Centres of Excellence for Adolescent Health and Development: A Case Study from Uttar Pradesh, India

Adolescents and young adult comprise a significant proportion of India’s population. Although, this group of the population faces serious challenges to their health and well-being. To promote their health and well-being, Centre of Excellence (CoE) at King George’s Medical University, Lucknow, India, serves as an advanced care facility for 10–24-year-old adolescents and young adult women. This paper reports the socio-demographic characteristics of, and health services availed to adolescents and young adults who are visiting the CoE in Lucknow, India. A total of 6038 beneficiaries received clinical services during June 2018–March 2022. Out of total clinical services, 38.37% counselling and 37.53% referral services were utilised. Menstruation (46.29%), sexual and reproductive (28.19%), nutrition (5.91%), and mental health (1.67%) related problems were highly reported. The age of beneficiaries is classified into three categories, i.e., 10–14, 15–19, and 20–24 years. Prevalence of overweight was highest among adolescents aged 20–24 years compared to other age groups. Other than nutrition, late-adolescent girls (15–19) faced more health problems than their counterparts. The percentage of beneficiaries decreased significantly during and post the COVID-19 period (<0.001). Therefore, age-specific programs are currently needed, and interventions need to be designed accordingly.


Introduction
Adolescents are recognized by the World Health Organization as the age group between 10-19 years and "young" as those in the 10-24 year age group [1]. The estimates suggest that one-fifth of the world's adolescents and young people reside in India [2]. It is a period of physical, hormonal, physiological, psychological, and behavioral changes. Adolescence is the transition from dependency to autonomy [3]. During this phase, adolescents and young people are exposed to various physical and mental health transitions [4]. According to Global health estimates (2016), in India, the adolescent mortality rate accounted for 844 deaths per 1,000,000 people [5]. Additionally, in India, adolescents and young women face many social cultural issues such as child marriage and early child bearing, which may result in many sexual and reproductive health (SRH) and nutritional issues. Therefore, promoting a healthy and disease free lifestyle during this phase and investing in adolescent and young people is key to reaching a better demographic dividend for the country [4]. Adolescents are part of many Sustainable Development Goals (SDGs) which are associated with reproductive health, nutrition, sexual and intimate partner violence also aim to generate evidence to work towards strengthening the ongoing adolescent programs such as RKSK, initiated by the Government of India, as well as increase utilization of the CoE-AHD services among adolescents and young adults.

Design and Setting
The current retrospective analysis is based on medical records of all beneficiaries of the Centre of Excellence (CoE-AHD) at KGMU, Lucknow, India from 1 June 2018, to 31 March 2022. This Centre is setup by the Government of Uttar Pradesh, India, in collaboration with MAMTA-Health Institute for Mother and Child (MAMTA HIMC) to support evidence-based programs for adolescent health and development in the State. As this centre has been set up in the Gynecology Department of KGMU, Lucknow, the beneficiaries visiting the CoE-AHD are mostly female. Additionally, it is important to mention that this analysis was not a medical experiment and did not require approval from the bioethics committee. Before counselling and clinical examination, all the beneficiaries agreed to share their details. Health practitioners took consent before the health examination.
The female population of Lucknow as per the 2011 census was 2.1 million. The current analysis includes girls and young females only. We have also included the beneficiaries between the age group of 10-24 years. The number of boys and male beneficiaries was negligible in the centre, hence they were excluded them from the analysis.

Socio-Demographic Profile
The socio-demographic characteristics of beneficiaries were identified by nine questions related to the following aspects: age, educational background, marital status, number of children, religion, caste, Below Poverty Line (BPL) card holder, occupation, and substance abuse.

Anthropometric and Physiological Parameters
All the beneficiaries underwent a comprehensive clinical examination. At first, body weight and height were recorded. The body mass index (BMI) was computed as follows: BMI = weight (kg)/height (m 2 ). The beneficiaries were categorized based on their BMI using the WHO International Standard [15]. The physiological measurements taken were systolic blood pressure (SBP) and diastolic blood pressure (DBP).

