shouldn’t think about the cost.

2. I can pay for them.

Explain to the participants various reasons for adolescents being more vulnerable to unsafe sexual practices.

Some Reasons for Unsafe Sexual Practices among Adolescents

Ignorance • Thinking that they are not vulnerable to pregnancy or STIs/HIV

• Lack of adequate or accurate information about protection

• Misleading information, like the media giving unrealistic notions of sexuality and usually omitting any mention of protection

Myths vs. Facts • Various myths related to contraceptive methods and their side effects, danger of contraception

• ‘Real men’ do not use contraception

Misconception • May believe that protection is not needed with a regular partner or if the partner looks healthy

Contd...


178

Some Reasons for Unsafe Sexual Practices among Adolescents

Denial attitude • Sex just happened; I wasn’t prepared

• I trust my partner and he/she would not expose me to any risk

• Sex cannot be planned, it has to be spontaneous

• None of my friends use protection, and it does not give satisfaction

Lack of access and availability

• Access to contraceptive services for adolescents is limited by law, custom or clinic/institutional policy

• Availability and cost of different methods may restrict access

• Irregular supply of methods available

• Spontaneous act – contraception not available when needed

• Provider’s attitude towards contraception may restrict availability to adolescents

Coercion • Partner not allowing use of protection

• Boyfriend wants her to get pregnant

• Forced sex

• Family coercion to conceive

Denial /Fear/Embarrassment

• Rejection from partner, peers

• Breach of confidentiality by people who make it available (health care providers, shopkeepers), judgemental attitude of people about adolescent sexual activity

• Fear of using something new – fear of the unknown

• Side effects from the method used

• Fear of keeping the contraceptive method at home, people will know that they are sexually active


179

Key Messages

1. Reproductive tract infections (RTIs) may be caused due to poor personal hygiene or through unprotected

sexual intercourse/contact.

2. RTIs that are transmitted sexually are called sexually transmitted infections or STIs.

3. Personal hygiene is very important to prevent some common RTIs which are not STIs.

4. Not all RTIs are STIs but all/any inflammation in the reproductive tract needs to be treated medically.

5. RTIs may cause lesions on the skin and hence increase risk of getting infected with STIs including HIV if sexual

intercourse takes place without a condom.

6. HIV can be transmitted sexually as well as through use of infected sharp objects like needle or razor, transfusion

of infected blood or from infected pregnant mother to baby in the womb. HIV leads to AIDS in the later stage.

7. The best way to prevent STIs is to adopt safe sexual practices. These involve (i) correct and consistent use of

condoms; (ii) being faithful to partner; and (iii) abstinence from sexual intercourse.

8. One needs to consult the nearest health facility or Adolescent Healthcare Centre (AHC) in case of any discomfort

or inflammation of the reproductive tract.

9. Refrain from sex during treatment of STI. Treatment of partner is equally important.

10. Complete the course of treatment as per the medical advice.


1. To educate peers on RTIs , STIs and HIV and help them understand differences between them.

2. To inform youth (only 14 years and above) about safe sexual practices.

3. To inform peers about HIV, its modes of transmission, consequences and ways of prevention.

4. To educate and convince peers about the importance of seeking medical help in cases of reproductive tract

infection.

5. To encourage compassion and non-discriminatory attitudes and practices towards people living with HIV and

their families.

6. In case of an HIV-positive peer, be sensitive to him/her, maintain confidentiality and help him/her to access

health services and participate in normal social and development activities in the community.

7. To talk to your mentors for support in arranging for condom demonstration if required; providing referral for

STI and HIV testing.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Reproductive Tract and Sexually Transmitted Infections and HIV and AIDS

module VI

responding to violence

183

Session 12Violence against Adolescents

IntroductionViolence against adolescents takes many different forms and the adverse effects of such violence are devastating. Some commonly identified forms of violence against adolescents in India are child/forced marriage, dowry-related harassment and killing, honour killing, accusation of witchcraft, worshipping the child as god or goddess, exorcism, corporal punishment (that includes slapping, hitting, burning etc.), ragging and bullying, forced labour, sexual abuse or forced sex. There are some new emerging forms of violence such as through social networking sites, also known as cyber crime or bullying. Adolescents are at risk for most of them. Much of the violence is perpetrated in the name of tradition, culture, religion or superstition and many stem from incorrect information about the methods of disciplining a child. There is also a huge information gap on the health, development and parenting needs of adolescents among parents themselves and society at large. Often violence like corporal punishment and child labour is condoned by parents and teachers in the name of discipline or poverty. In many cases violence perpetrated in the name of ragging and bullying and is overlooked as part of the process of making friends. The problem becomes even more serious as prevalent social norms create an unequal power relation between an adult and a child. It also prevents children, especially girls, from seeking help and support. Children have to endure serious injuries, mental trauma or even death. Any form of violence against children or adolescents is a criminal offence.

This section discusses violence, different forms of violence and its impact on adolescents.


1. To understand ‘violence’ and different types of violence in the context of adolescents

2. To understand the impact of violence on adolescents and why they are at risk

3. To understand the rights and entitlements of a child and an adolescent

4. To practise life skills to respond to situations of violence

Time:

2 hours

Material:

Photocopies of story and handouts; flip chart; loose sheets of blank paper; marker and sketch pens


184

Methodology:

Brainstorming, group discussion, case studies

12.1 Types of Violence and Identification of Perpetrator and Victim

Write the word ‘VIOLENCE’ at the centre of the board/flip chart and ask the participants to say aloud anything that comes to their mind in relation to that word. Write all the responses around the word ‘VIOLENCE’.

Some of the responses may be beating, hitting, slapping, burning with hot rod or cigarette, keeping children without food, locking in dark places, killing, fighting, rape, riots or murder.

Thank the participants and help the larger group understand the different responses. Inform the group that there are some forms of violence that children are subjected to by adults, often by people who are expected to be their well-wishers. On the flip chart, circle the responses that are or reflect child marriage, child labour, sexual abuse, corporal punishment, bullying and honour killing. Tell the participants that these will be discussed through group work.

Divide the participants into five groups. Give each group a case (given below) to discuss. Ask the group to choose a leader to present the discussions.

Group 1: Rahul, aged 12 years, studies in Class 6. One day after school, Rahul insists that his father take him along to the market. When his father asks him if he has school work to finish, Rahul lies that he doesn’t, thinking that he can complete it after returning. By the time Rahul and his father return from the market, it is quite late and they find that there is no electricity. His mother asks everyone to finish dinner and go to bed as there is not much oil in the lamp. Rahul is unable to ask his mother for the lamp to finish his homework as his father will then know the truth about his homework. As Rahul is tired, he feels he can do his homework in the morning. Next morning, Rahul is again unable to finish his homework and goes to school without it. When the teacher asks all students to submit their homework, Rahul states that he has not done his and the teacher gets very angry, ‘You are a lazy boy and you have no interest in studies. Why are you wasting your father’s money and my time? You should ask your father to put you in some job.’ When Rahul tries to apologize, his teacher hits him on the palm six times with a wooden ruler and makes him stand on the bench. Rahul’s palm is red and burning, he has tears in his eyes.

Activity 1

Activity 2

module VI: responding to violence

185

Discussion Points:

1. Does this story show any kind of violence?

2. Who is the victim and who is the perpetrator?

3. Was Rahul wrong? Why? What should Rahul have done?

4. Was the teacher wrong? Why? What should the teacher have done?

5. If you have to send a message to all elders against such violence, what will you say?

Yes, this is violence and is known as corporal punishment. Any form of physical, verbal or sexual abuse is violence. Rahul is the victim and his teacher is the perpetrator. Rahul may have been wrong in not understanding his responsibility and should have finished his home work, but children tend to make such mistakes. The teacher is wrong for not using positive ways of disciplining Rahul by reasoning with him, making him understand his fault, the importance of time and his responsibility to be a good student by completing his homework on time or perhaps during the games period. Children should be taught through positive disciplinary actions.

