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  • CAPTION: Adolescent client Tulika Shit has a lower respiratory tract infection. Many adolescents in this area have tuberculosis (TB) but don’t realize it. So Dr Ram Chandra Soren is checking whether her symptoms add up to this. ARSH clinics provide services that extend far beyond reproductive and sexual health. They are far more accessible to young people than the outpatient department (OPD) at the hospital is, ensuring they can get the services they need quickly. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Sujata Shit (right).
    IMG44841.jpg
  • CAPTION: Sahiya Anupa Devi brings two girls from her area to the ARSH clinic. Whenever adolescents come to their sahiyas with concerns that they themselves cannot solve, they are encouraged to bring them to this facility. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupa Devi, Shakuntala Kumari and Dipika Kumari.
    IMG45338.jpg
  • CAPTION: Sahiya Anupma Soren quizzes the girls on such subjects as the legal age of marriage, their daily nutritional needs and the foods that can provide these, the sort of medical advice that’s available for them, etc. There are two groups in the room. One is made up of married adolescents, aged 15-19, which discusses delaying the age of marriage, the different methods of family planning that are available, and antenatal care; the other consists of 10 to 14-year olds, with some school-going girls and some school dropouts, and this group focuses in a big way on nutrition, menstrual hygiene, and developmental changes. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Anupma Soren (standing, left) and multiple others.
    IMG44921.jpg
  • CAPTION: Sahiya Anupma Soren quizzes the girls on such subjects as the legal age of marriage, their daily nutritional needs and the foods that can provide these, the sort of medical advice that’s available for them, etc. There are two groups in the room. One is made up of married adolescents, aged 15-19, which discusses delaying the age of marriage, the different methods of family planning that are available, and antenatal care; the other consists of 10 to 14-year olds, with some school-going girls and some school dropouts, and this group focuses in a big way on nutrition, menstrual hygiene, and developmental changes. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Anupma Soren (standing, left) and multiple others.
    IMG44923.jpg
  • CAPTION: Sahiya Anupma Soren quizzes the girls on such subjects as the legal age of marriage, their daily nutritional needs and the foods that can provide these, the sort of medical advice that’s available for them, etc. There are two groups in the room. One is made up of married adolescents, aged 15-19, which discusses delaying the age of marriage, the different methods of family planning that are available, and antenatal care; the other consists of 10 to 14-year olds, with some school-going girls and some school dropouts, and this group focuses in a big way on nutrition, menstrual hygiene, and developmental changes. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Anupma Soren (standing, left) and multiple others.
    IMG44939.jpg
  • CAPTION: This is the Adolescent Reproductive and Sexual Health (ARSH) clinic at Ghatshila Community Health Centre (CHC). Atosi Shit (right) is an adolescent client, and Sarita Kumari Panna (left) is an ARSH Counselor. Here, Kumari is giving information on hygienic practices during the menstrual cycle in order to guard against infection and possible infertility. The ARSH clinics have been designed to provide health-related services to young people aged between 10 and 19 at a time when they are going through a lot of changes, both physically and mentally. This can mean anything from getting a small wound dressed to getting an abortion. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Atosi Shit (right).
    IMG44753.jpg
  • CAPTION: ARSH Counselor Sarita Kumari Panna explains the use of iron and folic acid tablets to Atosi Shit. Most of the adolescent girls (perhaps 80-90%) in villages like this are anemic. There is large-scale absence of awareness of how to ensure their diets contain iron and folic acid, especially with the rising popularity of fast food while young people are away at school or college. Girls are especially unaware, after their menstrual cycles start, about when they ought to have particular types of nutrition. This often results in menstrual problems and anemia. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Atosi Shit (right).
