Overall, 4853 women and 8158 adolescents were engaged in the intervention. Of the total, 68.2% of the women and 52.0% of adolescents were from Nagaur, and 31.8% of the women and 48.0% of adolescents were from Pali. The socio-demographic details of women and adolescents have been shown in Tables 3 and 4, respectively. Approximately 8% of the women had married before the age of 18 years. The majority of the population in the two areas were Hindus (96.4%). Around 86-87% of the adolescents and 85-87% of the women belonged to marginalized populations. More than two-thirds of the women who were enrolled in the intervention attended any education session in both districts. Sixty-nine percent and 62.5% of adolescents from Nagaur and Pali, respectively registered in the intervention ever attended an education session.
3.1 Qualitative assessment at baseline
The qualitative data at the baseline assessment has been divided into three main themes.
3.1.1. Perceptions on the utilization of maternal and child healthcare services by women
Women were aware of the antenatal care visits, the importance of taking a nutritious diet during pregnancy, and danger signs during pregnancy, such as fever, abdominal pains, and bleeding. Despite knowing the need to increase the dietary intake during pregnancy, only a few of them could add extra calories in the diet through nutritious foods. A lot of these women did not consume supplementary food supplied at Anganwadi centers because of its low quality. Women told that the government scheme of cash incentives for institutional delivery had promoted the uptake of antenatal care. However, most women did not visit the health facility within the first trimester. The socio-cultural norms and superstitious thoughts prevented women from disclosing their pregnancy status within the first three months.
If we visit a health facility within the first trimester, people will come to know. And evil’s eye will be on us. This will hamper the growth of our child. We do not want this.
Women regularly went for antenatal check-ups and other blood or urine tests. However, the consumption of iron-folic tablets was not common. The most common reason for not consuming iron-folic acid tablets was its side effects. Some of the women reported problems in accessing health facilities. Long distances to health facilities, lack of adequate staff, and lady doctors at primary health centers, an insensitive attitude of the frontline workers, and unhygienic surroundings were commonly reported problems in accessing health facilities. The uptake of postnatal care visits was low, and in fact, many did not know about it. Exclusive breastfeeding was a norm in the society, and early breastfeeding was common among women who were delivered in the institutions.
Most of the women knew about the family planning methods and ill effects of big families. However, the use of contraceptives was not common among newly married women. Most of these women had pressures from their families to give birth to a child soon after marriage.
We know about family planning methods. We know the slogan also. We two, ours two.
3.1.2. Perceptions of the adolescents about schooling, health and livelihood needs
School drop-outs were common among boys and girls. The reasons for drop-out among boys were pressure from the families to earn and contribute to the income of the family and lack of good quality teachers in schools. On the contrary, long distances to secondary schools, poverty, safety or security, and early marriages were the common reasons for the drop-out of girls. As a result of lower education, both boys and girls had limited opportunities for employment. Early marriage was common in both districts. Traditional customs, social pressures, and parents’ over dominance were reported as the reasons for early marriage in the areas.
An old custom of selling and auctioning their daughters is still common in some of the communities of Nagaur.
Poor sanitation and water-borne illnesses were common in the areas. Many adolescents were unaware of sexually transmitted diseases and HIV/AIDS. Girls often referred to their elder sisters for their reproductive health problems while boys did not share their reproductive health problems with anyone. Alcohol drinking, smoking, and tobacco chewing were common among boys and, to some extent, among girls. Adolescents lacked confidence, communication skills, and opportunities for skills training. Handyman jobs such as mobile repairing, electric appliances repairing, decoration, tenting, etc. were common among young people in the districts. Beautician and tailoring were preferred jobs among girls.
3.1.3. Perceptions of frontline workers on the utilization of services by women, inclusive service delivery in facilities and livelihood opportunities for young people
Anemia and low uptake of family planning methods among women were common problems in the areas. Frontline workers told that no discrimination was done based on castes while delivering maternal and child health services. Pregnant women visited Anganwadi centers regularly. Women from upper socioeconomic status preferred to deliver at home in the presence of skilled birth attendants while others preferred to deliver in institutions. Pregnant women underwent HIV/AIDS testing. Approximately one in three women had sexually transmitted infections. In addition, women used pills and copper T as family planning methods. Frontline workers told that consumption of iron-folic acid tablets was poor among adolescent girls. Frontline workers reported that the participation of women in livelihood schemes was more than men. The migration of the youth to the urban areas was common due to a lack of job opportunities in the intervention sites.
