Adolescent Health.pptx

ADOLESCENT HEALTH PROBLEMS

Specific Learning Objectives Who

are adolescents? Health problems common in adolescence and their management. Health programmes for adolescence Role of Family Physician in adolescent health

Adolescence- WHO Definition

“A period of biologically accelerated physical and sexual maturation, physiologically of major growth in personality and development, and socially of new status within and outside the family.” Adolescence: 10 – 19 years Early Adolescence: 10 – 13 years Middle adolescence: 14 – 16 years Late adolescence: 17 – 19 years Youth: 15 – 24 years Young people: 10 - 24 years

ADOLESCENT IN INDIA India

is home to 243 million adolescents – children aged 10 to 19 years – the most adolescents of any country. It accounts for about 21.3% of population of the country. Girls currently married (age group 1519yr) are 30%. Boys currently married (age group 1519yr) are 4.6%. Birth by age 18 year- 21.7%

BURDEN OF HEALTH PROBLEM  An

estimated 1.3 million adolescents died in 2012, mostly from preventable or treatable causes.  Road traffic injuries were the leading cause of death in 2012, with some 330 adolescents dying every day.  Other main causes of adolescent deaths include HIV, suicide, lower respiratory infections and interpersonal violence.  Half of all mental health disorders in adulthood appear to start by age 14, but most cases are undetected and untreated.

ADOLESCENT NUTRITION Nearly

half of adolescent girls aged 15–19 in India are underweight (unicef global database 2011) There is increase in nutritional requirement during this period of rapid Lack of sun exposure causes vitamin D deficiency.

ADOLESCENT NUTRITION Insufficient

dairy product intake in underprivileged girls leads to poor intake of protein and calcium Vitamin A deficiency is also an important issue in economically deprived adolescents. Undernutrition delays ◦ ◦ ◦ ◦

the onset of puberty and sexual maturation, result in stunting, poor bone mass accrual and reduced work capacity.

ADOLESCENT NUTRITION

ADOLESCENT NUTRITION A

large proportion of India’s adolescents are anaemic  Anaemia adversely affects these young people’s ◦ growth, ◦ resistance to infections, ◦ cognitive development and work productivity.  The

national Ministry of Health and Family Welfare (MHFW) launched a nationwide Weekly Iron and Folic Acid Supplementation (WIFS) programme in January 2013.

ADOLESCENT NUTRITION The services delivered under scheme:1) weekly iron and folic acid supplementation; 2) bi-annual deworming; and 3) nutrition counselling about how to improve diet and prevent anaemia.  Kishori shakti yojna to improve nutritional and health status of girls in age group of 1118 years.  Improving nutritional status of adolescent girls helps break the cycle of malnutrition and low birth weight babies.

MENTAL HEALTH PROBLEMS  Depression

is the top cause of illness and disability among adolescents and suicide is the third cause of death.  Other problems include: ◦ ◦ ◦ ◦ ◦

Adjustment disorder, anxiety disorder, delinquent behavior, poor body image, and low self-esteem.

 Completed

suicides are higher in boys  Attempted suicides are higher in girls

MENTAL HEALTH PROBLEMS-What can be done?  Building

life skills in children and adolescents and providing them with psychosocial support in schools and other community settings can help promote good mental health.  Programmes to help strengthen ties between adolescents and their families are also important.  If problems arise, they should be detected and managed by competent and caring health workers.

EARLY PREGNANCY & CHILD BIRTH  Complications

linked to pregnancy and childbirth are the second cause of death for 15-19-year-old girls globally.  Every year, some 3 million girls aged 15 to 19 undergo unsafe abortions.  Babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24.  Unmarried adolescents are likely to resort to unsafe method of abortions, which increases the risk of complication like septicemia and also mortality.

EARLY PREGNANCY & CHILD BIRTH  Adolescent

pregnancy are also at increased

risk of ◦ ◦ ◦ ◦

pre-eclampsia, preterm labor, prolonged and obstructed labor, and postpartum hemorrhage.

 Many

girls who become pregnant have to drop out of school.  Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects.

EARLY PREGNANCY & CHILD BIRTH  WHO

published guidelines in 2011 with the UN Population Fund (UNFPA) on preventing early pregnancies and reducing poor reproductive outcomes with 6 main objectives: ◦ reducing marriage before the age of 18; ◦ creating understanding and support to reduce pregnancy before the age of 20; ◦ increasing the use of contraception by adolescents at risk of unintended pregnancy; ◦ reducing coerced sex among adolescents; ◦ reducing unsafe abortion among adolescents; ◦ increasing use of skilled antenatal, childbirth and postnatal care among adolescents.

SEXUALLY TRANSMITTED INFECTIONS Early

sexual activity is not uncommon in India.  Adolescent are susceptible to these infections because ◦ biological (immature and incompletely estrogenised mucosa) and ◦ psychological factors (lack of preparedness, lack of familiarity with barrier contraceptives)  Vaginal

discharge is common in adolescent girls  Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorder of female genital tract. It can present with abdominal pain and vaginal discharge.

