Health behaviours & problems among young people in India: Cause for concern & call for action

What characterizes adolescents and youth?

Youth - the critical phase of life, is a period of major physical, physiological, psychological, and behavioural changes with changing patterns of social interactions and relationships. Youth is the window of opportunity that sets the stage for a healthy and productive adulthood and to reduce the likelihood of health problems in later years. A myriad of biological changes occur during puberty including increase in height and weight, completion of skeletal growth accompanied by an increase in skeletal mass, sexual maturation and changes in body composition. The succession of these events during puberty is generally consistent among the adolescents often influenced by age of onset, gender, duration, along with the individual variations. These changes are also accompanied by significant stress on young people and those around them, while influencing and affecting their relationships with their peers and adults. It is also an age of impulsivity accompanied by vulnerability, influenced by peer groups and media that result in changes in perception and practice, and characterized by decision making skills/abilities along with acquisition of new emotional, cognitive and social skills3.

Young people's health is vital and crucial

Most young people are presumed to be healthy but, as per WHO, an estimated 2.6 million young people aged 10 to 24 yr die each year and a much greater number of young people suffer from illnesses ‘behaviours’ which hinder their ability to grow and develop to their full potential. Nearly two-thirds of premature deaths and one-third of the total disease burden in adults are associated with conditions or behaviours initiated in their youth (e.g. tobacco use, physical inactivity, high risk sexual behaviours, injury and violence and others)8. The behavioural patterns established during this developmental phase determine their current health status and the risk for developing some chronic diseases in later years9. A significant reduction in the mortality and morbidity of communicable, maternal and neonatal disorders since 1990 due to concerted and integrated efforts1011 led to a shift in focus towards the health, safety and survival of the young people. It is crucial to understand health problems of this population, processes and mechanisms that affect their health, identify interventions and strategic approaches that protect their health and develop and implement policies and programmes.

The present review focuses on the health behaviours and problems affecting young people in the age group of 10-30 yr in India. The review also examines some policy initiatives and interventions and identifies issues that need to be addressed for health and safety of young people in India.

Undernutrition and micronutrient deficiencies

Data shown in Table I indicate a high prevalence of undernutrition and stunting in the age group of 10-30 yr that has an adverse bearing on their health. Data from Nutrition Survey of National Institute of Nutrition during 2001 and 2006 showed that more than half the population aged 10-18 yr was undernourished1516. This observation is also supported by other studies with sample size varying from 500 to 1000 with the prevalence of undernutrition in 10 to 24 yr ranging from 56.4 to 68.5 per cent171819. A school based study showed that 38.8 per cent of boys and 36.9 per cent of girls were stunted20, while a community based study showed that 51.7 per cent adolescents were stunted18. The prevalence of micronutrient deficiencies in rural area was as high as 25 per cent as reported by Choudhary et al19 with high prevalence of anaemia, more among girls, ranging from 30-82 per cent171821. Anaemic adolescent mothers are at a high risk of miscarriage, maternal mortality and still births; also, low birth weight babies with low iron reserves24. Poor nutritional status of adolescents is an outcome of socio-cultural, economic and public policies relating to household food security compounded by behavioural dimensions.

Table I Status of undernutrition and micronutrient deficiency in India

Overweight and obesity

Conversely, overweight and obesity - another form of malnutrition with serious health consequences is increasing among other young people in India and other Low Middle Income Countries (LMICs)8. A meta-analysis of nine studies in 2012 showed 12.6 per cent of children to be overweight and 3.3 per cent to be obese indicating the seriousness of the situation23. A review of a few select studies (Table II) during 2001 to 2012 showed a prevalence of overweight among children aged 10-19 yr to be 9.9 to 19.9 per cent; high in both boys (3 to 15.1%) and girls (5.3 to 13.3%) indicating early onset of obesity26272829303133 affecting more of urban school adolescents (3.4 to 6.5%)26272832 as compared to 0.6 per cent among the rural adolescents15 with significant gender variations262932. Studies from Karnataka2732 have shown a higher prevalence of obesity as compared to studies from northern India262830. It is clear that India is facing the dual burden of undernutrition and overnutrition as also seen from other reports3435. There is also a challenge of nutritional transition as Indians are moving away from traditional diets high in cereal and fiber to more western pattern diets high in sugars, fat, and animal-source food (fast food culture) that are closely associated with different non communicable diseases (NCDs) seen in later years3637.

