(2005-2012)

Reading Material for

ASHA
Book No- 3

Family Planning, RTI/STIs & HIV/AIDS and ARSH

Ministry of Health and Family Welfare Government of India

READING MATERIAL FOR ASHA

Reading Material for ASHA

Book No-3

Family Planning, RTI/STIs & HIV/AIDS and ARSH

JULY, 2006

Ministry of Health and Family Welfare Government of India

(2005-2012)

READING MATERIAL FOR ASHA

Contents
S. No. Particulars Acknowledgements 1. 2. 3. 4. 5. 6. Introduction Preventing Unwanted Pregnancies RTIs/STIs HIV/AIDS Adolescence: The Period of Growing Up Helping Adolescent Girls to Take Care of Themselves During Menstruation Page Nos. 5 7 9 21 25 28 31

Acknowledgements

Numerous people have contributed to the development of this reading material for ASHA. We acknowledge the contribution of the Mentoring Group of ASHA and other experts who have given their suggestions, valuable time and labour to bring out this reading material for ASHA. We are especially grateful to Shri Prasanna Hota, Secretary, Health & Family Welfare, Smt. S. Jalaja, Additional Secretary, Shri B.P. Sharma, Joint Secretary and Dr. D.C. Jain, Additional Director (Public Health, NICD) for their encouragement, constant support and guidance. We would like to thank United Nations Population Fund (UNFPA) and National Institute of Health & Family Welfare (NIHFW), for rendering support in organizing the reading material. We also acknowledge the important contribution of Dr. Dinesh Agarwal, Technical Adviser (Reproductive Health), UNFPA, India. I gratefully acknowledge the hard labour and sincere efforts put in by my colleagues Dr. Manoj Kumar, Assistant Commissioner (Training) and Dr. Himanshu Bhushan, Assistant Commissioner (Maternal Health). Dr. Narika Namshum Deputy Commissioner Training Division Ministry of Health & Family Welfare Government of India July 2006

Introduction

Book no. 1 helped you to familiarize yourself with your partners in your work in the village. In Book no. 2 you have learnt in general about your roles, simple measures to promote health and prevent diseases among women and children in your village. You have learnt in somewhat greater detail about maternal and child health care including newborn care and nutrition. In this book you will learn in detail about how to prevent unwanted pregnancy, the various methods that are available, the merits of each method, the side effects that need to be watched for and advice that needs to be given. You would also be learning about what advice to give to women and men who have complaints suggestive of reproductive tract infections or sexually transmitted infections. This book will also build on your information on the causes, transmission and prevention of HIV/AIDS. You know very well that there are many adolescents and young boys and girls in your village. In general, they may appear to be healthy, but they need advice and counselling for developing healthy habits. They may also need health care for some of the common problems. Also in some parts of our country, marriage takes place at an early age, so that pregnancy and child-bearing happens early in their life. Hence adolescent girls need to get proper care in pregnancy and childbirth. Adolescents need to be

READING MATERIAL FOR ASHA

told about the ill effects of early marriage and pregnancy. Over a period of time you will succeed in making sure that no girl below the age of 18 gets married. Adolescents also need knoweldge and skills to promote their health and prevent diseases. This book will help you in counselling the couples and individuals about family planning and how and when to get the services.

Preventing Unwanted Pregnancies

What is family planning?
Many couples want to either limit the number of children in the family or wish to wait for some time before having children. Similarly newly married couples may like to delay having children for two to three years. There are several ways by which couples can plan their familys size

Benefits of family planning

Using any family planning method for preventing pregnancies can lead to following benefits for the health of mother and children in the family.

Mother

Women with four or more children have greater risk of death during childbirth. Similarly older women have more problems during childbirth. If adolescent girls get married early i.e. before 18 years they start having children too soon. These girls are more likely to have complications or can die during childbirth. Also children born to these mothers have low birth weight and more likely to die in the first year.

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Children

If a woman has children too close i.e. less than 36 months interval, her own health and her childrens health suffer. Family with fewer children will be able to take better care of them, including their educational attainments, growth and development.

