Keywords ANM - ASHA workers - knowledge - practice - perception
Introduction
Every individual across the globe possesses an inherent right to good health, which
is pivotal for the progress of any society. Regrettably, there exists an uneven distribution
of health care resources between developed and developing nations.[1 ] In India, a country inhabited by 243 million adolescents, accounting for 21% of
the population, these young individuals constitute a substantial demographic and economic
force that shapes the nation's future. As adolescents' needs vary based on factors
such as gender, personal circumstances, and socioeconomic status, their distinct requirements
are apparent.[2 ] This phase of life, known as adolescence, marks the second decade and is characterized
by burgeoning potential and significant opportunities that pave the way for self-discovery
and autonomy. Adolescents undergo rapid physical, cognitive, and emotional development,
influencing their feelings, cognitive processes, decision-making abilities, and interactions
with their surroundings. This phase is a distinctive juncture in human growth and
is pivotal in establishing the foundation for long-term well-being.[3 ]
The research underscores that the adolescent demographic is often the initial underlying
cause of numerous noncommunicable diseases. Conditions like mental health disorders,
sexually transmitted infections, early pregnancies, and childbirth are prevalent among
adolescents. This age group's current health status substantially shapes adolescents'
future well-being.[2 ] Given the substantial population of adolescents and the associated disease burden,
the Indian government introduced the Rashtriya Kishor Swasthya Karyakram (RKSK) or
the National Adolescent Health Program in 2014, aiming to safeguard and enhance the
health of adolescents. The primary objective of the RKSK program is to ensure that
“all adolescents can realize their full potential and make informed decisions related
to their health and well-being.”[4 ]
Investing in the health of adolescents is imperative, as it yields immediate and positive
outcomes in terms of India's health objectives.[5 ] The RKSK program encompasses six priority areas: enhancing nutrition, promoting
adolescent sexual and reproductive health, addressing noncommunicable diseases, curbing
substance misuse, preventing injuries and violence (including gender-based violence),
and fostering mental health. To achieve optimal adolescent health, RKSK employs strategies
such as peer education, Adolescent Health Day (AHD), the Weekly Iron and Folic Acid
Supplementation (WIFS) program, and the Menstrual Hygiene Scheme (MHS).[6 ]
Facility-based interventions aim to provide health care services by engaging adolescents
and field workers, including auxiliary nurse midwives (ANMs), Accredited Social Health
Activist (ASHA) Workers, Anganwadi Workers, medical officers, and nongovernmental
organizations (NGOs).[7 ] Consequently, the role of community health workers (CHWs) becomes pivotal in disseminating
awareness about adolescent health within communities. CHWs in a primary health center
(PHC) context are individuals who are part of the local community and have undergone
specialized training to deliver essential health care services and support within
the area they serve. Assessing the extent of knowledge of these CHWs becomes instrumental
in enhancing the focus on adolescent health within the health care system. Furthermore,
a survey focusing on adolescent health highlighted that adopting the ABCDE approach
(Assess, Build, Create, Deliver, and Evaluate) significantly enhances the effective
implementation of RKSK.[8 ]
Methodology
Study Design
A cross-sectional study was carried out in Bellary district's Hagaribommanahalli and
Huvina Hadagali taluks ([Fig. 1 ]). The study was conducted between October 2021 and July 2022. A two-stage sampling
technique was employed. In the first stage, two taluks were selected using a lottery-based
approach. In the subsequent stage, a complete enumeration was performed using the
census method. The researcher included all available ANMs and ASHA workers in the
chosen taluks. This encompassed all the CHWs in Hagaribommanahalli and Huvina Hadagali.
The total count of CHWs working in PHCs across these taluks was 404. All the CHWs
in the PHCs of Hagaribommanahalli and Huvina Hadagali taluks were approached for participation
in this study.
Fig. 1 Study area.
Study Instruments and Administration Procedure
The study instrument was subjected to validation by five experts in the field. The
researcher administered a semi-structured questionnaire to the CHWs. The questionnaire
was translated into the local language to ensure ease of comprehension. Comprising
four sections, the questionnaire encompassed sociodemographic information, knowledge-based
queries, practice-related inquiries, and perception-related items. Data collection
from the respondents was conducted by trained public health personnel.
