School Dropouts among Adolescent Girls and Violence against Women: Strategies for Their Containment

School Dropouts among Adolescent Girls

It is not a very new phenomenon that those girls who are married at an early age, have to leave their schooling, and are exposed to the inevitable risk of early pregnancy, poor-childbirth related outcomes or complications, intimate partner violence, significant impact on the future prospects of childbearing, acquisition of sexually transmitted infections (due to poor knowledge about sexual and reproductive health or reluctance to approach health centers or negative attitude of the health workers), and impaired health standards and quality of life.^1,3,4 From an individual perspective, due to poor scholastic accomplishments, they remain dependent on men and have not many vocational opportunities, and thus cannot be a source of financial support to their families in times of need. Looking further, due to the loss of productivity, they don’t even have any role in the growth and development of the nation, which again is a serious cause of concern.^1–4

Improving School Retention in Adolescents

In order to respond to the prevailing challenges in Zimbabwe, where the trend of school drop-out or early marriage is a routine practice, the United Nations Population Fund has initiated a girls’ club – Sista2Sista, that provides a safe environment for these vulnerable adolescent girls to come out of their shell and discuss their concerns.⁵ This club came into existence in 2013 and is also supported by three European nations, with an ultimate aim to allow the girls to stay in school, and empower them to such an extent that they can reject child marriage and hence the associated sequels of the same.⁵ Further, it aims to help these adolescent girls in various ways, namely counseling about sexual and reproductive health, the scope and necessity of human rights, the importance of financial literacy, and the ways in which different difficult situations should be tackled. In fact, these adolescent girls are empowered with financial skills, so that they can develop self-belief to effectively respond to challenging situations, and at the same time pursue their education and support their family members. Acknowledging the lack of financial support, the club-initiated income-generating activities to help them in any possible way. In fact, since the launch of the program, a drastic reduction in the rates of school dropouts has been observed.⁵

Adolescent Girls and Menstrual Hygiene

Apart from various changes which occur at the personal level, numerous changes have been reported at a biological level, including the onset of menarche.⁶ Although menstruation is a normal physiological process, it is often associated with varied misconceptions (like a release of bad blood) or malpractices due to the lack of prior information which eventually accounts for different feelings (fear, shame, or guilt), rise in the incidence of reproductive tract or urinary tract infections, school absenteeism due to the apprehension of sudden menstrual blood leakage, scholastic backwardness, and reduction in sports participation or socialization with peers.^6–8

Even though it is a wrong opinion, still it is a fact that in most of society, the very event of menarche is an indicator of the girl being ready to be married and/or is sexually active, and hence it minimizes her chances of staying in school.⁷ Furthermore, apart from the factors like more investment by the family in the male child or birth order or long distance between school and home or poverty, other attributes like lack of access to sanitary napkins, poor awareness, poor toilet facilities or separate facilities to aid women in changing, cleaning or disposing of napkins, and easy access to soap and water for cleaning the body within the school premises, also plays a defining role in reducing school attendance.^8,9

Improving Menstrual Hygiene

Acknowledging the importance of menstrual hygiene in maintaining general health, living a life with dignity, and improving school attendance, it is extremely important to implement measures to ensure the provision of sanitary napkins, improve water sanitation and hygiene facilities in schools, and address the knowledge gap through providing education.^7–10 There is an immense need to develop comprehensive policies to improve menstrual hygiene; ensure that the desired information is passed on to the girls in a culturally acceptable way in schools; and involve different stakeholders to neutralize the existing shortcomings in the education system or the facilities.^8,9 In fact, the United Nations Population Fund has launched an initiative to make sanitary napkins with the help of female school students in Malawi by training them, which also includes the provision of information about reproductive health and hygiene.¹¹

Further, in order to ensure that these napkins are affordable, these napkins are extremely cheap, and reusable and the material used for manufacturing the same is locally available.^9,11 The initiative has started to deliver results with improvement in the attendance of girls and rising demands for napkins among the girls. In addition, attention has been given to reaching school dropouts and comprehensive improvement of reproductive health care in the nation.¹¹