    IMG44811.jpg
  • CAPTION: Dr Ram and his colleagues are forming what they call a 'chain of information', so that even if families don’t allow their youth to seek out the services they need in person, friends can pass on the news about what the ARSH clinic can provide. He observes that another problem is that most families think only of educating their boys on what they need, and just think about marrying their girls off. So it’s important to ensure that girls don’t fall through the net. These four girls are part of the discussion group that’s been established in Ghatshila. They have asked Dr Ram to come to the community college where they are studying nearby and take sessions for all the adolescent girls there to ensure they will then access the services they need. They therefore serve as the link between the college and Dr Ram. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Tulika Shit, Sujata Shit, Rakhi Shit and Atosi Shit.
    IMG44870.jpg
  • CAPTION: Adolescent Rakhi Shit is being taught about family planning methods. The counselor Sarita Kumari Panna is telling her about the different options available to her. This information is not considered something that should be given only after marriage; it is recognized that sexual activity could happen before as well, even though this is culturally unacceptable. Most of the girls here (and also the boys) are unaware that the condom is something that can be used to prevent STIs - including AIDS - and unwanted pregnancy. Owing to this ignorance, under-age pregnancies are quite common, and abortions - including unsafe illegal ones - are being sought. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Rakhi Shit (right).
    IMG44789.jpg
  • CAPTION: Dr Ram and his colleagues are forming what they call a 'chain of information', so that even if families don’t allow their youth to seek out the services they need in person, friends can pass on the news about what the ARSH clinic can provide. He observes that another problem is that most families think only of educating their boys on what they need, and just think about marrying their girls off. So it’s important to ensure that girls don’t fall through the net. These four girls are part of the discussion group that’s been established in Ghatshila. They have asked Dr Ram to come to the community college where they are studying nearby and take sessions for all the adolescent girls there to ensure they will then access the services they need. They therefore serve as the link between the college and Dr Ram. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Atosi Shit, Rakhi Shit, Sujata Shit and Tulika Shit.
    IMG44891.jpg
  • CAPTION: Packs of enough sanitary pads for five days are available from the ARSH clinic at the cost of just ₹ 6 (US$ 0.10). Out of this, ₹ 1 goes towards sahiyas’ incentives. Here, the medical officer is explaining the use of sanitary napkins, the cost and where more can be bought (for around ₹ 20) within the community. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Kusum Kumari Bara (left) and Pritee Kashep (right).
    IMG45294.jpg
  • CAPTION: This is Ratu CHC’s ARSH clinic. The sahiyas, sitting to the left, have accompanied some of the girls from their respective areas to the facility so that they can discuss issues that sahiyas can’t handle themselves. This has not yet been incorporated into the sahiya incentive system, yet some have already willingly started doing it. At the clinic, the girls meet with Multi-Purpose Health Worker (Female) staff, formerly (and often still, unofficially) known as 'ANMs' (auxiliary nurse midwives). LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Kanti Devi, Yasmin Kahtun, Rina Devi and Raj Kumari Sinha; children: Ayesha Khatun (entering the room) and multiple other people.
    IMG45275.jpg
  • CAPTION: Community COPE is promoting institutional delivery, and is raising awareness that the Government has set aside money to facilitate this through the Janani Suraksha Yojana (JSY) scheme. This roughly translates as 'New Mother’, and provides ₹ 1,400 for the mother and newborn child. This lady has received this money directly to her bank account, yet it turns out she’s unaware of this. Here, Vandana Maitry is assuring her that the money is there and she can withdraw it. During the initial days after birth, it’s especially important that the baby should get adequate nutrition. The system was changed to ensure mothers would get the money and it wouldn’t fall into the wrong hands, but the problem is that husbands or heads of households can also appropriate it under the new system. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Atosi Shit (right).
    IMG44747.jpg
  • CAPTION: Adolescent client Sujata Shit is getting her blood pressure checked. She came to the ARSH clinic complaining of weakness and a spinning head. Most of the girls with anemia have low blood pressure. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Sarita Kumari Panna (left) and Sujata Shit (right).
