Adolescent Health teaching tool for UG medical teacher.pdf

Adolescent Health
Dr PIYUSH GUPTA
Chapter 5

Definition and Importance of Adolescent Health
• Adolescence is a period of transition between childhood and adulthood
• A time of rapid physical, cognitive, social, and emotional maturing.
Definition of adolescence
• WHO defines “adolescence” as age between 10 and 19 years
• Government of India (National Youth Policy) defines adolescence as 13–19 years
• “Youth” refers to ages 15–24 years. Government of India defines this as 15–35
years
• “Young people” refers to ages 10–24 years
• “Young adults” refers to ages 20–24 years
• Early adolescence refers to age 10–13 years, middle adolescence refers to age 14–
16 years and late adolescence refers to age 17–19 years.

Girls
• Girls develop breast buds as the first sign of puberty
• Approximately 1 year after breast budding, girls reach their peak height velocity, and 1 year
later menarche ensues. After menarche, a girl usually grows only an additional 4–5 cm.
Boys
• Onset is heralded by an increase in testicular volume, followed by pubic hair growth, then
enlargement of the penis.
• Peak height velocity occurs 2 years after the onset of testicular enlargement. Adolescents
gain about 15–25% of their final adult height during their pubertal growth spurt.
Important
• Pubertal development starts 1–2 years earlier in girls as compared to boys.
• Appearance of secondary sexual characters before the age of 8 years in girls and 9 years in
boys, and nonappearance of secondary sexual characters by the age of 13 years in girls and
14 years in boys is considered abnormal.
• A girl who does not menstruate by 16 years should be thoroughly evaluated.
Pubertal Changes

Tanner Sexual Maturity Rating: GIRLS

Tanner Sexual Maturity Rating: Boys

1. Bodily changes cause emotional stress and strain as well as abrupt and rapid mood
swings.
2. Sexual attraction leads to a desire to mix freely and interact with each other.
3. Adolescence is characterized by an emerging capacity to reason in an increasingly
more sophisticated manner.
4. Adolescents have a sense of uniqueness and personal invulnerability.
5. This sense of personal invulnerability, coupled with a desire to test and master and
their newly emerging physical and mental capabilities, may also explain the risk-
taking behaviors observed during this age.
Cognitive and Developmental Changes

Adolescence is customarily divided into the stages:
(1) Early (age 11–14 years),
• Characterized by a focus on the physical changes that accompany puberty and
by concrete thinking. Separation from parents and the rise in peer group
influence begins during this stage but is not prominent.
(2) Middle (age 14–17 years) and
• Peer group influence and conflicts with parents peak. Risk-taking behaviors,
become common. Concerns about one’s developing sense of self and autonomy
become increasingly important.
(3) Late (age 17–21 years) (Table 5.4).
• The focus shifts to developing the capacity for intimacy in relationships and
defining one’s career goals and place in society.
PHASES OF ADOLESCENCE

Changes in Adolescence
1. Adolescence is accompanied by physical, cognitive, emotional, social and
behavioral changes due to interplay of various hormones during puberty.
2. Physically, an individual gains the final 15–20% of adult height; 50% of the adult
body weight; and 40% of the adult skeletal mass in adolescence.
3. Marshall and Tanner have described the appearance of secondary sexual
characteristics as sexual maturity ratings (SMR).
4. Adolescence is customarily divided into the three stages: early (11 to 14 years),
middle (14 to 17 years) and late (17 to 21 years).
IN A NUTSHELL

1. Medical diseases: Asthma, respiratory infections, tuberculosis, precocious or
delayed puberty short stature, and chronic disorders such as diabetes, celiac
diseases, heart diseases, etc.
2. Consequences of risk-taking behavior: Accidents and injuries, violence, homicide,
suicide, substance abuse
3. Nutritional problems: Undernutrition, iron deficiency, obesity, and eating
disorders—anorexia nervosa, bulimia
4. Reproductive health problems: Teenage pregnancy, abortion, menstrual problems,
and reproductive tract infections
5. Mental health problems: Substance abuse, violence, depression and suicide,
learning disorders, and other psychiatric disorders
Adolescent Health Problems

1. Nutritional problems
2. Sexual and reproductive health problems (including HIV/AIDS)
3. Noncommunicable diseases
4. Mental health problems
5. Substance use and abuse (tobacco, alcohol, and other substances)
6. Injuries and violence (including gender-based violence)
7. Endemic and chronic diseases: TB, malaria, asthma
Priority Health Problems Affecting Adolescents

