New Delhi in 5 resettlement colonies: Madanpur Khadar, Badarpur, Mangolpuri, Holambi Kalan and Dwarka.
Three years (November 2010-October 2013).
Over 30,000 households will directly benefit and at least 150,000 people within the communities will indirectly benefit by the end of the project.
Summary of main achievements: In the first year of the project more than 30,000 young people were reached. This included all young people reached directly and indirectly through peer education programmes, street plays, puppet shows, melas (fairs), group meetings and awareness sessions at the Health Information Centres (HICs) and rallies. The programme trained a total of 585 peer educators (299 male and 286 female). These peer educators reached out and sensitized a minimum of 15 other young people per month. In addition to this 22,523 community members were reached through the programme activities.
(Please note that the number of direct and indirect beneficiaries provided by the project implementing partners working in the resettlement colonies is 60,000. This is based on an estimate that the peer educators are additionally reaching other young people in their community which is the project intervention area and in schools who might be from far off areas, i.e. non project intervention areas. However, based on discussions between Plan India and the project implementing partners as well as the peer educators and young people accessing the Health Information Centres (HICs), it was decided that 30,000 was a conservative approximation of numbers reached, as there are overlaps between those benefitting from the peer education programmes and those participating and benefitting from the street plays, group meetings, puppet shows, attending the melas etc and so some of the 60,000 beneficiaries would be double counted).
Objective 1: Capacity building of adolescents by providing relevant information, knowledge on lifestyles and better choices that will help enhance responsive health seeking behaviour The project developed training curriculum comprising of 5 flip books, 5 technical documents and 5 facilitator guides which are being used for peer education on issues such as water and environmental sanitation, sexual and reproductive health and infectious diseases including TB, Dengue and Malaria. These training documents are titled as:
Training Kit on ‘Health and Wellbeing’
Training Kit on ‘Life Style Education’
Training Kit on ‘Menstrual Hygiene’
Training kit on ‘Reproductive Health’
Training kit on ‘Water and Sanitation’
Life skills is a cross cutting theme in all the 5 documents.
Cumulatively in Year one, 1100 young boys and girls were engaged and sensitized on the project in the five project areas directly through group meetings. Through these meetings, potential peer educators were also identified. During these meetings, the needs of young people were assessed and basic information was provided on topics such as water and sanitation, infectious diseases, changes in the body and sexual and reproductive health. The information provided to these young people was very basic and would be further reinforced through peer education.
Following the meetings, 585 peer educators (299 male and 286 female) were identified and then trained in twelve groups on the five thematic areas through intensive peer education training. After completing the training, each peer educator has been organizing individual and group meetings with young people to raise awareness on the thematic domains such as sexual reproductive health, general health awareness, water and environmental sanitation, menstrual hygiene. They have each been reaching out to a minimum of 15 other young people a month.
Additionally, capacity building on addressing gender norms and how these shape attitudes and behaviours of young people and influence their health choices was carried out in Mongolpuri. 80 boys and 50 girls participated in this training which covered issues of masculinity and femininity and some of the gender based underlying health determinants that influence access and uptake of services.
Health Information Centres (HICs) have been established in each of the 5 project areas and are reinforcing the peer education by providing supplementary information through group meetings, video shows, question and answer sessions, and library resources. The HICs have become popular and have catered to providing information to 2000 young people on their health and well being directly at 5 centres. The young people enjoy spending time at the HIC rather than idling on the streets. Young girls are allowed to leave their homes to go to the HIC which they otherwise would not have been able to do. Parents also feel that their children are channelling their energy into something useful and are observing positive changes in their children’s personalities and behaviour.
Through continuous meetings and counselling sessions with young people and their parents, there has been an increase in young people seeking health services for minor sexual and reproductive health problems. Previously young people were shy and did not access services due to the stigma attached to these sensitive issues. Young girls interviewed by the programme highlighted that prior to being trained by the HIC they were apprehensive about discussing their sexual health queries and problems. However, they now feel comfortable discussing these issues at home and seeking appropriate help.
The HICs and peer educators have been playing a critical role by making prompt referrals of young people with health problems (sexual and reproductive health, TB, Dengue, Malaria) to the health facilities. The peer educators on a monthly basis report on the cases referred by them in a specific reporting format. Peer educators referred 95 cases to the health facilities, and the HIC/project staff referred 165 cases to the health facilities. In total, 260 cases sought appropriate medical help at health facilities.