Table II Prevalence of overweight and obesity as reported in Indian studies

High risk sexual behaviour

High-risk sexual behaviour is a broad term covering early sexual activity especially before 18 years of age and includes unprotected intercourse without male or female condom use except in a long-term, single-partner (monogamous) relationship, unprotected mouth-to-genital contact except in a long-term monogamous relationship, having multiple sex partners, having a high-risk partner (one who has multiple sex partners or other risk factors), exchange of sex (sex work) for drugs or money, having anal sex or having a partner who does except in a long-term, single-partner (monogamous) relationship and having sex with a partner who injects or has ever injected drugs38. It is a known risk factor that puts individuals at risk for contracting HIV/AIDS and a range of other sexually transmitted diseases like gonorrhoea, herpes, genital warts, Chlamydia, syphilis, trichomoniasis, etc. The National Family Health Survey (NFHS) 3 (2005-06) indicated that 4 per cent of young women and 15 per cent of young men had ever experienced sex before marriage and only 14.1 per cent (14.7% urban vs 13.9% rural) of unmarried sexually active adolescent females used a contraceptive39. Young people aged 15 to 24 yr commonly engage in premarital sex more so in men (15-22%) as compared to women (1-6%)3940414243. Kumar et al40 in a study of 2,475 never married boys and girls noticed that only 22.3 per cent males and 6.3 per cent females reported consistent condom use for premarital sex in the last 6 months. A study from Gujarat observed that nearly 40 per cent males and 7.4 per cent females in the age group of 15 to 24 yr reported having multiple-partner sex, while 32.1 per cent males and 3.2 per cent females reported having paid/exchange (money/gift) sex44. Thus, data shown in Table III indicate that prevalence of high risk sexual behaviour among the young people is not only high but vary widely across studies and needs immediate attention to reduce the occurrence of HIV and related diseases.

Table III Prevalence of high risk sexual behaviour among young Indians

Common mental disorders

At least 20 per cent of young people are likely to experience some form of mental illness - such as depression, mood disturbances, substance abuse, suicidal behaviours, eating disorders and others8. A meta-analysis of five psychiatric epidemiological studies yielded an estimated prevalence of mental morbidity including 16 mental and behavioural disorders (classified into eight groups of organic psychosis, schizophrenia, manic affective psychosis, manic depression, endogenous depression, mental retardation, epilepsy, phobia, generalized anxiety, neurotic depression, obsession and compulsion, hysteria, alcohol/drug addiction, somatisation, personality disorders and behavioural/emotional disorders) of 22.2 per 1000 population among 15 to 24 years47.

Data available from community based studies on common mental disorders in India depict a high prevalence among the young people (Table IV), but comparisons and extrapolations need to be cautiously made due to variations across studies. The prevalence of overall psychiatry morbidity (depression, conduct disorder, social anxiety, panic disorder) among adolescents has varied from 12 to 16.5 per cent4849. Pillai et al observed a low prevalence of 1.8 per cent of DSM-IV disorders among adolescents aged 12-16 yr which was attributed to methodological factors and the presence of protective factors50. A six years follow up study in Chandigarh showed the incidence rate of psychiatric disorder to be 0.18 per cent per year among the 10-17 yr old adolescents51. Among the few specific common mental disorders, the prevalence of depression has varied from 0.1 to 18.5 per cent484952535455, conduct disorders from 0.2 to 9.2 per cent484953, and anxiety from 0.1 to 24.4 per cent484950535556 across different studies. Two studies showed prevalence of severe and extreme grade of depression in 11.2 per cent of the school dropouts and 3 per cent among the school going adolescents aged 13 to 19 yr and 18.4 per cent among the 9^th standard students using Beck's depression Inventory5254. Promoting mental health and responding to problems on a continuous basis requires a range of adolescent-friendly health care and counselling services in communities57.