The messages to elders against crude disciplinary action may be as follows:

1. Listen to me before passing judgement.

2. Help me understand my fault.

3. Make rules easy for me to understand, learn and practise.

4. Give us only as much as we can handle.

5. Accept that I can’t be the best in everything always.

6. Don’t beat, slap, hit, lock me up or scare me even if I am wrong.

7. Don’t shout at me, it is hazardous to your health as well.

8. Talk gently, be firm and calm when you discipline me.

9. Praise me when I am good.

10. Encourage me to carry out my duties well.


186

Group 2: Sangeeta, aged 15 years, lives with her parents and three younger siblings. Sangeeta’s mother is not well and so Sangeeta has to be at home to look after her mother and siblings. One day, Sangeeta’s aunt comes to meet them and tells her parents that she knows of a very good alliance for Sangeeta. She advises her parents that since their financial condition is not too good and Sangeeta is now a grown up girl, they should get her married this year itself. Sangeeta’s parents are grateful to the aunt and agree to Sangeeta’s marriage.

Discussion Points:

1. Why is Sangeeta not at school?

2. Do you think Sangeeta is enrolled in a school?

3. Is her aunt’s suggestion in the best interest of Sangeeta?

4. Are her parents right to accept the aunt’s proposal?

5. Is it a situation of violence? Who is the victim and who is the perpetrator?

6. What should the parents have said?

7. What should Sangeeta have done?

This is a situation leading to child and forced marriage, which is not only violence but also a crime. Sangeeta is the victim while parents, aunt and our society at large are the perpetrators as they treat a girl child as a burden and paraya dhan. Helping parents and taking care of family is a good thing but it should not take away one’s right to education, to marry after the legal age, to health and well-being and to have a career. Besides, Sangeeta’s marriage will not solve her parents’ problem as she will be at increased risk for child pregnancy, poor health, malnutrition and likely abuse at the husband’s house which will only add to their concern. Parents and Sangeeta should have refused this proposal and tried to explain to the aunt that this is not in anyone’s interest. Also, Sangeeta can seek help from friends, peers, senior members of the community like Mukhiya or Sarpanch to negotiate with parents and if necessary, she can inform the Child Marriage Prohibition Officer or Child Protection Officer.

Group 3: Pakhi is a 13-year-old girl who has been brought to the city by an uncle to work as a housemaid. Where Pakhi works, there are two children almost her age. Pakhi is happy to see the house and the children as she has seen such houses only on television. Pakhi loves watching television and playing with friends near the river in her village. But in the new house, Pakhi has to wake up at 5:00 am and help the lady of the house prepare breakfast and lunch packs for ‘Saheb’ and the children. Then she sweeps and swabs the floor, cleans utensils and helps another maid wash and dry clothes. At times she also has to go to the bus stop to bring the children back from school and carry their heavy school bags. Pakhi at times misses her parents and her friends at the village.


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Discussion Points:

1. Is Pakhi really happy and safe? Why?

2. Was her uncle right in bringing Pakhi to work as a housemaid? Why?

3. Are Pakhi’s parents also responsible for this? Why?

4. Does this story show any kind of violence?


6. What should Pakhi have done?

This is a grave form of violence and a crime as it involves forcing a child into labour and also involves trafficking of children. Many children are trafficked, either with the consent of parents or family members or through deceptive means, making it lucrative for the parents/family. No place is safer than one’s own home and no companionship is more reassuring than that of one’s own parents and childhood friends. Children should not be engaged in any form of labour (domestic or occupational) that is hazardous for their health and keeps them away from education, fun activities, parents and friends. Every year children go missing in huge numbers. They are kidnapped and trafficked for labour, prostitution, entertainment etc. In such cases, the child or a well-wisher should immediately report to police, Child Protection Officer, Panchayat members, NGOs through child helpline numbers or other government service providers (like teachers, ANM didi and doctor).

Group 4: Raju, a 12-year-old, has to be at home all alone after school as his parents return from work only late in the evening. One of his uncles, who lives near Raju’s house, often comes to see if he is okay. One day this uncle walks in when Raju is changing out of his school uniform. The uncle tells Raju that he will help him change and starts pulling Raju towards himself. Raju feels uncomfortable and pushes the uncle aside saying that he can take care of himself. The uncle is angry and threatens to complain to Raju’s father about his behaviour. Raju is scared that his father will beat him.

Discussion Points:

1. Is Raju a good boy?

2. Was his uncle right to help Raju change his dress when he doesn’t need any help?

3. Was Raju right to be curt with his uncle?

4. Is this a situation of violence?


6. Will his parents really punish Raju for his behaviour?

7. What should Raju do?

8. Do girls also face such abusive situations?


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Yes, this is a situation of sexual abuse that can be encountered by both girls and boys. It may happen at home or school or in any public space. It may be caused by close relatives, strangers, people in authority or even peers. No one can touch a child against the will of the child and not at all in a manner that makes the child uncomfortable, especially touching the private parts. Parents and doctors may examine the child’s body for cleanliness or if medical treatment is required. Every child has a right to privacy and a life with dignity. Watching a child when he/she is bathing or dressing, forcing him/her into sexual acts or to look at sexual pictures, or undressing in front of a child are all forms of violence. Raju is a good boy and not guilty of anything, so he should not be scared at all. He can go out of the house till his uncle leaves, run to a neighbour’s house or a place where there are many people or keep the doors closed and not allow anyone to come in without his permission. He should have informed his parents the very first time he felt any kind of discomfort with anybody. Raju should try his best not to confront the perpetrator when he is alone as he may harm him due to fear of being exposed in the community. Parents should help children talk about any discomfort related to their body or private parts so that they do not undergo unnecessary stress and helplessness related to any concern including abuse. If parents are not able to understand Raju, he can talk to the child helpline or peer educators who will help his parents understand the situation.

Group 5: Rizwan and Gaurav are 14-year-olds and have just been admitted to a higher secondary school. They are very excited and decide to go to school together. But on the first day of school, a few boys come to them during recess and tell them that to be in this school they need to keep them happy. They tell them that every student has to follow their commands. They ask them to bow down, holding their ears for 30 minutes. In the meantime they take away their lunch box. After that they use abusive language and some of them even beat and kick them. Rizwan is in tears while Gaurav is red with anger and embarrassment. While they are returning home, some seniors come and tell them that they should not speak about this to anyone and just accept it as a friendly gesture.

Discussion Points:

1. Was this a friendly gesture?

2. Have we ever faced such situations? How have we felt?

3. Were the other boys wrong? How?

4. Is it a situation of violence? Who is the victim and who are the perpetrators?

5. Should Rizwan and Gaurav talk to someone about this?

6. Does this happen to girls as well?

This form of violence is known as bullying or ragging. Rizwan and Gaurav are the victims while the other boys are the perpetrators. The elders, including teachers and parents, who tend to overlook such practices are also perpetrators. It is done by peers at schools, colleges, the playground, canteen or any place where peers meet. A gentle exchange of words can serve as an icebreaker between peers but abusive language,


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hitting, slapping, punishing or any physical, verbal or sexual abuse can never be a friendly gesture. Yes, it happens among girls as well, though it is less common, and still is violence. Adolescents facing bullying go through physical injury, depression, humiliation and social isolation as they stop going to school, playgrounds or any public place where they could meet peers. In some cases, children who are not able to cope with it commit suicide. One should immediately inform elders, especially parents and school authorities, about it.

Group 6: Angabeen, Silvia, Rehana, Senthil, Rashid, Laishram and Gayatri are friends from school and also on a popular social networking site. Each one of them has more than a hundred friends and they boast of their increasing number of online friends. One day Senthil gets a comment on his post ridiculing his favourite political leader. Senthil is very angry and writes back. He is threatened with a beating. This continues for some days. Senthil doesn’t remember this friend but goes to his page and writes more. Angabeen has posted a picture with her other friends (including Senthil, Rashid and Laishram) at a picnic party and tagged Silvia and Gayatri. This post also receives embarrassing comments. They are unable to track these people. They continue hiding the comments from their timeline, but they fear that people might have already read them. The friends are extremely upset and are thinking of closing their account. One day the friends got a message saying, “Hey friends, Surprise!! Don’t be upset. We were just joking – April Fool! Have fun. Let us meet in the park behind the city mall, with your school friends only : )”

Discussion Points:

1. What is the problem? Is it violence? Who is the victim and who is the perpetrator?

2. What is social networking? What are the popular sites? Do you use the internet?

3. Can violence happen on the internet?

4. How can one be careful on the internet so that we have the benefits without the risks?

5. How can we refrain from committing any online crime ourselves?

6. Do you think the friends should go and meet the perpetrators? Or should they close their account?


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The problem in this situation is that the friends are poorly informed and careless in making online friends through social networking site. Yes, it is violence known as cyber crime. The friends are victims while the unknown online friends are perpetrators. There is no need to close the account but one can bar all those one does not know and report their posts, tags etc., as an offence (option available on your own networking site). Yes, violence and crime happen on the internet, phone or any other modern medium. Modern technology if used with care is very valuable but if used carelessly may create huge risks and may endanger life too. However simple steps as listed below can help us prevent such risks:

1. Never give personal information (such as full name, phone number, address, email address, school name etc.) to people you meet online.

