MSSSS-EC Innovative Action Research Project 115, Gandhi Nagar, Oddanchatram, Dindigul District, Tamil Nadu, India European Commission DDDeeevvveeelllooopppmmmeeennnttt ooff MMooddeellss aanndd AApppprrooaaccchhheeesss tttooo iiimmmppprrrooovvee SSSeeexxxuuuaaalll HHHeeeaaalllttthh ooff YYooouuunnnggg,,, PPPrrreeevvveeennntttiiiooonnn ooofff PPPaaarrreeennnttt ttoo CChhiillddd TTTrrraaannnsssmmmiiisssssiiiooonnn ooff HHIIVV aanndd CCaarree aannddd SSSuuuppppppooorrrttt fffooorrr PPLLWWHHAA s CCCoooiiimmmbbbaaatttooorrree DDiissttrriicctt SSiittuuaattiioonnaall AAsssssseeessssssmmmeeennnttt January 2003 DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Acknowledgements We express our deepest regards to the Deputy Director of Health Services and district administration, Coimbatore district for giving us wealth of information on the background situation of the district required for this study under EC-IAR project in Coimbatore District. We are thankful to European Commission, for giving us this opportunity and to Catalyst Management Services who coordinated and catalysed the entire issue, and for being partners with us from inception to conception to delivery. We are lost in search of words to adequately express our feelings for their continuous monitoring, suggestions, and directions that helped us immensely during the study. Last but not the least we are grateful to all those citizens of Coimbatore district who participated in our study willingly, voluntarily, and enthusiastically. We also thank individuals and agencies – governmental, non-governmental, community based and private organisations in Coimbatore District – for their excellent co-operation, support, time and invaluable inputs to the study. On behalf of the research sub committee & research team, S.V.Raja Programme Manager 1 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Abbreviations Used in the Document AIDS Acquired Immune Deficiency Syndrome ANC Ante-natal Clinics ANM Auxiliary Nurse Midwife APAC AIDS Prevention And Control society BPL Below Poverty Line BSS Behaviour Surveillance Survey CBO Community Based Organization CMS Catalyst Management Services C&S Care and Support for people living with HIV/AIDS CSW Commercial Sex Worker DI Depth Interview DDH Deputy Director of Health services DRDA District Rural Development Authority DSA District Situational Assessment FGD Focus Group Discussion FHAC Family Health Awareness Campaign GOI Government of India HIV Human Immunodeficiency virus IVDU Intravenous Drug Users MO Medical Officer MSSSS Mother Saradadevi Social Service Society MSM Men Sex with Men NACO National AIDS Control Organization NGO Non Government Organization OBG Obstetrics and Gynaecology PD Project Director PLWHA Person living with HIV/AIDS PMP Private Medical Practitioner PMTCT Prevention of Mother to Child Transmission of HIV PRD Panchayat Raj Department 2 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 RC Research coordinator RCH Reproductive and child health RMP Rural Medical Practitioner/PMP RSC Research Sub Committee RTI Reproductive Tract Infection SHY Sexual Health of Young SSS Sentinel Surveillance Survey STD Sexually Transmitted Disease STI Sexually Transmitted Infection TNSACS Tamil Nadu State AIDS Control Society UN United Nations WHO World Health Organization 3 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 CONTENTS ACKNOWLEDGEMENTS........................................................................................................... 1 ABBREVIATIONS USED IN THE DOCUMENT ..................................................................... 2 EXECUTIVE SUMMARY............................................................................................................. 6 1 BACKGROUND.................................................................................................................. 10 1.1 HIV EPIDEMIC:.................................................................................................... 10 1.2 NEED FOR THE DISTRICT SITUATIONAL ASSESSMENT:.................................... 11 2 OBJECTIVES OF THE STUDY ....................................................................................... 12 3 METHODS........................................................................................................................... 13 3.1 PRINCIPLE:.......................................................................................................... 13 3.2 LIMITATIONS OF THE STUDY:.............................................................................. 14 3.3 RESEARCH DESIGN:........................................................................................... 14 3.3.1 Secondary data:................................................................................................ 14 3.3.2 Primary Data: .................................................................................................... 15 Universe for the Study: .................................................................................... 15 Unit of Sampling: .............................................................................................. 15 Sampling:........................................................................................................... 15 Sources of Information:.................................................................................... 16 Tools and Techniques...................................................................................... 17 Mapping Existing Programs and Organisations:.......................................... 18 3.3.3 Analysis:............................................................................................................. 18 4 BACKGROUND ON COIMBATORE DISTRICT........................................................... 19 4.1 DISTRICT PROFILE .............................................................................................. 20 5 FRAMEWORK FOR PRESENTATION OF FINDINGS ............................................... 22 6 TYPE OF BEHAVIORS/PRACTICES LEADING TO ACQUIRE STD/HIV/AIDS .... 24 6.1 SEXUAL HEALTH OF YOUNG .............................................................................. 24 6.1.1 Risky Lifestyle during Growing Up (Menstruation, Adulthood):................. 24 6.1.2 Sexual Behaviour: ............................................................................................ 25 Premarital Sex:.................................................................................................. 25 Extramarital Sex: .............................................................................................. 27 Sexual Abuse:................................................................................................... 28 Sexual Exploitation:.......................................................................................... 29 6.1.3 Prevalence of Infections (STI/ HIV): .............................................................. 30 6.1.4 Health Seeking Behaviour:.............................................................................. 30 6.2 PREVENTION OF PARENT TO CHILD TRANSMISSION OF HIV: .......................... 31 6.2.1 Pregnancy and Childbirth:............................................................................... 31 6.2.2 Lack of services:............................................................................................... 32 4 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 6.2.3 Lack of Awareness:.......................................................................................... 32 6.3 CARE AND SUPPORT FOR PLWHA ................................................................... 32 6.4 FACTORS THAT INFLUENCE THE TYPES OF RISKY BEHAVIOUR OBSERVED:.. 34 6.4.1 Knowledge, Attitudes, Skills & Practice: ....................................................... 34 6.4.2 Services: ............................................................................................................ 36 6.4.3 Support Systems: ............................................................................................. 37 6.5 BACKGROUND FACTORS THAT EXPLAINS THE TYPE OF BEHAVIOURS AND FACTORS:38 6.5.1 Socio-Economic-Cultural Factors................................................................... 38 6.5.2 Gender Roles, Discrimination:........................................................................ 40 6.5.3 Level of Epidemic in TN:.................................................................................. 40 6.5.4 Response to Epidemic:.................................................................................... 44 7 RESOURCES MAPPED IN THE DISTRICT.................................................................. 47 8 WAYS FORWARD............................................................................................................. 48 5 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 6 MSSSS-EC Innovative Action Research Project t o H DDDeeevvveeelllooopppmmmeeennnttt ooofff MMMooodddeeelllsss aaannnddd AAApppppprrroooaaaccchhheeesss ttooo iiimmmppprrrooovvveee SSSeeexxxuuuaaalll HHHeeeaaalllttthhh ooofff YYYoouuunnnggg,,, PPPrrreeevvveeennntttiiiooonnn ooofff PPPaaarrreeennnttt tttooo CCChhhiiilllddd TTTrrraaannnsssmmmiiissssssiiiooonnn ooofff HHHIIIVVV aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHAAA Coimbatore District Situational Assessment Executive Summary India has an estimated 4.1 million people in the country infected with HIV, an overall HIV adult prevalence rate of 0.8%. An overwhelming majority of these (90%) are in the age group of 15-44 years those who are sexually active and economically productive. Driven primarily by heterosexual transmission, HIV infection is moving steadily beyond its initial focus among commercial sex workers and their clients, STD patients and Injecting Drug Users (IDUs), into the wider population. There is now evidence to show that the HIV epidemic is fast spreading to the general population. MSSSS (Mother Saradadevi Social Service Society), implementing an Innovative Action Research Project, supported by European Commission with an aim to develop models and approaches in three program areas viz. Sexual Health of Young (SHY), Prevention of Mother to Child Transmission of HIV (PMTCT) and Care and Support for people living with HIV/AIDS (C&S). The project is pilot in nature, planned for five years in four districts of Tamil Nadu, India. The purpose of the project is to contribute to the knowledge base on intervention models addressing vulnerable communities in three program areas. The first step was to understand the situation in each district with respect to vulnerabilities of young towards acquiring STD/HIV/AIDS and Care and Support for people living with HIV/aids, for which this study was commissioned during January 2003. The objective of the study was to assess the existing status of sexual and reproductive health of young, prevention of parent to child transmission of HIV and assess their vulnerability to acquiring STI/ HIV and with respect to care and support services for PLWHA, in Coimbatore District, Tamil Nadu, India, with an aim to develop models and approaches for effectively addressing problems identified. The study was conducted by the Research Sub-Committee* set up for this purpose, and facilitated by the Catalyst Management Services Private Limited (CMS), Bangalore. * Research Sub-Committee (RSC) was formed out of the core group for MSSSS in Coimbatore. DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Main Findings: �� Though there are few agencies working in the district in the area