Some tangible results in improved healthy behaviour have been observed through focus group discussions and consultations with young people. Myths and misconceptions (resorting to quacks (Bengali doctors), following home remedies, using cloth during periods etc.) are gradually being dispelled by young people. Peer educators reported that 85 young girls are now resorting to gynaecologists for any ailment related to sexual and reproductive health problems (menstrual, reproductive track infections etc.). Among young men, 70 reported giving up habits related to some form of substance abuse (as collected by monitoring reports used by peer educators and project staff).
“Earlier I used to smoke and eat Tobacco, but since I have got in touch with the HIC I gave up all these bad habits”. Boy age 14.
Additionally, the programme has also contributed towards addressing some of the underlying social determinants of health that act as a barrier to young persons accessing health information and services. The programme has sensitized parents to the links between livelihood and health seeking behaviour and this has positively contributed towards change in attitudes and beliefs. This has made some parents think of the need to educate their daughters and become contributing members of the community as was evidenced by interviews carried out with community members by project staff. Several parents mentioned the need to delay marriage to avoid sexual and reproductive health problems associated with early pregnancy that they had learned from the HIC.
“I was married at the age of 15. However, now after attending the HIC I realize how important it is for my daughter to know her health needs and also earn a livelihood for herself as it will empower her. I want my daughter to be educated and work and not get married early. Both my husband and I are supportive and we encourage our daughter to come and learn from the HIC”. (Mother age 30, daughter age 15).
Objective 2: To establish community based actions on key infection The project has established 23 Community Stakeholder Groups (CSGs) which consists of men, women, community leaders and young people who live and work in the community and they have all been sensitised with the project. Through consultations, various pertinent health issues in the community such as water and environmental sanitation and infectious diseases (TB, Dengue and Malaria) and their required actions were discussed. They were also informed of the key issues that the programme identified in the resettlement areas. These include issues of substance abuse, early marriage, transportation problems to access services (Holambi Kalan), female health issues and lack of knowledge and information on sexual and reproductive and general health issues. Eventually, these groups will take a lead role in guiding the health aspects of their community and to ensure that young people’s health is taken into consideration.
The project has also carried out 314 community meetings with an objective to sensitize the community on project issues, which are very critical for young people’s health. During these meetings the emphasis was on the role that community members could play in improving young people’s health.
Health prevention and promotion, encouraging treatment seeking behaviours, low cost nutrition interventions and other health-related information has been provided through mass awareness activities. Some of these activities included street plays, puppet shows, video shows (on health issues), rallies, health talks and health melas (fairs). 52,523 Community members (including the 30,000 young people) have been reached and awareness has been raised on issues related to sexual and reproductive health, HIV and AIDS, gender, substance abuse, infectious diseases (TB, Dengue, Malaria) and water and environmental sanitation. The peer educators have been actively participating in organizing these mass awareness events.
As the project develops further, a formal referral system will be introduced where peer educators and HICs would provide referral slips to the young people to be referred to a health facility. These will be recorded and cross checked and verified with the referral slips at the facility level. The referral system will ensure that young people are followed up on accessing health services thus promoting health seeking behaviour.
Objective 3: Raising awareness and knowledge about access to available healthcare systems The project has initiated advocacy activities with key decision makers for access and uptake of health services for the young people. Partners have approached the civic body (Municipal Corporation of Delhi (MCD)) and familiarized them with the project and the focus on infectious diseases and the sexual and reproductive health needs of young people. Many of the issues that have come up are related to water and sanitation and include: lack of potable water, waste disposal, sewage maintenance which fuels infections by acting as a breeding ground for diseases such as Malaria, Dengue and water borne illnesses. Across the communities, water and sanitation issues are the main causes of infection and these could be mitigated through cooperative efforts of the community and government. The project is collaborating with the municipal corporation and carried out community sanitation training for community members, leaders and peer educators, and had attendance of 52 people. This training was conducted by a water and sanitation expert who informed the participants about degradable and non-degradable waste, solid waste management. Through a Participatory Rural Appraisal (PRA) this group developed an understanding on the correlation between community sanitation and health. During the training participants came up with their action plans on improving water and environmental sanitation conditions in Mangolpuri resettlement colony. This was followed by the community meetings and a cleanliness drive was planned where the community youth could set an example for others by collecting the community garbage and cleaning up accordingly. One block was identified to be a “model block” where young people participated in a cleanliness drive and distributed pamphlets and stickers to promote better sanitation.
