Associate Professor

IIHMR University

Jaipur, Rajasthan, India

Background

Over 640 million women currently alive were married as children.[1] Annually, around 12 million girls before reaching the age of 18 years are married; this depicts that every minute 28 girls are married below the legal age.[2] However, One in every five girls is before reaching 18 years of age is married.[3] The significance of human rights and freedoms for the girl child, and the elimination of harmful practices that violate these fundamental rights have been also emphasized in the International Conference on Population and Development in 1994 and its Programme of Action, and the Fourth World Conference on Women in 1995 and its Platform for Action called for the recognition. India has made progress in terms of child marriage prevention and improving health status of adolescents however, the estimates suggest that around 2 million girls each year, get married under legal age in India. While the rate has been declining from 26.8% per cent to 23.3.& per cent between2015-2016 and 2019-2021 it is still too high with regional variations.

Child marriage is a practice widely prevalent in Rajasthan amongst the states of the Indian union and other parts of the globe. The data of the National Family Health Survey 2020-21 observation included in the NFHS-5; having a marriage before 18 years of age has decreased to 25 % in the women of Rajasthan who are in between the age of 20-24 years. 4 percent with 10 percent decline in NFHS-4. But child marriage remains higher in rural areas, at 28 percent than in the urban areas. Marrying off girls before the age of 18 years this is among; 3 % of girls are forced into early marriage as compared to 15 percent. 1% within urban regions of Rajasthan, this disparity in rural and urban literacy rates was a result of various government initiatives implemented for the upliftment of rural populations.

Child marriage is considered as one of the indicators of gender inequality, and it means that its practice must be prevented by the year 2030.

In addition to the impact of child marriage on education, growing attention to this as a global development issue considering its increasing impacts on population health. Multinational organizations including, World Bank, government, the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF) have been working in Rajasthan towards preventing child marriage consequences on health. The Rajasthan government recently appointed additional officials in all 33 districts of the state to monitor the trends and drivers of child marriages. The state government has also been implementing various schemes and programmes to prevent child marriage including Beti Bachao Beti Padhao, Girl’s education policy, scheme for adolescent girls, child protection services etc.

Adolescence years are marked by extensive biological, psychological, and social changes. Especially in developing countries where majority of the world’s adolescent population resides, access to quality sexual and reproductive health and rights (SRHR) is a major concern[4]. Varied initiatives, programs, and interventions comprising educational programs, financial incentive schemes, and comprehensive healthcare services have been effective in increasing adolescents’ knowledge and access of SRHR services, thus further decreasing the unwanted pregnancies⁴.

In India, and specifically in regions like Rajasthan, child marriage has been a prevailing issue, with substantial implications on the health and overall well-being of adolescents. Girls being forced for child marriages often had to face challenges such as depression, violence, and so they are bound to drop out of schools and colleges, leading to early pregnancies and worsening their difficult situations[5]. Policies and programs like the Adolescent Reproductive and Sexual Health (ARSH) Strategy, School Health Programs, and Rashtriya Kishor Swasthya Karyakram (RKSK), have aimed to provide comprehensive frameworks for SRHR services, enhancing adolescent health access, and address various health issues⁵.

While there are positive improvements in various health indicators among adolescents, challenges in accessing healthcare services and ensuring adequate health insurance coverage still persists. The number of females facing permission-related challenges for treatment has been decreasing, but financial constraints still are the major challenge[6]. The COVID-19 pandemic has further exacerbated issues in adolescent health, comprising early marriages, violence, and reduced access to SRHR services.

Rationale

The child marriage has serious impact on overall wellbeing of a child by limiting him/her access to education, healthcare and other developmental opportunities. The Sustainable Development Goals (SDGs) have put emphasize on preventing child marriage to ensure equity in healthcare.

The decreasing rate of child marriage in Rajasthan should have an impact on increasing agencies of adolescents to make decision regarding age of marriage, and access to the healthcare services.

Therefore, the study focused on exploring the intricate relationship between healthcare access, health outcomes, and the socio-cultural factors influencing adolescents in Rajasthan. By assessing the effectiveness of delayed marriage and child marriage prevention programs, the study is providing valuable insights into improving adolescent health outcomes and identifying persistent challenges that require targeted interventions.

The study further explains the factors affecting decision making of adolescents, influencers, and health outcomes in five districts of Rajasthan namely- Bhilwara, Chittorgarh, and Sawai Madhopur. These districts had high prevalence of child marriage and have shown dramatic decrease in percentage of women aged 20-24 years married before 18 years of age.

Study Objectives

The purpose of the study as outlined in the rationale is to independently contribute to the healthcare outputs and outcomes among adolescents; to provide information to support evidence-based decision making; and to inform whether or how the improvement in child marriage indicators contributed to changing agency of adolescent girls in the high prevalence districts. The study focused on the integration of learning among stakeholders at all levels including district authorities, community, adolescents.

