Health impacting behaviour & morbidity: Implications for adolescent & youth health programmes in India

Young people (10-24 yr) form a critical and resourceful population for every country1. In India, they constitute about 35 per cent of the total population2. The transition from childhood to adulthood is a critical transition period characterized by biological, physical, emotional and social changes. Young people face several health problems related to nutrition, substance use, mental health, risky sexual behaviours, personal hygiene, injuries and violence34 impacting their development. These health problems can become chronic as age progresses56. Most risk factors (alcohol, tobacco etc.) for chronic diseases such as diabetes, hypertension and stroke are known to begin during this period57. To maintain optimal health and wellbeing among young individuals, it is essential to provide them with comprehensive healthcare services that address their preventive, promotive, curative, and rehabilitative requirements. However, health problems of young people have not received significant attention in routine healthcare delivery. Existing health programmes such as Rashtriya Kishore Swasthya Karyakram (RKSK)8 and Reproductive, Maternal, Neonatal, Child Health and Adolescent plus (RMNCHA+) are mostly service oriented and focus on immunization, education related to nutrition, sexual and reproductive health aspects9. Lately, there is some focus on adolescent girls under the National Health Mission (NHM)3810. Activities mostly involve school health examination, health promotion and conducting adolescent reproductive and sexual health (ARSH) clinics8. The key challenges for these programmes include poor engagement of frontline workers, limited usage of adolescent-friendly clinics11 and lack of a defined monitoring and evaluation framework12. An evidence-based, risk factor centric approach towards locally relevant health promotion and care delivery programmes for young people is needed.

As an initial step towards developing a State specific health programme based on empirical evidence, the Himachal Pradesh (HP) Department of Health and Family Welfare (DHFW), in collaboration with the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India, conducted a representative State level survey on adolescent and youth health. The primary objective of this survey was to estimate the prevalence of significant health related behaviours and issues among young individuals in HP, specifically focusing on nutrition, substance use (alcohol and tobacco included), mental health (primarily anxiety and depression), sexual behaviours, personal hygiene, as well as violence and injury (including road traffic accidents and other types of injuries). Due to lack of available programmatic data on population pertaining to youth health from the study area, with due permission of the Directorate of NHM, a prior report13 of this survey was first released to facilitate immediate uptake and utilization of this data

Material & Methods

The HP State National Health Mission (NHM) and Department of Health and Family Welfare (DHFW) in collaboration with National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, conducted a State-wide representative cross-sectional survey of young people (10-24 yr)1, as defined by the World Health Organization (WHO), between September 2014 and March 2015. A stakeholders’ workshop was conducted before the survey to seek inputs regarding the purpose, areas of enquiry, design, methodology and utility of the survey. The stakeholders consisted of programme officers of the DHFW and NHM, senior medical and public health officials, academicians and researchers of Shimla University and the Population Research Centre of HP along with young people and their parents.

Appropriate ethical principles were followed for the survey. Administrative approvals for the study were granted by the NHM, HP. Prior to conducting the interviews, written informed consent was obtained from all respondents, and for participants under the age of 18, guardian consent was obtained. The ethical approval for the study was obtained from the Institutional Ethics Committee of NIMHANS.

Sampling strategy: A stratified multistage cluster sampling strategy was adopted for the survey conducted in 12 administrative blocks of four districts (3 from each district), namely Shimla, Kinnaur, Kangra, and Sirmaur. The districts and their blocks were selected purposively based on the recommendations of the participants of the stakeholder workshop to ensure representation from the diverse sociodemographic as well as cultural characteristics of HP. Within each of these selected blocks, 30 clusters were selected. Villages in rural areas and wards in urban areas were considered clusters for the survey. The clusters were selected by population proportion to size sampling using the standard WHO 30 × 7 cluster technique14. Villages and wards listed as per the census of India 20112 served as sampling frame for cluster selection. Thirty clusters were selected from within the blocks to include a larger geographic area within the districts. Overall, 360 rural clusters and 30 urban wards were selected as clusters for the survey. All 360 rural clusters were from the districts of Kangra, Kinnaur and Sirmaur. All urban clusters were from Shimla since more than 50 per cent of the State’s urban population live in Shimla. This decision was aligned with the stakeholders’ recommendation. As a result, all 30 urban clusters were selected from Shimla urban district alone. The total estimated sample size was calculated to be 2730 with a confidence level of 95 per cent with a design effect of three. This sample size yields a power of around 85 per cent. The design effect of three was adopted as a thumb rule15. The information related to intra-cluster correlation for health impacting behaviours to calculate the design effect was not available.