    IMG44803.jpg
  • CAPTION: A trained ANM visits Bethany Convent School in Ratu, Ranchi, and teaches them on sexual and reproductive health through a game. The cards state the physical changes that occur for both boys and girls, and the boys are asked to segregate them by gender and put them in order. This is followed by a discussion. These sessions happen at the school biannually when the school health team visits. A lot more of this work is being done with girls as compared with boys. The reason is that for boys, suitable forums are not so readily accessible. For girls, there are the Mahila Samakhya schools and anganwadi centers. The latter come under the Government’s Ministry of Women and Child Development. The School Health Program, however, is a component of the Adolescent Health Program, which gives importance to both boys and girls. Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program) was launched this year, doing peer interventions with both boys and girls. LOCATION: Bethany Convent School, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Raj Kumari Sinha, Nikhil Tigga, Subhash Gope, Kuldeep Sahu, Ritesh Munda and Raj Kumar Prajpati.
    IMG45352.jpg
  • CAPTION: A trained ANM visits Bethany Convent School in Ratu, Ranchi, and teaches them on sexual and reproductive health through a game. The cards state the physical changes that occur for both boys and girls, and the boys are asked to segregate them by gender and put them in order. This is followed by a discussion. These sessions happen at the school biannually when the school health team visits. A lot more of this work is being done with girls as compared with boys. The reason is that for boys, suitable forums are not so readily accessible. For girls, there are the Mahila Samakhya schools and anganwadi centers. The latter come under the Government’s Ministry of Women and Child Development. The School Health Program, however, is a component of the Adolescent Health Program, which gives importance to both boys and girls. Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program) was launched this year, doing peer interventions with both boys and girls. LOCATION: Bethany Convent School, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adult: Raj Kumari Sinha; boys in the foreground: Ritesh Munda (left) and Nikhil Tigga (right).
    IMG45360.jpg
  • CAPTION: A trained ANM visits Bethany Convent School in Ratu, Ranchi, and teaches them on sexual and reproductive health through a game. The cards state the physical changes that occur for both boys and girls, and the boys are asked to segregate them by gender and put them in order. This is followed by a discussion. These sessions happen at the school biannually when the school health team visits. A lot more of this work is being done with girls as compared with boys. The reason is that for boys, suitable forums are not so readily accessible. For girls, there are the Mahila Samakhya schools and anganwadi centers. The latter come under the Government’s Ministry of Women and Child Development. The School Health Program, however, is a component of the Adolescent Health Program, which gives importance to both boys and girls. Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program) was launched this year, doing peer interventions with both boys and girls. LOCATION: Bethany Convent School, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Raj Kumari Sinha, Subhash Gope, Ritesh Munda, Nikhil Tigga, Kuldeep Sahu and Raj Kumar Prajpati.
    IMG45365.jpg
  • CAPTION: Health worker Dr Kusum Kumari Bara demonstrates the use of a mala chakra, a necklace made of red and white beads, to her client. It will help her know when it’s safer to have sex if she does not want to conceive. It is provided by the ARSH clinic free of cost. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Kusum Kumari Bara, Sabita Devi and Najmain Parveen.
    IMG45306.jpg
  • CAPTION: The Mahila Samakhya girls have split up into groups to draw the physical changes that occur in male and female bodies during adolescence. This is done pictorially, because this makes it easier for them to memorize. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Shobha Pareya, Ganga Purti, Sakro Hembrom, Hisee Murmu, Malti Laguri and Shobha Pareya.
    IMG45245.jpg
  • CAPTION: The Mahila Samakhya girls have split up into groups to draw the physical changes that occur in male and female bodies during adolescence. This is done pictorially, because this makes it easier for them to memorize. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Tara Among, Rajni Lakra, Roshni Hembrom, Birsi Mundu, Moni Suren.
    IMG45238.jpg
  • CAPTION: The Mahila Samakhya girls have split up into groups to draw the physical changes that occur in male and female bodies during adolescence. This is done pictorially, because this makes it easier for them to memorize. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Moni Suren, Rajni Lakra, Tara Among and Roshni Hembrom.