Access to Healthcare services among Adolescents

Undertake systematic review of literature and facts related to adolescents’ access to healthcare services in Rajasthan.

Impact of delay in marriage age

Assess the impact of delay in marriage age on health outcomes amongst adolescents.

Effectiveness of prevention efforts

Assess the effectiveness of child marriage prevention programmes in the selected districts.

Methodology

The study followed a criteria-driven approach using theory-based, mixed method approach and case- study methodology. The study was grounded in theory-based approaches to reflect how the child marriage prevention programmes intended to generate changes by addressing the underlying causes of the problem (i.e., child marriage) and its impact on health outcomes.

The study also featured Deep dive case studies (in-districts), and desk case studies (remote). Case studies fitted well into the study approach for several reasons. Firstly, it focussed on learning and case studies provided an opportunity for in-depth inquiry and informed our understanding about the research subject. Secondly, case studies are often used alongside as the case studies are a natural fit for realist approaches.[7] The study used mixed methods for data collection, that is, both qualitative and quantitative methods, for data collection and analysis.

The evaluation also applied human-rights-based approach and gender lens to the overall process. It supported a proper analysis of how unobserved gender norms and gender discrimination are influenced/changed for diverse groups of women and girls, men and boys.

Process

The process is divided into three phases as described below.

Inception Phase

The Inception phase a comprehensive desk review of essential documents was undertaken. Documents such as government reports, programmatic information, data, MIS, research studies and other relevant documents were reviewed. The documents were explored as per the research objectives and indicators.

Data collection phase

Following the desk review, the data collection commenced from March 2024. Data analysis was done continuously throughout the period as case studies are prepared and data from other sources become available.

Analysis and report writing phase

Primary and secondary qualitative data collected were analysed using content analysis interviews, focus groups. While qualitative data analysis, we used codes to various themes and analyse qualitative data from all secondary and primary sources.

Methods and Tools

Data collection methods

The following methods were used to reach the study objectives.

Desk review

The desk review, which began during the inception phase, continued throughout the study. Strategic, programmatic and operational documents at national, regional and district level were used for the preparatory phase of the study.

KII and FGDs

Primary data collection conducted using semi-structured key informant interviews (KIIs) and focus group discussions (FGDs). Primary quantitative data collection methods include compiling and analysing the data. The KIIs were conducted with district authorities such as Child Protection Officer, health department, WCD nodal officer, DHMO, PRIs, Aanganwadi etc. The FGDs were conducted with groups of adolescent boys (15-21 years) and girls (15-18 years years). In each district, there were 5 KIIs, 4 FGDs (2 with boys and 2 with girls) and 1 case study.

Districts	KII	FGD	Case study
Bhilwara	5	4	1
Chittorgarh	5	4	1
Sawai Madhopur	5	4	1
	15	12	3

Ethical considerations

Adolescent participation in the study was conducted in accordance with high ethical standards. The researcher followed guidelines for doing research and interacting with children and adolescents when interviewing teenagers.

Child-friendly: the tools were created with language and design that appeals to children.

Age-appropriate: based on the age group, choose the right techniques and resources.

Safe: made sure that kids won't be harmed during the data collection process.

Consent: made sure that plans are in place to secure the informed consent and assent of the teenager from parents or other guardians.

Result and Discussion

The study's systematic review revealed several critical insights into adolescents' access to healthcare services in Rajasthan. With a significant adolescent population of 15.7 million in Rajasthan, which is around 23% of the total population of state, several challenges in health care access and outcomes is observed. This demographic represents a potential dividend for the economy but also poses a risk if key health issues are not addressed[8].

An intergenerational effect is observed in the health and nutrition status of adolescents. Therefore, adolescence is one of the significant stages of the life cycle concerning health interventions.

However, the review identified several major health challenges pertaining to adolescents that require instant response in Rajasthan to deal with acute health issues, chronic illness, or poor health and impede their ability to reach their full potential. Among others, the key issues influencing the development of adolescents in Rajasthan and throughout India include high rate of child marriage, high prevalence of anemia, particularly among females and varied mental health related issues[9]. In response to this, several programs and interventions have been implemented in Rajasthan to address these issues and improve overall health outcomes among adolescents.