Other benefits

Some contraceptives i.e. condoms (both male and female condom) help in protecting against infections of genital tract including HIV/AIDS as well as preventing unwanted pregnancies. Some methods are good to regulate irregular bleeding from uterus. Use of family planning methods will allow women to exercise their right over their own bodies. If they do not wish to have more children then they can use contraceptives with discretion.

Different family planning methods

Pregnancies are caused by the union of egg produced by the woman and the sperm by the man. The egg (which later grows into a baby after union with the sperm) is produced inside the womb of the woman. When a sexual union between man and woman takes place, sperms released to the vagina of woman swim toward the egg in the womb. Union of egg and one of the sperms results in pregnancy. The walls of the womb provide nourishment to the egg. The egg unites with the sperm and grows into a baby. There are five main types of family planning methods: Barrier methods If the sperm does not reach the egg, pregnancy can be avoided. For example, when a man uses a condom, the sperm remains inside the condom only. Therefore, the sperms are not able to reach the egg inside the womb. Thus pregnancy is prevented.

Man

Sperm

Sperm enters the egg and unites with it Woman

Fetus, which grows into a baby

Egg

Hormonal methods This prevents the womans ovary from releasing an egg, make it harder for the sperm to reach the egg, and keep the lining of the womb from supporting a pregnancy. For example Mala N tablets.

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IUDs These are devices inserted inside the womb. They prevent the egg and sperms from fusing and also prevent implantation. Natural methods These help a woman to know when she is fertile, so that she can avoid having sex at that time.

Permanent methods
These are operations, which prevent a man or a woman to have any more children in future.

Barrier methods
You will be provided with condoms for distribution to women who need them. Women are shy to buy them from the market. Many do not know how to use them and where to keep them.

Condoms (Nirodh)

Prevent unwanted pregnancy and sexually transmitted infections including HIV/AIDS A new condom is to be used each time during sex Correct and consistent use of condoms is essential to prevent unwanted pregnancies

How to use condom?

You will be shown how condoms could be used

1. Open package carefully

2. Unroll condom onto erect penis before genital contact

3. Be sure to unroll condom all the way to base of penis

4. Remove penis from vagina while still erect and hold onto condom

5. Dispose off properly

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Dispose off the condom properly. Keep condoms in cool, dry place and away from sunlight. Keep a stock of condoms and show how to use them, and make condoms available.

What you have to do:

Advise families to use condom as a family planning method. Also explain that condoms prevent sexually transmitted infections. Make condoms available to all those who wish to use them. If the situation is suitable, you can show the couple how condom is used. Use a flip chart and a condom piece. Sometimes you will have to show it to the woman and ask her to share it with her husband. Some myths and doubts about condoms need to be answered. The misconceptions are: Condoms reduce pleasure of sex. A condom user is an easy person. If not properly used, condoms can burst during use. In that case, advise to use emergency contraceptive pills. The female condom is now available in cities, so that even women can use a condom. That is helpful when men are unwilling to put on condoms and it empowers women in risky sex situations.

Hormonal methods
Oral contraceptive pills
Oral contraceptives come in cycle packs of 28 pills. Only the first 21 of them contain hormones. The other seven pills contain iron supplements. One pill has to be taken each day. The iron supplement pills are taken after completing 21 hormone pills. Since most women are anaemic, the iron tablets are also helpful. These pills do not interrupt the sexual activity. Above all, unlike condom, OCP is a woman-controlled contraceptive method. There are several brands available

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in the market. Our ANM and PHCs have supply of MALA-N. You could keep a supply of these pills.

How to use OC
Start the pill from any of first seven days of start of menstrual bleeding and continue until the pack finishes. Start a new pack again. Taken regularly, the pill is almost 100 percent effective in preventing pregnancy. These pills do not cause abortion. If a woman forgets a days dose she should take both the missed and regular tablets together. But one must not miss it for more than two days. If missed for two days, advise her to take pills as soon as she remembers. She can continue taking the pill each day until the pack is finished and also use a condom for sex until seven hormonal pills are taken in a row. You should always mention about the common side effects of oral contraceptives such as nausea, mild headache, tenderness of breasts, spotting between periods and sometimes-irregular periods. Explain that these side effects are not signs of any serious disease. These usually become less or stop in three months. You should help women in getting examined by ANM/Medical Officer, before starting oral pills. You should give monthly supplies to women who have started oral pills after consultation with ANM/Medical Officer.