Data collection: Data collection for the survey was carried out by a team of six interviewers, all of whom underwent comprehensive training in interviewing skills, especially in eliciting sensitive information, the study’s specific protocol, research ethics, and the responsibilities associated with their roles. Following a two week residential training, the interviewers received an additional two weeks of field training.

Effective oversight and coordination of the data collection process was done by a programme coordinator (PC). The PC played a crucial role in monitoring all activities related to the survey.

The principal investigators (PIs) from NIMHANS were actively involved in the project and made repeat visits to the survey location in Shimla. During these visits, the PIs engaged in planning sessions, provided supportive supervision, delivered training, and monitored the field activities to ensure the survey’s overall success.

The research team employed digitization for data collection and management, facilitating timely monitoring of data both locally in Shimla and at NIMHANS in Bengaluru. This approach enabled efficient data verification, conducted daily by the program coordinator and a data entry clerk. Any identified errors in the data were promptly addressed by seeking clarification from the field team. The necessary changes were communicated to the PIs via email.

To maintain data quality, regular field monitoring was carried out by the program coordinator, ensuring accuracy and reliability of the data collection process. In cases where errors exceeded five per cent upon verification, the cluster in question would be considered for re-survey. However, no such clusters were found during the survey, indicating the robustness of data collection procedures.

Throughout the survey, particular attention was given to creating a comfortable and private environment for the respondents. This approach aimed to foster an atmosphere of trust and confidentiality. This facilitated collection of sensitive information such as sexual history, substance use, suicidal ideation and violence.

A pretested semi-structured schedule specifically developed on a digital platform was used for data collection. This schedule was provided in Hindi as well as English languages. The schedule had two sections16. Section 1 of the study focused on collecting household sociodemographic information. This involved conducting a line listing of all household members and capturing key sociodemographic information such as age, gender, marital status, education level, religion, and occupation. The aim was to establish a comprehensive profile of the households participating in the study. Section 2 delved into various dimensions of health related factors. It encompassed a range of questions covering different domains. It consisted of questions on nutrition, reproductive and sexual health, screening questions for risk of depression, anxiety and suicidality, questions on alcohol, tobacco (chewing/smoking), and other substance use, injury and violence. Further, there were questions on mobile phone use, peer influence, exposure and influence of media and health seeking practices.

The nutrition information included respondents’ predominant dietary patterns (frequency of consumption of eggs, meat, fish, and unhealthy processed foods) along with information on height and weight for calculation of body mass index (BMI) using the Quetelet index (weight in kg/height in cm²) to classify underweight, normal weight, overweight and obese individuals. Reproductive health questions included awareness about puberty, reproductive health and relationships, age at menarche and menstrual hygiene practices as well as sources of information.

The section on sexual health included data on individuals’ sexual activity, the number of sexual partners they had, and condoms usage patterns during sexual encounters. Additionally, participants were asked about their sources of information regarding sexual aspects. A set of 13 questions was used to identify potential cases of depression, anxiety, suicidal thoughts, and substance use involving tobacco, alcohol, and drugs (either injectable or oral). These screening questions were derived from the previous survey experience of the research team. Responding affirmatively to any of these questions directed participants to the relevant sections for more detailed information, including details such as age of initiation, current usage status, and potential dependence. To assess dependence on tobacco through smoking or chewing, the modified Fagerstrom questionnaire1718 was used. Alcohol and injecting/sniffing/oral drug dependence was evaluated using appropriate CAGE questionnaires1920. To determine the risk of mobile phone dependence, a set of six screening questions (answered with “YES” or “NO”) developed by the Centre for Addiction Medicine at NIMHANS was used. If a respondent answered affirmatively (YES)2122 to more than three of these questions, it indicated a potential risk of mobile phone dependence.