2. Be very careful about what you say and post (about yourself or friends in chat rooms or other public places like social networking sites like Facebook). Meeting someone you only met online can be dangerous (Never agree to meet anyone in person alone. Only do so with your parents’ permission; meet in a public place along with friends and/or a trusted adult).

3. Remember that people often lie online about who they are (Angel 14 could be a 48-year-old person).

4. Never respond to nasty, suggestive (sexual solicitations) or rude emails or postings.

5. Be a good online citizen and treat others as you would like to be treated.

6. Even if you are posting a picture that includes other people or friends, take their consent before uploading and tagging them. Not everyone likes their personal pictures to be online.

7. Never give your internet password/s to anyone, not even to your best friend.

8. Never accept emails, instant messages (like on Yahoo Messenger), or open files, pictures, texts from people you do not know.

9. Always tell your parents or someone you trust (if you experience anything that makes you uncomfortable like bad words, offensive pictures, nudity or anything scary).

10. Remember online crime can also be reported to police and the perpetrators can be easily tracked. So do report.

Understanding the Harmful Effects of Violence (You should be aware that this discussion may disturb those who have experienced/witnessed abuse. Tell all the participants that if anyone wants to share his/her personal experience, he/she can share it with you and that it will be kept completely confidential. Also, one should not disclose anything or make fun of anyone based on the discussions during the training.)

Explain to the participants that the purpose of this activity is to talk about violence in our lives and our communities. Now, tape five pieces of chart paper to a wall. On each paper write one of the five categories listed in the table.

Activity 3


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Categories Probable Responses

Violence used against me Bullying by friends, discrimination, punishment in school, eve-teasing etc.

Violence that I use against others Bullying a friend or junior, hitting siblings, hitting friends etc.

Violence that I have witnessed In school by teacher, at home by father hitting mother, discrimination, eve-teasing, online threats, sexual messages etc.

How I feel when I use violence Good, satisfied, angry, bad etc.

How I feel when violence is used against me Bad, frustrated, sad, angry etc.

Signs and symptoms of a child/adolescent going through any kind of violence:

1. Irritability

2. Poor appetite or overeating

3. Insomnia or hypersomnia

4. Low energy or fatigue

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness, self-criticism, self-blame

7. Depression

8. Suicidal thoughts

9. Anger or aggressive behaviour

10. Alcohol/drug abuse

Summarize the activity with the following facts:

1. A child may face violence such as bullying by adults or peers.

2. A child may be a victim or perpetrator of violence, but both ways it is the child who suffers the most affecting his/her health and development seriously.

3. No child should ever be hit, beaten up, slapped, undergo ear/hand twisting, be locked in dark places, discriminated against with respect to access to nutrition, health, education and recreation.

4. It is human to err and this is especially true for children.

5. Children can be disciplined through positive disciplinary actions like reinforcing the benefits of truth, honesty and disciplined life, helping them do their homework, spending time with them and giving them enough time for play and recreation.

6. Both girls as well as boys are at risk of violence, however girls suffer the most.


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7. Child marriage in itself is violence but also leads to increased risk of a number of other violent acts such as forced sex, sexual abuse, dowry-related torture; domestic violence (includes beating, hitting, verbal abuse, forced sex by husband and his family).

8. In any such situation where a child is not comfortable, he/she should call the helpline (give child helpline number) and inform parents, teachers and any adult whom they think is a well-wisher.

9. A responsible adolescent should never engage in a situation where violence is inflicted on anyone. If one feels that one is being forced to be violent, control your anger, keep your cool and try to resolve conflicts through peaceful means.

Key Messages

1. All adolescents, both girls and boys, are vulnerable to violence.

2. Caste, class, religion or regional disparities or situations of civil war and conflict increase the risk of violence.

3. Adolescents with disability or those with different sexual identity are at increased risk.

4. Violence against adolescents can be by an adult or minor, by elders or peers.

5. Violence takes various forms: corporal punishment, child/forced marriage, trafficking, sexual abuse, child

labour and internet-based crime are some common forms of violence against children and adolescents.

6. It is important to raise your voice against any act of violence, even at the first instance.

7. Silence only increases the frequency of violence and is not a solution.

8. Unite to fight violence and impunity for perpetrators.


1. To talk to adolescents between 10–19 years about different forms of violence.

2. To discuss with adolescents their experiences of violence and help them seek help.

3. To inform adolescents about child helplines and other avenues to seek support.

4. To help adolescents who are victims of violence to access first aid in case of injuries, medical and

counselling services.

5. To inform adolescents about various legal provisions protecting them from violence and ensuring justice to

the victim.

6. To educate elders and other community people about supporting girls and women by not stigmatizing them

and taking collective action against perpetrators.

7. To maintain confidentiality and the trust of victims and survivors.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Violence

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Session 13Gender-Based Violence

IntroductionThe term gender-based violence (GBV) is an umbrella term for any harmful act that is perpetrated against a person’s will based on socially ascribed (gender) differences between males and females. While GBV is usually targeted at women and girls, boys and men may also be victims. GBV may occur within a family or in a community and is perpetrated by persons in positions of power, including at times parents, family members, friends, police, guards and armed forces. It can take place in or is condoned by families, communities and institutions including schools, detention centres and religious facilities.

Some of the common forms of GBV in our country are female foeticide, female infanticide, honour killing, child/forced marriage, kidnapping for marriage, domestic violence, eve-teasing, stalking, molestation, rape (forced sex). Gender-based violence affects the survival of the girl child and veers her off the path of health and development like education, recreation, learning vocational skills, earning opportunities etc. The fear of such violence restricts her mobility and her life is controlled by elders, mainly male members in the name of protecting her sexuality, dignity and family honour. The social and health consequences include emotional trauma, neglect, isolation, stigmatization, depression, acute or chronic physical injury, unwanted pregnancy, sexually transmitted infections, HIV/AIDS, emotional and psychological trauma and sometimes death. Survivors of GBV (including rape, sexual exploitation and domestic violence) are at heightened risk of being abused again.

The brutal gang rape and death of a 23-year-old student, Nirbhaya, in Delhi has drawn international attention to the pervasive and extreme nature of GBV in our country. The people of India have demonstrated extraordinary sensitivity, support and activism and have stood with the government to bring justice to Nirbhaya.

This session is in continuation to the Day 1 session on gender identity and gender roles and will inform us more about what forms of violence take place based on the gender of a person, especially in the case of girls and women.


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1. To understand GBV and factors leading to it

2. To learn about forms of GBV

3. To learn how GBV can be prevented and addressed

Time:

150 minutes

Material:

Photocopies of story and handouts; flip chart; loose sheet of blank papers; marker and sketch pens

Methodology:

Brainstorming, group discussion, case studies

13.1 Gender Roles and Associated Risk of Gender-based ViolencePut up the flip chart where the activity on ‘Violence’ was done. Ask the participants to point out forms of violence against at girls and women. Ask them what creates such situations of violence and why.

Note down the responses and discuss them one by one. Tell the participants that much of such violence is rooted in the low status of girls and women in our society. Also there are some gender norms that expect a boy/man and a girl/woman to behave in a particular way. Such expectations create the risk situations for GBV.

Refer to Section 4.3 and discuss how some of the expectations can lead to risky behaviour.

Gender Roles Risk of Gender-based Violence

1. Boys are smarter, know everything

1. May indulge in high-risk activities – sexual initiation at an early age; experimenting with tobacco, alcohol etc., driving motorised vehicles without being fully trained.

2. May give in to peer pressure for alcohol or drugs. Over-consumption of alcohol influences decision making and increases vulnerability to forced or unsafe sex.