Emergency Contraceptive Pills (ECP)

Emergency contraceptive pills are pills to be taken within 72 hours of unprotected sex. These pills are taken only in some emergency situations. These pills are especially useful for those women who have been subjected to unprotected sex, slippage or bursting of condoms during sex or sexual violence. These pills are to be taken as soon as possible after unprotected sexual exposure preferably within 72 hours. These pills will also not work if the woman is already pregnant. She should take two tablets within an interval of 12 hours.
Take the first tablet as soon as possible within 72 hours of unprotected sex.

Take the second tablet 12 hours after you take the first tablet.

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Next monthly bleeding will take place within 14 days of scheduled day of monthly bleeding. These pills are now available at health centres and also at pharmacy shops. No prescription is needed to buy them. They are available as EC pills in the programme. Several commercial and social marketing brands are also available. ECPs, taken as per instructions, provide protection against unwanted pregnancy. Discourage repeated use of ECP and advise for choosing a contraceptive method. ECPs do not protect against infections like STI and HIV/AIDS.

What you should do:

You are a depot holder for OCPs (Mala N) You should explain all methods to the women and help them in making choices Start Mala N tablets after consulting with ANM/doctor that the woman is eligible for OCPs Tell her about side effects and when/where to approach a service provider Also provide information about ECPs and where these pills are available

Copper-T
This is a small T-shaped intra-uterine device (IUD). It is made of pliable plastic with fine copper wire wound around its stem. Two plastic threads hang by its stem. After insertion into the womb, Copper-T stays in place and is effective for a maximum of ten years. Some Copper-T devices available in the market are effective for shorter duration also.

How does the Copper-T work?

Copper-T works mainly by preventing sperms and egg from meeting. IUD makes it hard for sperm to move through the womans reproductive tract and reduces ability of the sperm to fertilize the egg. Possibly it also prevents implantation.

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Copper-T can be used

Within seven days of last menstrual period After six weeks of child birth This is the best time Only trained nurses and doctors should insert Copper-T Copper-T should be inserted only at health centres or hospitals Women can get Copper-T removed any time on demand

Copper-T is generally safe to use. However it is very critical that proper hygiene is maintained. Advise women to have check-up once after one month, then after three months and then once a year. Copper-T cannot be inserted at home because stringent cleanliness is needed during Copper-T insertion. The woman can go home immediately after putting Copper-T. Women should learn how to check the presence of Copper-T. Sometimes its gets expelled out of the womb. It is easy to learn technique of feeling the nylon threads in vagina. Copper-T cannot escape the womb and go up. It can be easily removed by a nurse with a gentle pull. Some women have pain and bleeding after inserting Copper-T. It stops after few cycles. If the condition does not improve then Copper-T can be removed. There are no after-effects if Copper-T is inserted after six weeks of delivery.

Removal
Copper-T should be removed after 10 years or earlier if woman wishes to have a child, or when she develops heavy bleeding, lower abdominal pain, or severe backache. You should help women in getting Copper-T removed at an appropriate facility.

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Your responsibilities:

Counsel women about FP methods including Copper-T Explain to them about the duration of protection and who can do insertion Accompany the woman to the nearest health centre for insertion Advise women on proper hygiene and cleanliness Educate women on natural family planning methods Talk about benefits of family planning to couples and individuals, boys and girls at different occasions. These issues can also be discussed in the meetings of self-help groups, adolescent groups. Include information about prevention of RTIs/HIV/AIDS also. Dispel any rumours or mis-conceptions about contraceptives in villages Find out the facilities where FP services are available such as NSV and female sterilization Accompany desirous men and women to a facility where sterilization services are provided. In some states there are monetary incentives for those motivating or accompanying sterilization or Copper-T acceptor Help nurse didi to contact women wanting to have a Copper-T insertion Promote male participation in family planning

Natural methods
There are also natural ways of preventing pregnancies. However, the woman has to learn many things that happen to her body during the menstrual cycle to adopt this method. Awareness of fertility means that a woman learns how to tell when the fertile period of her menstrual cycle starts and ends. Generally menstrual cycle of a woman lasts for 28 days. A woman is likely to be pregnant is she has sex during the fertile days (days 8-19 of the cycle). The natural method of fertility control includes: 1. Avoid having sex 2. Withdrawal 3. Safe period method 4. Cervical mucus method

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Safe period
Women with menstrual cycle between 26 and 32 days can prevent pregnancy by avoiding unprotected sexual intercourse on days 8 to 19, taking the day of starting of menstrual cycle as day one. You should know more about standard days method from your ANM.