The survey included inquiries about violence and injuries, specifically focusing on events that took place within the past year. Participants were asked about various forms of violence they may have experienced, the frequency of such incidents, the identity of the perpetrator, any hospitalization resulting from injuries, and details regarding instances where the participants themselves inflicted violence upon others.

Peer influence contained information on the number of peers, activities done with peers and their characteristics. Exposure to media (television, internet, video tapes, games and mobile) and related information (number of hours spent, type of use and kind of programmes they frequently watched) were collected.

The section on health seeking behaviour and knowledge, attitude, and practices (KAP) focused on information related to participants’ utilization of healthcare services. This included the type of healthcare facility sought for general ailments, reproductive health concerns, and mental health issues. Furthermore, data was collected regarding participants’ knowledge about ARSH and Kishori clinics, as well as their attitudes and practices towards healthcare.

Selection of households and study individuals: The standard cluster sampling method adopted by coverage evaluation surveys to select households and individuals was adopted for the study14. All individuals aged 10-24 yr within sampled villages and urban blocks were considered eligible respondents. During the survey, all eligible individuals present in the selected households at the time were interviewed. Within each cluster, a maximum of seven individuals were selected for the interview process. However, in cases where the number of eligible respondents exceeded seven during the final household visit, all available respondents within that household were interviewed. Data collection was mostly conducted early in the morning or late afternoon. This ensured that school-going respondents participated in the survey, thereby minimizing the selection bias associated with the non-inclusion of school-going eligible respondents.

A pilot survey was conducted in a village (outside of the sampled villages) within Shimla for two weeks following field training. This was conducted to assess the feasibility of study procedures, finalize questionnaires, digital tablets and data retrieval from the server and finalize survey logistics.

Descriptive analysis of data was performed. Proportions were estimated for factors such as underweight and obesity, tobacco smoking, chewing, alcohol and other substance use, violence, injuries, depression, anxiety, self-harm, etc. Chi-square test for independence or Fisher’s exact test was used, as appropriate, for categorical variables to test the significance of association between gender and all attributes. Independent t test was used for continuous variables.

Results

The survey achieved a high response rate of 99.18 per cent. For the analysis, nine respondents who partially completed the interview and eight respondents who refused the interview were excluded from the dataset. The mean age of boys (17.43±3.70 yr) and girls (17.56±3.73 yr) was similar. The majority of the participants were students (87.4%), unmarried (95%) and had at least (86.15%) 8-10 years of schooling (Table I). Gender distribution of respondents was similar with a slightly increased representation of boys (51.4 vs. 48.6%). Individual age distribution of the study individuals was similar to the age distribution of 10-24 yr as per the census of India 20112 (data not shown).

Nutritional status: Approximately half of the respondents (50.64%) had normal BMI (Table I). About 44.39 per cent were underweight [girls (49.04%) > boys (39.99%)]. Nearly 30 per cent of respondents consumed junk food at least once a week (Table I).

Sexual and reproductive health and hygiene: The mean age at menarche was 14.46 yr among girls in HP. The majority (77.75%) of respondents used sanitary pads and 21.14 per cent used cloth during menstruation (data not shown).

About 11.88 per cent of respondents had engaged in sexual intercourse in HP (boys – 14.72% vs. girls – 8.88%; Table II). Approximately 40 per cent had initiated sexual activity before 18 yr with almost 90 per cent before they attained 21 yr. Nearly half of the sexually active girls had never used a condom (49.6%). School teachers were the most important source of information about puberty (69.26%), reproductive health (56.75%) and relationships (48.12%).

Psychological wellbeing and addictive behaviours: In this study approximately eight per cent of young people from HP were current smokers. Overall, 5.35 per cent of young people in HP were current alcohol users (Table II). Alcohol dependence was seen only among boys (7.91%). About 19.62 per cent of mobile phone users were at risk of mobile phone dependence [boys (25.67%) > girls (13.22%)]. Overall, 6.94 per cent of young people in HP felt depressed and 15.54 per cent felt excessively anxious (girls – 19.19% > boys – 12.1%) (Table II).

