PREAMBLE We, the national professional associations as advocates and contributors to health and development of the people in India, coming together for promoting realization of the opportunity of demographic dividend presented by the biggest cohort of adolescents and young people in the contemporary history of India; recalling the commitments made by India to the framework of the Sustainable Development Goals (SDG),[1] in particular those relating to health and well-being, education, and gender equality; recalling the National Education Policy 2020 that seeks to align with the national commitment under SDG4 to "ensure inclusive and equitable quality education and promote lifelong learning opportunities for all by 2030", reaffirming the rights and principles enshrined in the constitution of India that relate to health and well-being of people as well as the country's commitment to the International Convention on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination Against Women, and others; reaffirming the right of every human being to the highest attainable status of health, including sexual and reproductive health, and the right to education; convinced that adolescents and young people are heterogonous groups, but as a combined force and a demographic dividend, are indispensable for the national economic and social development and represent great potential as change agents to transform the society; recognizing that crises like the coronavirus disease 2019 (COVID-19) pandemic, conflicts, natural disasters, and other situations increase the vulnerability of adolescents and young people and limit their access to quality education and health services including information on sexual and reproductive health, mental well-being, and so on; acknowledging that it is essential to strengthen the capacity of adolescents and young people by providing them with age-appropriate, scientific, and culturally appropriate information, skills, and services to make informed choices, adopt healthy behaviors, overcome gender inequalities, be safe from coercion, exploitation, and all types of violence, and lead healthy and fulfilling lives to realize their full potential; and acknowledging also the high cost of not doing this in terms of immediate adverse implications on health and well-being of adolescents and young people, disengagement within family and education system, and potential social disharmony in the long term. Proclaim our collective commitment to work with the whole society toward holistic healthy development and well-being of adolescents and young people of our country, where all adolescents and young people possess the knowledge, skills, attitudes, and values they need to transition to adulthood, maintain healthy and respectful relationships with others, and be prepared to become active, empowered, and responsible citizens and help the country to realize full potential of national social and economic development. CONTEXT Public health issues and challenges in adolescence India has a young population, and there are about 378 million young people (10–24 years) including 250 million adolescents (10–19 years).[2] They are generally perceived to be healthy, but there are several public health issues that are common in this age in India: Triple burden of nutritional disorders Under-nutrition, over-nutrition, and micro-nutrient deficiencies (like anemia) are common among girls and boys during adolescence.[3] Menstrual health and needs A large number of adolescent girls and young women have inadequate knowledge about menstrual health.[4] Many girls lack access to adequate facilities for menstrual hygiene, and with the associated social stigma, this may lead to school absenteeism and increased dropout. Substance use There is a significant use of tobacco, alcohol, and illegal substances among adolescents and young people that is detrimental to their health, education, and social outcomes.[3] Mental health issues Stress, anxiety, depression, self-harm, and suicides are common among adolescents and young people but under-reported.[5] There was an upsurge in these conditions during the COVID-19 pandemic and prolonged lockdown periods. Suicides have increasingly been reported among students from coaching institutes for competitive examinations in a city in northern India. Risks of Internet use The Internet and social media present, both, great potential for adolescent and young people's development and a significant exposure to new risks and dangers. Excessive use and overuse of the Internet interfere with sleep and formal learning in schools and colleges and present challenges to mental well-being. Exposure to inappropriate, incorrect, and harmful content like violence and explicit sexuality is associated with deleterious effects on their well-being and development. There is also an increased risk of cyber bullying, cyberstalking, and exposure to online sexual predators.[6] Early sexual experimentation Consequent to social-cultural changes, the opportunities for sexual experimentation and engagement have increased. Early sexual debut is more likely to be unsafe, leading to unintended pregnancy and sexually transmitted infections.[3] Early marriage and unintended pregnancies Child marriages (under 18 years age among girls) are progressively decreasing in India. Nevertheless, early marriage is associated with lesser use of modern contraception and higher fertility.[3] Adolescent pregnancies are associated with higher health risks for the mothers and their infants. Maternal mortality is the leading cause of death among adolescents and young women.[7] Early marriage and pregnancy also contribute to school dropout and disruption in social and economic activities. High unmet need for contraception Adolescents have higher unmet needs of family planning as well as for modern contraceptive methods compared to older age groups.