Cervical mucus method

The opening of the womb of the woman has a sticky fluid called cervical mucus. Typically the mucus is thin and sticky for two days before and after ovulation, which allows for easy passage of the sperm. This is the fertile period. In other days the mucus is thick, dry and breaks on stretching. These days are infertile. These natural methods need a lot of self-control and have a very high failure rate. Therefore it is advisable to adopt other contraceptive methods that have low failure rate in case the woman does not desire pregnancy. However, fertility awareness of a woman is desirable in case of couples with the problem of infertility to increase their chances of conception in many cases.

Your responsibilities:

Talk about fertility awareness in the meetings of womens groups. With ovulation awareness a woman can choose to conceive or avoid conception in that cycle. However, it is essential to caution the couple on the high failure rate of this method. If a woman has not conceived so far, fertility awareness can help in timing the sexual intercourse and increase their chance of conception. For contraception, the couple needs avoiding sexual intercourse in fertile period.

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Lactational Amenorrhea Method

Breastfeeding under certain conditions can prevent the ovaries from releasing eggs. This method does not cost anything, but it is most effective for only the first six months after childbirth. How to use breastfeeding for preventing pregnancy? If baby is less than six months old. If the woman has not had monthly bleeding after giving birth. If the woman is exclusively breast feeding the baby, (not even water) and feeding the baby whenever she/he is hungry, with not more than six hours between feedings, day and night. The baby does not sleep throughout the night without feeding. Use another method of family planning as soon as any of the following things happen: Baby is more than six months old, or Monthly bleeding starts, or Baby starts taking other kinds of milk or other foods, or starts sleeping for more than six hours during the night

Your responsibilities:

Communicate messages on the Lactational Amenorrhea Method during meetings Explain to women about three conditions necessary for practicing Lactational Amenorrhea Method Assist the women for contraceptive method if she is not conforming to three conditions.

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Permanent methods
Vasectomy (male sterilization)
This is a very small operation for permanently preventing childbirth. Vasectomy requires less time and not much trouble for men. No hospital stay is necessary. There are two methods for vasectomy Conventional vasectomy No scalpel vasectomy

Conventional vasectomy
The procedure takes a few minutes and the person can go home in an hour. An experienced doctor uses a scalpel to make a small slit in the scrotum, and finds the vas on each side. The vas is tied and cut to stop the sperms from reaching the semen sac. One stitch is required.

No scalpel vasectomy
The no-scalpel method uses only a needle puncture to complete the process. No stitch is required. So no need to come back for stitch removal. This method is becoming popular. Now doctors are being trained in this new technique. There are less side effects of NSV as compared to conventional vasectomy. This is a safe and easy method and requires only 10-15 minutes. Men commonly think that vasectomy causes weakness in work and sexual life. This is not true and there is no evidence about it so far. The testicles are not even touched in vasectomy. It is the testicles that secrete hormones and regulate sexual functions. Vasectomy does not affect this any way. There is a need to popularize vasectomy.

Why sometimes pregnancy occurs after vasectomy?

After vasectomy three months are needed to make the semen sperm-free. A condom has to be used during this period This point is often ignored by men and conception can take place. Condom use for three months after vasectomy can prevent chances of pregnancy.

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Tubectomy (female sterilization)

Tying and cutting the tubes that carry eggs (egg-tubes) is tubectomy. There are several ways of doing this procedure. In many states this operation is done using laparoscope (doorbeen). It blocks the meeting of ovum and sperms. This is a popular sterilization method in India.