Stakeholder sensitization and coordination meetings were organized for the 5 communities. The key stakeholders invited included: the 8 medical officers of the Health Department, 2 Malaria inspectors, 4 TB officers (from DOTS department), 1 Member of Legislative Assembly (MLA), 3 Municipal Councillors (responsibilities with MCD), 5 school principals and teachers, 1 Deputy Director from the Integrated Child Development Scheme (ICDS), Anganwadi supervisors (nutrition and pre-school centres run by the Department of Women and Child Development and they also deal with adolescent health), 2 Presidents of Resident Welfare Association (RWAs) and project partner staff. Pertinent health-related issues affecting the community were raised and the potential actions to address them were discussed at this forum. The Municipal Counsellor of Mangolpuri area has become the President of the Health Information Centre (HIC) committee to look into the issues of young people and ensure his cooperation and guidance for the welfare and development of young people.
Through coordination meetings, doctors and other stakeholders were sensitized on delivering services to meet the needs of young people. Some health professionals also engaged young people to help in informing the community on health issues. For instance, in Mangolpuri, young people with a Malaria Inspector carried out door-to-door awareness on Malaria and Dengue prevention during the monsoon season.
These sensitization meetings also serve the purpose of advocating and sharing information with relevant authorities to build partnerships and engage them on the health challenges of young people.
Objective 4: Addressing the immediate needs of the community in issues related to healthcare, hygiene, and sanitation Through the stakeholder sensitization and coordination meetings, as discussed above, pertinent health issues (water and sanitation, SRH, substance abuse, need for life skills etc.) were identified which the project seeks to address through working with young people at schools.
The Principals of at least 20 schools have been contacted in all the five areas and discussions were held on water and sanitation issues. The peer education module has been finalised, and the project is seeking approval from the Education Department to be able to run sessions in the schools. Post approval, the project team will be able to take sessions with the children and teachers in the schools and conduct water and sanitation related activities.
Other additional benefits (unanticipated results):
An Editorial Committee has been formed in the Mangolpuri area. This committee comprises of 6 members (3 young girls and 3 young boys). It plans to publish quarterly magazines containing articles and other creative writings of their HIC attendees. This committee will be primarily responsible for collection, selection and editing of all the material.
Different sessions are being held at the HICs other than the project thematic issues such as gender and violence, Independence movements, Indian constitution and rights etc.
Additional street plays have taken place prepared by HIC members/young people
5 Girls who had dropped out of school have been motivated to resume their education. Now they have got admission in distance learning/open school and in order to cover their educational gap they are also taking bridge tuition classes.
Partners faced challenges in recruiting local project staff from the project community. Through perseverance, they managed to get some staff from these communities or neighbouring communities. Eventually, all staff were on board by February 2011. The project staff have now established good rapport and trust with the young people and are able to move forward and influence young people in making healthy choices. In the Plan India Country Office there have been some staff changes and they are still waiting to fill the vacant post of Young Health Programme Project Manager. In the interim the project management is being successfully managed by other internal team members and no delays have been caused due to this.
There has been extreme heat and power cuts. March and April were very hot making it difficult for outreach activities and encouraging community participation. Power cuts affected HIC functions as well. The situation during the monsoon season also brings challenges as it gives rise to all forms of water borne diseases. The project has had to be flexible and be responsive accordingly and try and ensure that the key activities continue to address the needs of young people.
A major challenge has been discussing Sexual and Reproductive Health (SRH) in schools. The Chief Minister of Delhi and the Education Minister are not in favour of having sexual education in schools and this has made it difficult to discuss within the health clubs in schools. Hence, the project is addressing this issue by providing information through community level interventions and Health Information Centres. The project will however continue to advocate for the inclusion of SRH education in the school curriculum. School level interventions will focus on disease management and environmental issues. Stand-alone modules have been developed on separate themes such as water and sanitation, menstrual hygiene, lifestyle education, general health problems and sexual and reproductive health. The school authorities will be able to decide which modules they could endorse in the schools. It is likely that the school interventions will focus only on water and environmental sanitation, lifestyle education and general health problems. Sexual and reproductive health will be discussed at the HICs and through peer educators in the community. Teachers will be sensitized on adolescent health as well and they may be able to discuss these issues as the project progresses. However, it will depend upon the permission being granted to the project team to work in schools.
Talking about sexuality in the Indian context is taboo and poses many challenges. There are many myths and conceptions about this, as well as reluctance among parents and larger communities to discuss issues around sexuality. Sometimes parents also have incorrect information and they pass this on to young people, and eventually reinforce myths and misconceptions. Through community meetings, the project discusses these issues with parents and ensures that young people get the correct information through HICs and peer education.
Since the project deals with sensitive issues on sexual and reproductive health, some young people feel inhibited to ask questions. Therefore as a strategy, a question box has been installed at all HICs where girls and boys can anonymously drop in their queries, which would be addressed by the project staff during the group sessions on daily basis or through a Q&A board.
