By Shahida Sultan, Educationist & Early Childhood Development Specialist
“Women, children and adolescents still face numerous interrelated health challenges, underpinned by poverty, inequality and marginalization (WHO, 2015)”.
UNICEF adolescent demographics show that South Asia has the largest population of adolescents which is 340 million out of 1.2 billion overall population of adolescents at world level . Unfortunately, Pakistan is among those seven countries that cumulatively account for two-thirds of the world’s under-nourished population . Pakistan has more than 64% youth population including adolescent boys and girls, who have potential to contribute to sustainable development of the country, provided that they have access to nurturing environments and appropriate opportunities and platforms for active and productive engagement. The current malnutrition issues among children and youth, reflects a serious negligence on the part of the state. There are multiple factors which contribute to this dismal situation. In this brief analysis, nutritional issues among adolescents especially among young girls, are discussed in line with literature and current situation.
WHO (2015) has recognized “adolescents” as an integral group of global health and nutrition agenda by including it in its policy framework, called the global strategy for women’s, children’s and adolescents’ health (2016-2030) which promotes a life course approach to reduce poverty and promote resilience towards achieving Sustainable Development Goals (SDGs). WHO defines 'Adolescents' as individuals in the 10-19 years age group and 'Youth' as the 15-24 year age group. While 'Young People' covers the age range 10-24 years . UNICEF adolescent demographics show that South Asia has the largest population of adolescents which is 340 million out of 1.2 billion overall population of adolescent at world level . Pakistan has more than 64% youth population including adolescent boys and girls, who have potential to contribute to sustainable development of the country, given appropriate opportunities and platforms for active and productive engagement. Youth needs to be nurtured through focused interventions and programs to ensure their health, wellbeing and education which should be a one of the priority targets of the government. However, globally there is a crisis in terms of adolescent support programs and interventions. WHO report highlights, “Globally, millions of adolescents die or become sick from preventable causes. Too few have access to information and counselling and to integrated, youth-friendly services, and especially to sexual and reproductive health services without facing discrimination or other obstacles. In many settings, adolescent girls and boys face numerous policy, social and legal barriers that harm their physical, mental and emotional health and well-being. Among adolescents living with disabilities and/or in crisis situations, the barriers are even greater (p.29) ”.
Why Health and Nutrition is so Important for Adolescents?
Nutrition Evidence suggest that adequate nutrition is necessary not only for the physical health but for mental health and brain development and function as well. Throughout the lifespan of human life, specially during pregnancy and infancy are specially crucial periods for the formation of the brain and any nutritional deficiencies during pregnancy and infancy are likely to affect cognition, behavior, and productivity throughout the school years and adulthood (Prado and Dewey, 2015). Adolescence is one of the most rapid phases of human development during which fast physiological and psychological changes occur among children. However, the biological maturity precedes psychosocial maturity . These changes in adolescence have health consequence not only in adolescence but also over the life-course . This critical phase still provides a window of opportunity for focused interventions to accelerate any development delays from childhood. Some research evidence suggests that “some, but not all, of the negative effects of early undernutrition on brain development can be reversed through subsequent improvement in nutrition, health care, and enriched environments (Prado and Dewey, 2015, p.273)”. Another other evidence shows that Adolescence marks the last opportunity to reverse stunting . Therefore, interventions are essential at this stage for wellbeing of young adults.
According to a UN report, young people in some parts of the world suffer from poor health due to poor societal conditions, lack of awareness, customary attitudes and harmful traditional practices. Unhealthy environment, lack of support systems and inadequate or inappropriate health services lead to poor health conditions among young people. Further problems include the lack of a safe and sanitary living environment, malnutrition, the risk of infectious, parasitic and water-borne diseases, the growing consumption of tobacco, alcohol and drugs, unwarranted risk-taking and destructive activity, resulting in unintentional injuries .
Adolescent Health and Nutrition Challenges in Pakistan
Adolescence is a transitional period of physical and psychological development where young people need emotional support and proper health and nutrition to meet their rapid developmental needs. However, young adults, specially girls in Pakistan are highly likely to suffer several nutritional deficiencies due to poor dietary practices and lack of information about health and nutrition. No doubt that prevalent gender discriminatory practices against girls in having access to information, resources and a heathy diet is one of root causes of the problem.
National Nutrition Survey (NNS) 2018 of government of Pakistan has measured the nutritional status of young people between 10-19 years. The data in the given figures shows that 57 % young girls are anemic . The data also shows that adolescent boys have worse nutrition status compared to girls. For example, 21% boys are underweight compared to 12% of adolescent girls. Poor dietary intake patterns with marginal intake of fresh fruits and vegetable were observed which can be a contributing factor in the prevalence of anemia in the young women in present sample .
In Pakistan the situation of focused support services for adolescent health and wellbeing are event nonexistent, specially in remote isolated rural regions such as Gilgit- Baltistan (GB), AJK, Baluchistan, rural areas of KP, Punjab and Sindh. Particularly, the reproductive health needs of adolescents/young people are mainly neglected. In many cases there is a lack of information and lack of services to adolescent to help them understand their sexuality, including sexual and reproductive health, and to protect them from undesirable social habits in order to stay healthy.
Research shows that in Pakistan, household food insecurity especially in rural areas are key drivers of adolescent malnutrition. Adolescent in low income communities mostly depend on wheat and moderate dairy, whereas intake on fruits and vegetables or pulses, potato, eggs and meat is less. Adolescent girls rarely have access to nutritional food and mothers primarily make the household food decisions, with limited nutritional knowledge . Also, there is food insecurity is an issue in a large papulation. In its third quarterly report on the state of the economy, the State Bank of Pakistan (SBP) noted provincial disparities in terms of food security in Pakistan. In Balochistan, at least 30 per cent households experience hunger on a chronic basis) . Pakistan is among those seven countries that cumulatively account for two-thirds of the world’s under-nourished population.