Weekly Iron Folic Acid Supplementation

This scheme is a community-based intervention that addresses nutritional deficiency, iron deficit and anemia in adolescents from both rural and urban settings[10]. This scheme is particularly crucial in Rajasthan, where anemia prevalence is high, especially among adolescent girls[11]. It is focused towards covering boys and girls from class VI–XII of government, government supported and municipal schools as well as ‘out of school’ students[12]. The main components of the scheme are (1) monitored administration of weekly iron and folic acid supplements; (2) Target groups screening for moderate to severe anaemia and referral to suitable health facility; (3) Bi-annual de-worming and (4) Informational and counselling sessions aimed at enhancing dietary intake and preventing intestinal worm infestation[13][14]. The WIFS scheme has shown significant effectiveness in addressing anemia among adolescents in Rajasthan. Supervised supplementation ensures consistent intake of iron and folic acid, which are crucial in prevention and treatment of anemia. By targeting both adolescent group in-school and out-of-school, the scheme achieves wide coverage, including those who might otherwise be missed by school-based programs[15].

Adolescent Friendly Health Clinics.

This scheme also known as Rashtriya Kishor Swasthya Karyakram (RKSK), is a comprehensive initiative designed to address the various health requirements amongst adolescents in Rajasthan[16]. A wide range of clinical and counselling services on various adolescent health concerns are provided at AFHC, including non-communicable diseases, mental health, injuries, nutrition, substance misuse, and violence (including gender-based violence). Adolescent Friendly Health Services at varied levels of Health Centers are provided by trained service providers including MOs, ANMs and Counsellors   . The AFHCs scheme has significantly impacted adolescent health outcomes in Rajasthan. By offering a broad spectrum of services, the scheme addresses various health issues that adolescents face, contributing to their overall well-being.

The study "Assessment of the Quality of Sexual and Reproductive Health Services Delivered to Adolescents at Ujala Clinics: A Qualitative Study in Rajasthan, India" provides a comprehensive evaluation of the services offered at these clinics under the National Adolescent Health Programme, Rashtriya Kishor Swasthya Karyakram (RKSK)[17]. Based on the World Health Organization's (WHO) worldwide guidelines for high-quality health care services for teenagers, the research identifies serious shortcomings in the present service delivery framework. Through qualitative methods, including mystery client observations and in-depth interviews with counselors, the research identifies key areas needing improvement, such as enhancing counselors’ competencies, ensuring privacy and confidentiality, improving referral systems, and fostering a non-discriminatory environment. These findings underscore the necessity for targeted efforts to improve service quality at AFHCs, recommending enhanced training for counselors, better clinic facilities, and robust monitoring and evaluation mechanisms. The study calls for comprehensive measures to bridge these gaps, aiming to better meet the health requirements amongst adolescents and ensuring equitable access to high-quality sexual and reproductive health services.

Menstrual Hygiene Scheme

The objectives of this scheme is to increase awareness regarding health and hygiene practices among adolescent girls, by providing access to high-quality sanitary napkins, and safeguarding safe disposal of napkins in rural areas[18]Initially launched in 2011 across 107 districts in 17 states, the scheme provided rural adolescent girls with packs of six sanitary napkins, called "Freedays," for Rs. 6. ASHAs (Accredited Social Health Activists) are responsible for distribution, earning incentives per pack sold and receiving a free pack monthly. They also hold monthly meetings at Anganwadi Centers to discuss menstrual hygiene and other sexual and reproductive health issues[19].

As an innovative initiative, the Rajasthan government has introduced the "Udaan" initiative, distributing free sanitary napkins to females, enhancing menstrual hygiene and health outcomes for adolescent girls. Rajasthan's this initiative is a part of the state's broader efforts towards improved sanitation and menstrual hygiene[20]. The Udaan scheme aims to address the challenges faced by rural women in accessing and affording sanitary napkins, thereby promoting better menstrual hygiene practices.

The total amount of Rs 200 crore was allocated by Rajasthan government for the Free Medicine Scheme, this amount has been planned to be spent on distribution of menstrual hygiene products[21]. This initiative has highlighted the significance of investing in the overall health and well-being of adolescents and thus breaking taboos and stigma around menstruation. The Rajasthan government’s initiative towards distribution of free sanitary napkins, and expansion of dispensation through health and medical facilities as well as sensitization campaign, have significantly helped in creating much-required awareness around menstrual hygiene[22].

Adolescent health days

The Adolescent Health Day held quarterly is one of the crucial interventions under the RKSK program for improving coverage of preventive and promotive health services to adolescents and thus increasing awareness among adolescents, parents, families and stakeholders regarding issues and requirements concerning adolescent health[23]. AHDs are organised at the village level usually at Anganwadi Centres or other accessible public venues²³. Block adolescent health coordinator is the focal person responsible for coordinating AHD, and also to ensure availability of required services and commodities. ASHAs are responsible for increasing awareness regarding adolescent health requirements by engaging with their parents and families²³.