Factors Influencing Access to Health Care Services

It is not something new that each day, our health standards or ability to avail health care are influenced by a wide range of factors (viz. gender, relations, financial status, education status, etc.).¹² However, the extent of variability between different social groups precisely determines the inequity in the ability of any individual to obtain health care.¹² These facts very much operate among adolescents, especially among girls from low-resource settings, as often they drop out of their schools, are forced to get married, and even become pregnant before their body is ready to respond physically to the demanding needs of childbearing.^12,13 Similar sorts of challenges have been observed in Nepal, and the issue of poor accessibility (due to the distant locations of health-care facilities), and affordability, remarkably hinder the chances of availing health care in the region.¹⁴

Potential Strategies to Improve Adolescent Health Standards

In order to improve the health standards of adolescents and simultaneously deal with the socio-cultural practices, the nation already has an adolescent sexual and reproductive health program, legal provisions to ban child marriage before 20 years of age, and legalized abortion services in place, nevertheless, none of them are effective enough to meet the inequity which the adolescents encounter on a daily basis.^12–14 To improve the reach of the existing sexual and reproductive health program for adolescents and to neutralize the existing barriers (like distance, travel cost, timings of health facilities, privacy and confidentiality concerns, gender inequality, etc.), which have been overlooked since the launch of the program, the World Health Organization in collaboration with the national health ministry has revised the program.^12–14 In fact, an Innov8 approach was adopted to negate the issues of inequity, gender bias, social determinants of health, and human rights violations, with the help of a team of experts from different agencies.¹⁴ At the same time, extra attention has been given to ensure that services are delivered in an adolescent-friendly manner and to every one of them regardless of their geographical locations.¹²

Moreover, efforts must be taken to strengthen the reach of outreach services, improve community engagement, capacity building of health workers on adolescent-related services, and involve multiple sectors to respond to the social issues of early marriage or early pregnancy or reluctance/ignorance from adolescents to avail sexual and reproductive health care.^13,14 Furthermore, on the global front, the World Health Organization has formulated a Global Accelerated Action for the Health of Adolescents Implementation Guidance document to improve the different dimensions of adolescent health.¹⁴

Child Marriage

The practice of child marriage has persisted in society for centuries together, and even in the current date above 14 million girls are subjected to child marriage each year.² More than anything else, it is a social evil and is often determined by the prevailing trends of poverty, social norms, and discrimination against girls.^2,3 Further, the incidence of the same is extensively high in low- and middle-income nations and has attracted global attention due to the serious concerns associated with poor reproductive health and the negative sequels associated with early marriage.^15,16 Moreover, the consequences of early marriage are detrimental to the girls as they often drop out of school, have no poor vocational prospects or economic stability, no or minimal awareness about sexual and reproductive health, and have poor health care utilization.¹⁶

Additional Considerations

At the same time, they are often exposed to the risk of childbirth-related trauma and even increased risk of mortality due to avoidable causes. Further, more often than not the basic rights of these girls are often violated on a daily basis and they are exposed to exploitation, intimate partner violence, and different forms of abuse.^15,16 From the program managers’ perspective, there is a great need to empower children and adolescent girls from developing nations to safeguard their human rights and general well-being. However, acknowledging the fact that it is more of a social concern, there is an indispensable need to address all the factors which somehow neutralize the prevailing social norms.^16,17 Also, significant progress can be achieved only if local community leaders or stakeholders are roped in against the fight against the prevention of early marriage.

Child Marriages in Nepal and Role of Priests

In Nepal, the findings of a recent survey revealed that close to 25% of girls in the late adolescence phase are married, and they are often linked with early pregnancy as well. In fact, very poor awareness about the legal minimum age of marriage has been observed among the local population, which is an alarming public health concern.^17,18 In order to deal with this challenge, the United Nations Population Fund in collaboration with the concerned national department has aimed to involve the local faith leaders (like priests, astrologers, etc.) and ensure that the practice of child marriage is eliminated from their communities.¹⁸ The aim of such an approach is to build a strong workforce to fight against social evils like child marriage. In fact, these faith leaders are going through the girls’ astrological birth details, and based on their age, parents have been advised to postpone their marriage. This is a crucial step as any ignorance on their part can result in serious consequences on the lives of adolescent girls. Also, they are playing a defining role in creating awareness about the side effects of child marriage, early pregnancy and the concern of gender-based violence.^17,18