of HIV / AIDS prevention and care, the awareness level of the general public on STI/ HIV/ AIDS, health seeking behaviour, access to qualified health care, awareness on rights, capacity to seek help, and support systems, at the individual level are inadequate. �� Men of the district who are employed on daily wages, particularly those belonging to socially disadvantaged are habituated to alcohol consumption almost daily after work. Their behaviour under the influence of alcohol leads to unnecessary disputes with the family resulting in frictions within marriage. These men seek pleasure outside marriage and have sex with unknown partners, heightening the risk of acquiring HIV/AIDS �� The large tract of plantations in the district employ migrant youth from far away places (Tirunelveli, Kerala, Andhra etc) and are housed in a very clustered manner. It is reported that illicit sex is very common as there is no control system exists either in industry or in society. The lifestyles of these youth are very risky to attract HIV/AIDS. �� The huge population of industries in the district employ large number of youth of both sexes. It is reported that there is high incidence of sexual exploitation and abuse by supervisory level personnel. Welfare measures in the industries doesn’t focus on Sexual Wellbeing of the employees �� At the family level, factors increasing vulnerability were guardians’ limited ability to provide support, guide and counsel young on issues relating to sexuality, physical and sexual abuse, and alcohol abuse within the family. Gender equations within the family clearly limited women’s capacity vis-à-vis their male partners considerably, leaving them more vulnerable to HIV and other sexually transmitted diseases through males. �� Though there are many educational institutions in the district providing academic and vocational studies for the youth, no institutions focus on life skill education with emphasis on sexual health issues. Empowering the youth with adequate knowledge and skills on sexual and reproductive health issues is the need of the hour in combating the epidemic 7 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 �� At the community level, vulnerability of young was heightened due to lack of effective support systems to address youth problems, low position of women in the society compared to men, low literacy, low capacity to earn and high dependence on males. Current community initiatives focussed mainly on economic issues, and social and health issues were covered only by a few. The stigma attached to buying and using of condoms (that condom is used only in sex work/ multi partner sex) prevented many from even asking their partners to use this. Similarly, the stigma towards STI/ RTI prevented women from reporting and seeking treatment for it. �� The socio-economic condition of the poor, the income sources, earning potential of the individuals in the society, particularly those in the rural areas and their general health seeking behaviour doesn’t create a climate for the people to convert knowledge into actions to protect themselves and their dependants �� Non availability of counseling services, testing and treatment services even at district level, and number of private hospitals providing ANC services not equipped with HIV/AIDS related services �� A hospice (CSR charitable trust) is providing institutional care for PLWHA, but limited outreach due to lack of knowledge on availability of these services �� Stigma and discrimination are high towards PLWHA due to lack of sufficient knowledge on the transmission and prevention of HIV/AIDS. Limited knowledge on availability of services and support systems. Access and adoption to these services are also poor due to economic, cultural and social factors. �� There is poor knowledge on prevention of mother to child transmission of HIV and on availability of services and support systems. The study could not identify any institution that specifically works for PMTCT except Government Hospital. Project imperatives The study identified many factors that have the potential to address these above said issues. These are listed below. �� Interventions by various government and non government agencies created basic awareness on the disease and its spread. However these are found to be inadequate in the context of containing the rapid spread of the disease even in general population. The coordination among those working in the field seems to be lacking in the sense of integrated approach. 8 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 However, 99 Sensitizing the employers to incorporate sexual health of young in their welfare programs will help to address the issue among the working youth in an effective manner. 99 Sensitizing the educational institutions to incorporate life skill education with emphasis on SHY will educate the students to protect themselves from the diseases and empower them to lead a healthy life 99 Sensitizing the institutions working in various developmental activities for the vulnerable communities to address sexual health issues of youth through innovative approaches to carry the message for the youth not covered under the above two. 99 There is no coordination among those infected and also those who work for them to mobilise the resources available for them. A coordinated effort by different agencies working on care and support for PLWHA is needed. 99 Many interventions are available in areas of mother and child health being carried out by various government and non-government institutions. Sensitising them on the need of incorporating PMTCT as a part of their welfare activities will effectively reduce the incidence of HIV among the new born. 9 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 10 MSSSS-EC Innovative Action Research Project t o H DDDeeevvveeelllooopppmmmeeennnttt ooofff MMMooodddeeelllsss aaannnddd AAApppppprrroooaaaccchhheeesss ttooo iiimmmppprrrooovvveee SSSeeexxxuuuaaalll HHHeeeaaalllttthhh ooofff YYYoouuunnnggg,,, PPPrrreeevvveeennntttiiiooonnn ooofff PPPaaarrreeennnttt tttooo CCChhhiiilllddd TTTrrraaannnsssmmmiiissssssiiiooonnn ooofff HHHIIIVVV aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHAAA Coimbatore District Situational Assessment 1 Background 1.1 HIV Epidemic: The HIV/AIDS epidemic is classified as a pandemic – an outbreak of disease occurring at dangerously high levels in many locations around the world simultaneously. The first cases were recorded and identified in the United States in 1981 and the problem has intensified exponentially since then. The first Indian cases were documented in Chennai in 1986 and after a relatively slow initial phase, the disease took off in the early 1990s. Recently, India’s population of people living with HIV/AIDS passed the 4 million mark, but the epidemic is largely confined to the southern states. Tamil Nadu has one of the highest rates of infection (prevalence) in the country. It qualifies as a state of high prevalence because over 5% of high risk populations and over 1% of antenatal clinic attendees test HIV positive. At some sentinel sites as many as 10% of STD patients and 3% of ANC attendees have tested positive. It is estimated that over 25 million people would be infected with this deadly disease by 2010. Some quick stats on the pandemic - 41 million HIV infected worldwide - 16,000 new infections per day in the world - 7000 of them are youth in the age group of 10 to 24 years old. - 4 million HIV infected in India, and second highest in the world - India prevalence: 0.8% of general population - India incidence: 700,000 new HIV infections in 2001 - Modes of HIV transmission for cases reported in 2001 ♦ 83% sexual contact ♦ 4% needle sharing ♦ 4% tainted blood transfusion ♦ 2% MTCT - 620,000 HIV infections in Tamil Nadu - Tamil Nadu prevalence: 1.13% in ANC clinics (2001) 2.5% at NACO Sentinel Surveillance Sites (1999) DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 1.2 Need for the District Situational Assessment: The study is aimed to identify the vulnerability and causative factors leading to acquire STIs and HIV/AIDS and the situation with respect to care and support services with the participation and guidance of local stakeholders. The study also would reveal the responses to the epidemic at various levels by government, non-government, community- based organizations, corporate and others. Findings of the study would be used as a baseline, and to prepare a District Situational Assessment (DSA) report. Since the objective of the project is to the contribute knowledge base on intervention models in three program areas addressing vulnerable communities, this report would be useful in developing models and approaches in three program areas effectively with no duplication of interventions. 11 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 2 Objectives of the Study To assess the existing situation with respect to Sexual Health of Young, Prevention of Parent to Child Transmission of HIV and Care and Support for PLWHA in Coimbatore District, Tamil Nadu, India, with an aim to develop models and approaches for effectively addressing problems identified. Questions to be answered by the Study: a. What are the observed behaviour/ factors with respect to Sexual Health of Young, Prevention of Parent to Child Transmission of HIV and Care and Support for PLWHA. Issues related to: a) Growing up (menstruation, adulthood) b) Sexual behaviour c) Pregnancy and childbirth d) Prevalence of infections (STI, HIV) e) Health seeking behaviour b. What are the factors that explain the observed behaviour/ factors? Issues related to: a) Knowledge, attitude, skills, practice b) Services and support systems c. What are the background factors that influence the observed behaviour/ factors? Issues related to: a) Socio-economic-cultural factors b) Gender roles c) Level of epidemic, and country’s response to the epidemic d. Which are the agencies (government, multilateral, bilateral and other development initiatives) that work in Coimbatore District and what could be potential roles and areas of collaboration with these agencies? 12 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 13 MSSSS-EC Innovative Action Research Project 3 Methods 3.1 Principle: As can be seen from the scope explained above, the main purpose of the study is to understand situation to enable the Project to develop models and approaches to effectively address the problems. To this end, this piece of research is designed using following principles: �� Qualitative vs Quantitative Assessments: Many of the areas of assessment listed under the scope of the study are qualitative. The tools and methods used were accordingly designed. However, it was also found important that some amount of quantitative assessments would be made to understand the scale, overall picture and uniformity. To this effect, number-based analysis and presentations have been tried. �� Secondary Data vs Primary Data: There are number of studies conducted by National AIDS Control Organisation (NACO) and the Tamil Nadu State AIDS Control Society (TNSACS). Even though most address the ‘high risk groups’, there are some studies addressing general population, and youth. These are more of macro-level data and these were used along with micro-level assessment of situation, using primary survey by project staff. Data from both are used for analysis and interpretation in the research. �� Need to Cover Different Profiles: The profile of districts, villages, and youth vary widely within the project area of four districts. The vulnerability varies from profile to profile. Gender, accessibility, economic and social status, literacy, etc. affect the vulnerability. The program approaches need to be different for different profiles in a general community settings. The sampling therefore is made in such a way that these categories of profiles of youth are covered in the research. �� Statistical Validity vs Learning for a Purpose: The study was not aiming at providing a statistical validity to findings; rather selected samples purposively so that learning from different segments available. The sampling proposed later takes this into account. �� Gender Composition and Expertise in Team: The study tries to assess the situation involving girls and boys, and therefore the assessment team included men and women. The study also demanded expertise in various fields – HIV/ AIDS, working with adolescents, working in general community, work in Tamil Nadu, and ability to work with government and others, etc. The study team therefore was composed from both project staff and external resource persons. �� Participatory Assessments: The approach adopted by the study was participatory with youth themselves assessing the situation, and highlighting problems and DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 needs. The tools and methods adopted for the assessment therefore were facilitating discussions (like focus group discussions, use of some case studies, debriefing, etc.). 