Two methods of tubectomy

Mini-laparotomy is the conventional method
This involves opening the abdomen through a small incision and operating by hand. Local anaesthesia is given by injection. The mini-lap method needs hospitalization for two days. It is useful for post-childbirth tubectomy, when the womb is still high in the abdomen and easy to reach.

Laparoscopy
This involves inserting a laparoscope into the abdomen and applying tight plastic rings on the tubes. Laparoscopy can only be performed when the womb returns to its normal size and position (at least six weeks after childbirth). Although tubectomy performed by an experienced surgeon is usually successful, laproscopic sterilization may sometimes fail. Complications are rare in case of tubectomy; sometimes there may be internal bleeding, infections, and possible tubal (ectopic) pregnancy later if a tube happens to reopen. In cases of major complications attributable to sterilization, failure and unlikely event of death, you should help in accessing compensation available as per FP insurance scheme. You will get more information from your ANM.

Reversing sterilization (recanalization)

For all practical purposes, sterilization operations are permanent procedures. But, in unusual circumstances like death of all children, recanalization to join the cut ends of tubes together can be adopted by the couple. But in both men and women, only one in four such procedures succeed. These facilities are available in big hospitals only.

3 Reproductive Tract

Infections (RT Is) including Sexually Transmitted Infections (ST Is)

What are RTIs/STIs and how are they spread?
Many women suffer sexual infection, including abnormal discharges through the vagina, ulcers and sores in the genital region and pelvic infections. Men also generally have sexual infections. Reproductive Tract Infections (RTIs) are infections of the reproductive organs that are caused by various germs. Though RTIs can occur both in men and women, they are more common in women, because their body structure and functions make it easier for germs to enter. RTIs that spread through sexual contact are called Sexually Transmitted Infections (STIs). Reproductive organs can also get infected because of trauma during delivery, unhygienic practices during delivery and abortions, as well as overgrowth of germs normally found in the vagina. Poor general health, poor genital hygiene and early start of sexual activity are all factors that can make women prone to these infections. Many women suffer from reproductive health problems. Women are more vulnerable to these infections due to biological factors. Unequal power relations in matters of sex i.e. sexual violence, non-use of condoms by men also expose women to risk.

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Why are these diseases not addressed?

Women are usually too shy and unwilling to talk about problems such as abnormal vaginal discharge and genital ulcers. They have been taught to silently suffer problems related to sex. There is also a fear that if a woman is found to have RTIs, especially STDs, she will be labelled a loose woman. There is a reluctance to seek medical treatment because of inadequate sex education and less access to medical care. The decision-makers at home, like the mother-in-law, would allow a woman to be taken to a health worker if she suffers from pregnancy-related problems or infertility, but not for seemingly trivial symptoms like excessive vaginal discharge. Even our health system does not adequately respond to these needs. RTIs have been badly neglected because they do not kill the person directly. They usually remain inside a womans body, giving her chronic abdominal and back pain or making her infertile. Many women keep on suffering and remain silent.

Symptoms of RTIs
In woman

Abnormal vaginal discharge, which has bad smell and more quantity than usual Ulcers or sores over the external genitals Lower abdominal pain because of pelvic infection

In man

Discharge from the penis Ulcers

The presence of RTIs/STIs could also be indicated in men and women by the presence of: Pain or bleeding during intercourse Painful swelling in the groin Burning pain on passing urine Itching around the genitals Unless treated early, RTIs/STIs can lead to several complications, ranging from pelvic inflammatory disease (PID) and infertility, to increased risk of HIV infections, ectopic pregnancy, cancer of the cervix and death. There can be pregnancy-related complications like premature deliveries, low

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birth weight babies, stillbirths, abortions or birth defects. Newborns can also get eye infection from the mothers birth canal, eventually leading to blindness and pneumonia.

Abnormal vaginal discharge

Usually discharge can be normal if it is for short time and without other symptoms like itching or pain. Most women have normal discharge during inter-menstrual period, and pregnancy. It is normal to have a small amount of discharge or wetness that comes from the vagina. A change in the amount, colour and smell may mean an infection. Many infections of reproductive tract in women show as foul smelling or bloody-yellow, greenish or curdy discharge.