SEXUALLY TRANSMITTED INFECTIONS HIV-

◦ More than 2 million adolescents are living with HIV ◦ Although HIV deaths decreased in last 8 years but adolescents deaths are rising. ◦ Young people need to know how to protect themselves and have the means to do so. ◦ This includes being able  to obtain condoms to prevent sexual transmission of the virus and  clean needles and syringes for those who inject drugs.  Better access to HIV testing and counselling.

OBESITY  Among

school children, 5% obesity and 17-19% overweight has been reported.  Prevalence of obesity and overweight is higher in boys than in girls.  Causes:  Change in sedentary life style,  Increase consumption of calorie dense food and  decrease outdoor activity contribute to these disorders.  Obesity has strong association with ◦ asthma, ◦ sleep disorder, ◦ reflux disease, ◦ slipped femoral epiphysis, ◦ gallstones and fatty liver, ◦ metabolic derangements like type 2 diabetes, dyslipidemia, hypertension and polycystic ovarian disease

SUBSTANCE ABUSE Most

of the tobacco and alcohol use starts during adolescence. Alcohol(21%), Tobacco(14%), cannabis(3%), and opium (0.4%) are the most prevalent substance abuse in Indian adolescence.

VIOLENCE  WHO

defines violence as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychologic harm, maldevelopment or deprivation”  Physical and sexual violence are common in India.  20-30% of young females suffering from domestic violence and 5-9% young females reporting sexual violence (NFHS3).  Motor vehicle and industrial accidents are common in boys whereas burns are common in girls.

VIOLENCE The

FISTS mnemonic provides guidance for structuring the assessment of violence-

VIOLENCE Treatment cognitive-behavioral therapy involving the individual and family  specific family interventions (parent management training, multisystemic treatment)  pharmacotherapy.  Treatment of existing comorbid conditions, such as attention-deficit/hyperactivity disorder, depression, and substance abuse, appears to reduce aggressive behavior.

EATING DISORDERS ANOREXIA

NERVOSA:-

◦ Most Common among 15-19yr old. ◦ Charecterized by Body weight <85% of expected weight for age and height  Intense fear of becoming fat even though underweight.  Disturbed body image and denial that current body weight is low  In postmenarcheal girls, amenorrhea.

◦ Anorexia is commonly associated with depression, anxiety, suicidal ideation and/or Obsessive Compulsive Disorder.

EATING DISORDERS ◦ Profound weight loss may result in     

hypothermia, hypotension, dependent edema, b radycardia, hypokalemic metabolic alkalosis.

◦ Mortality is attributed to cachexia and suicide. MANAGEMENT-

◦ Psychotherapy (individual + family therapy) to establish appropriate eating pattern and normal perception of hunger and satiety. ◦ Nutritional rehabilitation (in severe cases NG/Parenteral nutrition) ◦ Antidepressant and antipsychotic drugs as required.

EATING DISORDERS BULIMIA:

◦ More common in girls between 10-19 yr of age. Charecterized by  Recurrent episodes of binge eating  Recurrent inappropriate compensatory behavior to prevent weight gain, such as self induced vomitting, misuse of laxatives, diuretics enemas, fasting or excessive exercise  both at least twice a week for 3 months.

Affected

patients have comorbidities like depression and psychosis. MANAGEMENT:- combination of psychotherapy and antidepressants (such as fluoxetine)

ADOLESCENT HEALTH PROGRAMMES

Kishori Shakti Yojana •

Key component of ICDS scheme which aims at empowerment of adolescent girls. Scheme- I (Girl to Girl Approach)

Scheme-II (Balika Mandal)

•Age group of 11-15 years

• Age group 11-18 years irrespective of income levels of the family

•Belonging to families whose income level is below Rs. 6400/- per annum

•Younger girls 11-15 years and belonging to poor families

Kishori Shakti YojanaObjectives • • •

• •

•

To improve nutritional and health status of girls in age group of 11-18 years To provide required literacy and numeracy skills through the non-formal stream of education To stimulate a desire for more social exposure and knowledge and to help them improve their decision making capabilities To train and equip the adolescent girls to improve/ upgrade home-based and vocational skills To promote awareness of health, hygiene, nutrition and family welfare, home management and child care Measures to facilitate their marriage only after attaining the age of 18 years and if possible, even

RMNCH+A Coverage targets for key RMNCH+A interventions for 2017 in Adolescents: Reduce anaemia in adolescent girls and boys (15–19 years) at annual rate of 6% from the baseline of 56% and 30%, respectively(NFHS 3) Decrease the proportion of total fertility contributed by adolescents (15–19 years) at annual rate of 3.8% per year from the baseline of 16% (NFHS 3)