3.2 Limitations of the Study: The methods used for data collection were largely qualitative; hence the report does not contain estimates regarding the size of a problem or the extent of its prevalence. Some data were obtained by recall method, which depended on human memory, hence prone for bias. It was the subjective perceptions and disclosures of respondents that were analyzed, and no objective assessment could be done. As every known sub group in the study universe could not be included, the results of the research might not represent the views and ideas of entire universe. Some of these limitations were managed through triangulation (explained in more detail under ‘Sources of Information’), and combination of primary and secondary data. Overall, the findings were found addressing the main purpose of the research. 3.3 Research Design: 3.3.1 Secondary data: An extensive search for secondary data through census, published data, internet and collection of books/ magazines/ publications from various government departments, non- governmental organisations and existing programs was undertaken. The purpose of collecting this data was to provide a background to the research, obtain a basis for selection of samples and provide useful information on the problem. The type of information collected were: Type of information Source of information a. Census data – population, segmented age-wise, gender-wise, caste-wise, religion-wise, block-wise Census of India publication b. Literacy, BPL, sex ratio Census of India publication c. Administrative map of the district with divisions District Collectorate d. Health indicators, health services availability Department of Health and Family Welfare e. Education – schools, colleges; various segments Department of Education f. Details of reported cases of violence, sexual abuse District Police Headquarters g. Prevalence of HIV/ STI District Hospital h. Epidemic Data NACO, TNSACS i. Programs in Development in the District District Rural Development Agency 14 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 j. Details of industries in the district District Industries Centre District Labour Office Most of this data were related to the year 2001 to 2003. 3.3.2 Primary Data: Universe for the Study: The universe for the study was youth (both male and female in the age group of 13 to 25), married men and women, elders and different players of the society in the district. Unit of Sampling: For the primary survey, a ‘village’ (in rural areas) and ‘ward’ (in urban areas) were considered as unit of sampling, as most of the development work at the grass-root level is planned and implemented through this administrative unit. The lowest level local government, community managed structures and elected bodies operate at this level. It was felt important to understand the situation at this level, as institutionalisation of the models could be planned in future through the existing constitutionally recognised structure. Within these units, the main group researched was the ‘youth (both male and female in the age group of 13-25), married men and women, elders and different players of the society’. Sampling: Based on the time and resource availability, a total of 24 sites (village/ ward) were selected for the entire project (covering all four districts), of which seven sites were selected in Coimbatore District. Given seven sites for the District, a multi-stage purposive sampling was followed. As a first step, seven sites were divided proportionately based on urban and rural population. Total Urban Rural Population 3285455 1629048 1656407 % Of Population 50% 50% Sites Distributed 7 3 4 The next step was to select the samples based on certain criteria that require representation in the study. These criteria are related to poverty, social status, etc. The information from the secondary data was available only at the ‘Block1’ level. Therefore, 15 1 An administrative unit, immediate next lower level to a District MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 it was decided to select blocks that satisfy these criteria, and select one sample village from these blocks (at random). The criteria that were used in selection of blocks were: Rural d factors Indicator Used Categor ies Pongalur Anaimalai Gudimang alam Madukarai High 33 Medium 33 Poverty Proportion of households below poverty line Low 33 High 33 33 Medium 33 33 Literacy Proportion of Illiterates Low High 33 Medium 33 33 33 Social Status Proportion of socially disadvantaged households Low High 33 Medium 33 33 Access to Govt. Health Services Population covered by Primary Health Centre Low 33 Main Representation of Economica lly poor, Illiteracy Socially Disadvanta ged Illiteracy, Poor access to health facilities Medium representat ion of BPL, Literacy and social status As can be seen from the table above, each block selected represent a ‘high/medium’ in at least one of the criteria listed. For the urban areas, one ward in Thirupur municipality and two wards in Coimbatore Corporation were selected at random. Sources of Information: A 360 degree consultation process was followed to provide information on the existing situation with respect to SHY, PPTCT and Care and Support. As the method used was highly qualitative, the information was to be triangulated through various sources. For each study site, the process included meeting a number of persons in various categories and triangulating information. 16 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 As the issues studied were very sensitive, and are usually discussed only among the peers, the respondents were categorised according to gender, marital status and age- group. The process is explained in the following diagram: Tools and Techniques A variety of tools were used (in each site) depending on the category of respondents, and the type of issues being studied is below. Tools Used Type of Issues Studied No. of Groups Category of Respondents Women: 13-18, Unmarried Women: 19–30, Married 3 Women – > 35, Guardians Men: 13-21, Unmarried Men: 22–35, Married Focus Group Discussions �� Information on behaviours, knowledge, attitudes, practices (individual and group) �� Services, support systems, environment �� In-depth exploration of reasons [Using story-line method] 3 Men – > 40, Guardians SHY, PPTCT and Care and Support for PLWHA Other Interventions (NGOs, govt.) Women – Unmarried – age: 13 – 18 years Guardians Males (>40) Female (>35) Opinion Leaders/ Village Administration/ Religious Leaders Men – Unmarried – age: 13 – 21 yeas Men – Married – age: 22 – 35 years Service Providers (health, education, legal, regulatory) Women – Married – age: 19 – 30 years 17 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Tools Used Type of Issues Studied No. of Groups Category of Respondents Interviews �� Discussions on general practices, causal factors, trends �� In-depth exploration 26 Village Administration Opinion Leaders Service Providers (health, education) Other NGOs in development Government officials Fieldwork in each site was preceded by a visit by the research team to the site. The purpose of the visit was to sensitize the local community leaders on the objectives of the study, the process and elicit co-operation, as the issues studied were very sensitive. For each site, a local contact was identified with the community leaders, who were with the research team for the entire study duration in each site. Mapping Existing Programs and Organisations: The development programs in the district (government, non-government, private) focussing on various themes like education, health, community organisations, HIV/ AIDS, etc. were mapped using a checklist (primary survey) and through analysing secondary data. This data is complied program-wise and geographical area-wise for further use in intervention planning. 3.3.3 Analysis: The data from field was compiled using MS Office package (for quantitative and qualitative data). The Field Unit Managers of the project, with the help of Senior Researchers undertook analysis of data. 18 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 4 Background on Coimbatore District Originally Coimbatore district formed part of the Kongu country the history which dates back to the Sangam age. It is found that in early days the area was inhabited by tribes, the most predominant among them being the Kosars who are reported to have had their headquarters at Kosampathur which probably later became the present Coimbatore. This district is an inland district in the southern part of the peninsula and is bounded in the north and east by Erode district and west and south by Western Ghats section. 