The following key challenges are evident in terms of Adolescent health and nutrition in Pakistan:
• Lack of awareness on adolescent health and nutritional needs
• Lack of evidence and advocacy on adolescent health and nutrition
• Lack of policies and programs for school children
• Lack of coordination and accountability mechanisms
• Lack of budget and financing for nutrition of adolescents
Analysis of the Current Situation
The following section provides a brief analysis of the current practices, challenges and issues.
• Public Awareness on Adolescent Health and Nutrition
As a country, there is a clear lack of focus on adolescent health and wellbeing in the context of Pakistan at the level of policy and practice. The Government of Pakistan has developed National Health Vision Document Pakistan (2016-2025) , however, it doesn’t mention adolescents for specific health and nutrition interventions. One can associate this lack of awareness with the cultural context as well since it is supposed to be a quiet phase with no mentions of physical changes and gender identities. Many nutritional and health related problems remain undisclosed and undiscussed. Adolescents rapidly forming their gender identities during this phase and appeared to look like adults due to their fast physical development. The children are expected to assume their gender roles with mental maturity while they are still struggling with their inner emotional transitions from childhood to young adulthood. They become socially and emotionally vulnerable during this transitional phase with lack of social emotional support from the immediate environment. A young girl from Sindh expresses her opinion how she learnt to understand her rights through participating in a program by UNICEF.
"Every time my grandmother tells me that I am a grown-up and should help with household chores – I tell her, I am still a child and I also have the right to play."
• Evidence and Advocacy
Evidenced based data is essential for targeted interventions in health and nutrition. A thorough online review was carried out for this paper, however, there is lack of data on adolescent health issues in Pakistan. NNS 2018 was one of very few sources found which provided some statistical evidence on this topic. The SUN Movement Strategy and Roadmap (2016-2020) has helped illuminate the importance of nutrition as a universal agenda – and one which is integral to achieving the promise of the Sustainable Development Goals (SDGs) . The SUNCSA chapter in Pakistan is very actively mobilizing government and civil society based organizations and public to scale up nutrition activities for a healthy national. Currently 164 organizations are members of SUNCSA Pakistan. This movement will ultimately raise awareness on the neglected issues nutrition in the context of Pakistan.
• Health and Nutrition Programs through School Curriculum
Most of the adolescent population is found in secondary and higher secondary schools. Thus the schools can provide strong platforms nutrition interventions for children an for whole group of communities. However, there is lack of such practice in education system of Pakistan. A few good examples can be found in the past but these were never institutionalized. For example, in June 2005, National Commission for Human Development (NCHD) launched School Health Program in 17 districts of Pakistan with funding from Bill and Melinda Gates Foundation. The programme covered 23,266 Primary Schools of these districts and benefited 1.86 million students . The program was implemented in collaboration with UNESCO. This seems an impactful program as many teachers and students benefited from this school health program.
• Lack of Coordination, Delivery and Accountability Systems
Children and families are the units of community and society. Nutrition interventions have to be introduced through one window approach to provide easy access to people. However, in Pakistan, the government, private sector and civil society based organizations lack cooperation for integrations of nutrition based services. According to National Health Vision Document Pakistan (2016-2025) , Health system in Pakistan faces challenges of vertical service delivery structures and low performance accountability within the government, creating efficiency and quality issues. Generally, unregulated for quality care and pricing, there is also duplication of services by the private sector. Also, the public sector is inadequately staffed and job satisfaction and work environment need improvement.
• Financing for Adolescent Health and Nutrition Programs
The government policy on health does not even recognize adolescents health and nutritional needs. The budget provision is also very minimal which could hardly meet any basic health needs. Government spending on health has always been less than optimal (0.6% of GDP) . Most part of the allocations to health is consumed by the secondary and tertiary care, leaving merely 15% for the preventive and primary health care . Donor funding is also very minimal.
Conclusion and Recommendations
After reviewing the current situation, it is learnt that a large number of adolescents are nutrition deficient especially majority of young girls are anemic in Pakistan. It is also learnt that adolescents are neglected in the national health and nutrition agenda of Pakistan. There has been a global focus on adolescents health and nutrition in the recent years and WHO has formulated strategies to guide member states to realize SDGs. However, Pakistan is lagging behind in this policy as well. The following recommendations are put forward for action to respond to the emerging issues identified in this paper, which are also in line with WHO recommendations:
• Raise awareness on the importance of adolescent health and nutrition among communities school students, management and other concerned stakeholders, through curriculum based activities in schools.
• Provide psychosocial support to children who are at health risks prevention of injuries, violence, harmful practices and substance abuse;
• Educate both parents and youth on sexual and reproductive health and educate them on prevention of and management of communicable and non-communicable diseases
• Building the capacities of teachers, educators and lady health workers to sensitize youth, children and communities on adolescent health and nutrition.
• Develop tools and mechanisms to assess adolescents’ health and nutrition issues through school screening programs
• Food insecurity in low income communities should be addressed through food fortification and supplementation programs by the government.
• Government should recognize and integrate adolescents for health and nutrition interventions and allocate an appropriate amount of budget for it
• The government health department should work in collaboration with other sectors including, education, agriculture, environment, technology and infrastructures to ensure that all sectors integrate health and nutrition in their policies and programs.
• Finally, research children and adolescents health needs to be carried out by concerned intuitions to inform policies and programs in this sector.