Adolescent Friendly Club Meetings

Meetings under the Adolescent Friendly Club (AFC) are a crucial component for the health intervention amongst adolescents. Under the supervision and guidance of ANM monthly AFC meetings are organized at sub-center level in Rajasthan, India. These meetings act as an platform for Saathiya from different villages to discuss the varied issues they confronted to adolescents during their weekly meetings[24].

School Level Health & Wellness Programme

Schools act as an significant component to help students in establishing long term healthy behaviours. In order to identify the significance of this, health promotional activities under the Health and Wellness component of the Ayushman Bharat Programme are organised at school level. This program was launched in Feb 2020 and is being successfully implemented at government and government supported schools at district level and also in aspirational districts[25].

Incentive based interventions

Several incentive based schemes have been rolled out by Rajasthan government in the state that are aimed to delay the age of marriage for girls in both direct and indirect manner. The two major schemes under this initiative which have successful in achieving the same are Community Marriage scheme and the Sahyog scheme.

Under the Community Marriage scheme, the total of Rs. 5,000 is given as an incentive to each couple who are marrying at a legal age. Moreover, a collective amount of Rs. 100,000 is also collectively incentivized to group marriages involving up to twenty couples.

If a girl marries after the age of 21, the incentive amount is increased to Rs. 10,000. This benefit is limited to the marriage of up to two daughters per family. In cases of group marriages with more than 20 couples, the District Collector has the discretion to make decisions regarding the incentives. It is mandatory for the Collector to verify the age certificates of all couples before registering the marriage and disbursing the funds[26].

The Sahyog scheme offers financial incentives to families from backward castes to delay the marriage of their daughters. A cash incentive of Rs. 5,000 is provided if a daughter is married between the ages of 18 and 21, and Rs. 10,000 if she is married after turning 21. Similar to the Community Marriage scheme, this incentive is applicable for up to two daughters per family.

Focus group discussions Findings

Twelve focus group discussions (FGDs) were conducted, six with adolescent girls (15–18 years old) and six with adolescent boys (15–21 years old), each with six–eight participants of the same gender. A research assistant meticulously transcribed every interview and focus group discussion. Following Clarke and Braun's six stages of thematic analysis—familiarization, coding, looking for themes, reviewing themes, defining and labelling themes, and writing up—thematic analysis was employed to analyse the data.

Table 2 presents the main themes and sub themes of the study⁹.

Main Themes	Sub Themes
Awareness regarding child marriage and access to healthcare	Understanding on the child marriage and its effect on health Participation in awareness programs and seminars Experiences with healthcare services and perceptions of their availability and quality
Effectiveness of Prevention Programs and Participation and Engagement of Adolescents	Ideal age for marriage Reasons for early marriage and associated health issues Decision-making          autonomy       and empowerment Perception of awareness programs’ impact on health and marriage decisions.

Participants across both boys' and girls' FGDs demonstrated a basic understanding of child marriage and its detrimental effect on health. Many adolescents articulated that marrying at a young age often leads to early pregnancies, resulting in further health complications.

"Child marriage makes girls have babies when they're too young, and it's really bad for their health. A lot of girls get sick because their bodies aren't ready for having a baby. They can get anemia and other problems. I know some girls who had to drop out of school because they got too sick. It's scary because it can be dangerous for both the mom and the baby. I wish people understood how harmful it is and stopped making girls get married so early."

Bhilwara FGD with Adolescent girl

Girls participating in the focus group discussions demonstrated a clear understanding of child marriage practice and how it impacts their overall health and wellbeing.  Many girls articulated that early marriage often leads to early pregnancies, which can result in severe health complications for young mothers. These complications include anemia, malnutrition, and higher maternal and infant mortality related risks.

Additionally, they mentioned the psychological impact of early marriage, such as stress and a lack of readiness for the responsibilities that come with marriage and motherhood.

"Child marriage is really bad for a girl's health. My cousin got married when she was only 16, and she had a baby a year later. I remember seeing her and how tired and sick she always looked. She got severe anemia, which made her very weak and pale. She couldn't do much because she didn't have the energy, and she was always dizzy. The doctors said it was because she was too young to handle being pregnant and giving birth. She even had to go to the hospital a few times because her condition was so bad. I was really scared for her and felt so sad because she used to be so full of life and fun. Now, she couldn’t play with us anymore or even go to school. She missed out on so many things because she had to take care of her baby and deal with her health problems. Seeing her like that made me realize how dangerous child marriage is. I don’t want that to happen to me or my friends.”

- Chittorgarh FGD with Adolescent girl

"However, child marriages are now reducing. Parents are starting to realize the potential of girls and are letting us study. Many programs and sessions are being held in our school, and now we know what the adverse effects of child marriage are. This has helped the girls in making their families understand this and made them realize how bad child marriage is for both boys and girls.”