3. May engage in eve-teasing and harassing of girls to demonstrate their ‘smartness’.

Contd...


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Gender Roles Risk of Gender-based Violence

2. Girls are innocent, shy and simple

1. May not share their opinion about choice of partner and marriage.

2. May give in to coercion.

3. May fear seeking help or support in situations of coercion and abuse.

4. Shyness or quietness may be misinterpreted by some boys/men as consent .

5. Promotes the misconception that when girls say ‘No’, they mean ‘yes’ – extreme risk.

3. Boys never cry 1. Prevents boys/men from expressing their anguish.

2. May resort to anger and violence to vent their pain.

3. May not be able to seek support even in coercive and abusive situations and continue under stress for a long time.

4. May even resort to substance misuse.

4. Men are brave and successful

1. May feign bravery and courage through unfair means including harassing girls/women.

2. Exercise unnecessary control over sisters, wives and other female members of family and punish them if they protest.

3. Prone to become self-appointed moral police, extremely hazardous for girls and women.

5. Husbands control wives and wives should be submissive to their husbands

1. One of the key reasons behind domestic violence. Women are prone to physical, sexual, mental and verbal harassment by husbands/partners.

2. Prevents women from resisting unreasonable demands of husbands and in-laws.

3. Don’t raise their voice against exploitation and coercion (rape, domestic violence).

4. Have limited or no control over reproductive health and may be vulnerable to unwanted pregnancy, sexually transmitted infections like HIV.

6. Boys/men work hard and so need comfort

1. Household chores by women are not recognized as hard work.

2. Forced sex by husband and others.

7. Daughters represent family honour

1. Son preference and bias; female foeticide and infanticide.

2. Girl child faces discrimination in nutrition, education, recreation and other opportunities for health and development.

3. Undue restriction on girl child in the name of family honour and at times killed.

4. Early marriage to transfer related responsibility to her husband and in-laws.

5. Sexuality of a female is controlled by men – father, brother, husband or son.


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13.2 Reducing Risks of Gender-based Violence among Adolescent Girls

Divide the participants into six groups. Ask each group to prepare a role play based on the case given to them. Tell them that they will all get a chance to be part of the group act.

Group 1:Rehana is a 15-year-old girl studying in Class 9. She loves going to school and is a very bright student. Rehana is friendly with all the boys and girls in her class. One day, one of the boys approaches Rehana and tells her that he likes her. Rehana ignores him. He continues to harass Rehana in different ways – stalking her on her way home, passing comments about her, leaving notes in her notebook, writing her name on the blackboard with love messages, sending messages through her friends. One day a teacher finds a note lying on the floor and reads the message. The teacher scolds Rehana in front of the class and tells her to bring her parents to school the next morning.

Rehana is very scared to tell her parents about this and ask them to come to the school. She has stopped going to school and is thinking of discontinuing her studies

Group 2:Radha, an 18-year-old girl, is married to Dharmendra. Radha had to leave her school when she got married but was assured that she could continue her studies from her in-laws’ place. However, when Radha requests her husband and in-laws to allow her to take admission in school, they refuse. They tell her that if she goes to school there will be no one to take care of the household work since her mother-in-law is not keeping well.

Group 3:Radha tries her best to keep her husband and in-laws happy, but she never gets any appreciation for her hard work. In fact she is made to work from early morning till late in the evening. She eats only after everyone else has finished eating. She is also beaten up for one reason or another by Dharmendra and her in-laws do not protect her. Last evening, when Dharmendra came late and Radha took a while to open the door, Dharmendra thrashed her with a cane. Radha has bruises all over her body. Radha is crying and cursing her fate.

Group 4:Lily and Vishal are in love. All the boys of her college know that. One day when she is having her tiffin, two boys come to her and throw her a chit saying, “We will wait for you”. Lily is afraid that they will tell her family about her affair with Vishal. What should Lily do?

Activity 1


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Group 5:Sofia is a very beautiful girl. All the boys want to be friends with her. Shishir is Sofia’s classmate. One day some boys plan to tease Sofia after tuition classes. Shishir opposes this and says that they should be ashamed to think of doing such a thing. The boys make fun of Shishir and say that he is not a ‘man’. Shishir sees Sofia coming and his friends moving towards her. What should he do? What should Sofia do?

Group 6:Ragini and Lalit are siblings. Few months ago a distant uncle had visited their house and stayed for some days. Ragini and Lalit don’t like this uncle as he tries to touch them in a way that makes them uncomfortable. The siblings have shared their dislike for this uncle with each other. One day their father informs them that the uncle will be visiting them again as he has some work in the town. Ragini and Lalit do not want the uncle to come home but don’t know how to convey their feelings to their father.

Invite the groups to enact the roles. Inform the participants that this is an activity in which all of them have an opportunity to act. First they need to identify the problem and the victim. The rule is that if anyone feels that the victim is not able to properly safeguard herself, then he/she can say ‘STOP’ or ‘FREEZE’ and replace the victim. Then demonstrate the way he/she would like to deal with such a situation. This can continue till some interesting ways of dealing with such situations come from the participants. Discuss the positives and negatives of each suggested way to help the participants identify smart, assertive and safe ways of dealing with such risky situations.

Discussion

The stories of Rehana and others are not uncommon in our society. Gender-based violence has serious repercussions on a girl’s life and future. Often, girls are forced to discontinue their education, forced into early marriages and are treated unfairly by parents, husband and in-laws. In the case of Rehana, in spite of the fact that it was not her fault she was scolded and blamed by her teacher. Unfair gender norms hold girls responsible for any act of violence that is committed against them. Men are rarely criticized. Rehana knew that if her parents or other people in the society got to know about the incident they would also have a judgmental attitude towards her and would question her character. The situation is similar for victims in the other stories who fear being stigmatized if they complain against the perpetrator. Radha too is suffering unnecessarily. Violence by husband and in-laws is called ‘domestic violence’. The Protection of Women from Domestic Violence Act, 2005 protects women against such violence but there are very few women who ever complain against their husband or in-laws as victims are further victimized due to associated stigma and discrimination.

Tell participants that domestic violence is so rooted in our tradition and culture that people refrain from reporting it to the police. Also, sometimes the police or those who need to protect us do not treat it as violence and the complainant is further victimized. However, not reporting violence is extremely dangerous for the victim as the violence will only increase and cause long-term harm to the victim.


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Tell the participants that often such violence can be prevented by acting on time. As adolescents, they need to learn to say ‘No’, communicate their thoughts and feelings assertively and not give in to any kind of force, pressure or threat. It is always better to share secrets with family and trusted friends rather than give in to blackmail.

Read out the case given below and conduct a discussion.

Group 4: Nirbhaya and her boyfriend are returning from the cinema and take a bus home. The two never think that the other people in the bus are not actually passengers but a group of ruffians on the lookout for easy prey to loot and abuse. Suddenly a few of them start passing indecent comments about Nirbhaya. When she and her boyfriend protest, they become violent. The two of them are brutally assaulted and Nirbhaya is raped by the men on the moving bus. No one hears their cries for help. Later they are thrown out of the bus.

Badly wounded, Nirbhaya and her friend are spotted by some local people and police and taken to the hospital. The police catch the men who committed this crime and they are put behind bars. The court has awarded the death sentence to all the accused except for one who is below 18 years, who will be in the custody of the juvenile home. Today Nirbhaya is no more but the courage shown by her, her friend, her parents and the whole nation will guide India to empower girls and women and make spaces (private or public) safe for them to live with high self-esteem and dignity.

Discussion Points:

1. Have you heard of Nirbhaya’s case in Delhi in 2012?

2. Who is the victim and who are the perpetrators?

3. Who else is responsible for such incidents? How?

4. Are public spaces safe for girls and women? Why?

5. Who makes public and private spaces unsafe for girls and women?

6. Do girls and women have the right to live with respect and dignity? Does a girl/woman have the right to engage in recreation, sports and fun activities?

7. Is it wrong for a girl or woman to aspire to make a place for herself in the society? Is she wrong to come out of her house to contribute to the nation’s growth and development?

8. Why did these men behave the way they did? Do you think that the expected role of men in a society has some influence on the behaviour of men who commit such crimes?