Injury and violence: Overall, 14.72 per cent of young people in HP had experienced injuries (Table II) in the past year (boys – 18.55% > girls – 10.66%). The majority of respondents reported falls (57.75%), followed by road traffic injuries (RTI; 25.12%). A higher proportion of boys reported RTIs (31.52 vs. 13.33%) compared to girls. Burns and animal bites are higher among girls (13.33 and 14.67%, respectively) compared to boys (3.99 and 9.42%, respectively). Approximately half of those who experienced RTIs (52.34%) and falls (53.66%) and 66.67 per cent with animal bites sought hospital care.

About 1/5^th (18.54%) of the respondents had experienced intentional injuries (boys – 24.32% vs. girls – 12.45%). Overall, 8.19 per cent of the respondents had experienced some form of interpersonal violence with a higher proportion (10.48%) among boys compared to girls (5.76%), whereas sexual abuse was five times more among girls as compared to boys. Overall, 2.69 per cent of respondents reported as having suicidal ideation (girls – 3.77% > boys – 1.68%).

Media and technology: Almost everyone (96.51%) in HP spent an average of two hours/day viewing television. Boys watched diverse programmes (movies – 38.76%, sports – 17.74%, serials/soaps – 17.67% and cartoons – 10.13%) while girls mostly watched serials/soaps (78.49%). Internet usage was higher among boys (50.07%) than girls (23.67%) (data not shown).

Health seeking behaviour: Majority of the young people in HP sought care at government hospitals for both general (84.39%) and mental illness (89%) (Table II), while their knowledge about adolescent and youth health services was found to be low.

Discussion

This was one of the first comprehensive and representative cross-sectional survey of 2895 young people, aged 10-24 yr in HP and found that being underweight (Table I), risk of cell phone dependence, feeling anxious, unintentional injuries and violence (Table II) were the top five health issues among the youth in HP. This study is unique in being a representative survey assessing the ten most important health-related aspects affecting the young in India348910. It throws light on the importance and relevance of health programmes of the young. As they form a considerable part of the demographic dividend, investing in their health becomes vital. Addressing these issues early in life is likely to reduce the development of nutritional problems, reproductive and sexual health problems, NCDs, mental health and injuries as adults.

Underweight and anxiety are generally considered a normal characteristic among the young. Both are observed to be more among girls as compared to boys. Injuries and violence are known causes of mortality and morbidity in this age group23. It is common among boys as compared to girls. The emergence of substance use, addiction problems, risk of cell phone addiction, etc. as the top ranked health problems is a matter of serious concern. As per anecdotal reports, these are increasingly becoming major health concerns among young people22. Furthermore, these risk factors (i) significantly contribute to NCDs including mental health in later life56924; (ii) can have individual, combined and cumulative effects; (iii) are progressive in nature leading to chronicity; (iv) can impact life and living (injury and violence leading to some form of impairment/ disability); and (v) are influenced strongly by existing social environments and peer influences. These data strongly indicate the importance of utilizing population-level data for evidence-based implementation of programmes. Further, these findings reiterate the need for gender responsive strategies to address underlying health inequities that influence young people’s health25.

To enhance the effectiveness of existing health promotion and care programmes such as the RKSK through ARSH Clinics8, the expansion of services and improved accessibility should be prioritized. Additionally, emphasis can be placed on providing iron and folic acid supplements through the weekly iron and folic acid supplementation (WIFS) programme, as well as ensuring the availability of subsidized sanitary napkins through the State NHM. Currently, the RKSK adapts a more disease-centric approach and is based within a healthcare setting where stigma can be a major barrier. This needs to shift towards a risk factor centric community-based intervention like the establishment of guidance centres as done under programme Yuva Spandana (meaning responding to youth) in Karnataka26. In line with this recommendation of risk factor-centric approach, the Ayushman Bharat programme (ABP)27 also proposes a comprehensive primary healthcare focus rather than a disease-specific and reproductive and child health focus. This is deemed as one of the strengths of ABP2728.

In addition to the prevalence of health impacting behaviours and conditions, this study looked at the source of health related information, current understanding and help seeking. The young in HP mostly accessed government health facilities for care but were underinformed about youth health and ongoing State health programmes similar to other studies29.