- Sawai Madhopur FGD with Adolescent girl

Boys also acknowledged the adverse effects of child marriage, though their understanding was often less detailed than that of the girls. They recognized that early marriage could lead to health problems for girls, but they also mentioned the economic and social pressures that contribute to this practice. Boys noted that families often marry off their daughters early due to financial difficulties or to follow cultural traditions. However, they did not discuss what are the potential effects of early marriage amongst themselves, and their focus remained on how it negatively affects girls.

“We know that marrying young can be bad for a girl's health, but in our village, many families marry their daughters off early because they can’t afford to keep them. It’s a tradition that’s hard to break.”

- Bhilwara FGD with Adolescent boy

“We know that marrying young can be bad for a girl's health, but in our village, many families marry their daughters off early because they can’t afford to keep them. It’s a tradition that’s hard to break.”

- Sawai Madhopur FGD with Adolescent boy

While boys were aware of the adverse health outcomes for girls due to child marriage, they did not talk much about the impact on boys. Their understanding seemed to be that child marriages are primarily detrimental to girls. This indicates a gap in awareness about how child marriage also affects boys.

Early marriage can lead to significant health outcomes for boys as well, including psychological stress, premature responsibilities, and limited educational and economic opportunities. Boys who marry young may face mental health issues due to the pressure of providing for a family at an early age, which can also lead to anxiety and depression. Additionally, the disruption in education and career prospects can hinder their long-term well-being and personal development.

Participation in Awareness Programs and Seminars

Girls reported higher participation in awareness programs and seminars focused on child marriage and access to healthcare compared to boys. Many girls mentioned attending sessions organized by schools and community health workers, which emphasized the early marriage risks and the advantages of delaying it.

"I attended a seminar where they explained how child marriage affects health and education. It was very informative; we participated in interactive workshops, watched educational videos, and engaged in group discussions. I shared what I learned with my friends and family."

- Sawai Madhopur FGD with Adolescent girl

They found these programs informative and empowering, providing them with valuable knowledge about the risks of early marriage and the importance of health and education. Many girls mentioned sharing what they learned with their peers and families, creating a ripple effect of awareness within their communities.

"I attended a program at my school where they talked about the dangers of child marriage, explaining how it affects our health and future prospects. The seminar included interactive discussions on how the girls who got married early in our community are facing challenges. The knowledge I gained from these activities helped me understand the severe consequences of child marriage on education and overall well-being. This newfound understanding gave me the confidence to have an open conversation with my parents about my future. I explained to them how early marriage could affect my health, my education, and limit my career opportunities. Through these discussions, I was able to convince my parents to let me continue my studies and not marry me off before the age of 20, allowing me to complete my graduation and aim for a good job. As a result, my parents are now much more supportive of my educational aspirations."

- Chittorgarh FGD with Adolescent girl

The verbatims from the FGDs conducted in the three districts of Rajasthan clearly provides qualitative evidence that educational seminars and awareness programs are effective in raising awareness about the challenges of child marriage, enhancing their knowledge regarding health and education impacts, and building the confidence of young girls to advocate for their futures. These programs are not only informing but also empowering participants in effectively changing their own lives and their communities, contributing to a broader shift in attitudes and practices regarding child marriage.

In contrast, boys expressed lower engagement in such programs, often finding them less relevant and engaging.

“We have these sessions in school, but they are mostly focused on girls. They talk about marriage and health issues that don’t concern us much, so we don’t pay attention.”

- Bhilwara FGD with Adolescent boy

“We have these sessions in school, but they are mostly focused on girls. They talk about marriage and health issues that don’t concern us much, so we don’t pay attention. They use the same materials and talk about the same things every time. We need more engaging activities and discussions that include boys and address our concerns.”

- Sawai Madhopur FGD with Adolescent boy

Experiences with Healthcare Services and Perceptions of Their Availability and Quality Girls generally reported positive experiences with healthcare services, attributing this to increased focus on their health through various programs and initiatives. Many girls mentioned regular visits to health centers for check-ups, receiving iron supplements, and accessing information on menstrual hygiene. They appreciated the support from healthcare providers and the availability of resources tailored to their needs.

“The health center in our village is very supportive. They provide us with iron supplements and sanitary napkins regularly. The nurses are friendly and explain things clearly. I feel comfortable going there.”

- Chittorgarh FGD with Adolescent girl

“We have sessions at the health center where they teach us about nutrition and hygiene. It’s very helpful. They also do check-ups and make sure we are healthy. I feel that the healthcare services have improved a lot.”

- Sawai Madhopur FGD with Adolescent girl

Boys shared mixed experiences with healthcare services, highlighting a lack of services specifically tailored to their needs. They felt that the healthcare system primarily focused on girls and neglected the health issues faced by boys. This lack of targeted services made them feel marginalized and less likely to seek help.