9. How we can make our home, community and public spaces like buses, trains, cinema halls, markets, schools, colleges etc., safe for our girls and women?

10. It is good to protest against and report all cases of violence against women. Comment.

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Discussion

Nirbhaya, also known as Jyoti, was gang-raped on a moving bus in December 2012 at Delhi. Besides the ruffians in the bus, we and our system are also responsible for this incident or any such violence against women in our community. We promote unequal norms in the society by not raising our voice against them. While our silence makes a girl helpless, it gives the wrong signal to a boy about his strength that is often used to violate the rights of girls and women. ‘Masculinity’ in our society is perceived more as physical power and strength which some boys and men take pride in demonstrating on weaker persons. They also have the wrong perception about women – that they are weak and should be confined to their houses. But in many instances, even if we witness any such violence or discrimination against girls, we prefer to remain quiet which is wrong. Our boys and men need to learn to respect the rights of girls/women. They have the same rights as any male member of the society.

Yes, it is our responsibility to raise our voice against any form of violence and report it (including sexual abuse and rape) to the authorities. It is not the victim who should feel guilt and shame, it is the perpetrators and their families who should have to hide. The courage shown by Nirbhaya, her friend and her parents is proof of the strength of a girl and her family. We can help a victim/survivor of such violence by being sensitive and empathetic, providing care and support and helping them return to the path of health and development at the earliest possible.

Give the participants a photocopy of the cases given below. Tell them to discuss the cases among themselves after the training and ask for clarifications if required.

The father of a 17-year-old girl tells her that he has fixed her marriage. The girl has no choice but to agree.

14-year-old Reema is asked to leave school and stay at home. This way she can take care of her younger siblings while her parents are away at work. Reema doesn’t want to give up her studies and requests her parents to allow her to continue. Her parents agree on the condition that she completes all the household chores before leaving for school and takes care of the home, her siblings and the cooking after returning from school.

Rano is scared to learn that one of her uncles is coming to their house and will be staying for a week. She doesn’t like this uncle. A few months back, he had forcibly had sex with her and told her that she should not tell anyone, not even her parents, as this was their personal secret. Rano didn’t like it but was scared to tell her parents fearing their anger. Also, this is a matter of family honour. When this uncle left, Rano thought she was safe and tried to forget the incident. Now that he is coming again, Rano is scared and wishes she could hide somehow.

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Seventeen-year-old Gudiya lives in a small town with her husband and in-laws. A year ago her parents married her off to Kunal, a 19-year-old shop owner. Gudiya is now three months pregnant and does not feel comfortable. Kunal wants to take her to the doctor. He asks his mother about it and she says that this is normal and that Gudiya should work hard as it will help the baby be active. She also tells Gudiya to eat less as it will make the pregnancy more comfortable. Gudiya follows her mother-in-law’s advice.

Discussion Points:

1. Who are the victims and who are the perpetrators?

2. Do these situations reflect some form of discrimination or violence? How?

3. Why do girls or any adolescent fear raising their voice against violence?

4. Are parents and elders always understanding and supportive if informed?

5. How can the victims be informed that they are being violated?

6. Who should be scared and feel guilty?

7. Is silence a solution to violence?

8. Is a girl victim a blot on the family honour?

9. What are the different ways to deal with such situations?

10. How can parents, siblings, friends and society help a survivor of violence return to the normal course of health and development?

13.3 Seeking Institutional Support

Ask the participants to remain in their respective groups and discuss and prepare an inventory of all persons in the community or in authority who can be approached for intervention and help in cases of GBV. Once they have completed the task, ask them to present what they have discussed. Discuss each presentation, providing inputs on key government authorities responsible for action on cases of GBV. It would be good to invite the local Child Protection Officer, Child Marriage Prohibition Officer or representative from the police/local thana to talk to the participants.

Tell the participants that as such violence is rooted in our tradition and culture, people refrain from reporting it to the police. Also, sometimes the police or those who need to protect us do not treat it as violence and the complainant is further victimized. However, not reporting violence is extremely dangerous for the victim and will only increase violence and cause long-term harm to the victim.

Activity 1


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Help the participants improve their list by giving the names of persons in the departments of Health (ANM, ASHA, doctors), Panchayati Raj (PRI members, Mukhiya, Sarpanch) and Education (teachers), NGO workers and the local police station who can be approached. Inform them about Child Protection, Child Probation and Child Marriage Prohibition Officers available in their blocks and districts. Also inform them about helpline numbers (child helpline, domestic violence helpline), if any.

Refer to various legal provisions to protect women from violence and bring justice in case of violence. Highlight the following as the right of every victim or complainant of GBV (to be arranged and provided by the police):

y Free legal aid

y Right to privacy while recording statement: Under section 164 of the Criminal Procedure Code, a woman who has been raped can record her statement before the district magistrate when the case is under trial, and no one else needs to be present. Alternatively, she can record the statement with only one police officer and woman constable in a convenient place that is not crowded and does not provide any possibility of the statement being overheard by a fourth person.

y Time does not matter: The police cannot refuse to register an FIR even if a considerable period of time has elapsed since the incident.

y Email to the rescue: If, for some reason, a woman cannot go to the police station, she can send a written complaint through an email or registered post addressed to a senior police officer of the level of Deputy Commissioner or Commissioner of Police.

y Cops cannot say ‘No’: A rape victim can register her complaint at any police station under the Zero FIR ruling by Supreme Court.

y No arrests after sunset: According to a Supreme Court ruling, a woman cannot be arrested after sunset and before sunrise.

y You cannot be called to the police station: Women cannot be called to the police station for interrogation under Section 160 of the Criminal Procedure Code. This law provides Indian women the right to not be physically present at the police station for interrogation. The police can interrogate a woman at her residence in the presence of a woman constable and family members or friends.

y Protect your identity: Under no circumstances can the identity of a rape victim be revealed. Neither the police nor the media can make the name of the victim public. Section 228A of the Indian Penal Code makes the disclosure of a victim’s identity a punishable offence.

y The doctor cannot decide: A case of rape cannot be dismissed even if the doctor says rape has/had not taken place. A victim of rape needs to be medically examined as per Section 164A of the Criminal Procedure Code, and only the report can be taken as proof.

A few helplines for women in distress:

Women’s Helpline:1091

Central Social Welfare Board/ Police Helpline: 1091/1291

Child Helpline: 1098


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Key Messages

1. Gender-based violence is a serious violation of women’s human rights.

2. Break the silence: Keeping the violence and the abuse a secret does not protect any one from being abused,

the abuse is more likely to continue.

3. When we treat GBV as a private issue, we allow it to continue.

4. GBV is not a sign of discipline and love; it is a sign of domination and control.

5. Balancing power does not mean losing power because power does not come in limited supply. It is not a

quantity, it is a feeling.

6. Victims of GBV need to be taken immediately to nearest medical/health centre for first aid, treatment and

counselling support. Most of the health centres have good referral contacts to ensure legal aid, care and

support to the victim/survivor.


1. To talk to adolescents between 10–19 years about GBV.

2. To discuss how boys can help reduce violence against women within the family as well as in the community.

3. To inform adolescents about the rights and entitlements of women and various legal provisions.


5. To help adolescents who are victims of violence access first aid in case of injuries, medical and

counselling services.

6. To educate elders and other community members on supporting girls and women by not stigmatizing them

and instead taking collective action against perpetrators.

7. To maintain the confidentiality and trust of victims and survivors.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Gender-based Violence

module VII

my rights and entitlements

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Session 14Child and Adolescent Rights

IntroductionAll human rights are applicable to adolescents (10–19 years) as to any adult. The Constitution of India has special provisions to ensure survival, protection, development, health and happiness of its children. In addition, our Constitution grants all the states positive discrimination in favour of girls and women. We also have a National Committee for the Protection of Children’s Rights (NCPCR), an independent body to take measures to protect the rights of children across the country. The Government of India has ratified the Convention on Rights of a Child (CRC) of United Nations, which means that the Central and State Governments are committed to ensure the rights of children as stated in the CRC. In addition, our country is also a signatory to the Convention on Elimination of All Forms of Discrimination against Women, CEDAW.