    IMG45264.jpg
  • CAPTION: This is the group aged 10-14. The song the sahiya is leading is about the nutritional requirements of the adolescent age group, and how nutrition affects their mental, physical, and social development, as well as how important it is for future generations. They are singing in Santhal, the local tribal language. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Multiple people.
    IMG45015.jpg
  • CAPTION: Mahila Samakhya takes on young women who’ve been abandoned or sexually abused, and teaches them with a view to mainstreaming them back into society, including the area of sexual and reproductive rights. It is a national-level NGO, and is working in 11 districts in Jharkhand. Last year, EngenderHealth worked with the Government to bring Mahila Samakhya into the Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program). They have since trained 27 Sayogini and district-level trainers on adolescent issues. From these, they identified 14 to train outreach and frontline workers in facilitation. They are now organizing trainings in the field, contributing to demand generation for adolescent health services. In this image, Aditi Ranjan has arrived at Mahila Samakhya's residential school in Ratu, Ranchi with Dr Satya Mohapatra. The latter is the Program Manager of the Tarunya ARSH India programme; Aditi is the Senior Program Officer with responsibility for four districts in Jharkhand, including Ranchi. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Aditi Ranjan, Dr Satya Mohapatra and Rajni Lakra; children: multiple people.
    IMG45169.jpg
  • CAPTION: The Mahila Samakhya girls have split up into groups to draw the physical changes that occur in male and female bodies during adolescence. This is done pictorially, because this makes it easier for them to memorize. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Moni Suren, Rajni Lakra, Tara Among and Roshni Hembrom.
    IMG45262.jpg
  • CAPTION: This is the group aged 10-14. The song the sahiya is leading is about the nutritional requirements of the adolescent age group, and how nutrition affects their mental, physical, and social development, as well as how important it is for future generations. They are singing in Santhal, the local tribal language. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Multiple people.
    IMG45034.jpg
  • CAPTION: The Mahila Samakhya girls have split up into groups to draw the physical changes that occur in male and female bodies during adolescence. This is done pictorially, because this makes it easier for them to memorize. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Shobha Pareya, Ganga Purti, Sakro Hembrom, Hisee Murmu, Malti Laguri and Shobha Pareya.
    IMG45253.jpg
  • CAPTION: Class photo at Mahila Samakhya's residential school in Ratu, Ranchi. Mahila Samakhya takes on young women who’ve been abandoned or sexually abused, and teaches them with a view to mainstreaming them back into society, including the area of sexual and reproductive rights. It is a national-level NGO, and is working in 11 districts in Jharkhand. Last year, EngenderHealth worked with the Government to bring Mahila Samakhya into the Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program). LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Malti Laguri (left) and Rajni Lakra (right); children: multiple people.
    IMG45266.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata, Kajal Namata and Sunita Murmu .
    IMG44965.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata, Kajal Namata, Anjana Hembrom and Sunita Murmu.
    IMG44959.jpg
  • CAPTION: The trainer is teaching the girls about the menstrual cycle, what it means for them, and how they can take care of their needs after it begins. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adult: Rajni Lakra; children: multiple people.
    IMG45174.jpg
  • CAPTION: Mahila Samakhya students act out a role-play. In the play, the old lady’s granddaughter has just started menstruating. She is worrying about what’s happening her, so goes to her grandmother and asks why this is suddenly happening to her. The old lady reassures her that it happens to every woman; that it also happened to her, and that there’s nothing to worry about, everything will be alright. The girl who then comes along is playing the role of a sahiya. She is visiting the household, and reassures the girl that it’s a natural process for all young girls, and goes on to explain how to take care of nutritional intake including supplementation during this period, and also how to be clean and hygienic. She then assures her that if she experiences very bad pain, she can come to her for some medicines. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Ganga Purti (sitting in front), Salomi Horo (lying down) and Shobha Pareya (sitting behind).
    IMG45198.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata and Kajal Namata.
    IMG44972.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata and Kajal Namata.