3.2 Qualitative data from the end line evaluation
3.2.1 Perception of women on the change in maternal and child healthcare knowledge and practices
Pregnant and lactating mothers told that a woman should marry when she is at least 20 years old and should undergo pregnancy at least 2-4 years after marriage. They were aware of the importance of pregnancy care.
A woman should have a child four years after marriage. A woman is weak in the early years of life and would give birth to a weak child. She should enjoy her married life before getting pregnant and understand her relations.
According to them, nutritious food is the major factor that keeps a pregnant woman healthy. There was a high production of milk and milk products in their villages, which they thought were nutritious and would keep them healthy. Women relied on mothers-in-law and Anganwadi workers in their villages for maternity care. Bleeding, abdominal pain and high fever were reported as the most common danger signs during pregnancy. Most of the women were aware of the antenatal check-ups, immunization of child, anemia, iron-folic acid consumption, and blood tests during pregnancy. However, barriers in accessing health services persisted, such as long distances to the facility from villages, lack of enough medical staff, and disrespectful attitude of the health center staff. Despite these barriers, many women had delivered in a health facility.
We should get abdominal ultrasonography done, take medicines and vaccines, blood tests, registration at Anganwadi center, and receive nutritional counselling. We need to get our children immunized to protect them against disability and illnesses. We need to consume iron-folic acid tablets because of anemia. We did not face any problem while taking iron-folic acid tablets.
There are problems such as midwives are not available at the centers. They come for delivery mainly, and the sub-center is quite far from our village. In case we fall sick or develop complications, we had to travel a long distance to access services. Moreover, it’s difficult to call an ambulance or any other transport because of a lack of good roads. (A woman during FGD)
We tend to arrange our vehicle for transport to the hospital for delivery, or we hire a taxi. We had even rented a vehicle for this purpose. We had to pay rupees 2000-4000 for the vehicle, but it is ok. We had to face more problems if we deliver at home.
Most of the women told that they knew about the sources of nutritious food, but could not afford to prepare them. Most of the women worked in fields and earned around INR 300 per day. Women knew about exclusive breastfeeding practice and its importance.
We need to give the yellow milk that comes out initially to our child and breastfeed them until six months of age. But we need to give ‘ghutti’ (a combination of Ayurvedic medicines) at the time of birth to the child. It’s a tradition in our villages, and we could not avoid it.
Most of the women had heard about family planning methods. They were aware of the side effects of multiple pregnancies and a big family. They recited a slogan, ‘We two, ours two’ in the local language (Hindi). However, they told that the use of contraception among newly married couples was low. Their attitude towards the use of contraceptives was not positive.
We were totally unaware of the family planning methods earlier. However, in the meetings organized by the MAMTA organization, we were told about them.
We know about Copper T, sterilization, etc. We are also given condoms by midwives for husbands. But our husbands don’t use them. Why should we take condoms from health workers if we have to undergo sterilization? After sterilization, we had complaints of lower backache and weakness. We had to do a lot of household work, including chopping grasses in the fields. If we fall sick, how will the work at home be managed?
We found that women had little or no information about HIV/AIDS or sexually transmitted infections. Many women were referred for HIV testing during pregnancy, but they were unaware of the reasons for the testing. Women received postnatal care visits to frontline workers and increased their diets during pregnancy.
3.2.2 Perceptions of adolescents on the change in the knowledge and practices related to health and nutrition
Adolescents knew that education is important, and they need to complete their schooling. Boys were employed as labor at construction sites on daily wages.
Boys drop out of school and search for jobs. They find jobs at construction sites and are paid up to Rs. 700 daily.
Many adolescents did not report that they visited youth centers during their leisure time. Early marriage was reported in the interviews. Mostly girls were married off early before the legal age of marriage. The common reasons of early marriage cited were traditional beliefs, societal pressure, and parent’s wish.