Data Processing
Statistical Package for Social Sciences (SPSS) version 23.0 software was used for data processing and analysis. Descriptive statistical methods were used to summarize the socio-demographic information of the beneficiaries. The continuous data were expressed as "mean ± standard deviation (SD)" and discrete data as "frequency and percentage". To examine the significant changes in the beneficiaries and health issues between pre-COVID-19 and during and post-COVID-19 period, chi-squared test was used. The association was considered significant at p-value < 0.05. Table 1 summarizes the socio-demographic characteristics of the analyzed population. A total of 6038 adolescents and young adult females visited the CoE-AHD between 2018 and 2022. The majority of the beneficiaries that visited the centre were in the age group of 15-19 years (55.0%), followed by 20-24 years (38.2%), and 10-14 years (6.8%) age group. The mean age of the beneficiaries was 18.94 ± 2.72 years. The proportion of 15-

Data Processing
Statistical Package for Social Sciences (SPSS) version 23.0 software was used for data processing and analysis. Descriptive statistical methods were used to summarize the sociodemographic information of the beneficiaries. The continuous data were expressed as "mean ± standard deviation (SD)" and discrete data as "frequency and percentage". To examine the significant changes in the beneficiaries and health issues between pre-COVID-19 and during and post-COVID-19 period, chi-squared test was used. The association was considered significant at p-value < 0.05. Table 1 summarizes the socio-demographic characteristics of the analyzed population. A total of 6038 adolescents and young adult females visited the CoE-AHD between 2018 and 2022. The majority of the beneficiaries that visited the centre were in the age group of 15-19 years (55.0%), followed by 20-24 years (38.2%), and 10-14 years (6.8%) age group. The mean age of the beneficiaries was 18.94 ± 2.72 years. The proportion of 15-19-year-olds was high compared to beneficiaries in the other age groups in the analysis period. There was an increasing trend in the number of visitors from 2018 (2.9%) to 2022 (12.3%) among Schedule caste and Schedule tribe females. Education-wise analysis reveals that out of total beneficiaries, 36% were graduates, and 14.7% had never enrolled in school. More than three fourth of the participants (77.0%) were unmarried. The majority of the respondents were from non-working categories (97.9%).

Physiological and Anthropometric Characteristics of the Beneficiaries
Physiological and anthropometric characteristics such as height, weight, blood pressure, and BMI from 2018-2022 (up to march) are shown in Table 2. Analysis shows that mean height and weight were high among young adults (20)(21)(22)(23)(24) across the observation years. The overall mean height among 20-24 years was (152.58 ± 3.34) and weight (49.79 ± 6.99), respectively. Regarding BMI, early adolescent (10-14) girls had low BMI (16.94 ± 3.41) compared with late adolescent and young adult females. Overall, an increase in the mean of physiological and anthropometric parameters was seen in the late age of adolescent and young adult females ( Table 2).    Table 4 shows the distribution of counselling, clinical, and referral by year and age group. We observed that late adolescent girls (15-19 years) received the highest counselling services (n = 3319) compared with other age groups. On the other hand, only 410 beneficiaries from early adolescent age group (10-14) received counselling services. We found that out of total counselling, 41.06% of the beneficiaries further availed themselves of clinical services. It was also observed that those beneficiaries who received clinical services were further referred to appropriate departments. Figure 2 shows changes in the beneficiaries' services during pre-and post-COVID-19 periods. We found that all three services (counselling, clinical, and referral) decreased from the pre-COVID-19 period to the post-COVID-19 period. For instance, the counselling services were 56.64% during the pre-COVID-19 period and 43.09% during and after the COVID-19 period. Table 4. Distribution of counselling, clinical, and referral of beneficiaries by year and age group.

10-14 Years Age Group
Year

Year-Wise Prevalence of Beneficiary Health Problems
In Figure 3, we found that beneficiaries mainly visit the facilities for sexual and reproductive health, menstruation, nutrition, NCD, mental health, violence, and other health problems. Counselling related to menstruation was most commonly reported across the year. Sexual and reproductive health issues were the second most common reported counselling, followed by nutrition-related issues. Mental health and vio-

Year-Wise Prevalence of Beneficiary Health Problems
In Figure 3, we found that beneficiaries mainly visit the facilities for sexual and reproductive health, menstruation, nutrition, NCD, mental health, violence, and other health problems. Counselling related to menstruation was most commonly reported across the year. Sexual and reproductive health issues were the second most common reported counselling, followed by nutrition-related issues. Mental health and violence-related counselling were rarely reported. Other health problems (body ache, cough, fever, etc.) were also observed during the analysis period.

Year-Wise Prevalence of Beneficiary Health Problems
In Figure 3, we found that beneficiaries mainly visit the facilities for sexual and reproductive health, menstruation, nutrition, NCD, mental health, violence, and other health problems. Counselling related to menstruation was most commonly reported across the year. Sexual and reproductive health issues were the second most common reported counselling, followed by nutrition-related issues. Mental health and violence-related counselling were rarely reported. Other health problems (body ache, cough, fever, etc.) were also observed during the analysis period.