    IMG44982.jpg
  • CAPTION: Mahila Samakhya students act out a role-play. In the play, the old lady’s granddaughter has just started menstruating. She is worrying about what’s happening her, so goes to her grandmother and asks why this is suddenly happening to her. The old lady reassures her that it happens to every woman; that it also happened to her, and that there’s nothing to worry about, everything will be alright. The girl who then comes along is playing the role of a sahiya. She is visiting the household, and reassures the girl that it’s a natural process for all young girls, and goes on to explain how to take care of nutritional intake including supplementation during this period, and also how to be clean and hygienic. She then assures her that if she experiences very bad pain, she can come to her for some medicines. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Foreground, from left to right: Salomi Horo, Shobha Pareya, Sita Kujur and Ganga Purti; background: multiple people.
    IMG45234.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata and Kajal Namata.
    IMG44960.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata and Kajal Namata.
    IMG44987.jpg
  • CAPTION: Sahiya Anupma Soren takes a monthly session with the 15-19-year olds. The discussion covers delaying the age of marriage, antenatal care, where the ARSH clinic is and what it does, the methods of family planning that the facility can help with, and what their respective pros and cons are. The Government requires these sessions to be conducted monthly. Sahiyas are given an incentive of ₹ 75 per session they lead. The girls are asked to come on a regular basis, as the knowledge imparted builds over time. LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Anupma Soren, Pritilata Giope, Sarshati Hansda, Maya Namata and Kajal Namata.
    IMG44957.jpg
  • CAPTION: The trainer is teaching the girls about the menstrual cycle, what it means for them, and how they can take care of their needs after it begins. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Adult: Rajni Lakra; children: Salomi Horo (standing front), Holika Lakraand (standing back) and multiple other people.
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  • CAPTION: Mahila Samakhya students act out a role-play. In the play, the old lady’s granddaughter has just started menstruating. She is worrying about what’s happening her, so goes to her grandmother and asks why this is suddenly happening to her. The old lady reassures her that it happens to every woman; that it also happened to her, and that there’s nothing to worry about, everything will be alright. The girl who then comes along is playing the role of a sahiya. She is visiting the household, and reassures the girl that it’s a natural process for all young girls, and goes on to explain how to take care of nutritional intake including supplementation during this period, and also how to be clean and hygienic. She then assures her that if she experiences very bad pain, she can come to her for some medicines. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Foreground, from left to right: Shobha Pareya, Sita Kujur, Ganga Purti and Salomi Horo; background: multiple people.
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  • CAPTION: Mahila Samakhya students act out a role-play. In the play, the old lady’s granddaughter has just started menstruating. She is worrying about what’s happening her, so goes to her grandmother and asks why this is suddenly happening to her. The old lady reassures her that it happens to every woman; that it also happened to her, and that there’s nothing to worry about, everything will be alright. The girl who then comes along is playing the role of a sahiya. She is visiting the household, and reassures the girl that it’s a natural process for all young girls, and goes on to explain how to take care of nutritional intake including supplementation during this period, and also how to be clean and hygienic. She then assures her that if she experiences very bad pain, she can come to her for some medicines. LOCATION: Mahila Samakhya, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Ganga Purti (walking with stick) and multiple other people.
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  • CAPTION: Dr Jagannath Hembrom is the Medical Officer-in-Charge in Chaibasa in the Jharkhand district of West Singhbhum. The facility here is recognized as the best clinic in the state. In addition to FLWs, he also trains medical officers and outreach workers. He is particularly passionate about working with adolescents. He also serves as a referral point, where sahiyas are unable to answer adolescents' particular questions or meet their particular needs. Dr Jagannath has even been recognized for his training talents at the national level. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Jagannath Hembrom.
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  • CAPTION: These are sahiyas attached to Ghatshila CHC who've been trained on adolescent reproductive and sexual health, and in how to communicate with adolescent girls on these issues. At the beginning of the sessions they conduct at the anganwadi center (literally: 'courtyard shelter' in Hindi), they start with a song about the importance of young women taking care of their health as they grow up and how important adolescents are in bringing change in their society in the long run. The song includes mention of how everyone has the power to take decisions on their own health, and to change both themselves and society as a whole (which includes the importance of completing Higher Secondary education). LOCATION: Pawra Anganwadi Centre (AWC), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dipali Baskey, Rupali Shit, Bhasa Sharma, Anupma Soren and Sombari Tudu.