[3] Social norms and gender-based violence Gender-based violence (GBV) including harassment and sexual violence and physical and psychological violence are present in our society and are often reinforced by gender norms that justify these. Limited access to timely and relevant information and quality sexual and reproductive health (SRH) services Lack of access to timely and scientific information on sexuality and reproductive health and responsive services for adolescents and young people, especially girls, increases the risk of unintended adolescent pregnancy, unsafe abortion, human immune deficiency virus (HIV), and other sexually transmitted infections (STIs). Poor information and awareness also lead to a lack of self-confidence in understanding sexuality and managing related situations and to decreased utilization of the required services. Limited societal awareness, cultural barriers, and dialogue Parents, teachers, and other members of society often have limited awareness of SRH needs of adolescents and their concerns. In addition, cultural barriers and social stigma related to sexuality prevent a healthy dialog with the adolescents, especially girls, before and around puberty. Society's reaction and response to adolescent behavior Recent media coverage that gained public attention demonstrates a lop-sided response to the adolescent sexual curiosity that manifested as a finding of contraceptives in the bags of school students in a metro city.[8] The reaction adopted by local authorities points out to inadequate awareness of adolescent sexuality and deep social and cultural overlay in managing the situation. Restrictive legal and policy framework There is a need for ensuring consistency and coherence across multiple existing government policies and laws that affect adolescents and young people so that there are barriers to provision of information and services to adolescents (legally minors). It is required to strike a balance between the ethical and human rights for adolescents to seek sexual and reproductive health education and services and the need for parental consent as well as the provisions of child protection laws like Protection of Children Against Sexual Offences (POCSO) Act. Box 1 enlists the public health issues and challenges in adolescence.Box 1: Public health issues and challenges in adolescenceOpportunities Given India's young and dynamic population, investing in health and education will ensure economic and social empowerment of young people and will help in realizing the demographic dividend, leading to rapid economic growth for the country. Global International Technical Guidance on Sexuality Education (UNESCO, UNAIDS, WHO and partners), 2018, provides an evidence-based framework for a holistic and comprehensive education covering the common health risks faced by Indian adolescents mentioned above.[9] The technical guidance informs that the evidence shows that it is possible to implement effective education and information programs for SRH that are aligned with the laws, policies, values, and culture of a country. Such programs lead to improved knowledge, acquisition of appropriate skills and attitudes about reproduction and social relationships, and a reduction in risk of pregnancy, STIs, HIV, and GBV. In India, there are presently several significant opportunities for provision of information and knowledge and developing skills and attitude among adolescents and young people toward realizing the demographic dividend for national development. Adolescent Education Program (AEP) The Government of India has been implementing the revised adolescence education program developed by the National Council of Educational Research and Training (NCERT) through state AIDS control societies in coordination with the State Councils of Educational Research and Training (SCERTs) for adolescents both inside and outside formal schools since 2013. The aim is to empower adolescent learners to acquire knowledge of their needs and concerns related to the period of adolescence and develop life skills that enable them to practice informed and responsible behaviors.[10] However, the scale-up has been slow: only an estimated 25% schools are implementing AEP and some states are not implementing it at all. Rashtriya Kishor Swasthya Karyakram ((RKSK), National Adolescent Health Program) The Government of India is presently implementing this national program under the National Health Mission (NHM) since 2014 with the objectives to promote healthy lifestyle, reproductive and sexual health, nutritional status, substance misuse prevention, violence-free living, and mental and emotional well-being.[11] This builds upon the previous phase of the national adolescent health program (RCH-II ARSH strategy) implemented during 2005–2014 that also emphasized provision of appropriate information to adolescents in health services and in schools. National Education Policy 2020 This policy provides another huge opportunity with expanding school enrolment and educational opportunities with modern pedagogy, full equity and inclusion, and emphasis on character building of children including creativity and critical thinking, life skills, and ethical and human values, all of which contribute to the wider goal of national building.[12] School Health and Wellness Program (SHWP) Ministries of Health and Education have jointly launched the intensified school health program through health and wellness school initiatives. This proposes the curriculum-based participatory learning process by trained school teachers in collaboration with trained health workers and peer educators in the schools.[13] Digital technology expansion Access to mobile devices, Internet connectivity, and usage rates are growing rapidly in India. The information and communication technology has tremendous potential to reach young people, especially those who are the hardest to reach. However, a careful approach is required to minimize multiple risks of unsupervised and excessive use of screen-based activities. A young population, combined with increasing rates of Internet connectivity and use in India, could be a decisive advantage in promoting awareness, self-respect and esteem, health, well-being, and effective behaviors for respectful treatment of self and others as well as self-care. The technology also provides an opportunity for rapidly engaging with parents, families, teachers, other gatekeepers, and stakeholders to ensure a supportive and safe environment for the growing adolescents and young people. Call to Action We, the related national professional associations, strongly recommend immediate actions by all actors to support large-scale programs for information, education, and services toward healthy development of all adolescents and young people everywhere in our country. We commit ourselves and call upon other stakeholders to support and facilitate, without delay, the following actions