Table IV Common mental disorders among young Indians

Stress

Stress is a consequence of or a general response to an action or situation arising from an interaction of the person with his environment and places special physical or psychological demands, or both, on a person. The physical or psychological demands from the environment that cause stress, commonly known as stressors and the individual reaction to them take various forms and depends on several intrinsic and/or extrinsic factors. Significant difficulties have been experienced in quantifying and qualifying stress. Some studies have tried to quantify the stress levels among young people, while others have given a mean stress score (influenced by methods of measuring stress)5859. Sahoo et al55 using Depression Anxiety Stress Scale (DASS) observed that 20 per cent young adults experienced stress. Dabut et al60 using life stress scale found that among adolescent girls studying in 12^th standard from Hisar and Hyderabad, 47.5 and 72.5 per cent, were in the moderate category of family stress; financial stress was reported by 60 and 50 per cent and, 90 and 85 per cent had moderate level of social stress, respectively. Sharma & Sidhu in a study, among adolescents aged 16-19 yr using self-made questionnaire based on Bisht Battery of Stress found that 90.6 per cent adolescents had academic stress61.

Suicide

According to the World Health Organization (WHO) estimates about one million people commit suicide each year62. In India, nearly 1,36,000 persons voluntarily ended their lives in a suicidal act as per official reports in 201163. The official report indicates that age specific suicide rate among 15-29 yr is on the rise increasing from 3.73 to 3.96 per 1,00,000 population per year from 2002 to 201163 (Fig. 1). About 40 per cent of suicides in India are committed by persons below the age of 30 yr64. The Million Death Study using RHIME (Representative, Re-sampled, Routine Household Interview of Mortality with Medical Evaluation) method revealed the annual mortality rates to be 25.5 and 24.9 per 1,00,000 population among males and females aged 15-29 yr65, respectively. Other studies have shown incidence among young individuals to vary from 100.1 to 72.2 per 1,00,000 population66. Study from Bangalore showed that of the 5115 attempted suicide covering all age groups, 2.1, 8.4 and 28.6 per cent individuals were in the age group 10-15, 16-20 and 21-25 yr, respectively; and among 912 completed suicides, 2.2, 16.2 and 21.6 per cent were in the age group 10-15, 16-20 and 21-25 years, respectively67. The suicide rates among young females were high (152 per 1,00,000) compared to suicide rates among young men being 69 per 1,00,000 as reported by Aaron et al66 with similar observations by other authors6568. Soman et al69 found an age specific suicide incidence rates among males and females aged 15-24 yr to be 5.1 and 8.1 per 1,00,000 population per year69. Suicidal ideas and attempts were also found to be high in Chandigarh70 and South Delhi71 with nearly 6 per cent of individuals aged 11-17 yr and 15.8 per cent adolescents aged 14 to 19 yr reporting suicidal ideas, while 0.4 per cent students aged 11-17 yr and 5.1 per cent students aged 14 to 19 yr reported suicidal attempts.

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Fig. 1

Completed suicide among 15-29 yr per 100,000 population from 2002 to 2011 (rate/1,00,000 population). Source: Ref. 63.