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  • CAPTION: Dr Ram Chandra Soren, the area’s Medical Officer-in-Charge, notes that adolescents tend to be reluctant to visit their CHCs, preferring private clinics and 'quacks', because they assume that they will not get what they need there, or that there will be insufficient privacy. He assures them that they can get what they need from the ARSH clinic with full privacy and confidentiality. Changing awareness about this has resulted in significant positive changes, such as a marked reduction in septic abortions. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Ram Chandra Soren.
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  • CAPTION: During the first day of the training, the participants are divided into three for group work. In this exercise, the groups have been asked to consider the various developmental changes that occur socially, physically, and mentally among adolescents, and what the consequences of these are. This group is listing out the consequences of the various physical changes that occur in the body. For example, breast development among girls leads them to bend forward slightly, which can cause them pain in the lower back and waist region. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Ruby Kumari, Bela Sarkar, A Sharada and Dr Jagannath Hembrom.
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  • CAPTION: The final group is listing out the various mental and social changes experienced by adolescents. One of these is the development of attraction to the opposite sex. It is impressed upon participants that this is something natural that happens to everyone, and that it should not be condemned as something 'bad'. Another is that girls start wanting to make themselves appear as beautiful as possible to others. Boys, meanwhile, might like to drive very fast in front of others, or smoke and take drugs. The group is considering the consequences of these things and how they may be addressed. After discussing these things, the groups join together and discuss what they have each found. This then leads to the enactment of role-plays. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Kalpana Mahato, Savita Horo, Dr Jagannath Hembrom, Krishna Chakrabarty and Shobha Kumari Nirali.
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  • CAPTION: This group is considering sexual changes that adolescents go through. The idea that these things should even be discussed is often resisted by the trainees, and this often comes up in a big way during the first day of training. However, as the days unfold, they are encouraged to open up and relax, and generally a much more positive attitude to such discussion evolves by the end of the program. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Suhagini Kisku, Sefali Dandapat and Sarojini Mahato.
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  • CAPTION: The final group is listing out the various mental and social changes experienced by adolescents. One of these is the development of attraction to the opposite sex. It is impressed upon participants that this is something natural that happens to everyone, and that it should not be condemned as something 'bad'. Another is that girls start wanting to make themselves appear as beautiful as possible to others. Boys, meanwhile, might like to drive very fast in front of others, or smoke and take drugs. The group is considering the consequences of these things and how they may be addressed. After discussing these things, the groups join together and discuss what they have each found. This then leads to the enactment of role-plays. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Ratna Das Banerjee, Kalpana Mahato, Savita Horo and Krishna Chakrabarty.
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  • CAPTION: The final group is listing out the various mental and social changes experienced by adolescents. One of these is the development of attraction to the opposite sex. It is impressed upon participants that this is something natural that happens to everyone, and that it should not be condemned as something 'bad'. Another is that girls start wanting to make themselves appear as beautiful as possible to others. Boys, meanwhile, might like to drive very fast in front of others, or smoke and take drugs. The group is considering the consequences of these things and how they may be addressed. After discussing these things, the groups join together and discuss what they have each found. This then leads to the enactment of role-plays. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Standing: Dr Jagannath Hembrom; sitting: multiple people.
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  • CAPTION: During the first day of the training, the participants are divided into three for group work. In this exercise, the groups have been asked to consider the various developmental changes that occur socially, physically, and mentally among adolescents, and what the consequences of these are. This group is listing out the consequences of the various physical changes that occur in the body. For example, breast development among girls leads them to bend forward slightly, which can cause them pain in the lower back and waist region. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Ruby Kumari, Bela Sarkar, A Sharada and Dr Jagannath Hembrom.