The age of marriage should be 24 for boys and 22 for girls, at least. By this age, boys and girls are mature and they know how to run a family. And before this age, girls should study. Child marriage is wrong. Girls are not mature before the age of 18 years, and it’s difficult for them to handle themselves, their families, and child. Big responsibilities at an early age are not good.
It was perceived that both boys and girls had a very comprehensive knowledge of sexual and reproductive health rights. They were able to explain what are the typical bodily changes and growth among boys and girls. Adolescents reported that they had been benefited by coming to the meetings organized during the project. Talking about sex education was considered taboo, and most of the people were hesitant in talking about it openly. However, boys and girls considered that men should be equally responsible for household work. They told that girls should also be given an opportunity to study, work, and drive. Adolescents were aware of contraceptives, such as condoms and pills.
We had benefited from the meetings. Nobody made fun or cracked jokes in the meetings. We were hesitant and afraid to discuss reproductive issues in the beginning. But later, we could discuss issues openly; such as menstruation, night falls, AIDS.
When I first had periods, I cried and was anxious. My mother helped me in using pads. If the period doesn’t come on time, we are even more worried. Periods are delayed if you are sick or have anemia. Parents asked us to avoid eating sour and cold foods during periods. Sometimes, we feel bad and think it would have been really nice if we were born as boys and not girls. Periods are a bit frustrating.
Adolescents were aware of the ill effects of alcoholism and drugs on health and family.
Boys often get addicted to drugs. Friends put pressure to start drinking. But it is bad. Excessive drinking weakens the body. Binge drinkers could not understand the needs of their families and become incapable of handling their families. Such drinkers often beat their wives, and the whole environment of the family gets disturbed. Their liver gets damaged, and the mind is equally affected.
Adolescents wanted to switch to newer job opportunities such as teaching, computer work from conventional jobs such as construction workers, daily wage labor, etc. However, lack of life skills, confidence, and opportunities often prevented them from fulfilling their dreams.
3.2.3 Perceived changes according to frontline workers and VHSNC members in the livelihood opportunities and service utilization by women and adolescents
There were limited job opportunities for young people in the intervention areas. Frontline workers reported that they did not practice discrimination between marginalized and non-marginalized populations. Frontline workers told that they provided antenatal and postnatal care, counselling on breastfeeding, immunization, and complementary feeding to all women coming to the health facilities.
We tried our best to reach the unreached population; however, there were certain castes that did not approach for services.
We keep a woman for three days post-delivery in the hospital. After that, we do home visits 7 times.
People were still hesitant to discuss HIV/AIDS openly. Commonly, family planning methods were adopted by females and not males.
Mainly females undergo sterilization or other methods of contraception. We are told by women while counselling for family planning that since males have to go for work, it would be difficult for them to go for work if they fell sick due to sterilization.
According to the members of VHSNC, the facilities in schools for education had increased. The enrollment of girls has increased, and drop-out had decreased in schools.
Nobody marries before the age of 25 nowadays. Most of the children complete education until the 10th standard, but we have been trying to make it up to 12th for all. Children from marginalized families mostly study in government schools. We award the meritorious students with cycles. There are two government and private schools in our area. My two daughters also study in schools. They are in 10th and 12th standard.
VHSNC members reported that child marriage had dropped in the area due to strict action by the police. Youth information centers were effective in transferring health-related knowledge among young people.
If we come across any news about the child marriage, we inform the police and stop it. MAMTA has helped us in guiding and promoting action against child marriage. We have to keep motivating people not to marry their children before the age of 18 years. Illiterate parents are often interested in child marriage.
3.2.4 Financial literacy and livelihood promotion training program
Nagaur: Of the total 210 young people who attended the training, 171 were in the age group of 16-19 years, and 39 were in the age group of 19-25 years. Hundred and sixteen (55%) out of the total 210 were girls, and 94 were boys (45%). Around 23% of the young people were linked with employment. Young people were linked with jobs in the computer training center, tailoring center, and beauty parlor.
Pali: Of the total 164 young people who attended the training, 123 were in the age group of 16-19 years, and 40 were in the age group of 19-25 years. Eighty-nine (54.6%) out of the total 163 were girls, and 74 were boys (45.4%). Around 61% of the young people were linked with employment. Young people were linked with jobs in the computer training center, tailoring center, photography, and beauty parlor.