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Tobacco use

The vast majority of tobacco users worldwide begin the use of tobacco during adolescence. Currently, more than 150 million adolescents use tobacco, and this number is increasing globally57. NFHS-3 revealed that 40 per cent of males and 5 per cent of females aged 15 to 24 yr consumed tobacco nationwide21. Systematic review of 15 studies across India aged 13-15 yr showed a median prevalence of tobacco use (ever users) to be 18.2 per cent; 14 per cent among males and 6.3 per cent among females72. Global Youth Tobacco Survey (GYTS) 2006 and 2009 across India covering 13 to 15 yr old adolescents in 180 schools highlighted an increase in the current users of any form of tobacco from 13.7 to 14.6 per cent and current users of cigarette from 3.8 to 4.4 per cent from 2006 to 200973. A study from Karnataka showed 4.9 per cent point prevalence and 5.1 per cent life-time prevalence of tobacco use among adolescents aged 13-15 yr74, while a study from Noida city indicated that 11.2 per cent of adolescents aged 11 to 19 yr were users of any kind of tobacco75. Other studies have shown 9.8 to 20.3 per cent life time prevalence of any tobacco products among adolescents7677. Gender variations for usage of any kind of tobacco varied from 2.9 to 8.5 per cent in boys and 1.5 to 9.8 per cent in girls78. The study in Noida city also found that 8.8 per cent of adolescents aged 11 to 19 yr were ‘ever smokers’ (including current smokers), 4.6 per cent were ‘ever tobacco chewers (including current chewers), 3.7 per cent were ‘exclusive smokers’ and 2.5 per cent were ‘exclusive tobacco chewers’75. Data from several studies (Table V) clearly point to the fact that tobacco addiction is emerging as a big threat among young Indians.

Table V Prevalence of tobacco use in young people

Harmful alcohol use

Harmful drinking among young people is an increasing concern in many countries and is linked to nearly 60 health conditions. It increases risky behaviours and is linked to injuries and violence resulting in premature deaths57. A national review on harmful effects of alcohol reported greater social acceptability of drinking, increasing consumption in rural and transitional areas, younger age of initiating drinking, and phenomenal socio-economic and health impact, more so among young people81. Data from the National Household Survey (NHS) by United Nations Office on Drugs and Crime (UNODC), 2002 covering urban and rural areas of 24 States of India revealed a prevalence of 21.4 per cent of alcohol use among men aged 12 to 18 yr82. The World Health Survey - India reported that among individuals aged 18 to 24 yr, 3.9 per cent were infrequent heavy drinkers and 0.6 per cent were frequent heavy drinkers83. The NFHS-3 survey showed that 1 per cent women and 11 per cent men aged 15-19 yr and 1.4 per cent women and 28.8 per cent men aged 20-24 yr consumed alcohol21. Other population based studies have shown the prevalence of alcohol consumption varying from 1.3 to 15.6 per cent across studies84858687 with a high consumption among males (12.6 to 20.7%)8889 and more in urban (5.2%) as compared to rural (7.3%) areas90 (Table VI).

Table VI Alcohol use prevalence and patterns among young adults

Other substance use disorders

Substance abuse apart from tobacco and alcohol is one of the major emerging problems among the young population and needs to be tackled effectively. The National Household Survey by UNODC showed that 3.0 per cent of males consumed cannabis and 0.1 per cent opiates82 with common substances used being alcohol, tobacco, cannabis, cocaine and heroin8486888990919293. Studies have shown that non tobacco substance abuse is common, nearly 30 per cent, among street children92 with 57.4 per cent of the male street children aged 6 to 16 years having indulged before coming to the observation home88. Around 43 per cent adolescents indulge in substances abuse93 with 58.7 per cent of the students having used one or more substances at least once in life, while 31.3 per cent regularly use one or more substances94. Chaturvedi et al reported that among 10-29 yr old individuals, apart from tobacco and alcohol use, 2.2 per cent of men and 0.3 per cent of women were opium users84. The use of prescription drugs (benzodiazepines and opiods) has also been a matter of great concern with its overuse being 16.2 per cent91. Data on prevalence of injecting drug users available in India, showed that 5.6 and 14.4 per cent of the males in the age group of 20-24 yr and 25-29 yr, respectively were injecting drug users95. The data from the National Health Survey suggested that about 0.1 per cent of the male population (12-60 yr) reported ever injecting any illicit drug. Injecting drug use was reported more often from the NE region of the country82.