There is more female participation in comparison to males. These forums provide opportunities to those girls who would not otherwise be allowed to get out of their homes. Furthermore, these forums also provide access to appropriate and adequate information which is limited among girls but not among boys. Boys receive this information from magazines, the internet and peers. Creative and fun activities will have to be integrated in the project to attract young boys.
All 5 project areas are heavily populated, and lack basic amenities/facilities in relation to health, water, sanitation and education, which are common features of any slum community in India. The project has engaged young people and communities and has received an overwhelming response. Whilst this is very positive, the level of popularity in all 5 project locations is becoming difficult to manage particularly due to the increase in numbers of young people visiting the HICs. In some areas there is a lack of space or trained staff to cater to them and hence a strategy needs to be developed to better manage this or to expand the project and increase the number of HICs. To meet the above challenge, the HICs now have separate timings for boys and girls with monthly meetings for parents. The separate timings for boys and girls are adjusted according to their school timings. In all the 5 resettlement areas, girls attend school in the morning shift and the HIC after school and boys attend school in the afternoon shift and the HIC during the morning. This timing also applies to out-of school youth.
The project requires that the staff be continuously trained to deal with the emerging health issues raised by young people. The diversity and range of issues is large – sexual and reproductive health, water and environmental sanitation, substance abuse, TB, Dengue and Malaria and this requires that the project staff are well informed and updated, and have adequate resources to address the queries of young people. The project staff have been made familiar with all the project modules. Resources on the topics have also been made available at the HICs. Where staff are unable to respond to a specific issue, they research these from other experts and provide the information at a subsequent session or refer them to other appropriate resources. Further, the project coordinator works closely with the project staff to continuously build their capacities to address the challenges that the project staff encounter at the project sites. In addition, the Plan technical health adviser acts as a sounding board and expert on technical issues related to the health and well being of young people.
It has been a challenge to reach out to the young people in the 19-24 age group as most of the boys in this age bracket are engaged in jobs and the young girls are either getting married or they are not coming out of their homes due to traditional beliefs being of an age ready to marry. To address this challenge, the project is encouraging this age range to visit on Saturdays or days when they are off work. They are also involving the parents of young people to discuss adolescent health needs and the importance of engaging the young people in the programme. The project will also reach out to girls who are younger than 18 to build their capacity and bring about behavioural change on issues of early marriage and early pregnancy before they reach this age group.
Bringing convergence with diverse stakeholders is a challenge e.g. Water issues are being dealt with by Department of Drinking Water Supplies; Sanitation by the Delhi Municipal Corporation; and school sanitation by the Education Department. There is a need to bring these various departments together through stakeholder workshops in order to foster better coordination. For example, issues of infectious diseases are related to poor water and environmental sanitation. These issues could be addressed through infrastructural support and collaboration with the municipal corporation.
In Mongolpuri site, as a pilot which could be rolled out to the other project sites to ensure project sustainability, the project has formed a HIC committee, headed by the Municipal Councillor, comprising of 9 members who includes young people, parents and a people’s representative. This committee will play an important role in the planning and monitoring of the HIC. All decisions related to the HIC are being taken by HIC committee members. For example the HIC members unanimously decided to keep affordable quarterly fees of 10 Rupees for all HIC users. This fee was introduced to create a value for the HIC and foster learning on how to run a sustainable institution, which caters to the health and social development needs of the young people and the community. After the project gets phased out, if there was support from the whole community and it didn’t deter users, the committee could increase the fee so that they could bear the expenditures of the centre. This will need to be decided after some evaluation of the user fees. There are even aspirations to register the HIC committee under the Society Registration Act so that they can in future function independently and get the grant support from Government and NGOs. In this way, this HIC centre could be developed and nurtured as a sustainable model so that it could also be replicated elsewhere.
Engaging the community through Community Stakeholder Groups has been instrumental in instilling ownership. The project has tried, where possible, to recruit local staff from the community. The 585 peer educators selected and trained are from the communities themselves and they are taking this learning forward to other young people in the schools and vicinity. The team of young people have been performing street plays on project themes to increase community awareness. The project intends to provide some participants with professional training in Year 2 so that they can acquire professional skills in drama and in future they can use it as a livelihood opportunity for themselves.
The project will sensitize teachers and health staff based in Government institutions on adolescent health issues. Through the stakeholder sensitization and coordination meetings, relevant Government authorities and community leaders have been engaged and will be extending support to the project. The project is also being linked to existing Plan and partner programmes supported by donors and operating in an integrated way.