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  • CAPTION: This group is considering sexual changes, such as the start of the menstrual cycle. Girls tend not to be aware that this is coming up, as parents and even the health system tend not to orient them on it. Then, when bleeding happens for the first time and it shows through a girl’s clothes, she may feel very embarrassed. So adolescents, schools, parents, and other family members all need to be sensitized. A similar example in the case of boys is night emissions after 'wet dreams'. The first time this happens, the boy may be very startled. In the rural Indian cultural context, boys are unlikely to want to talk about it with parents or healthcare professionals, nor are these people likely to want to talk about what's happening for them. Often, boys will consult 'quacks' or low-cost books available in local markets, and may get information that's far from the truth. Again, ways to tackle this must be considered. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Sunita Patra, Jayashree Sawayan, Dr Jagannath Hembrom, Suhagini Kisku and Sefali Dandapat.
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  • CAPTION: The final group is listing out the various mental and social changes experienced by adolescents. One of these is the development of attraction to the opposite sex. It is impressed upon participants that this is something natural that happens to everyone, and that it should not be condemned as something 'bad'. Another is that girls start wanting to make themselves appear as beautiful as possible to others. Boys, meanwhile, might like to drive very fast in front of others, or smoke and take drugs. The group is considering the consequences of these things and how they may be addressed. After discussing these things, the groups join together and discuss what they have each found. This then leads to the enactment of role-plays. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Standing: Dr Jagannath Hembrom; sitting (far side, from left to right): Kalpana Mahato, Savita Horo, Krishna Chakrabarty and Shobha Kumari Nirali.
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  • CAPTION: The training of frontline workers (FLWs) is very participatory, and it is not held exclusively in classrooms. There is a lot of group work, which the master trainer facilitates, as well as role-plays wherein case studies are acted out. Service providers are taught not only on how to counsel children, but also their parents. EngenderHealth is measuring the effectiveness of what it’s doing in different ways. One involves looking at how those they train perform using a performance to standard tool. Knowledge is tested, counseling is observed, and a check on what services are being given is carried out. If there are gaps, an effort is made to consider how these might be addressed. Another considers how many adolescents (male and female, across different ages) are accessing these services, and which services specifically. So far, it has been noted that male take-up has been slightly lower than female. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Left: Dr Jagannath Hembrom; right: multiple people.
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  • CAPTION: Training of frontline workers (FLWs) is being rolled out in phases. Topics include developmental changes among adolescents and their consequences; nutritional requirements and how to meet them, plus what happens if they are not met; family planning; reproductive tract infections (RTIs) and sexually transmitted infections (STIs); menstrual hygiene; non-communicable diseases; and how to counsel on all of these things. Of these, counseling takes the major focus. LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Left: Dr Jagannath Hembrom; right: multiple people.
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  • CAPTION: A trained ANM visits Bethany Convent School in Ratu, Ranchi, and teaches them on sexual and reproductive health through a game. The cards state the physical changes that occur for both boys and girls, and the boys are asked to segregate them by gender and put them in order. This is followed by a discussion. These sessions happen at the school biannually when the school health team visits. A lot more of this work is being done with girls as compared with boys. The reason is that for boys, suitable forums are not so readily accessible. For girls, there are the Mahila Samakhya schools and anganwadi centers. The latter come under the Government’s Ministry of Women and Child Development. The School Health Program, however, is a component of the Adolescent Health Program, which gives importance to both boys and girls. Rashtriya Kishor Swasthya Karyakram (RKSK) (National Adolescent Health Program) was launched this year, doing peer interventions with both boys and girls. LOCATION: Bethany Convent School, Ratu (block), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Raj Kumari Sinha.
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  • CAPTION: Shanti Toppo is married. She would like there to be a gap before she has her second child. Health worker Dr Kusum Kumari Bara suggests two options for her, firstly the Copper T, which allows the user to delay pregnancy for a longer period, and secondly the condom, which must be used by her husband. It is stressed that the condom is the only thing that also prevents spread of reproductive tract infections (RTIs) and sexually transmitted infections (STIs). The service provider then suggests that it is a good idea to come back along with her husband, so that he can also understand these things. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Kusum Kumari Bara (left) and Shanti Toppo (right).