Non-communicable diseases (NCDs)

NCDs include a number of conditions that are behaviour linked and lifestyle related in nature. Indian population, especially young people, is passing through a nutritional transition and is expected to witness higher prevalence of adult non-communicable diseases such as hypertension, diabetes and chronic lung diseases in the coming years.

At the Indian level, a few studies have shown hypertension among the young people to vary from 2.4 to 5.9 per cent comparable to global level (4.5%)96979899. In another Indian study, hypertension (first instance) was seen in 10.10 per cent of normal weight, 17.34 per cent of overweight and 18.32 per cent of obese children100. The prevalence of youth-onset type 2 diabetes is increasing worldwide in parallel with the obesity epidemic. Study from Chennai reported a temporal shift in the age at diagnosis of type 2 diabetes to a younger group with a prevalence of 3.7 per cent among 20-29 yr101. A study from Delhi also reported a high prevalence of insulin resistance in post pubertal children which was associated with excess body fat and abdominal adiposity102. Chronic lung diseases are also increasing among the young and globally, approximately one in ten young people have asthma99. A study among the school going children (5-15 yr) using modified ISAAC questionnaire in Jaipur city showed 7.59 per cent children to have asthma (in last 12 months)103 and 4.9 per cent in another study in South India104.

Road traffic injuries (RTIs)

Road traffic injuries (1,85,000 deaths; 29 per cent of all unintentional injury deaths) are the leading cause of unintentional injury mortality in India105. National Crime Records Bureau (NCRB) report of 2011 of India showed that 31.3 per cent of the road traffic deaths were seen among 15 to 29 years individuals63 (Fig. 2). Transport Research Wing of the Ministry of Road Transport & Highways (MORTH) revealed that of the total road accident casualties, 30.3 per cent were in the age group of 15-24 yr106. The Registrar General of India (in 2001-03) showed that motor vehicle injuries contributed to 3.7 per cent of deaths in 5-14 years and 6.9 per cent deaths in 15-24 years (1.7 and 12.4% in females and males, respectively)107. A survey of 20,000 households covering 96,414 individuals in Bangalore found that deaths due to RTIs among children aged 6-15 yr ranged from 5 to 20 per cent and serious injuries from 10-21 per cent and over half of all killed and seriously injured in RTIs occurred to the young adults aged 16-45 yr, more so among those aged 16-30 yr108. The Bangalore Injury Surveillance Project has reported that 38.9 and 36 per cent in 15-29 yr age group had fatal RTI in urban and rural areas, respectively, while 36 per cent had non-fatal RTI in both areas among the same age group109. Sharma et al from Chandigarh110 reported that RTI constituted 11 per cent of the total unnatural deaths among 16-20 yr age group. The incidence of non fatal RTIs among children examined in a few studies revealed that the age-sex adjusted incidence rate among 5-14 yr age group was 18.5 per cent and the age-sex-adjusted annual rate of RTI requiring recovery period of >7 days was 5.8 per cent111. The same authors reported an annual non-fatal RTI incidence rate adjusted for sex among 10-14, 15-19 and 20-29 yr of 23.5, 30.1 and 20.9 per 100 persons per year, respectively112.

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Fig. 2

Trend of road traffic injuries among 15-29 yr old individuals from 2002 to 2011 in India. Source: Ref. 63.

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Violence

The 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, psychological harm, mal development or deprivation”113. Interpersonal violence among youth ranging from minor acts of bullying to severe forms of homicide contribute greatly to the burden of premature death, injury and disability; harming not just the affected but also their families, friends and communities. An average of 565 adolescents and young adults between the ages of 10 and 29 yr die each day as a result of interpersonal violence across the world114. NFHS-3 from India revealed that 27 per cent married young females experienced physical, sexual, or emotional violence by their spouse and 7 per cent of all females and 11 per cent of married females experienced sexual violence21. Studies from India (Table VII) reported that 19 to 42.8 per cent of adolescent females had experienced domestic violence115116 and 25.3 and 32.2 per cent of young married women experienced physical and sexual violence within marriage, respectively117. Deb et al118 in a sample of students aged 14 to 19 yr showed that 20.9, 21.9 and 18.1 per cent of the children experienced psychological, physical and sexual violence, respectively. Sharma et al121 showed that 13.5 per cent adolescents aged 14 to 19 yr had threatened or injured someone with a weapon in the past 12 months; 49.1 per cent boys and 39.6 per cent girls reported being involved in a physical fight in the past 12 months. Both the genders were commonly involved in inter-personal violence as shown by Baruah and Baruah119 where 42 per cent males and 49.6 per cent female aged 15-29 yr had indulged in interpersonal violence and 48 per cent males and 60.4 per cent females had indulged in self inflicted violence.