19 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 4.1 District profile The district is divided into 19 development blocks and also contains 1 Corporation, 4 Municipalities, 59 Town Panchayats and 389 Panchayats. The total geographical area of the district is 7469 Kms and the headquarters is Coimbatore. The density of population in this district is 469, which is higher than that of state’s 429. The total population of the district is 35.08 lakhs and the rural urban ratio being 48:52 and the SC/ST ratio being 17%. The district has the population growth rate of 1.44% which is almost same as the state’s 1.4%. The sex ratio of the district is 952, which is lower than the state sex ratio of 986. The literacy rate of the district is 66.35, which is slightly higher than the state literacy rate of 62.66. But in gender wise the male literacy level is 76.45 which shows high deviation from the female literacy rate of 55.73. The total labour force in this district is 45.13% of which 44.5% depend on agriculture for its livelihood. The district has been fortunate in having premier agricutural institutions, viz. the Tamil Nadu Agricultural University and the Sugar Cane Breeding Institute. The main cereals cultivated in this district are paddy and sorghum. In addition to these, commercial crops such as cotton, sugarcane and oilseeds are also cultivated. The total cultivated area is 3585 sq.kms of which irrigated is 1420 sq.kms. Scanty rainfall and poor sub-soil reserves necessitate the local agriculturists to depend largely on irrigation projects or other sources such as wells, rainfed tanks, etc. Important rivers, which contribute considerably towards irrigation, are Amaravathi and Noyyil, Bhavani, Palar, Aliyar. The chief sources of irrigation in the district are a number of wells, which play a significant role in the irrigation of the area followed by the rivers, canals and a few rainfed tanks. The district is not endowed with any remarkable mineral wealth. There is nothing conspicuous or significant about the minerals in the district except for the abundant felspar. Plentiful availability of limestone has helped the growth of cement industry. There are various companies engaged in the quarrying of limestone, gypsum, quartz and feldsper. The Tamil Nadu Cement Corporation has also entered the field very recently. Next to Chennai, Coimbatore is the most industrialized district in the State. The textile industry, engineering industry, handlooms etc., have contributed in no small measure, towards stabilising the industrial base of the districts economy. Coimbatore city has rightly been called the Manchester of south India and could be compared with Mumbai or Ahmedabad in the north as regards textile industry is concerned. The growth of engineering industries and their concentration in Coimbatore has been rather remarkable. The enterprising nature of the people has helped the growth of industries in the district very much. Hand spinning of cotton, handloom weaving, basket making, etc., thrived in ancient times in the region and these products were much 20 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 in demand everywhere due to their excellent quality. These traditional industries of early days have not only survived the development of modern industries but also prospered alongside. These industries still make significant contribution towards the industrial prosperity of the district. The district has a well-developed system of communication network. Coimbatore city is directly linked with the state capital by air, rail and road. There is a good motorable road linking Coimbatore with the state capital and all other district headquarters also. The district also has a good tele-communication network, which covers almost all areas of the district including rural areas. 21 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 5 Framework for Presentation of Findings The framework used for analysis of data and presenting findings is below (please use links to move to relevant sections in the electronic copy). Three types of factors are being analysed – the first one being the observed behaviour and the other two related to explanatory factors and background factors that influence the behaviour. The research tries to provide disaggregated findings for various profiles depicted below: Types of behaviours and practices leading to poor sexual and reproductive health of Young (a) Risky Lifestyle During Growing Up (Menstruation, Adulthood) (b) Sexual behaviour (c) Prevalence of Infections (STI/ HIV) (d) Health Seeking Behaviour Factors that influence the type of risky behaviour observed Background situation that explains the factors and type of behaviour (a) Knowledge, attitudes, skills and practice (b) Services (c) Support Systems (a) Socio-economic-cultural factors (b) Gender roles, discrimination (c) Level of epidemic (d) Response to epidemic (policy and approach) 22 MSSSS-EC Innovative Action Research Project Rural/ Urban Male/ Female Literate/ Illiterates High/ Medium/ low prevalent districts Socially disadvantag ed/ Others BPL/ Others Varying Access to services DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 [For presentation purposes, and provide readability to the document, the following terms are used which provide an extent/ degree of the problem. Most – reported in 90% or more FGDs; Many – reported in more than 60% and less than 90% of FGDs; Some – reported from 30% to less than 60% of FGDs; Few – sporadic, less than 10% of FGDs.] 23 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 6 Type of behaviors/practices leading to acquire STD/HIV/AIDS 6.1 Sexual Health of Young 6.1.1 Risky Lifestyle during Growing Up (Menstruation, Adulthood): Adolescence is characterised by rapid and significant physical changes, psychological and behavioural changes. At this stage sexuality is awakened and reproductive capability is established at a pace, which is unique to each individual. Society and the context in which children grow into adolescents have an enormous impact on physical, psychological and sexual development. 24 MSSSS-EC Innovative Action Research Project While majority of the participants of this study support the idea of introducing sex education in schools a small minority feels that introduction of sex education in schools may motivate the adolescents to experiment with sex. Youth across all sites correctly and uniformly reported physical and social changes that occur during adolescence. Though they know the parts of their body, they have shyness to talk about their genitals. Slow and unconscious attraction towards opposite sex and thereby a sense of shyness towards opposite sex is developed. Most of the respondents of this study reported that these changes occurred between the age of 10 and 15 for girls, and 12– 16 for boys. The main source of information on sex and sexuality are peers, media and elders. The adolescent boys learn about sex from yellow journals and books. They often watch pornographic films. For them sexuality means intercourse and reproduction. Girls, rural respondents and illiterates are hesitant to talk about sex and sexuality when compared to others. Most boys and girls experienced these changes once they occurred, and had hardly any previous scientific information on these changes, their importance and necessity. Regarding sex education in schools there is mixed response. While majority of the participants of this study support the idea of introducing sex education in schools a small minority feels that introduction of sex education in schools may motivate the adolescents to experiment with sex. Those who are positive to the idea of school sex education also differ with the age at which students should be exposed to this education. Many opined that sex education might be taught separately for boys and girls. The educated are responding better to the idea of school sex education. Dropout among school going children is more from the age of 13 (8th standard) onwards. Poverty is the main reason for children discontinuing their studies. The other reasons DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 quoted are lack of interest in studies, to pursue training in vocational trades, to get married and so on. Availability of employment to youth for menial wages is also an motivating factor for the youth to drop out of schools. This is particularly true in Tiruppur town where not only the youth from the vicinity but also many from far away places get employment in textile units. At adoloscent stage girls are expected to help their mothers in their house hold chores and are often forced to stay at home attending to these while boys are allowed to go anywhere they want. Boys spend their time in teashops, watching movies and in the company of peers. Though the poor value spending time with their children, their economic condition force them to work overtime and are not able to give attention to their children in their stage of growing up. Though the poor value spending time with their children, their economic condition force them to work overtime and are not able to give attention to their children in their stage of growing up. Boys have better knowledge of physical changes than girls do. In the same way boys speak more than girls on these changes that occur to them at adolescent stage. Though there is no great change in the awareness level across social borders, the economic level of people do make differences in the awareness level. The rich have greater access to different media, which the poor cannot afford and hence have greater awareness than the poor do have. The literate people have the advantage of getting knowledge through the print media that the illiterates don’t have. However, the quality of material read by the adolescents is a matter of concern since in the absence of formal education and approved text for the adolescents to gain knowledge they mostly read yellow journals that are of circulation among their peers. 6.1.2 Sexual Behaviour: Sexual behaviour of youth in the district revealed very early sexual debut for boys and girls, and wide prevalence of premarital, extra marital and sexual abuse (both within marriage and outside). 25 MSSSS-EC Innovative Action Research Project Premarital Sex: Though the society values sexual purity pre-marital sexual relations are prevalent across all social barriers. Boys reportedly start trying out sexual intercourse at the age of between 16 and 20. In the same way the age of sexual debut for girls is in the range of 14 to 16. Though the males walk away after Youth involving in Premarital Sex Relatives and Neighbours 15% Friends/lover 23% Students 23% Co workers 39% DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 50 14 36 43 14 43 57 14 29 0 20 40 60 80 100 % o f s i t e s Total Male Female % of sites reported incidence of Premarital Sex Low Medium High the incidents without any visible consequences, it is reported that the guilt of committing the act troubles them. While for the female the consequences are pregnancy, and followed by stigma in the society and some resort to extreme steps like attempting suicide. Repeated abortion at their tender age and contracting sexually transmitted diseases and the health hazards associated with that spoils the life of the adolescent girls. The rich indulge more and they easily conceal it, where as the actions of poor are exposed. The educated take precautions whereas the illiterate is not conscious of that. In case both the boy and girl involved in premarital sex belong to the same community, they are forced into marriage. In case of sex affair between a higher caste boy and lower caste girl the matter gets settled in favour of the boy. Injustice is done to the girl and her family. The situations where premarital sex incidence happens are, �� Co workers 5 �� Students 3 �� Friends/lover 3 �� Relatives and Neighbours 2 The impact of premarital sex was high and often only affects the female and particularly the economically low and socially disadvantaged. This was true for both rural and urban settings. Sex within Marriage: Sexual activity within a marriage starts as soon as one gets married and the age of girls at marriage is reported to be ranging from 16 to 20 and for boys it is 25. Women have no say in marriage decisions and are highly influenced by parents and relatives. Often girls are forced into marriage against their desires that leads to unhealthy family life. This is more among illiterate people living in rural areas. Both men and women Fed up with non- cooperation of wife in sex, men seek pleasure outside the marriage and indulge in sex with others particularly commercial sex workers. 