Some of the rights have to do with basic physical needs to grow and be healthy. For example, one has the right to food, water, shelter and basic health care. Some of the rights have to do with how other people treat us – with dignity and respect – while some have to do with our need to be cared for, to grow and develop and be a part of a community. An adolescent has the right to education, to express his/her ideas and opinions, to access information and to participate in making decisions about issues that affect him/her. He/she also has the right to be protected from all forms of violence and discrimination (irrespective of class, caste, religion, region, sex, gender identity, sexual orientation, sex or age). In this session, we learn more about the rights and entitlements of adolescents.


1. To build awareness of the rights of a child and an adolescent

2. To understand why it is important to know our rights and entitlements

3. To learn about various rights and entitlements enjoyed by children in India

4. To learn about various legal provisions, programmes and schemes that extend protection to rights of children and adolescents

Time:

40 minutes


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Material:

Chart papers; flip chart; sketch and marker pens; slide projector

Methodology:

Brainstorming, group discussion, case studies, PowerPoint slides

14.1 Understanding Rights and Entitlements

Divide the participants into three groups. Tell them briefly about Aladdin’s magic lamp. Tell them that each of the groups has found a magic lamp and each participant is allowed to ask for two or three wishes that will be fulfilled. Ask the participants to prepare a list including every member’s wish and present it to the larger group. Some of the responses may be as under:

1. A good house

2. Life with parents

3. Chocolates and cola

4. No beating at all

5. Meeting with celebrity of their choice

6. Job that pays well

7. Three meals a day

8. Higher education

9. Become a famous person

10. Disease-free life

Go through the lists one by one and help the participants understand what in their wish list is a right that they are entitled to as citizens of India, such as education, nutrition, a life free of abuse of any kind, learning and earning opportunities, health information and services.

Inform the participants that ‘The Indian Constitution accords rights to children as citizens of the country and acknowledges their special status. Recognizing that children are especially vulnerable and need urgent attention and protection in childhood which is time-bound (as children outgrow childhood), the Constitution includes some special provisions and laws for children’.

Six Fundamental Rights (as per the Constitution of India)

y The right to equality

y The right to freedom

y The right to freedom from exploitation

y The right to freedom of religion

y Cultural and educational rights

y The right to constitutional remedies

Activity 1

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14.2 Rights of a Child and an Adolescent (Optional)

With the help of a PowerPoint presentation, inform the participants about the Constitutional Rights (as per the Constitution of India) of all children and adolescents.

SLIDE 1

Clauses under The Constitution of India protecting the rights of a child: y Article 14: Guarantees equality before law and equal protection of laws to every citizen y Article 15: Provides the right against discrimination on grounds of race, caste, sex, place of birth or residence y Article 15(3): Special provisions for girl children y Article 21: Ensures all citizens right to personal liberty and due process of law y Article 23: Provides protection from trafficking and bonded labour y Article 29: Interest of minorities y Article 46: Deals with rights of weaker sections to be protected from social injustice and all forms of exploitation

(SC, ST, OBC, gender, lower economic strata, minorities) y Article 46: Promotion of educational interests of weaker sections y Article 47: Raising level of nutrition and standard of living of its people and the improvement of public health.

Special Child Rights under the Indian Constitution y Article 21A: Right to free and compulsory elementary education for all children 6–14 years y Article 24: Protection from any hazardous employment up to age 14 y Article 39(e): Protection from abuse and being forced by economic necessity to enter any occupation

unsuited to their age or strength y Article 39(f): Right to equal opportunities and facilities to develop in a healthy manner and in conditions of

freedom and dignity and guaranteed protection of children and youth against moral and material abandonment

Ask the participants if they know about child rights and United Nations Convention on the Rights of the Child (UNCRC). Inform them that the CRC is an international resolution proposed by the United Nations (a platform where all countries discuss their international and national level concerns and look for solutions) and the Government of India is a signatory to the convention. This means that the Government of India is committed to ensuring these rights to children.

According to the UNCRC, child rights are minimum entitlements and freedoms that should be afforded to all persons below the age of 18 regardless of race, colour, gender, language, religion, opinions, origins, wealth, birth status or ability and therefore apply to all people everywhere. One right cannot be fulfilled at the expense of another right. There are four broad classifications of these rights. These four categories cover all the civil, political, social, economic and cultural rights of every child.

Activity 1

Activity 2


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Convention on the Rights of the Child

Right to Survival: A child’s right to survival begins before it is born. According to the Government of India, a child’s life begins 20 weeks after conception. Hence the right to survival is inclusive of the child’s right to be born, right to minimum standards of food, shelter and clothing and the right to live with dignity.

Right to Protection: A child has the right to be protected from neglect, exploitation and abuse at home and elsewhere.

Right to Participation: A child has a right to participate in any decision making that involves him/her directly or indirectly. There are varying degrees of participation as per the age and maturity of the child.

Right to Development: Children have the right to all forms of development: emotional, mental and physical. Emotional development is fulfilled by proper care and love of a support system, mental development through education and learning and physical development through recreation, play and nutrition.

Divide the participants into two groups and provide each group with a case study as given below.

Group 1: Sona is a 17-year-old hard-working girl. She works at a shop in the town as a helper and helps her family. For the last few days, she has been feeling nauseous and dizzy. Sona shares this with a co-worker who asks her if she has had her period on time. She replies that she has missed her period for the last few months but she didn’t worry much as her periods are often irregular. The lady tells Sona that she should immediately see a doctor and not tell anyone else about this. Sona is scared. The next day after work the lady takes Sona to a nearby lady doctor’s clinic where the doctor examines her. The doctor is harsh with Sona and asks her if she is married. On learning that Sona is unmarried, the doctor loses her cool and says something to the nurse and another helper present there. She asks Sona since when she has missed her period, but Sona doesn’t remember the exact month. The doctor confirms that Sona is pregnant and that she needs to conduct an ultrasound to assess the stage of pregnancy. Sona is crying all through and pleads with the lady and the doctor to help her. With the help of the lady she calls a man who had promised marriage to her but the man denies any such promise and says he is not responsible for this pregnancy and that she should not call him again. Sona and her co-worker continue trying his number but it is switched off.

The next day, when Sona reaches the clinic, the doctor informs her that if she has to conduct an abortion, Sona has to bring her parents along and Rs. 20,000 in cash. She says that it will be done in another place and no one else will come to know about it.

Activity 3


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Discussion Points:

1. Do you think that there is violence happening in this situation? If yes, who is the victim and who is the perpetrator?

2. Was the lady right in taking Sona to the doctor?

3. Was the doctor’s behaviour ‘friendly’? Why?

4. Was the doctor charging too much for her service? Why?

5. Does Sona have other options for an abortion?

Group 2: Mohsin, 16 years, and Sunder, 17 years, are friends. They are often together and spend a lot of time with some other older men in the community. One day Sunder complains of mild flu and discomfort during urination. Mohsin confirms that he is also not well and is having some discharge from his penis. The boys are very uncomfortable and don’t know whom to talk to. But when the symptoms become really painful, they visit the local health centre. When they reach, there are a number of patients walking in and out of the doctor’s cabin. The male attendant in the waiting area asks them about their problem. The boys just say that they need to see the doctor. The male attendant keeps insisting that they tell him why they need to see the doctor and then gives each of them a waiting number. After two hours, Mohsin’s turn comes and he goes in to see the doctor. Since the doctor is tired, he calls in a few more patients so that he can clear the crowd quickly. The doctor keeps asking Mohsin about his problem, but Mohsin is embarrassed to tell him the truth in front of other people and instead tells him that he has fever. The doctor gives him medicine for the fever and suggests rest. When Sunder goes inside, he tells the doctor that he is having some pain during urination. The doctor looks at him and asks him to tell him everything in detail. Other patients also start looking at Sunder. Sunder cannot say a word. The doctor asks him to hurry as he has many more patients to attend to. Sunder is shaken.

Discussion Points:

1. Do you think that there is a violation of rights happening in this situation? If yes, who is the victim and who is the perpetrator?

2. What might Mohsin and Sunder be suffering from?

3. Were Mohsin and Sunder right in consulting a doctor?

4. Is it right for the male attendant to ask too many questions?

5. Was the doctor’s behaviour ‘friendly’? Why?

6. Do you think the doctor should have showed a little more patience with the boys?

7. If you were a doctor, how you would have dealt with Mohsin and Sunder?


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Inform the participants about the sexual and reproductive rights of adolescents with the help of the following slides:

SLIDE 2

The following sexual and reproductive rights are based on rights that are grounded in core international human rights instruments and other international conventions and charters.