Violence Against Women

Globally, violence against women is one of the major public health concerns and is an important determinant of their human rights violations. In fact, global estimates suggest that one in three women has been exposed to physical sexual violence in their life span.¹⁹ These acts of violence not only cause a significant impact on women’s physical, mental, sexual, and reproductive health but even augment the risk of death. Further, it has been recorded that close to 40% of women’s murders are performed by an intimate partner, which explains the grave nature of the problem.¹⁹ However, this problem of violence and human rights violation increases enormously in cases of humanitarian emergency, be it a natural disaster or a civil/armed conflict due to the lack of governance and order, no fear among the perpetrators of being punished, and the prevailing gender inequality among various societies.^19,20

The ongoing conflict in Yemen has resulted in a disastrous impact on the civilian people. The available estimates reflect that thousands of innocent people have been killed, millions have been internally displaced, and more than 12 million people are in urgent need of humanitarian assistance.^20,21 Further, due to the total interruption of routine health care, lack of welfare services by the local government, and no avenues for education or occupation in the affected regions, many families have been coerced into extremes of poverty.²¹ This poverty and the resulting strain have done nothing good for women instead they have become quite vulnerable to different forms of violence and exploitation, not only by the outsiders, but even by their own family members. Moreover, this unending war and its consequences have affected all, at all possible stages, including their livelihood, daily life, and relations. This is quite evident as a significant rise in the incidence of domestic violence and divorce rate has been observed. At the same time, women have been exposed to trafficking, early marriage, early childbearing, and pregnancy-related adverse complications.^20,21

Role of Health Sector in Preventing Violence against Women

The health sector has a major role in extending support to women who have been exposed to violence, and assisting them to have a better life.²² This is predominantly because of the extra opportunity that the health professionals have to come in contact with the survivors of violence in contrast to any other stakeholder. In fact, it has been revealed that women who have been exposed to violence, use health services more than their non-abused women counterparts.^22,23 Furthermore, these survivors of violence have an immense trust in the health care providers and often disclose their sufferings to them.^21–23

Role of Healthcare Professionals in Preventing Violence against Women

Considering that health professionals are more often than not the first point of contact for these women, they have to express their support by being respectful and not being judgmental.^22,23 The need of the hour is that health providers become active listeners and use not only their ears, but even their eyes and hearts, and show empathy and understand the feelings of women behind what they say, to help them in all possible dimensions.^23,24 Currently, health professionals from most nations are devoid of the skills/training which is required to effectively respond to violence, and concerns pertaining to lack of privacy and confidentiality due to infrastructure constraints are quite common.^22,24 As a matter of fact, only 50% of nations have any services to support and extend care to violence victims. Even in nations that have these services, they are plagued by lack of coordination, due to which they are expensive, requires long waiting time, and their coverage is restricted.^21–25

Furthermore, most of the nation has no inbuilt legal provisions to safeguard the interests of women and minimize their suffering.²⁶ In fact, the health workers should adhere to five steps to ensure that not only women express all their concerns, but also deliver a wide range of supportive services to them.^26,27 These include listening to her closely and without judging her stand, inquiring about their needs and problems, validating her incident by assuring her that you trust her, enhancing her safety by protecting her from subsequent incidents, and extending support through all possible linkages.^24,26 However, in order to attain these skills by health provider, training alone won’t help, instead the need is that they should be empowered so that they not only acquire such skills but even apply them to address violence.^25,27 In an attempt to respond to this a global action plan has been formulated to strengthen the role of the health system to respond to violence against women and girls and children.^26–28 This also calls for a multi-sectoral response and integration of violence prevention activities into the national health strategies, and timely allocation of resources.^26–28

Assistance to the Victims

In order to assist these vulnerable women, shelter homes have been established in cities, with the collaboration of the United Nations Population Fund.²⁶ These shelter homes apart from providing temporary residence, are extending sexual and reproductive health care, psychological support, referral services, and vocational opportunities (like craft or sewing, etc.).²⁶ In an attempt to expand the reach of these services, a network has been established between all these shelter homes, and even linkages have been established with the local police to guide vulnerable women to these homes, so that appropriate support and health care can be extended to them. Even though these shelter homes are not as well as homes, amidst the ongoing war, it offers a safe place for women to live without worrying about their security and away from violence.^21,26

Violence incidents in South Sudan

South Sudan has reported multiple incidents of civilian conflicts since it started in December 2013.²⁹ The national government has not been successful in bringing an end to the ongoing conflict and thus all routine welfare and healthcare services have taken a toll on the same. In fact, since the battle between rebel groups has been accentuated, the violence and brutality towards the common man have just escalated with each day.²⁷ It won’t be wrong to say that not even a single individual has escaped from the adverse consequences of the conflicts, with thousands of people being killed. Furthermore, these conflicts in different parts of the nation have resulted in the displacement of more than 2 million people, migration of people to sub-standard makeshift arrangements, mass killings, gang rape, abduction, trafficking, sexual harassment, violation of human rights, and extensive damage to the health care establishments and other important institutes of public health importance.²⁹