Causes of abnormal vaginal discharge

Lack of genital hygiene, especially during menstruation can facilitate infections. Use of unclean instruments during delivery, abortions by unauthorized providers. Sex without condoms especially when partner is suffering from some infections.

It is important to remember that these infections are easily preventable and curable.

Preventing infections

Advise women and families to have deliveries in hospitals only. Deliveries should be conducted by skilled persons only. Abortions at registered hospitals only. Maintenance of genital hygiene during menstruation. Avoiding unsafe sex by use of condoms - women cant always insist on condom use by partner. They need to learn negotiation skills for condom use. Availability of female condoms may also save women in such situations. Women should be encouraged to seek treatment from qualified providers. You can help women get services by going with them to PHC/hospital in city. Women generally feel shy and awkward to talk about it. Complete treatment as advised by a qualified doctor is a must. The partner should also receive treatment in cases of STIs. Women

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especially find it difficult to convince their husbands to get treatment as well and use condoms. You should counsel the family (including her husband) and seek the help of ANM/MO wherever required.

Sexually Transmitted Infection (STI) in men

The urethral discharge
The complaint of urethral discharge is very common in men. Germs are the only cause of any pus from urethra. The most common germ causes yellow/white pus bead in the morning before first urine is passed. It is not always painful. Untreated, it causes bad kinks in the urethra and chronic infection. Men with such a complaint should consult a qualified doctor immediately.

Prevention

For prevention, the best policy is to avoid multiple sex partners, or risky sex behaviour. Early and complete treatment cures the infection and stops the spread to the next partner. Sex is best avoided during treatment. Educate people on this illness and remove undue fears about them. This may save them hundreds and thousands of rupees. It is important to examine and treat the spouse or partner, as he/she will be infected also.

The spouse/partner may already have had this infection and illness in form of vaginal discharge and burning during urination. The infection may get inside the womb and cause pain and fever. It may become chronic if not treated early and properly. Therefore, always ask for any complaints, which the woman partner may have.

Your responsibilities:

Raise awareness about the causation, transmission and prevention of RTIs and STIs. Emphasize the importance of early treatment and partner management. Distribute condoms and emphasize on promotion of condom and safer sex behaviour.

HIV / AIDS

HIV is an infection
A very minute organism causes HIV. A person having HIV germs in the blood is considered as HIV positive. One cannot tell if a person is having HIV infection, as this cannot be identified without a blood test. HIV can be transmitted through following routes: Through unprotected sexual intercourse (vaginal, anal) with a person having infection. Through blood transfusion when blood is taken from HIV positive individual. Through contaminated needles used previously in an HIV positive person. From HIV positive pregnant woman to child during delivery or afterwards.

HIV is not transmitted by

Touching and kissing a person Playing, swimming together Using common bathrooms and toilets Mosquito bites Sharing other utility items

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Risky sexual behaviour

The main cause of HIV/AIDS spread is risky sexual behaviour. Sex with many partners without use of condom is risky sexual behaviour. It is not only due to having sex with many but also because many people stay away from homes and families for long periods of time, e.g. truck drivers. Women are more affected by HIV/AIDS in India as this is directly related to her economic and social status and gender inequalities. The existing social and gender norms have great impact on sexual activity and risk behaviour of men and women, which affect women more than men. Women also find it difficult to motivate their partners to use condoms or approach services for treatment of infections. In our country more than 85 percent of HIV transmissions take place through the sexual route. There are no high risk groups but there are some people who have high-risk behaviour. HIV/AIDS can strike anybody depending on your behaviour.

The window period

After exposure to risky situations, HIV test will be positive only after 612 weeks. This is the window period. So one has to wait for this period to get an HIV test done.

AIDS is the disease

AIDS may occur many years after getting HIV positive, but the person is infected during this period. AIDS is a serious disease without permanent cure, though we have some medicines to reduce its severity. Suggestive symptoms of AIDS: Continuous weight loss. Persisting diarrhoea. Repeated fever or illness lasting more than one month. The minor features include chronic cough, itching, rash on body and genitals, oral thrush (fungal infection), bubos, and illnesses coming too often. There is stigma associated with AIDS and often women suffering from AIDS have been abandoned by their families. We can help in removing stigma about AIDS. We can also help the patients to get in touch with support network for HIV positive people.