Prevalence of Health Problems among Early Adolescents, Late Adolescents, and Young Beneficiaries
We found that amenorrhea, dysmenorrhea, and white discharge were the most frequent health problems reported by all beneficiaries. Within the sexual and reproductive health (SRH) problems reported by beneficiaries, white discharge (12.89%),

Prevalence of Health Problems among Early Adolescents, Late Adolescents, and Young Beneficiaries
We found that amenorrhea, dysmenorrhea, and white discharge were the most frequent health problems reported by all beneficiaries. Within the sexual and reproductive health (SRH) problems reported by beneficiaries, white discharge (12.89%), ovarian cyst and its related problems (5.63%), bleeding, and pain (3.54%) were frequently reported. For menstruation-related problems, a total of 2795 cases were reported. Out of that, dysmenorrhea and amenorrhea (17.27% each) were the most common menstruation reported problems and highly observed in early and late adolescent girls (10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Only 12 cancer patients visited the CoE for cancer-related symptoms. Under the mental health issues, depression, behavioral disorders, learning problems, and emotional disorders were reported, but the cases were less observed. In the nutrition issues, Ante Natal Care (5.13%), anemia (0.46%), and iodine deficiency (0.31%) were reported. Other health problems, such as body ache (15.42%) etc. were also reported ( Table 5).
Beneficiaries visited the CoE-AHD for all health-related issues during the pre-and post-COVID-19 period reported in Table 6. A total of 56.64% beneficiaries visited for counselling during the pre-COVID-19 period and 43.36% during and post-COVID-19 period. We found a significant decrease in beneficiaries who visited the CoE-AHD for treatment (<0.001). For example, sexual and reproductive health problems (<0.001), menstruation-related problems (<0.001), nutrition (<0.05), and other health problem (<0.001) have significantly decreased during and in the post-COVID-19 period.

Discussion
The Centre of Excellence for Adolescent Health and Development is the Government of Uttar Pradesh and MAMTA's flagship intervention that provides adolescent-friendly health services. The present analysis focuses on adolescent and young adult females who visited the CoE-KGMU from June 2018-March 2022. We summarized our findings in three services (counselling, clinical, referral) in line with the objective of the analysis. The learnings from this CoE would strengthen the ongoing RKSK program initiated in the State, spearheaded by the National program implementation of the Government of India. The strength of the RKSK program has been its health promotion approach; there has been a paradigm shift from the existing curative clinic-based services to promotion and prevention by reaching adolescents in their own environment, such as schools and communities. The school-based interventions have increased outreach of preventive health and its messages, and influenced utilization of services in these centres (CoE). Additionally, it has also increased referral services from adjoining districts. Eight papers have already been published to strengthen state specific programming. The initiative has also led to an inter-sectoral approach through the state health program where different departments have now come together to improve adolescent health.
However, holistically, adolescent health is still at a nascent stage in the country. Even though RKSK was launched in 2014, it started rolling out in the states only in 2016. It has been only five years since its implementation started, and the last two years of service were affected by the COVID-19 pandemic. In this analysis we have shown how the outbreak of the COVID-19 pandemic, and the subsequent lockdown in 2021, decreased the number of beneficiaries from the pre-COVID-19 period to the post-COVID-19 period. During the counselling services, we observed that very limited numbers of SC/ST caste-based beneficiaries visited the CoE-AHD. A similar finding was observed in a study conducted in three states of India (Bihar, Chhattisgarh, and Odisha) among pregnant adolescent girls, which found that SC/ST adolescents were less likely to use health care services than other castes [17].
The analysis shows that SRH and menstruation-related problems were most prevalent during 2018-2022. The highest prevalence of SRH and menstruation-related problems were reported in the late adolescent age group (15-19 years), as compared to early adolescent and young adult females. This finding was supported by another study that focused on adolescents and young adults, which found that 78.3% of adolescent females already had coital initiation, which could be a major reason for the SRH issues among late adolescent girls (15-19 years) [18]. Prior studies have reported that adolescents who were married at a very young age were more likely to have SRH complications than those married as adults [19].
The current analysis also found that among SRH problems, white discharge (12.89%), ovarian cyst (5.63%), and bleeding and pain (3.54%) were major issues that were reported. A similar observation was found in a hospital-based retrospective study among adolescents (10-19 years), that white discharge was the most common reproductive health problem among adolescent girls [20]. A significant reduction in counselling for SRH problems (<0.001), menstruation-related problems (<0.001), nutrition (<0.005), and other health problems (<0.001) from the pre-COVID-19 period to the post-COVID-19 period was observed. The cases of mental health problems were also observed in the pre-and during and post-COVID-19 period. Our finding was in line with the previous study findings that during the COVID-19 pandemic, nearly 27.5% of adolescent girls from central India between 15 and 20 years had high levels of psychological distress [21]. A previous study also reported that during the COVID-19 period, young girls had chronic shortages of sanitary napkins, and their difficulties in accessing the napkins increased significantly. These kinds of crises were one of the primary causes of SRH problems among adolescents [12].
Another major finding of this analysis is that ANC check-ups were majorly reported, followed by anemia and iodine deficiency. A previous study reports that those adolescent girls consuming IFA tablets were less likely to be anemic compared to those not consuming IFA tablets (OR = 0.09, p < 0.001) [22]. Under mental health problems, the prevalence of depression was observed more in late adolescent and young adult women. There is prior evidence which shows that depression and stress are more prevalent among schoolgoing adolescent girls [23]. Therefore, there is a need for scalable mental health strategies, especially for the late adolescent age group and young adults.
A total of 12 cancer cases were reported during the analysis period. All cancer cases were reported in the late adolescent and young women age group. In contrast to our findings, a previous study found that prevalence of cancer was higher among the 24-30 age group compared to adolescents and young adults (10-24) [24]. It may be because our analysis focused only on adolescent and young women. Furthermore, vomiting, chest pain, weakness, and liver-related problems were frequently reported health issues by adolescent and young beneficiaries. Our analysis also found that a negligible number of beneficiaries were currently using any kind of substance. This finding is in congruence with a previous study conducted by Global Adult Tobacco Survey in Uttar Pradesh, which found that less than 3.2% of women currently smoke tobacco [25]. In our data we found that a very small proportion of adolescent girls and young adult women came to the hospital for violence-related issues, which could be due to the stigma related to reporting violence and its after effects.