Data Collection and Ensuring Data Quality
The researcher personally visited the health centers where the participants were located
and provided them with a clear understanding of the study's nature and objectives.
Following a concise presentation, the researcher gave the participants an informed
consent form and guided them through its contents. The participants were informed
that they retained the right to withdraw from the study at any point, and their involvement
was completely voluntary.
Data Analysis
The data collection process involved the collection of information in a paper-based
format, which was subsequently entered into the Epicollect5 mobile application. The
analysis of the collected data was carried out using SPSS Version 20. Categorical
variables were summarized using frequencies and percentages, including age, education
level, marital status, designation, and experience. The variables related to knowledge,
practice, and perception levels were presented in percentages. The chi-squared test
was employed for association between variables such as age, education, marital status,
designation, and experience with the outcome variables. A significance level of p < 0.05 was utilized to determine statistical significance.
Ethical Considerations
Before the study commenced, ethical clearance was secured from the Institutional Ethics
Committee with the approval number INST.EC/EC/162/2021-22 at KS Hegde Medical Academy,
Nitte (Deemed to be University). Additionally, permission was sought from the relevant
authorities to conduct the study.
Results
This study encompassed 404 CHWs, comprising 336 (83.2%) ASHA workers and 68 (16.8%)
ANMs. The breakdown of respondents according to the sociodemographic attributes is
depicted in [Table 1 ]. The average age of the CHWs was 38 ± 6 years, with the entirety of the respondents
being females. Among the participants, 132 (32.7%) fell within the age bracket of
36 to 40 years, while 127 (31.4%) were aged above 40 years. The educational attainment
of the CHWs was categorized using a revised version of the Kuppuswamy scale, revealing
that 254 (62.9%) CHWs had completed their secondary education. This was followed by
26 (6.4%) who had obtained a graduation degree. Moreover, a significant portion, namely,
356 (88.1%) of the respondents, were married. Notably, 319 (79%) of the participants
had undergone training under the RKSK program.
Table 1
Sociodemographic characteristics of the community health workers (n = 404)
Variables
Number
Percent
Designation
ANM
68
16.8
ASHA
336
83.2
Age (y)
25–30
54
13.4
31–35
91
22.5
36–40
132
32.7
>40
127
31.4
Education
8–10
254
62.9
12 (PUC/ITI)
124
30.7
>13 (UG, PG)
26
6.4
Marital status
Unmarried
15
3.7
Married
356
88.1
Widowed
33
8.2
Experience (y)
2–5
65
16.1
6–10
75
18.6
>11
264
65.3
Formal training
Yes
319
79
No
85
21
Abbreviations: ANM, auxiliary nurse midwives; ASHA, Accredited Social Health Activist;
ITI, industrial training institute; PG, postgraduate; PUC, preuniversity course; UG,
undergraduate.
The distribution of knowledge was classified into two categories, aligning with the
RKSK guidelines: correct and incorrect. A significant proportion the CHWs, comprising
389 (96.3%), were aware of the specified age range for adolescents according to the
RKSK guidelines (10–19 years). However, only 198 (49%) knew the accurate acronym for
the RKSK program. Furthermore, nearly 392 (97%) CHWs were well-informed about the
target demographic addressed by the RKSK program, while 389 (96.3%) were acquainted
with the program's objectives.
Regrettably, a notable percentage, namely, 227 (56.2%) of the respondents, lacked
awareness regarding appropriate contraceptive methods for adolescents. Additionally,
310 (76.3%) were not informed about the reasons for injury and violence prevalent
among adolescents. Likewise, approximately 237 (58.7%) were unfamiliar with the recommended
day for conducting AHD as outlined in the RKSK guidelines.
Knowledge of the CHWs was categorized based on a median value of 10. Participants
scoring below 10 were classified as having inadequate knowledge, whereas those scoring
above 10 were deemed to possess sufficient knowledge. Among the total participants,
158 (39.1%) exhibited insufficient knowledge concerning the RKSK program, while 246
(60.9%) demonstrated a satisfactory level of knowledge ([Table 2 ]).