“Healthcare services are available, but they mostly focus on girls. We feel awkward discussing our issues because there are no specific sessions for boys. We need more male health workers who can understand our problems.”

- Sawai Madhopur FGD with Adolescent boy

“When we go to the health center, they ask us why we are there. It’s like they don’t expect boys to need health services. We need more awareness about boys’ health issues and dedicated services for us.”

- Bhilwara FGD with Adolescent boy

Incentive-based interventions have been notably effective in reducing the number of child marriages in Bhilwara, Chittorgarh, and Sawai Madhopur. These interventions include financial incentives for families to delay their daughters' marriages until after the legal age.

“My family was considering getting me married at 17, but when they learned about the incentive for marrying after 21, they decided to wait. The money is a big help for us.”

-Bhilwara FGD with Adolescent girl

KII Findings

The interviews were carried out with various stakeholders, including Child Protection Officers, health department officials, WCD nodal officers, DHMOs, PRI members, and Aanganwadi workers. These interviews aimed to gather insights on the effectiveness of ongoing schemes, initiatives, and programs in delaying the age of marriage and enhancing healthcare access and outcomes for adolescents.

The findings are organized to reflect the key themes and areas of inquiry addressed during the interviews. This structure includes an overview of respondents' roles, their understanding of child marriage prevalence and impact, health outcome indicators, awareness of child marriage consequences, effectiveness of prevention programs, the role of government and NGO initiatives, and recommendations for improvement.

Respondents acknowledged that child marriage remains a concern but noted a significant decline in its prevalence over recent years. This decline is attributed to various targeted interventions and increased awareness programs. Key factors identified include socio-economic conditions, traditional practices, lack of education, and gender inequality. However, ongoing efforts are addressing these root causes effectively. Primary health issues among adolescents include anemia, early pregnancy complications, and malnutrition. Increased awareness and health education have been pivotal in addressing these issues. There is an increasing uptake of family planning methods and improved nutritional practices among adolescents. This is attributed to dedicated family planning services and nutrition programs implemented in the regions.

Respondents frequently engage with adolescents about the consequences of early marriage and its impact on health. These discussions have led to a heightened awareness and understanding among adolescents. There is a notable increase in the utilization of health services by adolescents. Awareness programs about the health impacts of early marriage have encouraged more adolescents to seek healthcare services proactively. Schemes such as distribution of sanitary napkins was highly beneficial in eliminating the stigma around menstruation and thus enhancing conversation on these topics among adolescents.

“The normalisation of conversations around menstruation is as critical as the dispensation of hygiene products because numerous taboos, misinformation, superstition, and ignorance still surround the subject. Hopefully, the awareness programs being anchored by the state government as well as civil society organizations will lead to social and behavioral change and more communities will understand the consequences of unhygienic menstrual management, approximately 1.2 crore women in the age group of 15 to 45 years would benefit from the Menstrual Hygiene Scheme (MHS) in the state. Such initiatives depict that the state government is sensitive towards recognizing the issues and needs related to menstrual health. These steps will go a long way in protecting women and girls from developing menstrual hygiene-related diseases like fungal, urinary tract, and reproductive tract infections. All young girls deserve correct information and resources to manage their menstrual health. We, on our part, will continue to work with all stakeholders at the grassroots level to make a difference,”.

-Bhilwara KII with Aanganwadi worker

The child marriage prevention programs have also been effective in delaying the age of marriage. Respondents observed that adolescents, particularly girls, are more empowered to make informed decisions regarding marriage and healthcare. There is a positive shift in the decision-making abilities of adolescents. More adolescents are now advocating for their rights and are involved in decisions about their health and marriage.

"The child marriage prevention programs have definitely made a significant impact. We've observed a noticeable delay in the age of marriage among adolescents, particularly girls. These programs have provided them with the knowledge and confidence to make informed decisions about their lives. They are now more aware of their rights and the health implications of early marriage."

-Bhilwara KII with health department officials

Adolescent participation in prevention programs is high. Interactive and engaging formats, peer education, and involvement in community activities have increased their active participation. Successful strategies include school-based education programs, community mobilization, and involvement of local influencers and role models. These strategies have effectively engaged adolescents in preventing child marriages and promoting healthcare access. Government initiatives such as the Beti Bachao Beti Padhao campaign, conditional cash transfers for delaying marriage age, and health education programs have significantly contributed to delaying marriage and improving healthcare access. NGO initiatives complement government efforts by providing grassroots support, running awareness campaigns, and offering healthcare services tailored to adolescents. Collaboration with local communities has enhanced these efforts.