26 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 have idea of sex. The sources are pornographic films, the electronic media and print media for men while for the women the sources are elderly women in the families, peers etc. In some discussions it was stated that some women find it difficult to adjust with the smell of alcohol the men consume and often don’t cooperate with their husbands in sex if he has consumed alcohol. The illicit contacts some men have with women other than their wives also create troubles in their families and their wives refuse having sex with them. In these circumstances often women are forced against their wishes by their husbands to have sex with them. These behaviours lead to quarrels between husband and wife and result in handling the women very roughly and some times these leads to separation of husband and wife. Extramarital Sex: Prevalence of extramarital relation is reported in almost all the places where this study was taken up. Men who go out to work cultivate this practice more. Alcoholism a very common evil prevalent everywhere especially among the daily wages classes, is the root cause of many problems in families. Women find it difficult to bear the smell of the alcohol and often refuse co-operating with their husbands in sex. This is the case with those who have sexual contact with women outside their marriage. For fear of getting STDs the wives of these men avoid having sex with them. Because of non co-operation to sex by their wives men seek pleasure outside marriage visiting sex workers and in these acts contract sexually transmitted diseases and passes the same to their spouses. Persons involving in extra-martial sex Unsatisfaction with wife 36% Others 21% Drivers 14% Migrant workers 29% 0 2 4 6 8 10 Total Male Female No.of sites reporting incidence of extra-marital sex Low Medium High The number of sites that reported persons involved in this are mostly Unsatisfied with wife 5 Migrant workers 4 Drivers 2 Others 3 27 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 In lower class both men and women are involved in extramarital sex and are more common in these communities than others. The reasons cited for men involving in extramarital sex are reported as being an alcoholic, taking advantages of his position as the sole bread winner of the family, unsatisfied with their wives, greater opportunities at workplaces. The reasons cited for women involving in this are reported as greater opportunity at workplaces and unsatisfied with their husbands. The major effect on health and lifestyle due to extramarital affairs are �� Acquiring diseases like STD/HIV/AIDS �� Physical and mental health get affected �� Worsening of the economic condition of the family �� Divorce, suicidal attempts etc The people mostly affected due to extramarital affairs are socially disadvantaged and illiterate women in rural settings. The support system available for them is mainly parents, relatives and community-based organizations such as self-help groups, where as urban women has formal support systems such as women police stations, women associations ( Maathar Sangam), etc. Sexual Abuse: Taking advantage of the vulnerability of women to physical, social and economic assault, men indulge abusing women sexually. This is reportedly happening everywhere in the district. The victims are women who are alone in the home or in any other lonely places, widows, destitute etc. Sexual abuse is reported in places of work like textile units, poultry units, educational institutions and even in police stations. 55 19 26 57 19 24 52 19 29 0 20 40 60 80 100 % o f si t e s Total Male Female % of sites reporting sexual abuse Low Medium High It is reported in 24% of the male FGDs that the prevalence is high and 19% & 57% reports it is medium and low. The circumstances for sexual abuse is reported as in o Alone in homes 7 o Public places 7 o Ag.fields 6 o workplaces 4 o Schools/colleges 4 28 o poultry farms 1 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Prevalence of sexual abuse is reported to be high in urban areas compared to rural. The persons involved in abuse are owners, co- workers, supervisors, drunkards, schoolmates etc. It is reported as richer and literates in urban are mostly involved. The victims are widows, destitute, women who are alone in their homes, migrating women particularly those involving in construction work etc. The socially disadvantaged people living under below poverty line are the main victims. Sexual Abuse - Circumstances Ag.fields 21% workplaces 14% Schools/colleges 14% poultry farms 3% Alone in homes 24% Public places 24% The support system available for the victims to tackle these issues is reported to be family members, friends, police stations and CBOs/NGOs. Even though for the rural poor adoption to these services are limited and sometimes nil. Sexual Exploitation: Sexual exploitation is reported in every site where interview was done as a part of this study. This practice is reportedly happening among people involved in the construction work, in textile units, poultry units and other places where women folks are employed. The victims are mainly young women belonging to socially disadvantaged groups. The people who involve in exploiting the women are supervisors at work spots, business owners and others who extract work from the women. Yielding to these men benefits the victims with reduced workload and better wages. Incidence of sexual exploitation is reported by males as high in 21% of the sites, medium in 14% of the sites and low in 11% of sites, whereas in females it is reported high in 18% of the sites and medium in 21% of the sites and low in 14% of sites. The major support systems existing to tackle the issues are reported to be Police station, Women welfare association, Political party(DYFI) , Panchayath President 25 36 39 23 31 46 27 40 33 0 20 40 60 80 100 % o f si t e s Total Male Female % of sites reporting sexual exploitation Low Medium High 29 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 The major effect on health and lifestyle due to exploitation are 99 Contracting STD/HIV/AIDS 99 Social stigma and discrimination 99 Physical and mental health affected 99 Unable to get married 6.1.3 Prevalence of Infections (STI/ HIV): FGDs reveals that the persons participated are having low level of knowledge on STD and high level knowledge in HIV/AIDS both in urban and rural. Still concrete Myths and Misconception about the disease particularly related to treatment. Even though the study doesn’t focus much about the prevalence of infections in the district some secondary data collected from various government institutions are useful to understand the magnitude of the problem. Among the number of reported cases low caste people seeking treatment in GH and high caste people seeks treatment in Private Hospitals. Totally there were 4076, 2220 and 2175 STDs cases registered with Government Hospitals of Coimbatore, Thirupur and Udumalaipet respectively during the year 2002. Totally 793 cases were tested in VCTC at GH. Out of that nearly 209 cases have found to be infected with HIV at 26% in the year 2002. 6.1.4 Health Seeking Behaviour: Because of the poor economic conditions of majority of the population and social stigma attached to the STDs and also on account of the non-availability of drugs available locally, infected persons seek medical advice and treatments only at the advanced stage of the disease. Rich, educated persons prefer private hospitals and specialists, while poor or illiterate people prefer government hospitals or traditional treatments. Patients prefer doctors of the same sex, which makes it hard for women, as female doctors are scarce. In general, everyone would like to be able to use private hospitals bec ause the quality of treatment is higher there, they are assured confidentiality, and the behavior of the medical staff is good. Due to the high cost of such facilities, they are not available to most people, who must instead use government hospitals, if they seek treatment at all. People avoid government hospitals due to the lack of quality treatment, the rough behavior of medical personnel and lack of confidentiality there. Reasons for not taking treatment Affect social status 5% Careless of the disease 11% Unaware of treatment services 16% Hesitation 21% Fear of stigma 21% Shyness 26% 30 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 There are some dangerous ideas people have towards healing of STDs as applying the latex of some plants where the reality is the latex will burn the skin and may even injure the part of application. Yet another popular idea prevalent is that having sex 6.2 Prevention of Parent to Child Transmission of HIV: 6.2.1 Pregnancy and Childbirth: The reported age of pregnancy and first childbirth for a woman was around 17, usually one year after the marriage. Within the marriage, there was an urge to get the first child as the neighborhood starts talking about inability of the couple to give birth to a child, and particularly affects the women most. Women don’t have any say in decisions regarding number of children, spacing between childbirths. It is reported even their physical health is not considered for having sex and children. This situation seems to be better in urban areas, where women are considered while taking decisions related to pregnancy and childbirth. Support system reportedly available Panchayat president/Mana ger 29% Political )party(DYFI 14% Women Welfare Association/SH G 28% Police station 29% There is good awareness about the contraceptive methods among the population. It is observed that in some places women have better awareness than men on condoms and other birth control methods. Men don’t show interest in wearing condoms and some have the opinion that wearing condoms will reduce the pleasure of sexual intercourse. Women only compel men to wear condoms to protect them from sexually transmitted diseases. But women find it difficult to buy condoms either because they don’t go out or because of shyness to buy the same. Women talk about some local methods of birth control by eating some fruits and some foodstuff. There is no scientific background to these methods. Further these local methods may only prevent pregnancy but not protect in any way from the spread of STDs. 0 10 20 30 40 50 60 Total Male Female Knowledge on Contraceptives Low Medium High 31 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Other reasons for not using condoms are stated as • Hesitation to purchase condoms • Confident of not infected with any diseases • Non availability of condoms It is reported that the condoms are available with local PHCs, Government Hospitals, Medical shops, Petti shops, VHNs, but they are shy to purchase from these sources. Men don’t bother about wearing condoms. There are reports that men hesitate to wear condoms stating that wearing condoms reduces their sexual pleasure. 6.2.2 Lack of services: Non availability of counseling, testing and treatment services even at district level, and number of private hospitals providing ANC services not equipped with HIV/AIDS related services. 