Strengths and Limitations
A major strength of this data is the robust sample size which gives us an estimation of the general adolescent health problems. The availability of strong data for adolescent and young adult women would help policy-makers and researchers to strengthen the adolescent health system. Another strength of the analysis was the retrospective data from the last 5 years which covered all the RKSK themes, especially in pre-COVID, during and post-COVID times. A limitation was that we could not measure all possible health aspects of adolescent and young adult health. Another limitation was that the current analysis focuses only on females; therefore, problems related to boys were not reflected. Lastly, this analysis was based on only one health facility, KGMU, Lucknow, India; therefore, the result does not reflect the actual scenario of the state or region.

Conclusions
Adolescents and young adult women face many SRH problems. Therefore, there is a need to have access to timely, integrated, high-quality, multi-disciplinary SRH health services to ensure effective assessment, treatment, and support. In terms of age-wise health effects, late adolescent girls were more vulnerable. Therefore, it is essential to develop age-specific screening tools. To achieve comprehensive health care for this population, we need to have a multi-dimensional approach covering various aspects of health problems, with a particular emphasis on SRH and mental health. Additionally, the scientific rigor of the tools needs be have more precision and needs to be designed for specific diseases to get real estimates.
Adolescent and young adults (10-24 years of age) are highly recommended for promoting the RKSK services throughout India. The findings also urge the government to invest in adolescent and young adult health programs across India. There is a need to include SRH and menstruation-related education in the school teaching curriculum that will help in the prevention and promotion of reproductive and sexual health-related problems. At the same time, it will also help in combatting the stigma related to it. There is also a need to educate parents regarding the nutritional requirements, and to adopt a diet appropriate for adolescents and young adults.
We should aspire to scale up such adolescent-friendly health centres in different states of India. This will further help in early detection of adolescent health problems. We need to enable the visit of SC/ST beneficiaries in the CoE-AHD adolescent-specific health awareness program, which must be included in the hospital-based curriculum. Counselling and screening of adolescent and young adult females should be done on a regular basis so that it can be an effective strategy to control the existing diseases and to update the occurrence of any new disease. Additionally, there is a need to include adolescent and young adult males in CoE-AHD, KGMU. It will help to address the adolescent-related problems more comprehensively. Gender inclusive interventions are important to improve health outcomes.
Author Contributions: D.M., S.K.R. and R.R. conceptualized and created the framework for the manuscript. S.D. and Q.N. preparing the data for analysis. R.R. and K.S.D. contributed to data analysis and R.R. writing and preparation of the manuscript. D.M. and S.K.R. review and editing the manuscript. S.M. supervision of whole project. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This analysis did not require ethical approval as this analysis has utilized existing (secondary) data, and therefore, no direct interaction was made with human beings. The data do not have any identifying information (anonymous in analysis).

Informed Consent Statement:
This analysis has utilized existing (secondary) data, and therefore, no direct interaction was made with human beings. The data do not have any identifying information (anonymous in analysis).

Data Availability Statement:
The dataset for the adolescents and young adult women generated and analyzed during the current analysis is available from the authors upon reasonable request.