to ensure that all adolescents and young people, in schools, colleges, and other educational institutes like coaching centers, as well as those outside the educational institutes, receive all the age-appropriate, scientific, and evidence-based information. There should be harmonization of multi-sectoral policies and strategies to protect the health and education rights of all adolescent girls and boys and young women and men. Education system to implement comprehensive information and education programs and addressing the cognitive, emotional, physical, and social aspects of health and well-being of adolescents and young people in variety of educational institutions, starting from 5 years of age. Such a system should provide age-appropriate scientific information and necessary skills to understand their responsibilities to remain healthy and to be able to develop respectful social relationships and realize positive or negative consequences of their choices for their own well-being and that of others. Health system to collaborate with the education system in providing information and skills, especially related to sexual and reproductive health with the aim of promoting holistic healthy development and well-being of adolescents and to provide acceptable and accessible health services through facility-based and community-oriented adolescent-friendly health approaches. Whole society to come together to provide a safe and supportive environment for providing ample opportunities to all adolescents and young people to acquire necessary information, skills, attitudes, and values as well appropriate services, in school or out-of-school, for maintaining good health including sexual and reproductive health and overall well-being, and prevent harm to self and others. Our collective aim is to equip them with the correct knowledge, skills, attitudes, and values that will enable them to live life and thrive with good health, well-being, and dignity. Recommended strategies Engage all actors and beneficiaries Increase awareness and engagement of all relevant stakeholders, gatekeepers, and beneficiaries – including adolescents and young people, parents and families, community, government functionaries, political and religious leaders, teachers, civil society organizations, technical and financial partners, and international organizations. Ensure collaboration Ensure strengthened collaboration and synergy of action between different sectors (e.g., education, health, social welfare, child protection, finance, justice, and media) at all levels, in particular between education and health departments. Intergenerational dialogue Promote through formal and informal programs an ongoing dialogue among adolescents, young people, parents–families, and teachers on overall health and well-being; sustain efforts to increase the comfort level of adolescents, parents, and teachers to discuss issues related to sexuality, reproduction, social relationships, gender, and so on; and facilitate use of appropriate education and health services. Reduce social stigma around adolescent sexuality Take collective actions to reduce social and cultural stigma, deconstruct taboos, and stereotypic beliefs and examine andre-engineer social and gender norms that can be detrimental to the health and well-being of adolescent girls and boys and young people. Scale-up implementation of comprehensive education and information programs with good quality in schools Education and health departments to scale up effective implementation of existing programs like Adolescence Education Program (AEP), RKSK, and School Health and Wellness Program (SHWP), and ensure that formal and non-formal education includes comprehensive, scientifically accurate, age-appropriate, and culturally sensitive curricula from early childhood to higher education, which are easily accessible to children, adolescents and young people, and girls and boys alike in and out of school settings everywhere. While undertaking this, keep an ongoing dialogue and collaboration with all the staff members of educational institutes and parents to ensure their comfort and capabilities. Capacity building and training of teachers Strengthen the training programs for teachers through pre-service and in-service settings to build their capacity to comfortably deliver quality comprehensive health education and information programs using participatory and learner-centered pedagogical approaches as well as develop and disseminate appropriate teaching materials and guidance tools to support this function and for continued engagement with parents. Linking with adolescent health services The health department must strengthen provision of adolescent friendly health services including SRH services as per the RKSK and collaborate with the education sector for improving the quality and coverage of school health services under SHWP. Such linkage would provide appropriate and effective referral services from educational institutions to health services. Strengthen monitoring and evaluation The Government should strengthen the monitoring and evaluation systems for effective monitoring of the performance of health and education systems through collection and analysis of good quality and disaggregated data to inform the decision-making process and program management. Invest in documentation and research to understand the situation and keep abreast of the evolving needs of adolescents and young people. The recommended strategies are summarized in Box 2.Box 2: Recommended strategiesAction now We reach out to policy makers and all relevant stakeholders across the society for collectively developing and sustaining a public movement for provision of comprehensive health education for children, adolescents, and young people to support their healthy development and well-being with a sense of urgency so that India realizes the demographic dividend in her progress toward becoming a developed economy and a prosperous and peaceful society. Acknowledgement: Members of the Recommendation Committee Dr. Harish Pemde, Immediate Past President, AHA; Dr. RG Patil, Joint Secretary, AHA; Dr. Suhas Dhunde, Treasurer, AHA; Dr. Piyali Bhattacharya, AHA EB; Dr. Shamik Ghosh AHA-EB; Dr. A Chenthil, AHA EB; Dr Deepak Gautam, AHA-EB; Dr. Prashant Kariya, AHA-EB. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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