6.2.3 Lack of Awareness: Awareness on PPTCT is low both in rural and urban sites and there is no organization works focusing on prevention of parent to child transmission of HIV 6.3 Care and Support for PLWHA �� The study suggests that there is an increasing trend in the number of PLWHA. Though officially reported figures was low, during the field interactions many opined that the actual figures could be higher as most are not reported in government records and many are not aware of the disease and cause of death. �� Even aware, they are not preferred to go for treatment or related services due to fear of stigma and discrimination �� Social stigma and discrimination are high towards PLWHA due to lack of sufficient knowledge on the transmission and prevention of HIV/AIDS. �� Limited knowledge on availability of services and support systems. Access and adoption to these services are also poor due to economic, cultural and social factors. �� A hospice (CSR trust) is providing clinical based care and support services in the district with limited in-patient facilities. No community based services for those infected with HIV in the district �� There is neither network of people infected with HIV nor service providers network functioning in the district for providing care and support services 32 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Awareness on STI/HIV/AIDS There is very poor general awareness about STIs. The educated youth are better informed of the diseases. There are a lot of misconceptions about these diseases and the channels of spread of these diseases. Some people practice very crude and dangerous treatment methods those have no scientific backing. These treatments will only harm the patient than giving any cure to the disease. There is reasonably good awareness about the cause and spread of HIV. They identified that it spreads through unsafe sexual contact, injections using unsterilized needles and syringes, untested blood transfusions, multiple sexual partners, shaving blade, mother to child transmission and through breast milk. Some people hold the view that HIV spreads through toilets, mosquito bites etc. Awareness on mother to child transmission is also low and they thought there are 100% chances for the virus to pass on to child from an infected mother. % of knowledge level on HIV/AIDS 40 48 33 52 48 57 8 4 10 Total male female High Medium Low There is very poor awareness on the treatments available for opportunistic infections. People are aware that right now there is no vaccine or cure for HIV/AIDS, but taking siddha medicines and nutritive food can prolong the life. Literacy and economic condition play a vital role in undergoing treatment for their infections. Because of the stigma attached to the disease, people prefer to take treatment from far away places. Since poor cannot afford to travel for long distance and pay for the treatments, they don’t go for treatments immediately. The rich find their infections in the earlier stages and get treated whereas the poor wait for the symptoms develop and undergo treatment in the later stages. Also the women don’t prefer to get treated in hospitals for the problems in their private parts if the doctors are of opposite sex. Knowledge level on PPTCT 5 5 5 6 4 7 6 5 2 31 19 43 0 0 0 0 20 40 60 80 100 120 Total male female Nil Low Medium High 33 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 n 34 MSSSS-EC Innovative Action Research Project People generally tend to show discrimination to those infected with HIV/AIDS, but it is particularly high in the case of women. Infected are refused employment opportunities due to fear of contracting HIV/AIDS. The daughter-in-laws particularly in the rural are often blamed and ostracized by the family members, alleging they are the source for the transmission of the virus to their son. There is no formal support system existing to provide care and support services for those infected, and discriminated by the society. Knowledge on STD 19 5 33 45 33 57 31 57 5 5 5 5 Total Male Female High Medium Low Nil 6.4 Factors That Influence the Types of Risky Behaviour Observed: 6.4.1 Knowledge, Attitudes, Skills & Practice: �� Hesitation on the part of parents, elders, teachers to talk about sex and sexuality to the young When adolescents undergo physical, psychological and emotional changes, they get fear and a sort of shyness. They don’t know the reason for these changes and how to handle the pressures in life at those stages. The parents, teachers and elders who are supposed to educate about these are hesitant to talk about that and the reasons for the same are 99 Traditional behaviours in the culture that elders don’t talk about these matters to the young openly 99 They think it is too early for them to know about these 99 They think educating the young in these areas will make them to experiment it 99 The teachers think their image will be brought low by students 99 They think that the young come to know about these things through various other sources like books, media, peers, which are improper �� Young particularly girls are dropped out of schools after attaining puberty and made to sit at home often alone Even though school-going children dropped out of school are common in rural areas for various reasons of which the following two are significant. 99 Fear of getting spoiled 99 Traditional practice prevailing DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 �� Adolescents at the age of pursuing their education in schools and colleges are forced to work In this district many adolescents in the age of their teen and twenties are made to work in textile units, poultry units, and manufacturing units and in construction business. The underlying reasons for this is 99 Poor economic conditions of families. 99 The pressure to earn at early ages. 99 Employment opportunities available to them. Traditional practice prevailing �� Adolescent, particularly boys loitering in the villages with bad company and experimenting drinking, smoking, sex. 99 Parents don’t spend time with their children particularly the boys during their adolescent period when they need to be cared for 99 Young are not acquainted with life skills to tackle the stress/pressures they experience during this period. 99 Life skill education is not included in their academic curriculum. 99 Lack of importance for education and no motivation to the adolescents to continue their studies. 99 No avenues for the dropouts to get engaged. �� Forced marriages, violence within marriage 99 Mindset of the society in not consulting the girls about their choice for marriage 99 Parents urge to see their children get married before they get spoiled 99 Domination of men over decisions taken in the family 99 Unruly behaviour of men at home after consuming liquor 99 The wives forced to have sex with their life partners whenever they want it �� Involvement in premarital sex 99 The urge of the young to experiment sex before marriage 99 Greater opportunities and conducive atmosphere for them to involve 99 Exploitation by superiors at workplaces �� Yielding to sexual exploitation 35 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 99 Poor economic condition 99 For fear of loosing the job 99 Fear of oppression by the higher caste people �� Poor adoption of safer sex practices, frequent pregnancies and abortions. 99 Poor access to contraceptives, particularly in rural areas 99 Myths and Misconceptions prevailing over contraceptive methods 99 Shyness to purchase condoms in rural areas 99 Unwanted pregnancies and unsafe abortions caused because of forced sex 6.4.2 Services: Health services The study focussed on the awareness of health services by young for RTI/ STI treatment, and treatment for opportunistic infections if HIV positive, access to these services, adoption level and perception of quality of these services. General health seeking behaviour of the community too was discussed to understand whether the attitude towards health was the same for all diseases or specific to STI/ RTI/HIV/AIDS treatment. Awareness on availability of services to treat RTI/STI/HIV/AIDS was low, particularly among the rural women. People in rural used to go for treatment for any common disease/illness only when the pain is become unbearable. Availability of health services is poor when compared to urban, where there are many private hospitals. Primary Health Centres and unqualified doctors are the available health services for the people in rural. People mention that treatment for the disease is available in the government hospitals at Pollachi and Coimbatore. Literacy and economic condition play a vital role in undergoing treatment for their infections. Rich people find their infections in the earlier stages and get treated quickly whereas, poor wait till the symptoms develop. They visit hospitals for treatment only when they become physically worn out and couldn’t attend to any work. Also the women don’t want to undergo treatment in hospitals for the problems in their private parts if the doctors are opposite sex. The some of the reasons cited during the FGDs for not accessing the health services for their STIs are listed below 99 Lack of women-friendly services (place of checking, counselling, women doctors) 99 Lack of confidentiality while accessing formal institutions/ doctors 99 Doctors spending very less time in patient management; sometimes ill-treated patients 99 Non-availability of doctors, or too much of waiting time for doctors 36 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Particularly, women reported that they faced embarrassment in taking treatment for STIs, and did not discuss these in open. In focus group discussions, majority reported that local doctors/ Quacks [registered medical practitioners (RMP), traditional healers and faith healers] as the primary source for health services, as they were available readily, accessible at their doorsteps, maintain confidentiality and affordable to the target population. Counselling and testing services Counselling and testing services are only available at district government hospital and some private hospitals in the urban areas. The knowledge about these services is limited to urban. Counselling services provided by NGOs are limited to high-risk behaviour groups and not focusing on general community, which is highly the need of the hour. Many of the people don’t access services from the district hospitals due to 99 Lack of women-friendly services (place of checking, counselling, women doctors) 99 Lack of confidentiality while accessing formal institutions/ doctors 99 Doctors spending very less time in patient management; sometimes ill-treated patients 99 Non-availability of doctors, or too much of waiting time for doctors 6.4.3 Support Systems: Familial In the event of any untoward incident related to sexual behaviour like abuse, exploitation, sexual violence etc parents take care of the young. But these happenings are caused by people of higher level of influence in the society and getting justice is often next to impossibility. Even though the family is supporting those infected with HIV/AIDS, there is no sufficient awareness among the people on how to properly support them. The affected may at the most get food and shelter but not psychological support, nutritive food etc. The daughter-in-laws particularly in the rural are often blamed and ostracized by the family members, alleging they are the source for the transmission of the virus to their son. They are usually sent out after the death of their husband and their parents take care of them for the remaining years. Community In the event of any untoward incident related to sexual behaviour like abuse, exploitation, sexual violence etc the local committee called ‘ Katta Panchayat ’ looks into that and the judgement normally favours the socially and economically stronger. To contain the after 37 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 effects of the incident the victims are normally paid money or threatened with dire consequences. Community generally tend to stigmatise and discriminate those infected with HIV/AIDS for fear of contracting the HIV/AIDS. They are refused employment, not only because of the fear of contracting the disease but also branding them as anti social elements. Community based organizations such as women SHGs, fans association, farmers association are not ready to take care of