"The level of adolescent participation in our prevention programs has been incredibly high. We’ve seen firsthand how using interactive formats makes a huge difference. For example, when we organize health fairs or interactive workshops, the adolescents are much more engaged. Peer education has been a game-changer; when they hear from someone their own age, it just clicks for them."

-Chittorgarh KII with WCD nodal officer

"Conditional cash transfers for delaying marriage age have provided families with a tangible incentive to keep their daughters in school longer. This financial support has been crucial for many families. One father told me that the program allowed him to afford his daughter’s education and keep her from marrying early."

Chittorgarh KII with PRI member

Implementing these initiatives has seen substantial successes, including increased school enrollment, delayed marriages, and improved health outcomes. Challenges include persistent cultural norms and limited resources in remote areas.

The overall responses from health department officials, PRI members, and Aanganwadi workers highlight the high level of adolescent participation in prevention programs. Interactive formats, peer education, and community activities have significantly engaged adolescents. Successful strategies such as school-based education programs, community mobilization, and involvement of local influencers and role models have effectively prevented child marriages and promoted healthcare access. Government initiatives like Beti Bachao Beti Padhao, conditional cash transfers, and health education programs, alongside complementary NGO efforts providing grassroots support and tailored healthcare services, have significantly contributed to delaying marriage and improving healthcare access for adolescents. Collaboration between government bodies, NGOs, and local communities has been pivotal in enhancing these efforts.

The findings indicate that various schemes, initiatives, and programs being implemented in Bhilwara, Chittorgarh, and Sawai Madhopur are successfully delaying the marriage age and enhancing healthcare access and outcomes for adolescents. The concerted efforts of government bodies, NGOs, and community stakeholders are creating a positive impact on the lives of adolescents, empowering them to make informed decisions about their health and future.

Conclusion and Recommendations

The study highlights the persistent issue of child marriage in India, particularly in Rajasthan, despite significant progress in recent years. This positive trend has also had a notable impact on the access to and outcomes of healthcare services among adolescents in the state. The findings of the study underscore the effectiveness of several initiatives, including Weekly Iron Folic Acid Supplementation (WIFS), Adolescent Friendly Health Clinics (AFHCs), Menstrual Hygiene Scheme (MHS), Adolescent Health Days, Adolescent Friendly Club Meetings, School Health & Wellness Programme, and Incentive-based interventions. These programs were the most effective in delaying the age of marriage and consequently improving health outcomes among adolescents.

By addressing the root causes of child marriage and implementing targeted interventions, Rajasthan has made significant strides towards ensuring the well-being and empowerment of its adolescent population. However, continued efforts are needed to sustain and build upon these achievements, with a focus on further reducing child marriage rates and enhancing access to comprehensive healthcare services for all adolescents in the state. Rajasthan can continue to advance the rights and health of its youth and work towards attaining the Sustainable Development Goals with cooperative efforts and continued commitment from governmental and non-governmental partners.

Recommendations

To further enhance the progress, it is recommended to:

Expand and Improve Healthcare Services:

Increasing the access and availability of adolescent-friendly health clinics (AFHCs) in both urban and rural areas.

Ensuring that tailored healthcare services are provided to adolescent girls and boys for addressing their specific needs, focusing on comprehensive sexual and reproductive health (SRH) services.

Strengthen and Monitor Incentive-Based Schemes:

Strengthen and monitor existing incentive-based schemes, such as the Community Marriage scheme and Sahyog scheme, to ensure they effectively delay marriage age.

Introduce additional financial incentives for families who prioritize their children’s education and health over early marriage.

Expansion of Comprehensive Adolescent Health Services:

There is a need to expand the access and availability of comprehensive adolescent health services, including reproductive health, mental health, and nutritional support.

Investing in the establishment of more Adolescent Friendly Health Clinics (AFHCs) and integrating adolescent health components into existing healthcare facilities can ensure that adolescents have access to quality healthcare services tailored to their specific needs.

Multi-sectoral Collaboration and Policy Integration:

Foster multi-sectoral collaboration and policy integration to address the underlying socio-economic determinants of child marriage and adolescent health.

Coordinating efforts across government departments, civil society organizations, and community stakeholders can facilitate the implementation of holistic strategies that address the root causes of child marriage and promote the overall well-being of adolescents.

Additionally, integrating adolescent health components into existing policies and programs, such as education and social welfare schemes, can ensure a comprehensive approach to promoting adolescent health and rights.