In fact, even the quality of life of survivors has failed to improve as there is no inbuilt mechanism in the nation to provide care and support them in their rehabilitation. Also, most of the victims and the survivors of the abuse have reported a high prevalence of mental illnesses, and once again there is an extensive human resource shortage to either provide psychiatric care or counseling through the trained staff to empower people to have a normal and healthy life.^25–27 It is disheartening to see the pace of relief activities and is quite evident that the nation and the communities will suffer for many years to recover and rebuild the infrastructure. Especially from the perspective of women and girls, they have been sexually victimized and subjected to all possible forms of sexual and physical abuse.^24,26 The experiences of the civilian survivors have been heart-wrenching, and many international agencies have come forward to support these vulnerable groups of women. Owing to the enormous stigma associated with rape survivors, and due to the prevailing social practice in the nation where women are only held responsible for such incidents, the provision of mental support has been recognized as an important element of care.²⁹

Role of the United Nations Population Fund

The United Nations Population Fund is assisting the victims of ongoing sexual violence and is providing appropriate referrals to extend post-rape medical care (including emergency contraception to prevent pregnancy and post-exposure prophylaxis to prevent the acquisition of human immunodeficiency virus infection) and psychological support with the help of trained health professionals or social workers.²⁹ The ultimate aim is to deliver holistic, effective, sympathetic and confidential care to the survivors of sexual assault. In addition, some midwives have also been trained across the nation to ensure the provision of sensitive post-trauma care. Further, even emergency reproductive health kits and dignity kits have been distributed to thousands of women and girls, through support from other nations.^28,29

Female Genital Mutilation (FGM)

Globally, FGM has been acknowledged as a serious practice violating the fundamental rights of girls and women. The current global estimates suggest that in excess of 200 million females living today have been subjected to the practice of FGM.³⁰ Though, it has no associated medical advantages, it is a very common practice among girls between infancy and 15 years of age, especially in Africa, the Middle East, and Asia. In fact, the practice has been associated with both acute (like severe pain, bleeding, infections, delayed healing, deaths, etc.) and chronic (such as urinary-vaginal-menstrual complaints, more risk of childbirth adverse consequences, psychological trauma, etc.) complications.^30,31

Moreover, it is anticipated that in excess of 3 million girls are at risk of this practice on an annual basis. The public health concerns associated with FGM have been acknowledged worldwide, and it has become a global priority to eliminate the practice to ensure a better quality of life among women.^30,32 However, despite the stand of international agencies for zero tolerance of FGM, the practice is quite prevalent in different parts of the world. Among African nations, Ethiopia has recorded an extremely high prevalence of FGM and the national government has shown high levels of political commitment and even launched different educational programs to bring an end to it.^29–31

Factors Promoting FGM

A wide range of socio-cultural factors have been identified for the persistence of the practice in the families and the communities in the region like social norm (doing what others are doing), prevailing thoughts that it has an indispensable role in the growth of a girl and to condition her for adulthood/marriage or that girls become clean and beautiful after removal of unclean body parts, to maintain premarital virginity (as the fear of the pain of opening it will avert extramarital sexual activities), and encouragement by community or religious leaders and other stakeholders (viz. women, men, religious or community leaders, health workers, policymakers, mass media, etc.).^31–33 Furthermore, more often than not the decision to subject their daughter to FGM is made by the mother as it is socially expected that she is the sole caretaker for them in all different aspects. In fact, attributes of a mother (like age, knowledge about the ill-effects of FGM, attitude, educational status, religion, etc.), play a crucial role in the persistence of the practice or its transmission from generation to generation. However, exposure to different modes of mass media or better financial status is associated with a reduction in the practice of FGM.^30–32

Prevention and Control of FGM

As a part of the continuation of the care and support activities in the nation, the United Nations Population Fund is supporting a marriage girls club in high prevalent regions, to prevent both child marriage and FGM. The ultimate aim is to empower the girls to stand up for their basic human rights. In this club, local women play a major role and create awareness among other peers about the adverse effects of child marriage and FGM, and their experiences.^30,34