1. The right to life

2. The right to liberty and security of the person

3. The right to equality, and to be free from all forms of discrimination

4. The right to privacy

5. The right to freedom of thought

6. The right to information and education

7. The right to choose whether or not to marry and to found and plan a family, and to decide whether or not, how and when, to have children

8. The right to health care and health protection

9. The right to benefits of scientific progress

10. The right to freedom of assembly and political participation

11. The right to be free from all torture and ill treatment

SLIDE 3

Rights of adolescents infected with or affected by HIV1. People living with HIV are entitled to all human rights.

2. Children infected with or affected by HIV are entitled to all human rights and rights assured under CRC.

3. They have the right to live without discrimination of any kind.


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Summarize the activities with the following:

1. Like any other right, adolescents also enjoy sexual and reproductive health rights.

2. These rights are reflected in international charters and conventions and have been ratified by the Government of India.

3. To ensure these rights to adolescents, the Government of India has introduced a special programme called Rashtriya Kishor Swasthya Karyakram (RKSK) and the participants are all important links in this programme.

4. The key features of the (RKSK) are as follows:

� Separate health centre or room in the existing clinic for adolescents with separate waiting area

� Separate timing for boys and girls; timing convenient for adolescents

� Dedicated doctor for the adolescent health centre

� Privacy to adolescents when sharing their concerns with the doctor

� Confidentiality of the concerns or condition of the adolescent client

� Doctors and other staff not to discriminate, judge adolescents on basis of the act that caused the medical condition

� Doctors and other staff to be gentle while talking to adolescents and avoid using harsh words

� Doctors and staff to be sensitive to adolescents and their mental condition at the time

� Help them with positive actions

� Provide counselling to help them deal with the situation and take precautions to prevent them in future

14.3 Laws that Protect RightsAsk the participants to speak of any legal provision, programme or scheme they know that protects these rights of children. Write down the responses.

Summarize the activity by talking about the following:

1. Laws to Ensure Protection of Child Rights

y Right of Children to Free and Compulsory Education Act, 2009 (provides for free and compulsory education up to 14 years of age)

y Prohibition of Child Marriage Act, 2006

y The Child Labour (Prohibition and Regulation) Act, 1986

y The Juvenile Justice (Care and Protection of Children) Act, 2000

y The Immoral Traffic (Prevention) Act, 1956

y Protection of Women from Domestic Violence Act, 2005

y The Protection of Children from Sexual Offences Act, 2012

y The Young Persons (Harmful Publications) Act, 1956

y The Commissions for Protection of Child Rights Act, 2005

y The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995

y Decriminalization of same sex relation (Article 377)

y Food Security Bill


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2. National Policies, Programmes and Strategies on Protection of Child Rights

y National Youth Policy, 2000

y National Population Policy, 2003

y National Plan of Action on Children, 2005

y National Strategy and Plan of Action on Child Marriage, 2013

3. National Programmes and Schemes to Realize Child Rights

y Sarva Shiksha Abhiyan (universal access to primary education)

y Integrated Child Protection Scheme

y Integrated Child Development Services

y Rajiv Gandhi Adolescent Girls Empowerment Scheme, SABLA

y Rashtriya Kishor Swasthya Karyakram (with focus on sexual and reproductive health and rights of adolescents)

y Mahatma Gandhi National Rozgar Guarantee Scheme(also known as Mahatma Gandhi National Rural Employment Guarantee Scheme – MGNREGS) for parents and adolescents above 18 years

Other schemes available in the state and district may be added.

4. Committees, Bodies and Key Persons to Ensure Child Protection

y National and State Human Rights Commissions

y National Commission for Protection of Child Rights (NCPCR)

y State Child Rights Committees

y Elected members from district and Panchayat

y District Magistrate

y Child Marriage Prohibition Officer

y Child Protection Officer

y Teachers

y Doctors

y Parents

y All adults

Reiterate that the primary responsibility for the care and upbringing of children remains that of the parents, with the community and the larger society also having their respective obligations towards them.


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Key Messages

1. All human rights are applicable to all children, including children of India.

2. Our government and commissions on human rights and child rights are accountable for violation of rights

of children.

3. In spite of all efforts, many children and adolescents are devoid of even the basic rights due to extreme poverty,

gender, caste or religion.

4. Discrimination and violence against a child due to his/her caste, religion, region, disability or sexual orientation

is violation of rights.

5. Children have right to voice their opinion and those above 18 years have the right to vote and can fight

elections after 21 years of age.

6. With all basic rights of survival, an adolescent has the right to compulsory education upto 14 years, right to

delay marriage, right to information, counselling and service on sexual and reproductive health concerns.


1. To talk to adolescents between 10–19 years and make them understand what are rights and entitlements.

2. To inform adolescents about rights and entitlements.

3. To inform adolescents about various legal provisions, national and state programmes and schemes to protect

their rights.

4. To build the capacity of adolescents to raise their voice and demand realization of their rights.


6. To be vigilant and identify adolescents whose rights are being violated.

7. To promote the rights of children through awareness campaigns involving adolescents from the community,

keys persons in community and government and non-government workers.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to Rights and Entitlements

module VIII

health and environment

217

Session 15Community Sanitation and Hygiene

IntroductionPoor community hygiene and environmental conditions are important causes of illness in our country. Waste disposal in houses and in communities is inappropriate while stagnant water and open potholes become breeding grounds for mosquitoes causing malaria and dengue. Sanitation coverage is very low and there is widespread open defecation. Our soil, water and air are getting contaminated every day. Availability of safe drinking water is still a challenge. Factory waste is let out into rivers without being treated. Smoke from factories and vehicles has raised the levels of harmful pollutants in the air. Bronchial asthma and other respiratory conditions are on the rise among children and young people. Our agricultural produce is exposed to chemicals in the form of pesticides and fertilizers beyond permissible limits to meet market demands. Cattle are treated with harmful drugs to increase milk production. In addition, many human activities like encroaching into green areas are leaving fewer trees to absorb carbon dioxide exhaled by us.

Healthy living demands action to maintaining community hygiene and a pollution-free environment. We receive a lot from nature and it is time that we give back to Mother Nature in our own small ways. Each one can contribute towards maintaining community hygiene and sanitation reducing activities that pollute our water, soil and air. This session attempts to illustrate the connection between health and environment.


1. To understand the significance of community hygiene and waste disposal

2. To learn ways in which community hygiene can be maintained

3. To understand the impact of global warming and climate change on health

4. To learn how an individual can contribute to reducing the pace of climate change

Time:

30 minutes

Material:


Methodology:



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15.1 Community Hygiene and Waste Disposal

Divide the participants into three groups and name them ‘Water’, ‘Air’ and ‘Soil’. Tell each group that it has to act as per the name given to it. Ask each group to discuss its importance for a healthy life within the group and make a list. Also, each group should prepare a detailed list of reasons for its contamination and its effect on human life. The group work would look somewhat like this:

Group 1: Water

Water is important because…

Water is being contaminated by…

Stagnant water or consump-tion of contaminated water will lead to…

Our body needs water to survive.

It quenches our thirst.

We need water to bathe.

We need water for cooking food.

We need water to rear fish.

Human and animal faeces; bodies

Dumping of solid wastes including glass, plastic and aluminium

Household waste dumped in open water bodies

Hospital waste

Industrial Waste (contains pollutants like asbestos, lead, mercury and petrochemicals)

Breeding ground for mosquitoes

Infections like malaria and dengue

Diarrhoea, jaundice, typhoid

High toxic content in agricultural crops and fish consumed by human beings

Group 2: Air

Air is important because… Air is being contaminated by…

Breathing polluted air will lead to…

We need fresh air to breathe.

Without air no life can survive.

Without fresh air, we will choke.

We need air to make fire for cooking and other work.

Cutting down of trees, hence fewer trees to absorb carbon dioxide

Emission of harmful gas from factories; comfort amenities like air conditioners, refrigerators etc.

Example: Bhopal tragedy

Bronchial asthma

Acute respiratory disorders

Tuberculosis, pneumonia – more due to coughing by infected person without covering mouth (for example, with a handkerchief) or improper sputum disposal.