Table 2
Distribution of respondents based on their knowledge of RKSK (n = 404)
Questions
Correct, n (%)
Incorrect, n (%)
Age of adolescents mentioned in the RKSK program
389 (96.3)
15 (3.7)
Full form of RKSK
198 (49.0)
206 (51.0)
The target group for the RKSK program
392 (97.0)
12 (3.0)
Objectives focused under the RKSK program
389 (96.3)
15 (3.7)
Reasons to conduct the Adolescent Health Day
364 (90.1)
40 (9.9)
Who organizes the Adolescent Health Day
389 (96.3)
15 (3.7)
Who are the beneficiaries of the Adolescent Health Day
357 (88.4)
47 (11.6)
Suitable contraceptive methods for adolescents
177 (43.8)
227 (56.2)
Methods used for nutritional evaluation among adolescents
377 (93.3)
27 (6.7)
Reasons for noncommunicable diseases among adolescents
306 (75.7)
98 (24.3)
Reasons for injury and violence among adolescents
94 (23.7)
310 (76.3)
Preferred day to conduct the Adolescent Health Day as per the RKSK guidelines
167 (41.3)
237 (58.7)
Reasons for mental health issues among adolescents
266 (65.6)
138 (34.4)
Abbreviation: RKSK, Rashtriya Kishor Swasthya Karyakram.
Out of the entire pool of respondents, 390 (96.5%) affirmed that they upheld the confidentiality
of adolescents' health matters. Additionally, 334 (82.7%) participants reported documenting
activities as part of the RKSK program. Moreover, 337 (83.4%) CHWs indicated that
they organized AHD every 3 months. In comparison, 313 (77.5%) of these workers supplied
sanitary napkins, iron and folic acid (IFA) tablets, and condoms to adolescents (see
[Table 3 ] for detailed data).
Table 3
Distribution of respondents based on practice of RKSK program at the field level
Variables
Frequency
Percent
Confidentiality
Yes
390
96.5
No
14
3.5
Documentation
Yes
334
82.7
No
70
17.3
Frequency of conducting AHD
Once in 3 mo
337
83.4
Once in 6 mo
8
2.0
Once a year
30
7.4
Not at all
29
7.2
Location of conducting AHD
Schools
183
45.3
PHC
90
22.3
Community
131
32.4
Commodities during the RKSK program
Sanitary napkins
17
4.2
IFA and albendazole tablets
72
17.8
Condoms
2
0.5
All the above
313
77.5
Abbreviations: AHD, Adolescent Health Day; IFA, iron and folic acid; PHC, primary
health center; RKSK, Rashtriya Kishor Swasthya Karyakram.
The practice of RKSK activities among CHWs was evaluated, and the results were categorized
using a median value. Participants scoring below 4 were classified as having correct
practices, while those scoring above 4 were considered incorrect. The findings revealed
that 321 (79.5%) CHWs adhered to the RKSK guidelines and correctly implemented the
RKSK activities ([Table 4 ])
Table 4
Distribution of participants' total score on the RKSK practice questionnaire (n = 404)
Practice
Frequency
Percent
Correct (total score <3.9)
321
79.5
Incorrect (total score >4)
83
20.5
Abbreviation: RKSK, Rashtriya Kishor Swasthya Karyakram.
[Table 5 ] presents the analysis of the relationship between the age and education of respondents
and the knowledge level of CHWs concerning the RKSK. The results indicate that neither
the respondents' age nor their education showed any significant association with the
knowledge of CHWs about the RKSK program. Neither the respondents' marital status
nor their work experience exhibited any significant association with the CHWs' knowledge
concerning with the RKSK program. The designation of respondents significantly correlates
with the knowledge level of CHWs concerning the RKSK.