those infected. Legal, regulatory Police stations and courts are the regulators existing in the district for the issues related to SHY. The district administrative grievance cell, human rights organizations etc are some of the legal support system existing but access to these services are very limited on account of lack of awareness on availability of these services and fear of facing the wrath of the village leaders. These organizations are also not sensitive in these areas. There are no voluntary organizations working in the area of providing legal support to the victims. No organization could be traced by the study that provides legal service to PLWHA. Some NGOs are found to be working in care and support and providing psychological support, awareness to individual, family and community etc. 6.5 Background Factors That Explains the Type of Behaviours and Factors: 6.5.1 Socio-Economic-Cultural Factors Economic status The lifestyle of people and susceptibility to the disease has direct relations to the economic conditions of the people. The poor are not able to sustain the education of their children beyond certain level, and are forced to drop out of school and get gainful employment. The youth in the workplaces at their tender age succumbed to various pressures and influences, live a risky lifestyle. In the event of any untoward incident related to their sexual health, the economically weaker are not in a position to get justice and are forced to swallow the incidence. Even they are not able to access quality services. This study reveals that most of the people living in rural areas and also a sizeable numbers in urban are poor and falls in this vulnerable category. This district has 26% of BPL population∗ . Social status 38 ∗ Provided by revenue department, Coimbatore district MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 People of different castes are scattered thorough out the district. In rural areas people of one community will not get along well with of people of another community. There is a divide between people belonging to SC/ST communities and others. These socially advantaged are oppressed and suppressed by other communities. The lifestyle of these people makes them highly vulnerable to contract STD/HIV/AIDS. It is observed that alcoholism and the associated evils are much prevalent among them. This district has 17% of SC population and about 1% of ST population Literacy Literacy has a direct bearing to the lifestyle of people. Importance of education is not being felt by the rural communities, particularly by the socially disadvantaged. The illiterates have very poor knowledge, attitude and practices which makes them vulnerable to acquire STD/HIV/AIDS. Access and adoption to various services is poor. Reaching the illiterates with interventions is proving futile in view of cultural practices that over rule them. The literacy level in Coimbatore district is 76.45% for the males and 55.73% for the females. Cultural norms, taboos, customs People of Tamil Nadu have high sensitiveness to various religious and traditional practices being followed by generations. These blind practices often make them lead a risky lifestyle there by making more chances to contract STD/HIV/AIDS. Girl children are not allowed to attend schools after puberty. During menstruation they are not allowed to perform ‘poojas’, attend functions, etc. Household decisions are taken by men and women have no say in that. This holds good even for sex and number of children. 39 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 6.5.2 Gender Roles, Discrimination: Gender discrimination, particularly affecting the women, reportedly happening from the stage of births itself. By and large people prefer male children. According to the most, boys were less expensive, could serve as the heir to family property, could earn money for the family, and did not require protection. Only wealthy families could afford the burden of having a female child. Poor and socially disadvantaged families found it difficult to raise girl children as they had to incur huge expenses on puberty ceremony and dowry, girls could not inherit property, they left their home after marriage to live with their in-laws, and they needed more protection while growing up. Girls were considered more of a burden, and particularly for families that were poor and socially disadvantaged. 6.5.3 Level of Epidemic in TN♣ : Status of epidemic, in HRG and in general population India is experiencing HIV epidemic at various magnitudes in various states. The states like Tamil Nadu, Andhra Pradesh, Karnataka, Manipur and Nagaland are having high prevalence of infection. Among them Tamil Nadu accounts for 45% of total reported AIDS cases in India. Since 1995 the prevalence among antenatal women was increasing till 2001. After that there has been a sustained decline in the prevalence among antenatal women. In all India level also there has been a decline in new infection in 2002. The occupations of the spouses of ANC women tested positive are mostly unskilled labourers, which include agricultural workers. The second largest group was wives of drivers. The trend of HIV infection among those attended STD clinics is steadily rising since 1994 when the surveillance for HIV infection among STD patients was started. There was a decline in 1994 but the infection had gone up to 14.8 in 2002. HIV infection among ANC over the years 0 0.5 1 1.5 1994 1995 1995 1996 1997 1998 1998 1999 2000 2001 2002 Trend of HIV infection among STD clinic attendees 0 5 10 15 20 1994 1995 1995 1996 1997 1998 1999 2000 2001 2002 40 ♣ Sentinel Surveillance in Tamil Nadu - 2002 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Rural and urban divide Residence of Positive Women Rural 66% Urban 34% Residential Status of positive STD patients Rural 57% Urban 43% The positivity was more among rural women compared to urban women. The proportion was almost two thirds. The HIV positivity rate among rural women was 1.24%. Majority of ANC women who were positive for HIV were in the age group of 20 to 29 years i.e 88%. The positivity rate among this group was high (1.19%). This shows it affects the early adult period of women. The HIV infection is more among illiterate women compared with educated women. As the educational status increased the prevalence of infection decreased. The proportion of positive STD clients was high among rural population compared to urban population. People residing at rural area (13.98) had a slightly higher prevalence rate compared with urban population (13.29). The HIV infection is high among women in rural and urban population. The proportion of HIV prevalence was high in 30 to 44 years age group followed by 20 to 29. The prevalence rate among the female in less than 20 years age was considerably high compared with male. It is observed that the infection was higher in lesser-educated population compared with higher educated group. Moreover as the educational status increased the HIV prevalence decreased. Latest data on BSS and general population Some salient observations of the Behaviour Surveillance Survey, Round 2 in Rural Tamil Nadu, conducted by Tamil Nadu State AIDS Control Society are listed below. The target group covered by the survey include commercial sex workers, client of CSWs, unemployed youth, students, hostlers, male and female – agricultural/livestock workers, artisans, weavers, cottage workers, construction & quarry workers and male construction supervisors 41 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 Awareness on STD/HIV/AIDS �� The awareness of HIV/AIDS is at least 15% higher than STD, amongst all the target group respondents �� The clients of CSWs exhibited better awareness levels on all attributes compared to other groups �� Students and hostlers portrayed better awareness of HIV/AIDS compared to other groups �� Amongst the male workers, supervisors are far ahead in the awareness levels of diseases, prevention methods and recalling of symptoms �� Though the female workers had indicated high unaided awareness of HIV/AIDS, when it came to recalling symptoms and identifying prevention methods, they were largely ignorant. The awareness and recall of condoms as prevention method for HIV/AIDS, is still very low amongst female workers. �� Though unaided awareness level of HIV/AIDS is high amongst all the target groups, most of them are having misconceptions in the prevention methods and in the reasons for contracting HIV/AIDS �� It is observed that the awareness level of STD and HIV is high among structured groups like CSWs, clients, students and hostlers, whereas it is comparatively lower amongst unemployed youth, male and female workers. Sexual behaviour �� Supervisors had reported of having twice the number of casual sexual partners when compared to other male workers �� Inspite of the awareness levels being high on use of condoms as a prevention method for HIV/AIDS, condom usage is still at its nascent stage among all the groups contacted including sex workers and their clients �� The female workers had fared better compared to the male workers in condom usage/insisting usage, with their casual partners. �� Even the knowledgeable supervisors had not deemed it fit to use condoms while indulging in casual sex. �� Hostlers and students had reported higher condom usage when compared to male workers and unemployed youth �� Condom usage is higher amongst all male groups when visiting CSWs, whereas it is lower during their casual sexual encounters 42 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 �� The risk perception is quite low amongst all categories and most of the high-risk groups, particularly the CSWs and their clients perceive negligible risk �� Female workers had indicated a substantially higher occurrence of symptoms compared to male workers �� Female workers and the youth were not much concerned by the occurrence of the disease symptoms and most of them had reported of not having taken any medicines �� CSWs and clients had indicated highest disease occurrence on account of their high-risk sexual activity and the encouraging aspect is that most of them had resorted to medication Youth �� Amongst the youth higher awareness levels had been reported from north and west. But inspite of higher awareness level, most of the youth were found to have misconceptions on the prevention methods and reasons for contracting the diseases �� Televisions is the most commonly accepted source for details on these diseases and this is followed by news papers and magazines �� 22% of the unemployed youth and 9% of the students and hostlers contacted have had an intercourse already �� 8% of the unemployed youth and 2% of the students and hostlers were having casual sexual partners. 