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You can help in preventing HIV/AIDS

Prevention of HIV/AIDS is the only effective way of escape through this deadly disease. Following points are important: Creating awareness in community about risk and causation and advising men and women to avoid sex with many persons. Consistent and correct use of condoms to prevent infection. Counsel for HIV testing. Women are caregivers for the family. When they are HIV positive, they may not get the required family support and care. Counselling for the family is very important. Emphasize use of condom and partner management, early detection and treatment of STIs. In some hospitals there are special services for pregnant women. This involves counselling, blood tests and provision of drugs to HIV positive mothers. This will reduce the risk of infection to the baby. Awareness among adolescent boys and girls about healthy family life including sex education is important. Blood testing facilities are available at most district hospitals. Here blood test for HIV/AIDS is done along with counselling services.

Role & responsibilities of ASHA:

Raise awareness about, causation, transmission and prevention of HIV/AIDS Promote use of condom as a method of dual protection Counsel persons having risky sexual behaviour to undergo HIV/AIDS testing at nearby VCTC Assist HIV positive/AIDS patients to access ART

Adolescence : The Period of Growing Up

Adolescence is a period of rapid physical and emotional development. This period starts around 10 years of age and extending till 19 years. This is the period of rapid growth and development. They experience changes in their bodies and minds during this time. It is important that you give due attention to the health of adolescents, as the health and productivity of the nation depends on them. As part of growing up, adolescents will go through puberty. Puberty is the time in life when the body undergoes changes from that of a child to an adult. You already know about the chemicals in the body called hormones cause these changes. Because there are so many changes happening during puberty, adolescents find it difficult to adjust to these changes and often they need support. Not only does the body change, but the emotions of adolescents change too. How they think and feel about themselves, family and friends may seem different. As adolescents go through puberty, they like to take important decisions for themselves, take on more responsibilities and become more independent.

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Changes in girls
Breasts: In most girls, puberty starts with breast growth. When breasts start to develop, one may notice small, tender lumps under one or both nipples that will get bigger over the next few years. When breasts first begin to develop, it is not unusual for one breast to be larger than the other. However, as they develop, they will be alike in size and shape. Hair: Soft hair will start to grow in the pubic area (the area between legs). This hair will eventually become thick and very curly. Hair grows under the arms and on the legs. Body shape: Hips get wider and waist will get smaller. Body will also begin to build up fat in the stomach, buttocks, and legs. This is normal and gives body the curves of a woman. Body size: Arms, legs, hands, and feet may grow faster than the rest of the body. Skin: Skin may get more oily. This is because glands are growing too. Almost all teenagers get acne at one time or another. Menstruation: During this period menstrual cycle, or period begin. Most girls get their periods between 9 and 16 years of age.

Changes in boys
Body size: Arms, legs, hands and feet may grow faster than the rest of the body. Body shape: Adolescents will get taller and shoulders will get broader. They will gain a lot of weight. During this time, many boys experience swelling under their nipples. This may cause them to worry that they are growing breasts. During puberty, muscles will also get bigger. Voice: Voice will get deeper. This may start with voice cracking. Hair: Hair will appear under arms, on legs and face, and above penis. Chest hair may appear during puberty or later, although not all men have chest hair. Skin: Skin may get more oily and may sweat more. Penis: Penis and testes will get larger. Boys get erections due to an increase in sex hormones. Erections occur when the penis gets stiff and hard - sometimes for no reason. This is normal. Body will also begin to produce sperm during puberty. This means that during an erection, adolescents may also experience ejaculation. This occurs when semen (made up of sperm and other fluids) is released through the penis. This could happen during sleep. This is called a nocturnal emission or wet dream.