Activity 1

Contd...

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Air is important because… Air is being contaminated by…

Breathing polluted air will lead to…

Smoke due to crackers; burning fossil fuels like wood, coal, oil; burning plastics etc. Smog keeps the pollutants trapped in lower atmosphere

Vehicles unchecked for pollution

Cement industries

By virus and bacteria through coughing of infected person (without covering mouth with cloth) or spitting

This leaves the virus and bacteria in the air.

Group 3: Soil

Soil is important… Soil is being contaminated by…

Contaminated soil will lead to…

To grow our crops and vegetables

To grow trees and plants

To construct buildings

Human and animal faeces

Use of fertilizers beyond permissible limits

Pesticides and other chemicals through factory waste

Frequent crops preventing soil from recovering its nutrient value

Household waste that is non-biodegradable and those like menstrual cloths and pads

Hospital waste

Skin problems, may even result in cancer

Severe health conditions due to exposure to chemicals and toxic waste

Vegetables, fruits and crops with high levels of harmful chemicals

Poor yield and nutrient value of agricultural products

Some vegetables like spinach have high levels of chemical deposit that do not go even after washing and cooking

Once the groups have prepared their charts, ask each group to stand facing another one. Now ask each group leader to present the group’s work. Add wherever required to make the list comprehensive and ensure that the participants are able to recognize the effects of poor sanitation, waste disposal and environment-polluting activities resulting in infections and diseases. Once all three groups have presented, thank the participants.


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Explain to the participants that it is very important to maintain sanitation (both at personal and community levels) in order to avoid risk of various diseases like diarrhoea, malaria and dengue. Drinking impure water can cause diarrhoea, dysentery, typhoid and hepatitis. Similarly, improper sewage and garbage disposal can lead to the spread of contagious diseases through rats, mosquitoes, flies, cockroaches and stray dogs. Also, apart from sanitation, there are other human activities (like cutting trees and burning fossil fuels) that cause more than 80 per cent of environmental pollution and climate change. It is equally important to educate people about how certain activities pollute the environment and contribute to climate change and how this can be addressed.

Ask the participants to regroup into three new groups. Give each group a case study to discuss. After 10 minutes, ask the groups to present their response.

Case Study 1:

Sona and Shefali are 17-year-old girls. They are embarrassed that they have to defecate in the open. They hear about sanitary latrines from the ANM and talk to their parents about building one in their home. But their parents refuse saying, “We cannot have a latrine inside the house. It is against our culture.” The girls are very disappointed and don’t know what to do.

Discussion Points:

1. Why do you think Sona and Shefali are disappointed?

2. Is it possible to convince their parents?

3. What will you do to sort out this problem?

Case Study 2:

Seema is the 24-year-old mother of two children. The older one is 4 years old and the younger one is 1½ years old. Seema finds it very difficult to manage the children and household work. Since the children are young, they go to the toilet two to three times a day and Seema has to clean them every time. Sometimes she washes her hands with ash or soap, sometimes she forgets. One day her younger child falls sick with high fever and diarrhoea.

Discussion Points:

1. Can you identify the source and transmission of infection the child is suffering from?

2. Do you know that diarrhoea is the major cause of infant death in India?

3. What precautions should Seema have taken?

4. Can you list few health messages on hygiene and sanitation?

Activity 2


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Case Study 3:

Mohit is a 16-year-old boy who is very worried due to increasing incidence of diarrhoea in the village. The villagers don’t maintain hygiene and sanitation. Most of the time, people dump garbage outside their house and prefer to go out to the fields for defecation.

Discussion Points:

1. What do you think is Mohit’s concern?

2. Can he do something about it?

3. How would you convince the villagers to take measures to maintain hygiene and sanitation?

Derive the important points from the case studies. Discuss the importance of hygiene and highlight that we need to not only maintain hygiene and sanitation at home but also maintain clean surroundings to prevent diseases. Highlight the traditional mindset of parents on hygiene and sanitation which prevented the adolescents’ participation in decision making in the first case study. Explain that in the second case study, the source could be the mother who is not regular with hand washing with soap, a hygienic practice; the human excreta contaminates our hands and the food fed to the child who becomes the host for such infections. Make sure that the participants identify the problem and suggest possible solutions.

Ask the participants to list how we can help our community maintain hygiene and sanitation and reduce contamination of water, air and soil. Ask a volunteer to list the responses on a chart paper. Put up the chart paper on the wall for reference. Explain some of the ways that are crucial and can be addressed by adolescents such as the following:

y Stopping defecation in the open by promoting toilet use

y Management of biodegradable and non-biodegradable waste

y Keeping water bodies clean

y Reducing carbon emission

y Minimizing use of fertilizers and pesticides in agriculture

The chart may read as under:

1. Stop defecation in the open by promoting use of toilets and hand washing with soap.

2. Promote hand washing with soap every time eatables are handled or before eating.

3. Always keep eatables covered and away from flies.

4. Ensure proper washing and storage of utensils (with clean water and away from flies).

5. Construct sanitary latrines at home (it is important for both privacy and safety, especially for females, and community hygiene).

Activity 3


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6. Use public toilets when out of the home; do not urinate on walls and trees.

7. Promote waste disposal system through latrines or burial in the ground. Burial of excreta in deep pits is one of the convenient ways of disposal. Covering it with mud or soil also helps in preventing flies from sitting on it and contaminating food and spreading infections, but should be avoided as it may not be totally risk free.

8. Advocate building separate public toilets for men and women with continuous water supply.

9. Educate people to keep toilets and public utilities clean and sanitized. Ventilators or inlets for light and air are important to ensure that toilets are free of germs and flies that contaminate food.

10. Create awareness that unclean water (such as water after washing,from the toilet, from other household work etc.) should be allowed to pass through a separate conduit.

11. Avoid bathing, using soap for cleaning utensils and clothes near the hand pump, wells or in rivers.

12. Don’t dump waste in water bodies like ponds, rivers and naalas; they will only become breeding grounds for mosquitoes; also check that there is no water stagnation such as in water coolers, flower pots, vases, old containers etc.

13. Advocate for a community mechanism for waste collection.

14. Separate biodegradable waste (easily decomposed waste like vegetables, food products etc.) from non-biodegradable waste (that does not decompose but can be recycled like paper, plastic, glass etc.).

15. Make a pit in your backyard to dump biodegradable waste rather than throwing it on to the streets; give away paper, plastics and other non-biodegradables for recycling.

16. Promote community mechanism to dump and dispose of waste at a place far from habitation.

17. Promote facilities at home and in schools for disposal of menstrual pads.

18. Hospitals should follow rules for the disposal and management of hospital waste strictly.

Summarize by informing the participants of following:

1. It is important to ensure community sanitation and hygiene for good health.

2. Open defecation and poor waste disposal are two major reasons for infections.

3. A human life needs all three natural resources, that is, water, air and soil. Contamination of any one will impact our health adversely.

4. The common causes of illness and death among infants and children in our country can easily be eliminated if we take care of hygiene and sanitation at personal as well as community levels.

5. Open defecation is most commonly spread by these Fs:

Fingers (Hands) Fluid (Water Supply)FieldFeet Flies

6. It is our duty to educate people about community hygiene and sanitation and take steps to keep our environment free of any kind of infection and pollution.


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Key messages

1. Open defecation and improper hand washing is the root cause of infections like diarrhoea.

2. Every house should have sanitary toilets (pour-flush sanitary toilets).

3. Community and public places, especially schools and colleges, should have separate toilets for men and

women with continuous water supply.

4. Every house and village should have a proper waste disposal mechanism.

5. One should learn how to differentiate between and manage biodegradable and non-biodegradable waste.

6. Plant trees and reduce cutting of green trees so that carbon dioxide is absorbed adequately.

7. Reduce carbon emission and use of pesticides.


1. To talk to adolescents between 10–19 years and make them understand why community hygiene and

sanitation is important.

2. To educate peers on how to maintain community hygiene and sanitation.

3. To create awareness in community on hygiene and sanitation.

Refer Peer Educator Resource Book to deliver messages and clarify doubts related to elements of Community Sanitation and Hygiene

training module for peer educators - National Health Mission

Documents

Transcript of training module for peer educators - National Health Mission