RMNCH+A: Priority interventions 1. Adolescent nutrition; iron and folic acid supplementation 2. Facility-based adolescent reproductive and sexual health services (Adolescent health clinics) 3. Information and counseling on adolescent sexual reproductive health and other health issues 4. Menstrual hygiene 5. Preventive health checkups

New Initiative: National Iron Plus Initiative

RMNCH+A: AFHS ◦ Adolescent Friendly Health Services include             

Reproductive health services Sexual & reproductive health education Contraception Pregnancy testing andoptions MTP STD/HIV Screening, counselling, treatment Prenatal and Post natal care Well baby care Nutritional Services Growth and Development monitoring Anticipatory guidance regarding substance abuse Counseling on life skill development Screening for various disorders

RMNCH+A: AFHS Services

at sub centre: ANM Adolescent Information and Counseling Centre will be made functional by MO and ANM at PHC on weekly basis. At CHC, DH/SDH/ and Medical College: Adolescent Health Clinics(daily basis) Special focus will be given to establishing linkages with Integrated Counseling and Testing Centres (ICTCs) and making appropriate referrals for HIV testing and RTI/STI management

RMNCH+A: Scheme for promotion of menstrual hygiene among adolescent girls in rural India

This

scheme promotes better health and hygiene among adolescent girls  Sanitary napkins are provided under NRHM’s brand ‘Free days’. These napkins are being sold to adolescent girls by ASHAs

RMNCH+A: Preventive health checkups and screening for diseases, deficiency and disability  Components of School Health Programme include screening, basic health services and referral  Bi-annual health screening is undertaken for students (6–18 years age group)  Implementation of School Health Programme Team consist of: - 2 Medical Officers (MBBS / Dental / AYUSH qualified) - 2 paramedics (one ANM and any one of the following Pharmacist/ Ophthalmic Assistant/Dental assistant)

SOCIAL CHALLENGES MEDIA PEER

PPRESSURE POVERTY ILLITERACY EARLY MARRIAGE ACADEMIC AND EMOTIONAL STRESS DISCRIMINATION LACK OF SEX EDUCATION

ROLE OF HEALTH CARE PROVIDER Identifying

risk Establishing rapport Confidentiality Consent(<12, 12-18, >18) Nutritional intervention Providing health information Contraception

ROLE OF HEALTH CARE PROVIDER Referral

to social services, psychological evaluation and support

◦ National Commission for Protection of Child Rights Act 2005 consider a person below 18 yr as a child. ◦ It is mandatory for a health care provider to report all cases of child abuse (even suspected) to the chairperson of the commission (online/writing). ◦ Doctors are protected in case of erroneous reporting but punishable if they fail to report.

ROLE OF HEALTH CARE PROVIDER Adolescent

immunisation

CHECKLIST FOR ADOLESCENT HEALTH VISIT History

from parents and adolescents ◦ History of presenting problem ◦ Parental concern on growth and development ◦ Academic success; school absenteeism ◦ Diet intake including calcium, protein and iron intake; junk food ◦ Menstrual history; sleep problems

CHECKLIST FOR ADOLESCENT HEALTH VISIT History

on questioning of adolescents ◦ Emotional problems; relationship with family and peers ◦ Outlook toward physical and sexual changes ◦ Involvement in relationship or sexual activity ◦ Awareness about safe sex and contraception ◦ Specific problems related to sex

CHECKLIST FOR ADOLESCENT HEALTH VISIT History

on separate questioning of

parents ◦ Relationship with family ◦ Level of communication on sensitive matters Physical

◦ ◦ ◦ ◦

examination

Anthropometry Blood pressure, obesity, acanthosis Sexual maturity rating Signs of malnutrition, anemia and vitamin deficiency ◦ Signs of skin and genital infection

CHECKLIST FOR ADOLESCENT HEALTH VISIT ◦ Level of general hygiene ◦ Signs of trauma; abuse ◦ Signs of drug abuse and tobacco abuse Counseling

◦ Nutritional intervention ◦ Hygiene practices ◦ Building rapport between parents and adolescents ◦ Providing information and sources on sex education

CHECKLIST FOR ADOLESCENT HEALTH VISIT Investigations

◦ ◦ ◦ ◦

Hemoglobin level Blood sugar, lipid profile Genital swab Ultrasound of ovaries

Referral

◦ ◦ ◦ ◦ ◦ ◦

Counselor Dietitian Psychiatrist Gynecologist Voluntary and confidential HIV testing Social services, child protection agencies, support groups.

References OP

Ghai- Essential Pediatrics Nelsons Textbook of Pediatrics UNICEF Global Data – 2013 Integrated Child Development Services Scheme. Kishori Sakati Yojana. Available from: http://wcd.nic.in/KSY/ksyguidelines.htm . A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health(RMNCH+A) in India. Ministry of Health & Family Welfare Government of India February 2013

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