1. Behavior contributing to unintentional violent injuries
2. Tobacco use
3. Alcohol and other drug use
4. Sexual behaviors contributing to unintended pregnancy, STD and HIV
5. Unhealthy dietary behavior
6. Physical inactivity
Priority Health-risk Behaviors in Adolescents

These factors increase the likelihood of adolescents making decisions that contribute
positively to their health and development and decrease the likelihood of engaging in
risky behavior.
1) caring and meaningful relationships;
2) positive school environment;
3) structure and boundaries for behaviors;
4) having spiritual beliefs;
5) encouragement of self-expression; and
6) opportunities for participation and contribution.
PROTECTIVE FACTORS

Health Issues in Adolescence
1. Though adolescence is considered relatively a healthy period, but many health risk
behaviors such as smoking, alcohol consumption, sedentary lifestyle are formed in
this age, which are responsible for significant morbidity and mortality in the adult
life.
2. Health problems encountered in adolescence can be broadly grouped as medical
and nonmedical.
3. Apart from medical issues, mental health issues, drugs, and injuries and violence
are the major causes of morbidity and mortality in adolescents.
4. Protective factors increase the likelihood of adolescents making decisions that
contribute positively to their health and development, and decrease the likelihood
of engaging in risky behavior
IN A NUTSHELL

Adolescent Sexuality
A. Sex
• The terms sex and sexuality often confuse the adolescents.
• The term sex is often used for the intercourse whereas it denotes the biological
difference between women and men.
• The goal of sex drive is biological sexual maturity, i.e., capacity to love, mate,
reproduce and care for the young ones.
B. Sexuality
• It includes the sum of person’s personality, thinking and behavior toward sex.
• It includes the identity, emotions, thoughts, actions, relationships, affection,
love, feelings, caring, sharing, and the intimacy the person has and displays.
• The negative aspect of sexuality includes sexual coercion, eve teasing, sexual
harassment, rape, and prostitution.

• Adolescents develop and become aware of their sexual drives and feelings.
• They also tend to explore the various aspects/ dimensions of being sexual.
• They are likely to be curious and try to experiment.
• Many adolescents adopt high-risk behavior due to the numerous myths and lack
of skills—especially the ability to negotiate and to deal with peer pressure
effectively.
• Consequences of unsafe sexual behaviors include adolescent pregnancy, unsafe
abortions, and sexually transmitted infections (STIs).

• Globally, 15% of all births are to women 15–19 years old.
• Nineteen percent of total fertility in India is contributed by girls in the 15–19 age
group.
 Adverse effects
˗ ↑morbidity and mortality.
˗ Malnutrition in fetus and mother.
˗ Premature labor, spontaneous abortion, and stillbirths.
˗ Pregnancy-related hypertension and anemia.
˗ Young mothers are also likely to have a higher incidence of poor childcare and
poor child feeding practices.
Adolescent Pregnancy

Unsafe Abortion in Adolescents
• Can result in complications such as hemorrhage, septicemia, injuries, infertility,
and death.
• Abortion also has psychological consequences such as depression.
• Adolescent abortions are estimated globally at 2.5 million per year,
representing 14% of all unsafe abortions. Most of them are performed illegally
or under hazardous circumstances.
Sexually Transmitted Infections
• Each year, >1 out of 20 adolescents contract a curable STI.
• At least one-third of total estimated new STI cases occur in young people.
• More than half of all new HIV infections reported globally are from the age
group of 15–24 years.

Adolescents need to have clear, accurate and precise information to understand the
various aspects of human sexuality, sexual roles and responsibilities. Promoting the
sexual and reproductive health of adolescents involves the implementation of the
following:
 Proper information that will help adolescents understand how their bodies work
and what the consequences of their actions are likely to be.
 Social skills that will enable them to say no to sex with confidence and to negotiate
safer sex.
 Counseling to make informed choices.
 Health services can help adolescents to stay well, and ill adolescents get back to
good health.
PROMOTING THE SEXUAL AND REPRODUCTIVE HEALTH

1. Sexuality is broad term, which includes the sum of person’s personality, thinking
and behavior toward sex.
2. Nineteen percent of total fertility in India is contributed by girls in the 15–19 age
group.
3. Adolescent pregnancy and breastfeeding puts both mother and child at higher risks
of morbidity and mortality.
4. To function as effective and well-adjusted adults, adolescents need to have clear,
accurate and precise information to understand the various aspects of human
sexuality, sexual roles, and responsibilities.
IN A NUTSHELL

Recommended Diet for Adolescents
• Increased demand of calories and proteins
• The “growth spurt” results in a 50% increase in calcium and 15% increase in iron
requirements.