References

1. UNICEF, Child marriage around the world: https://www.unicef.org/stories/child-marriage-around-world. OHCR and women’s human rights and gender equality https://www.ohchr.org/en/women/child-and- forced-marriage
2. UNFPA and UNICEF, Global Programme to End Child Marriage: https://www.unicef.org/documents/global-programme- phase-ii- programme-document-theory-change.
3. Meherali, S., Rehmani, M., Ali, S. and Lassi, Z.S., 2021. Interventions and strategies to improve sexual and reproductive health outcomes among adolescents living in low-and middle-income countries: a systematic review and meta-analysis. Adolescents, 1(3), pp.363-390.
4. Sahadevan, S., Dar Iang, M. and Dureab, F., 2023. Effect of Adolescent Health Policies on Health Outcomes in India. Adolescents, 3(4), pp.613-624.
5. Okunogbe, A., Meekins, M., Saalim, K., Conti-Lopez, M.A., Benabaye, R.M., Mendoza, O.M., Julio, R., Stan, L. and Bisson, C., 2023. Utilization of adolescent health services during the COVID-19 pandemic: evidence on impact and adaptations from a rapid assessment survey in the Philippines. BMC Public Health, 23(1), p.493.
6. Yin, R. (2017). Case study research and applications: Design and methods. Sage publications. https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Rajasthan-R4-Adol-brief-EN.pdf
7. Kamala, Verma., Girish, Chandra, Baniya. (2022). Prevalence, knowledge, and related factor of anemia among school-going adolescent girls in a remote area of western Rajasthan. Journal of family medicine and primary care,  doi: 10.4103/jfmpc.jfmpc_1372_21
8. Dr., Ajad, Singh., Dr., Malti, Kapoor. (2023). Challenges and Opportunities for Young People in Rajasthan's Labour Market: A Study of Labour Force Participation Trends and Factors. International Journal of Research Publication and Reviews,  doi: 10.55248/gengpi.2023.4155
9. Kamala, Verma., Girish, Chandra, Baniya. (2022). Prevalence, knowledge, and related factor of anemia among school-going adolescent girls in a remote area of western Rajasthan. Journal of family medicine and primary care, doi: 10.4103/jfmpc.jfmpc_1372_21
10. Claudionei, Vicente, Cassol. (2023). Healthy Cities for Adolescents: Learnings and Reflections From Bhubaneshwar and Jaipur City. S.M.A.R.T. environments,  doi: 10.1007/978-3-031-32840-4_5
11. Oxford Analytica. (2023). Making key act work may be tough for India’s Rajasthan. Emerald Expert Briefings, (oxan-db).
12. Sukhender, Kumar., Narendra, Jangid., Munish, Kumar, Bawa. (2022). Unqualified health care providers and rural public health in rajasthan. International journal of advanced research,  doi: 10.21474/ijar01/15405
13. Atul, Khajuria., Raju, Sehrawat. (2023). To evaluate the hematological markers in patients having nutritional anemia attending National Institute of Medical Sciences Hospital of Jaipur, Rajasthan.   doi: 10.4103/DYPJ.DYPJ_75_22
14. Radhika, Dayal., Mukta, Gundi. (2022). Assessment of the quality of sexual and reproductive health services delivered to adolescents at Ujala clinics: A qualitative study in Rajasthan, India. PLOS ONE, 17(1):e0261757-e0261757. doi: 10.1371/journal.pone.0261757
15. Dayal, R., & Gundi, M. (2022). Assessment of the quality of sexual and reproductive health services delivered to adolescents at Ujala clinics: A qualitative study in Rajasthan, India. PloS one, 17(1), e0261757. https://doi.org/10.1371/journal.pone.0261757
16. Anju, Rajendra. S, (2023). Menstrual Hygiene Management (MHM): A Scheme for Improving Women Welfare. International Journal For Multidisciplinary Research, doi: 10.36948/ijfmr. 2023.v05i03.3551
17. Sonali, G., Choudhari. (2023). Menstrual Hygiene Problems and Challenges Faced by Adolescent Females in Rural Areas: A Narrative Review. Cureus,  doi: 10.7759/cureus.40438
18. Singh, A., Chakrabarty, M., Singh, S., Chandra, R., Chowdhury, S., & Singh, A. (2022). Menstrual hygiene practices among adolescent women in rural India: a cross-sectional study. BMC Public Health, 22, Article number: 2126.
19. https://www.mordorintelligence.com/industry-reports/india-feminine-hygiene-market
20. UNICEF. (2019). https://www.unicef.org/media/91341/file/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf
21. NHM, Adolescent Health. (2024) https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1249&lid=493
22. NHM. RKSK. (2020). https://nhm.hp.gov.in/storage/app/media/uploaded-files/AFC%20guidelines-1.pdf
23. MHFW & MHRD. Operational Guidelines on School Health Programme under Ayushman Bharat. (2018). https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/AH/guidelines/Operational_guidelines_on_School_Health_Programme_under_Ayushman_Bharat.pdf
24. Government of Rajasthan. SJE. (2024). https://sje.rajasthan.gov.in/Default.aspx?PageID=77