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Your responsibilities:

Young people may have several questions about their body, sex and sexuality, and how to remain healthy. Sexuality refers to expression of sexual feelings. There is attraction towards opposite sex. They need information, and services. You should inform and help the adolescents in getting services through the nearest government hospital, i.e., for health care and also during pregnancy, institutional delivery, access to contraceptives and services for RTIs/STIs and menstrual problems. Males also need information and advice. You may like to visit schools and talk to the young on these issues. Alternatively, you can plan the visit of nurse didi to come to school and talk to the adolescents. If there are any adolescent groups in the village, you should meet them periodically. You may provide information on health issues and seek their cooperation and support in our health work. You may also be required to go with them to the sub-centre or PHC for health services. Adolescents need support in the community. You can talk to Panchayat members, teachers, parents, local leaders and SHG members to provide information on the subject. You need to find out if Anganwadi Centres run a programme for adolescent girls: called Kishori Shakti Yojana. Adolescent girls receive more food under this scheme. Talk with adolescents in the meetings of Nehru Yuva Kendra Sangathan (NYKS), Yuvati Mandals and other youth groups on promoting health and preventing diseases.

Helping Adolescent Girls to Take Care of Themselves during Menstruation

Staying clean
Generally girls living in small towns and cities use sanitary pads for protection during menstrual period, if they can afford them. These are readymade soft cotton pads worn inside the underwear to catch the blood as it leaves the vagina. These pads should not be reused. Some girls prefer to make their own pads out of folded cloth or wads of cotton. These pads must always be clean and dry when worn. They should be changed several times a day and disposed of by burning outdoors in a large empty tin. If cloth is used, they should be washed well with soap and water and dried in the sun. Sun light is the cheapest disinfectant available in nature. In villages there are certain restrictions imposed on adolescents during menstruation. Those restrictions (Donts), which are harmful should be discouraged, such as not taking bath during menstruation or not doing any physical work. It is advisable to wash outer genitals well with water every day to remove any blood that is left.

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READING MATERIAL FOR ASHA

Changes in bleeding
Sometimes, the ovary does not release an egg. When this happens, the body makes less hormone, which can cause changes in how often and how much a woman bleeds. Girls whose monthly bleeding has just begun or women who have recently stopped breastfeeding may bleed only every few months, or have very little or too much bleeding. Their cycles usually become more regular with time. Women using hormonal family planning, sometimes have bleeding in the middle of the month. Older women who have not yet gone through menopause may have heavier bleeding or bleed more often than when they were younger. As they get closer to menopause, they may stop having monthly bleeding for a few months and then have it again.

Pain with monthly bleeding

During monthly bleeding the womb squeezes in order to push out the lining. The squeezing can cause pain in the lower belly or lower back, sometimes called cramps. The pain may begin before bleeding starts or just after it starts.

Tips for taking care

Do exercise, walk and run Rub your lower belly. This helps the tight muscles to relax. Fill a plastic bottle or some other container with hot water and place it on your lower belly or lower back. Or, use a thick cloth you have soaked in hot water. Drink tea with ginger. Women in your community may know of other remedies that work for this kind of pain. Take a mild medicine for pain with doctors advice.

Pre-menstrual syndrome (PMS)

Some women and girls feel uncomfortable one or two weeks before their monthly bleeding begins. They may have one or more of a group of signs that are known as pre-menstrual syndrome (PMS). Women who have PMS may notice: Sore breasts A full feeling in the lower belly Constipation (when you cannot pass stool) Feeling extra tired

HELPING ADOLESCENT GIRLS TO TAKE CARE OF THEMSELVES DURING MENSTRUATION

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Sore muscles, especially in the lower back or belly A change in the wetness of the vagina Oiliness or spots (pimples) on the face Feelings that are especially strong or hard to control Craving for certain foods and increased hunger and thirst.

Many women have at least one of these signs each month and some women may have all of them. A woman may have different signs from one month to the next. For many women, the days before the start of their bleeding is a time of unrest. But some women say they feel more creative and able to get things done. These symptoms disappear within a few days after the start of the menstrual period.

Roles and responsibilities of ASHA:

Advise to

Eat less salt. Salt makes the body to keep extra water inside, which gives the full feeling in the womb. Try to avoid caffeine (found in coffee, tea and some soft drinks like cola) Try eating whole grains, dalia, soyabean, peanuts, fresh fish, meat, milk or other foods that are high in protein. When body uses these foods, it also gets rid of any extra water, so that belly feels less full and light.