Table 5
Association of social variable with community health workers' knowledge
Variables
Inadequate, n (%)
Adequate, n (%)
Test statistic
p -value
Age (y)
25–30
20 (37)
34 (63)
4.292
0.232
31–35
33 (36.3)
58 (63.7)
36–40
46 (34.8)
86 (65.2)
>40
59 (46.5)
68 (53.5)
Education
8–10
108 (42.5)
146 (57.5)
4.964
0.174
12
44 (35.5)
80 (64.5)
>13
6 (24)
20 (76)
Marital status
Unmarried
2 (13.3)
13 (86.7)
4.558
0.102
Married
144 (40.4)
212 (59.6)
Widowed
12 (36.4)
21 (63.6)
Experience (y)
2–5
25 (38.5)
40 (61.5)
0.192
0.908
6–10
31 (41.3)
44 (58.7)
>11
102 (38.6)
162 (61.4)
Staf f
ANM
19 (27.9)
49 (72.1)
4.282
0.039
ASHA workers
39 (41.4)
197 (58.6)
Abbreviations: ANM, auxiliary nurse midwives; ASHA, Accredited Social Health Activist.
Discussion
In the current investigation, it was observed that 32.7% of the respondents fell within
the age range of 36 to 40 years, with an average age of 38 ± 6 years. This is consistent
with a survey conducted in Saudi Arabia, where the age of 63.5% of the participants
were between 35 and 39 years.[9 ] Notably, 62.9% of the individuals had completed their secondary education, while
88.1% were married. These findings align with a study conducted in Ethiopia, which
reported a similar marital status distribution with approximately 62.3% of the participants
being married.[10 ] The study also found that 79% of the participants had undergone formal training,
a statistic resembling a study conducted on health service providers where approximately
60.68% of respondents had received training on adolescents' sexual and reproductive
health.[11 ]
Regarding knowledge of the RKSK program, 60.9% of the respondents in the current study
demonstrated adequate understanding. This is comparable to findings from a study in
Madhya Pradesh that reported that 70.3% of participants were knowledgeable about the
RKSK program. Additionally, 96.5% of the participants stated they maintained confidentiality
about the adolescents at the field level. These results are consistent with a survey
conducted in 2018 that revealed that 90% of adolescent consultations with health care
providers were treated confidentially.[12 ]
[13 ]
Regarding practices related to the RKSK program, 82.7% of the participants reported
documenting the RKSK activities, and 83.4% indicated conducting AHD every 3 months.
Furthermore, nearly 77.5% of the CHWs supplied the adolescents with essential items
such as sanitary napkins, IFA tablets, albendazole, and condoms. A study in Gujarat
also found that ASHA workers primarily assisted with the WIFS program and the AHD.[14 ]
The perception of the CHWs was assessed based on the statements they provided. Notably,
all the participants strongly concurred with the views on implementing the RKSK program
in every PHC and educating adolescents about nutrition. They acknowledged that organizing
the AHD improves adolescents' health knowledge and education about sexual and reproductive
health, ultimately aiming to reduce teenage pregnancies. Similar perceptions were
documented in a study conducted in Saudi Arabia, where health care providers were
seen offering separate health care wards and services tailored to adolescents' needs.[9 ]
Conclusion
The results of our study reveal that knowledge of the CHWs regarding the RKSK program
remains below the desired level. Enhancing the initial and ongoing training for CHWs
in the RKSK program could yield positive outcomes. It is commendable that implementing
the RKSK program at the field level showcased effectiveness. However, there is room
for improvement, particularly regarding the frequency of conducting the AHD within
communities and the diligence of documentation. Addressing these aspects would warrant
dedicated attention. Comprehensive training for each CHW across every taluk within
their respective PHCs as part of the RKSK program would serve to fortify adolescent
health and the CHWs' understanding, practices, and life skills across a spectrum of
health dimensions. This includes nutrition, mental health, sexual and reproductive
health, communicable and noncommunicable diseases, curbing violence and injuries,
and preventing substance abuse. Given the employment of the questionnaire approach
in this study, the depth of exploration with the CHWs was limited. Furthermore, potential
limitations encompass respondent and recall bias, considering that the training was
undertaken some time ago.