• Conditioning factors: Worm infestations, diarrhea, poor environmental sanitation,
and menstruation in girls contribute to malnutrition.
• Cultural factors: Food habits custom, beliefs, tradition, attitudes, religion, food fads,
cooking practices, and social custom.
• Socioeconomic factors: Poverty, ignorance, insufficient education, lack of knowledge
regarding nutritive value of foods, large family.
• Gender issues: Girls are discriminated against in both quantity and quality of food.
• Eating pattern: Dependance on JUNCS, negative influence of media, and availability
of fast food on a click.
Factors Influencing Adolescent Nutrition

• Adolescent girls are at particularly high risk of anemia (upto 66%) and malnutrition.
• Even boys are found anemic up to 45%.
• Stunting is prevalent in 37.2% boys and 41.0% girls in India.
• Two-thirds suffer from chronic energy deficiency of the third degree, with body
mass index below 16.
• Almost half of the adolescents are not getting even 70% of their daily requirements
of energy.
• Almost 25% are getting <70% of RDA of proteins.
ADOLESCENT UNDERNUTRITION

• Deficiencies of iodine, iron, and vitamin B12 are common among adolescents,
causing delayed growth spurt, stunted height, delayed/retarded intellectual
development, anemia, and increased risks in childbirth.
• Intake of most foods, except cereals, millets, roots and tubers, is below the
reference daily intake (RDI) in adolescents.
• Consumption of green leafy vegetables, fruits, pulses and milk is grossly inadequate.
• Prevalence of overweight and obesity is also high because of sedentary lifestyle.

Eating Disorders: Anorexia and Bulimia
• Eating disorders are psychological disorders that typically start during
preadolescence or adolescence and are often due to extreme disturbance in eating
behavior.
• Three most prevalent disorders are:
˗ Anorexia nervosa,
˗ Bulimia nervosa, and
˗ Binge eating disorder.
• Symptoms of eating disorders include the following: a distorted body image, skipping
most meals, unusual eating habits, frequent weighing, extreme weight change,
insomnia, constipation, skin rash, dental cavities, loss of hair or nail quality,
hyperactivity, and high interest in exercise.

• Occurs more commonly in adolescent girls shortly after completion of puberty.
• Characterized by deliberate weight loss induced by the adolescent by reducing food
intake, in relentless pursuit of thinness.
Etiology
• Common in girls with excessive dependence, low self-esteem, high anxiety, and
affective disorder. Their families are overprotective.
• Now thought to be a disorder of mood or problem in identity development.
• A complex interaction between sociocultural, biological and psychological factors
contributes.
ANOREXIA NERVOSA

1. Persistent restriction of energy intake leading to significantly low body weight.
2. Either an intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain.
3. Disturbance in the way one’s body weight or shape is experienced.
Diagnostic Criteria

 Young females begin to eat less and less food, leading to profound weight loss and
emaciation.
 Associated with self-induced vomiting or purging.
 There may be a history of excessive exercise, use of appetite suppressants, or diuretics.
 Complain of abdominal pain and bloating of abdomen even with ingestion of small
amounts of food.
 Weight loss >30% leads to lethargy, cachexia, and generalized weakness.
 There is undernutrition of varying severity, with resulting secondary endocrine and
metabolic changes and disturbance of bodily functions including amenorrhea.
 The mortality is 10% and is due to electrolyte imbalance, cardiac arrhythmias or congestive
heart failure, hypothermia, and hypotension. Bone marrow hypoplasia, constipation,
esophagitis, hypophosphatemia, potassium depletion, hypochloremic alkalosis, and
elevation of BUN may also be present.
Clinical Manifestations of Anorexia Nervosa

Treatment involves a combined approach of
(1) individual and family psychotherapy,
(2) behavioral modification, and
(3) nutritional rehabilitation.
Those with associated depression may require antidepressants.
TREATMENT: Anorexia Nervosa
Role of parents: They should be fully involved in their child’s therapy. Psychotherapy
helps children improve their self-esteem, peer relationship, and resolving parental
conflicts.