Table VII Prevalence and pattern of violence among young people

Multiple health behaviours and co-morbid conditions

It is important to highlight that some behaviours and conditions listed above and several others not covered here do not occur in isolation but are often seen as coexisting behaviours and as co-morbid conditions. It is widely acknowledged that tobacco and alcohol use coexists, while binge drinking is closely linked to road crashes and violence. Alcohol is linked to more than 60 health problems and a variety of social issues ranging from domestic violence to diabetes. Similarly, depression and obesity are closely linked to a number of NCDs and depression in particular with suicides. The Health Behaviour Study in Bangalore covering nearly 10,000 individuals aged 18 to 45 yr from urban, rural, slum and transitional areas reported that 30 per cent had more than five behaviours/conditions existing in the same individual122. Evidence from National Household Survey showed that over 26 per cent adult men found to be alcohol users also had higher prevalence of STIs123. Thus, it becomes apparent that while addressing one problem becomes critical, addressing multiple issues in an integrated manner becomes a need in health policies and programmes.

Responding to the challenge

The importance of investing in youth has been recognized in India's Constitution. One of the Directive Principles of State Policy, states that “…it is imperative that children are given opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity and that childhood and youth are protected against exploitation and against moral and material abandonment”124. Policies and programmes focussing on education [National policy on education (1986 modified in 1992)125, Sarva Shiksha Abhiyan126, Rashtriya Madhyamik Shiksha Abhiyan]127, welfare [National Policy for the Empowerment of Women (2001)128; Balika Samridhi Yojana, 1997129; National Policy on Child Labour, 1987]130, employment (Swarnjayanti Gram Swarozgar Yojana)131 and others (National Policy for Persons with Disabilities)132 have included young people and highlight health as one of the components. In many of these, the detailed implementation – monitoring and evaluation plan are not elaborated in detail and their impact needs to be examined in detail.

Some of the health policies and programmes have also given a place for youth; a few have a specific youth health focus while others make an indirect mention. The Implementation Guide for State and District Programme Managers under National Rural Health Mission notes that “friendly services are to be made available for all adolescents, married and unmarried, girls and boys”133. Some of these are also focussed on mothers and children. The National Population Policy 2000, the National Health Policy 2002 and the National AIDS Prevention and Control Policy 2002 have all articulated India's commitment to promoting and protecting the health and rights of adolescents and youth, including those relating to mental, and sexual and reproductive health134. The Recent National Programme on Prevention and Control of Cancer, Cardiovascular Diseases, Diabetes and Stroke also has a focus on health promotion and early recognition of health impacting behaviours.

The exclusive National Youth Policy of 2003 driven by the Ministry of Youth Affairs & Sports has attempted to focus on special requirements of youth, covering 13 to 35 years, further subdivided into 13-19 years and 20-35 years. The adapted strategies include youth empowerment, gender justice, inter-sectoral approach, and an information and research network. The priority target groups under the policy include rural and tribal youth, out-of-school youth, adolescents particularly females, youth with disabilities and adolescents under special circumstances like victims of trafficking; orphans and street children135. A number of State-specific policies and programmes also exist that highlight State strategies for meeting the needs of youth134. It is also apparent that the impact of these policies on health of youth has not been evaluated for its coverage, comprehensiveness, efficacy and effectiveness.