5% of the unemployed youth and 2% of the students and hostlers were visiting CSWs �� Most of the youth did not prefer in using condoms �� 2% of the youth were reported to be having homosexual relationship and was higher in east and west at 4% each 43 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 6.5.4 Response to Epidemic: National response to the epidemic Soon after reporting of the first few HIV/AIDS cases in the country in 1986, Government recognized the seriousness of the problem and took a series of important measures to tackle the epidemic. By this time AIDS had already attained epidemic proportion in the African region and was spreading rapidly in many countries of the world. Government of India without wasting any time initiated steps and started pilot screening of high-risk population. A high powered National AIDS Committee was constituted in 1986 and a National AIDS Control Program (NACP) was launched in year 1987. Initial activities focused on the reinforcement of program management capacities as well as targeted Information, Education and Communication (IEC) and surveillance activities. Actual preventive activities like implementation of education and awareness program, blood safety measures, control of hospital infection, condom promotion to prevent HIV/AIDS, strengthening of clinical services for both STD and HIV/AIDS gained momentum only in 1992. The National AIDS Control Organization implemented the first National AIDS Control Program from 1992-1999, which aimed to reduce the spread of HIV and the impact of AIDS through massive prevention strategies. The second phase of the program, NACP-II, is currently being implemented. The NACP is implemented through an autonomous and decentralized institutional structure, with NACO formed as an autonomous society, and with each state government forming their own societies, affiliated with NACO. The NACO’s role is to develop policies, strategies, program approaches, ensure funding for various programs, monitoring and evaluation, and implementing national level common programs. The State level AIDS Control Societies (SACS) are responsible for planning, implementing and monitoring their programs. NGOs, CBOs, research institutions, training organizations, government departments, and other private agencies are partners of these State AIDS Control Societies in implementing the program. NACP has five main program components and sixteen sub-components. �� Prevention of HIV infection in high-risk population (Targeted Intervention, STI care and Condom Programming) �� Prevention of HIV infection in low-risk population (IEC and Social Mobilization, Blood safety and Occupational exposure, Counseling and Voluntary Counseling and Testing, Women and Children, Youth) �� Program Strengthening (Surveillance, Training, Monitoring and Evaluation, Technical Resource Group, Operational Research, Program Management) �� Capacity building for low cost community care (Care and Support) �� Intersectoral Collaboration (Workplace interventions, Inter ministerial links) 44 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 The NACP - II envisages NGOs as critical partners for its programs through targeted interventions, voluntary testing and counseling and school AIDS education activities. Program strategies for prevention and care: Targeted interventions Initially, it was believed that there were just two high-risk populations: commercial sex workers and truck drivers. Today, many other groups have been identified. They are migrant labor, industrial workers, refugees, fishermen, slum dwellers, hotel and lodge workers, domestic helpers, street children and men who have sex with men. Strategies with high risk populations tend to be specific, targeted interventions, i.e. o Behavior Change Communication: A multi-level approach to promote and sustain risk-reduction behavior through tailored messages in a variety of communication channels. o Condom promotion: Awareness on condoms, developing attitudes to buy and use condoms, and skills to use o Counseling and Referral o Networking and Advocacy o Enabling Environment Care and Support for people living with HIV/AIDS Strategies for care and support are less coordinated and tested. They are often carried out by NGOs acting independently and on a small scale. o Home care: family members, health care workers, or CBO volunteers are trained to provide quality, compassionate care to HIV/AIDS patients in their homes o Hospice care: health care workers are trained to care for patients long term in a fixed setting More details are available with International Association for Hospice and Palliative Care (www.hospicecare.com). Prevention of Mother to Child Transmission of HIV Institutions involving in PMTCT services are very less, and mostly offered by Government. The main strategies involved in providing these services are ♦ Primary prevention of HIV among parents to be (eligible couples) through awareness programs ♦ Prevention of unwanted pregnancies among HIV infected women through counseling, family planning services 45 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 ♦ Prevention of transmission from mother to child by using prophylactic anti retro viral regimens State response to the epidemic The State AIDS Project Cell was formed in January 1993 and was initially functioning under the Control of the Director of Medical Education, Chennai. The State AIDS Project Cell was re-constituted as the TAMIL NADU STATE AIDS CONTROL SOCIETY (TNSACS) registered under the Tamil Nadu Societies Registration Act, with effect from 11.5.1994, with the Secretary, Health and Family Welfare Department, as the President of this Society and a senior I.A.S. Officer as the Member Secretary cum Project Director, to tackle the problem of AIDS in a more effective manner. After its registration in May 1994, the State AIDS Control Society, started its activities more vigorously in full swing with the guidance and support of its Executive Committee, Technical Advisory Committee and Ethical Scientific Committee constituted by the Government. The main components, strategies and intervention under the AIDS Control Program are explained in following paragraphs. The main program areas under the AIDS Control Program are: Blood Safety and Training, Targeted Intervention, Control of Sexually Transmitted Diseases (STD), Information, Education and Communication, Care and Support for AIDS patients, Training, Sentinel Surveillance, Program Management, Advocacy and Social Mobilization. The Behavioral Surveillance Survey (BSS) and Sentinel Surveillance Survey (SSS) are TNSACS strong suit, as well as providing funding for NGOs. They are the main coordinating body for AIDS work in Tamil Nadu, as well supply information regarding trends in HIV prevalence/incidence, awareness, behaviors, and high risk populations. TNSACS plans to strengthen and support the existing infrastructure to address HIV prevention and care at the local, grassroots level. STD clinics are being set up across all 29 districts of Tamil Nadu, equipment is being upgraded, alternative medicine is being used more confidently and condoms are being distributed freely. TNSACS is tackling the problem of HIV/AIDS prevention and control on various fronts using different strategies to create awareness among different sub-population groups. They currently support over 200 NGOs and are represented in all 29 districts of Tamil Nadu. Recently, it has moved away from micromanaging and more towards awarding medium and large size grants. They operate a Legal Cell program, which informs patients of their rights regarding testing, confidentiality, right to treatment and also advocates for policy change. They also formed the Indian Network of Positive People, the first efforts at a nationwide network of HIV positive patients. Additionally, they selectively trained doctors on proper, full, compassionate AIDS care in the PRAM program (Physicians Responsible for AIDS Management). These various efforts are beginning to show results. Tamil Nadu can boast of the highest awareness level in the country - nearly 96 per cent. 46 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 7 Resources Mapped in the District The resources available in the District (institutions, programs), was mapped through discussions with various government and non-governmental organizations during the baseline survey conducted by the project There are 42 non-governmental organizations mapped in the survey, which are working in development interventions in the district. Nearly six NGOs were particularly focusing on STD/HIV/AIDS prevention and care& support programs. NMCT, IMAYAM, RICE, SAVE, SOWKIYAM and FIRE are working among STD/HIV/AIDS prevention and care. Particularly RICE, SAVE, SOWKIYAM and FIRE are specifically focusing on targeted interventions, working with high risk behavior groups like truck drivers, commercial sex workers, slum women etc. NMCT, IMAYAM are the organizations working in care and support for PLWHAs, providing care and support services to PLWHAs and their children. Some of the services include psychological support to individuals, family and community counseling, nutritive food, self-management, OIT, IGPs etc. TNSACS, APAC, and various bi-lateral and International NGOs supported to NMCT, IMAYAM, RICE, SAVE, AND FIRE organizations for implementing the programs. There are four Networks for the positive people existing in the district formed by different organizations and the resources and services available in the district are tapped in favour of PLWHA. The Coimbatore District Government Hospital has a fully established department of STD/HIV/AIDS medicine unit, which is doing a pioneering work in the field of HIV/AIDS & STDs and playing a significant role. VCTC is also available in GH which is providing counseling, testing and referral services. The Department of Obstetrics and Gynecology in District Government Hospital is running a PMTCT program and it is staffed with qualified counselors and dedicated doctors. This department is also training the doctors and paramedics who are working in the district on HIV/AIDS diagnosis and management. DOTS treatment is also available in GH for the TB patients associated with HIV. DGH, there are 8 Taluk hospitals and 68 Primary Health Centers and 469 Sub health centers in the district implementing health and family welfare services at gross root level through qualified doctors and Village Health Nurses. Nehru Yuva Kendra, a central government organization, through its youth volunteers formed a red ribbon club and implementing HIV/AIDS awareness program through out the district. 47 MSSSS-EC Innovative Action Research Project DDDeeevvveeelllooopppmmmeeennnttt ooofff mmmooodddeeelllsss aaannnddd aaapppppprrroooaaaccchhheeesss iiinnn SSSHHHYYY,,, PPPPPPTTTCCCTTT aaannnddd CCCaaarrreee aaannnddd SSSuuuppppppooorrrttt fffooorrr PPPLLLWWWHHHAAA CCCoooiiimmmbbbaaatttooorrreee DDDiiissstttrrriiicccttt SSSiiitttuuuaaatttiiiooonnnaaalll AAAsssssseeessssssmmmeeennnttt ––– JJJaaannn 222000000333 8 Ways forward The study identified many factors that have the potential to address these above said issues. These are listed below. �� Adolescent pressure experienced by the school/college going youth need to be tackled by providing life skill education. Life skill education with focus on SHY to the students will be of great help in improving the sexual and reproductive health of young. �� Sensitisation of employers (Tea industries at Valparai) to incorporate sexual health of young in their welfare measures will address to the youth working in industries. �� Identifying institutions working in developmental interventions and sensitising them to incorporate SHY as a program component will go a long way in reaching the youth not covered by any of the above two (school going and working). �� Many interventions are available in areas of mother and child health being carried out by various government and non-government institutions. Sensitising them on the need of incorporating PMTCT as a part of their welfare activities will effectively reduce the incidence of HIV among the new born. �� Coordinating and sensitizing the service providers in the district (Government, NGOs, CBOs, etc) who have the potential to deliver care support services and networking the people with HIV/AIDS for creating a demand for these services 48 MSSSS-EC Innovative Action Research Project