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  • CAPTION: The lady on the right is a sahiya. She serves as a link between the health system and the community, working at the grassroots in villages. Every village has at least one sahiya. They help health service professionals understand what community needs are and what issues community members are facing. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Ram Chandra Soren (left) and Rupali Shit (right).
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  • CAPTION: Dr Ram Chandra Soren is the area’s Medical Officer-in-Charge. He oversees the ARSH clinic here. He says that they’ve seen a lot of changes since the clinic opened. At first there were around 20 clients; this has grown to approximately 250. Though he studied and started his career in Orissa, Dr Ram is originally from this community and this gives him a great level of acceptance among the community members, which makes it very easy for him to communicate with them. People also know that he’s approachable outside of the regular office hours. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Ram Chandra Soren.
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  • CAPTION: Shanti Toppo is married. She would like there to be a gap before she has her second child. Health worker Dr Kusum Kumari Bara suggests two options for her, firstly the Copper T, which allows the user to delay pregnancy for a longer period, and secondly the condom, which must be used by her husband. It is stressed that the condom is the only thing that also prevents spread of reproductive tract infections (RTIs) and sexually transmitted infections (STIs). The service provider then suggests that it is a good idea to come back along with her husband, so that he can also understand these things. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Kusum Kumari Bara (left) and Shanti Toppo (right).
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  • CAPTION: While Shanti Toppo discusses contraceptive options with the health worker, another ANM checks her blood pressure. This is because she has been complaining of a spinning head and pains in her abdomen. The cause of this might be anemia, though there are other possibilities as well.<br />
LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Kusum Kumari Bara, Raj Kumari Sinha and Shanti Toppo.
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  • CAPTION: Shanti Toppo is married. She would like there to be a gap before she has her second child. Health worker Dr Kusum Kumari Bara suggests two options for her, firstly the Copper T, which allows the user to delay pregnancy for a longer period, and secondly the condom, which must be used by her husband. It is stressed that the condom is the only thing that also prevents spread of reproductive tract infections (RTIs) and sexually transmitted infections (STIs). The service provider then suggests that it is a good idea to come back along with her husband, so that he can also understand these things. LOCATION: Adolescent Reproductive and Sexual Health (ARSH) clinic, Ratu Community Health Centre (CHC), Ranchi (city), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Dr Kusum Kumari Bara (left) and Shanti Toppo (right).
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  • CAPTION: This is a training of frontline workers (FLWs): auxiliary nurse midwives (ANMs) and lady health visitors (LHVs). The latter supervise ANMs. Across the state, there are more than 2,000 FLWs. The Government-approved plan states that these individuals must have five days of training on adolescent reproductive and sexual health matters. It is being conducted by Dr Jagannath Hembrom, a ‘Master Trainer’. His role is more as a facilitator than a teacher. There is a pool of 67 such master trainers in Jharkhand, and Dr Jagannath is recognized as one of the best of these.  LOCATION: Ghatshila Community Health Centre (CHC), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Left: Dr Jagannath Hembrom; right: multiple people.
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  • CAPTION: Community COPE members come to ask a householder about what her expectations of the health system are and what she feels ought to be done to get more people into the Government-run Community Health Centre (CHC). She says she’s happy with what she’s been accessing, but reveals a lack of awareness of what she is actually entitled to. Shyam Bahadur Sonar is therefore suggesting that she should discuss her needs with knowledgeable community members. Kalicharan Namata (second from left) is one of the two adolescent representatives in Community COPE, and has an important role in bringing adolescent voices into the community dialogue. LOCATION: Pawra (village), Ghatshila (block), Purbi Singhbhum (district), Jharkhand (state), India. INDIVIDUAL(S) PHOTOGRAPHED: Shyam Bahadur Sonar (left) and Rupa Namata (right).
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