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Holistic approach

In Gujarat’s Sabarkantha, this government project teaches teens about reproductive and mental health

For Kashish, 16, “menstruation” isn’t a bad word. Her voice ringing with confidence, she explains that she’s “fine with body changes”. She has sat down with her mother and sister and explained the benefits of using sanitary napkins and how to dispose of them. For Kashish, menstruation isn’t a deeply-ingrained matter of shame or shyness — it’s a “natural process”.

A class 11 student at CK Girls High School, Idar, Kashish is one of an estimated 90,000 adolescents in Sabarkantha district, Gujarat, to have participated in a state government scheme to educate children about various aspects of adolescent health. Called the Rashtriya Kishor Swasthya Karyakram, the programme was launched in 2014 with the combined resources of the state’s departments of health and education, and Integrated Child Development Services.

The RKSK’s goal is to reach 253 million adolescents with “special focus on marginalised and undeserved groups”. As its website explains, the scheme’s key drivers are community-based interventions like outreach by counselors; facility-based counselling; social and behaviour change communication; and strengthening of adolescent-friendly health clinics. For this purpose, 225 medical and paramedical staff have been trained and 126 clinics identified. According to Gujarat’s Health and Family Welfare Department, the project currently covers 1,200 primary schools and 1,069 secondary and higher secondary schools.

In Sabarkantha, the RKSK has a more holistic approach to the health and welfare of adolescents. It includes six components covered across three phases: nutrition and reproductive health; mental health and substance abuse; and gender-based violence and non-communicable diseases.

Learning the science and language of menstruation has been particularly helpful for someone like Kashish. “When my cycle started for the first time, I was scared. I cried a lot,” she explains. “I didn’t like that feeling — sitting alone, not moving anywhere, not touching utensils, keeping my stuff separately in one corner. It was very isolating.”

Under the RKSK scheme, she and other girls from classes 6 to 12 were taught about the reproductive system. A sanitary pad vending machine was installed in her school, and that’s how she learned how to use a sanitary napkin in the first place. She was allowed to supply sanitary napkins to her mother and sister too. So far, 20 sanitary napkin vending machines and 300 disposal incinerators have been set up in the district.

“Earlier, my mother and sister would use cloth while menstruating and drying the cloth wasn’t an easy task,” Kashish says. “There are many girls in my colony like this, who were not drying the cloth in sunlight, which is a must. But they would feel like they have to hide the cloth, so no one can see it. After my intervention and explaining the process to them, the practice has been discontinued.” That’s not all: Kashish has told family members there will no longer be “seclusion” when someone is menstruating.

The students study inappropriate touch and anger management too. Sagar, another student of CK Girls High School, says she doesn’t like vegetables and would constantly fight with her mother over it. “After learning anger management, now I don’t fight with my mother,” she says. “Last week, she cooked something I don’t like. Instead of throwing a tantrum, I quietly left the place and sat alone for a few minutes. This actually works when we lose our cool.”

Chetna Patel, a nodal teacher under the RKSK at the school, says it hasn’t been easy talking to the girls freely about these “taboo” topics. “When we started talking, all the girls would keep their heads down,” she recalls. “There was a feeling of shame among them. Some giggled and tried to avoid paying attention to what was being discussed.”

A year later, Patel says there’s a marked difference. “The girls have become expressive. They are openly discussing their problems and issues. The most interesting thing is they’re voluntarily discussing these topics in their neighbourhoods too.” Some students are still forced to endure isolation while menstruating at home, Patel admits, but she’s hopeful of change. The school’s sanitary pad vending machine is refilled four times a day — this is how extensively it is used. The school has also installed an electric incineration unit for disposal of used sanitary pads.

Menstruation isn’t the only delicate topic. Jigar, a teenage student of MM Patel High School, says he used to masturbate more than twice a day, leading to feelings of shame and guilt. Subsequently, he met a counsellor and was advised to attend health education classes conducted under the RKSK programme. The first thing he was told, Jigar says, is there’s nothing wrong with masturbation. “They also helped me divert my attention towards sports and other activities,” he adds.

Jigar says he feels confident now. He’s no longer guilty.

When the RKSK was launched in 2014, the biggest question was how to implement it in Sabarkantha. A programme of this kind did not exist until then, as Newslaundry confirmed from Iliyas Qureshi, a school board member with the Ahmedabad Municipal Corporation.

“We were in a dilemma,” says Dr Manish Fency, chief district health officer of Sabarkantha. “The district mainly consists of rural and Adivasi populations, with low literacy rates and firm beliefs. It was difficult to penetrate with scientific education…To talk about reproductive health was next to impossible.”

According to Fency, a majority of Sabarkantha’s population believes in Bhuva, a “demigod”, or messenger of god. “For many health-related matters, including pregnancy, they depend on Bhuva or Dayan. We roped in mentions of Bhuva and Dayan while talking about nutrition for adolescents and antenatal care. This is how we built the population’s faith in counsellors, health officials and schoolteachers.”

During field visits by monitoring officers, Fency says they identified deficiencies in communication and counselling skills among their own counsellors. “A skilled counsellor is a necessity while dealing with a sensitive age group like adolescent. So capacity-building of trainers was a must before launching the programme. We used materials from Unicef and an NGO named Chetna, as well as that provided by the RKSK. It took us two months to prepare resources.”

Chetna, based in Ahmedabad, joined hands with the health department to conduct a reproductive health pilot project in 73 villages of Talod block in Sabarkantha between 2013 and 2016. According to the NGO’s director Pallavi Patel, during that period, Chetna found high dropout rates for girls, no proper knowledge of using and disposing of sanitary napkins, resistance to discussions on sexual and reproductive health, and discomfort by adolescents in accessing services from adolescent-friendly health clinics. Schoolteachers were ill-equipped in dealing with these issues.

This is information that the district’s health officials used to roll out the RKSK programme in Sabarkantha. Special material on information, education and communication was prepared, and doctors and counsellors were trained. Every week, RKSK counsellors, doctors and officials from the Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy visit schools here. Unlike other districts in Gujarat, every school in Sabarkantha has a nodal teacher under the RKSK.

Chandni Parmar, assistant programme manager of the RKSK in Sabarkantha, says: “During puberty, adolescents go through a series of physical, mental and emotional changes. During this time, they also get involved in risky sexual behaviour and anti-social activities. Some of the behavior may last a lifetime. They need regular discussions and correct information. Now our counselors are holding structured educational classes for adolescents to learn about the body and bodily processes, including reproductive organs and their functions.”

Classes are designed in a way that students can relate to them easily. Parmar says, “In the first phase, nutrition was covered. Using the example of our national flag which has three colours, we explained that it’s important for different food colours, like orange, white and green, to be on our plate.”

Fency says the programme is fully funded by Unicef. “We needed a constructive programme implementation, so based on the pilot programme we replicated this in the entire district. As there was low education rate, high dropout rate and people firmly rooted in beliefs, we initially faced many difficulties. There was a time when people were not ready to listen to us. Things are okay now.”

This ground report has been produced as part of the TMR 2019 Fellowship, an initiative by The Media Rumble to facilitate exchange of ideas between journalists and media houses from across India. The fellowship is supported by the Population Foundation of India.

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