Teachers played a significant role in providing information to young people in HP. Enhancing their involvement in youth health promotion and ensuring the availability of counselling and support services in strategic locations can yield better results. Training teachers through the RKSK programme can be supportive and effective in reducing stigma in the long term. Targeted advocacy and Information, Education, and Communication (IEC) efforts need to be implemented across various issues, addressing concerns ranging from the perception of stigma related to mental health to the availability of services. The media, including both print and visual platforms and social networks, can play a crucial role in shaping the opinions, attitudes, beliefs, and behaviours of young people. Engaging the media more effectively can help inform young individuals about positive health practices and their beneficial impact.

This requires convergence of activities for significant influence on their attitude and behaviour. Furthermore, services and facilities need to be augmented for both general (example: health promotion and risk reduction) and specific programmes (example: psychosocial and counselling services, nutrition programmes, de-addiction services, mental health services, etc).

The concept of health and wellness centres (HWCs) under the ABP2728 is a good opportunity, given the reach and positioning of the centres. Among the components of HWCs, expanding health services closer to the community, community mobilization and health promotion among the young would serve the purpose27283031.

This study had certain limitations. The age group identified for this survey is debatable due to the lack of standard definition for youth32. As per the WHO, adolescents are aged between 10-19 yr. United Nations define youth as those aged between 15-24 yr32. The current National Youth Policy of India defines youth as 15-29 yr33 reduced from the earlier definition of 15-35 yr. However, during the stakeholder consultation, it was decided to adapt the United Nations definition of ‘young people’ (10-24 yr)1 which includes both adolescents and youth, for the survey. It can be argued that the issues of study individuals are likely to be different in different age groups. However, the health-impacting behaviours assessed are likely to commonly affect all age groups in the study. Purposive selection of blocks and districts for the survey restricts the generalizability of the results. However, considering the time and other resource constraints of sampling, the stakeholder’s recommendation to represent the geo-socio-cultural diversity of HP was the best option available. Shimla was selected as the only urban cluster. More than 50 per cent of the State’s urban population live in Shimla and is likely to be representative of other urban areas of HP. This was done as opined by the stakeholder consultation for operational convenience since the remaining 50 per cent is scattered across the remaining districts of HP. In addition, the selection bias associated with such selection cannot be ruled out. The 30 × 7 cluster sampling technique utilized in this study was primarily developed to calculate the prevalence of immunization among children; however, this sampling design is thought to be sufficient for most sampling techniques related to community health factors34. Certain questions on sexual behaviour and habits might be socio-culturally sensitive and underreporting could have influenced the study results. However, given the rigorous training of field investigators and the informed consent process, this can be considered minimal.

In conclusion, despite these limitations, the present survey highlights the significant burden of different health issues of young individuals within HP. The key health concerns for young people that require specific attention are underweight, dependence on technology, anxiety, injuries and violence, as well as mental health problems including substance use. These areas have been identified as priority health issues requiring focused efforts. All these issues are linked either directly or indirectly to ongoing nutrition and epidemiological transition and are behaviour related. The results of this survey iterates a strong need for strategic investments to develop, integrate and implement adolescent and youth health programmes focussed on these issues with inputs regarding the influence of media and technology; low healthcare seeking, source of information for important and sensitive issues in HP. The focus needs to be on maintaining positive health through integrated care interventions, risk reduction and health promotion with a life course perspective. These interventions need regular monitoring and evaluation through repeat surveys to assess their efficacy and effectiveness.

Declaration: This survey was commissioned by the Directorate of National Health Mission (NHM) as part of the National Rural Health Mission activities towards strengthening of adoloscent and youth health, and mental health programme in the State of Himachal Pradesh. In order to ensure prompt uptake and utilization of this programmatic data which was lacking in this area a prior survey report of this study was first released with due permission from the Directorate of NHM. Following the submission of the report, The Directorate of NHM and Directorate of Health in Himachal have initiated the opening of Nayi Disha Kendr in about 100 institutions across the State. These are dedicated centres with a dedicated health counsellor supporting adolescents and/or youth with issues related to their health.