• Predominantly seen in adolescent females
• Characterized by recurrent episodes of binge eating accompanied by purging
through vomiting, overuse of laxatives, enemas, diuretics, fasting, or excessive
exercise.
• Eating binges may occur as often as several times a day but are most common in
the evening and night hours.
BULIMIA NERVOSA

These episodes must occur at least once a week for 3 months to meet the diagnostic criteria for
DSM-V classification. Some of the salient features of this condition are as follows:
• Rapid consumption of large amounts of high calorie food with no apparent change in weight.
• Binging is often followed by purging, which is often done secretly.
• Evidence of binge eating: Hiding food or discarded food containers and wrappers, stealing,
hoarding food.
• Evidence of purging: Frequent trips to bathroom, especially after meals, signs and/or smells of
vomiting, presence of empty containers or packages of drugs such as laxatives or diuretics.
• Excessive exercise or fasting, frequent weighing, peculiar eating habits or rituals, preoccupation
with food, body weight and image.
• Overachieving and impulsive behaviors.
Physical signs of bulimia nervosa include dental enamel erosion, odor on the breath, skin changes
such as calluses/ scarring on the dorsum of hands caused by self-inducing vomiting, enlargement
of salivary glands, and edema.
Clinical Features

• Early diagnosis and management are the mainstay
• Requires a multidisciplinary team approach comprising of physician, therapist and a
nutritionist medical and nutritional intervention with the
• Aim of restoring weight, nutritional rehabilitation, and treatment of complications.
• Family-based treatment is often the mainstay of psychological intervention.
• Coexisting mental illness such as anxiety and depression are also treated.
• Selective serotonin uptake inhibitors (fluoxetine, sertraline, etc.) are used in
resistant cases.
Treatment: Bulimia Nervosa

Mental Health Problems
PREVALENCE
• As per WHO “globally, one in seven 10–19-year-old experiences a mental disorder,
accounting for 13% of the global burden of disease in this age group” and is considered
most common non-communicable disease (NCD) in this age group.
• In any given year, about 20% of adolescents will experience a mental health problem, most
commonly depression, anxiety, or behavioral disorders.
• In India, the prevalence of psychiatric disorders among adolescents under 16 years is 12.5%.
In addition,
• Almost half of the mental illnesses diagnosed in adults have their onset in the adolescent.
ETIOLOGY
Risky behavior (such as unsafe sex, hazardous/drunk driving, smoking), self-harm, physical
inactivity, educational failure, and school dropout are associated with mental health problems.

• Mental illness can present in a variety of ways.
• Changes in mood and behaviors are important indicators of mental well-being.
• Unexplained aches and pains, inability to concentrate, disruptions in sleep habits,
changes in appetite and eating, heightened irritability, agitation, and moodiness
should alert to presence of a mental illness.
• Persistence of symptoms for >2 weeks are important “Red flags” for depression.
The HEEADSSS approach (Table 5.7) can help the clinicians assess whether an
adolescent is mentally well or ill and, if they are ill, to assess the severity of the
illness.
ASSESSMENT

1. Body image
2. Sexuality conflicts
3. Scholastic pressures
4. Competitive pressures
5. Relationship with parents
6. Relationship with siblings and peers
7. Finances
8. Decision about present and future roles
9. Career planning
10. Ideological conflicts
Areas of Stress in Adolescents
Common psychosomatic
symptoms include recurrent
abdominal pain, headaches,
chest pain, and chronic
fatigue. Nonspecific
symptoms include dizziness,
syncope and/or tiredness

• Ask this directly without any hesitation, e.g., “Have you ever felt so bad that you
felt like committing a suicide?”
• Asking about suicidal behavior does not precipitate or trigger it.
• Any suicidal ideation should prompt a more careful assessment of the patient’s
suicide risk and must include a referral to a mental health expert.
• Previous suicide attempts are often a strong risk factor for future attempts.
• Ensure that adolescents have access to quality and affordable mental health
services.
Suicidal Behavior

• Illiteracy, economic background, unemployment, and family disharmony increase
vulnerability to drug abuse.
• Consumption of tobacco, alcohol, and illicit substances by adolescents is rising.
Tobacco
• Globally, 300 million young people (10–24 years) smoke. 50% of these to die of
tobacco-related diseases.
• Some begin as 10-year-old. The earlier adolescents start using tobacco, the more
likely that they will get addicted.
SUBSTANCE ABUSE

Alcohol
• Most common cause of substance use related death of young people.
• Associated with poor scholastic attainment, increased drop out from school, drink
and drug driving delinquency, early pregnancy and family difficulties. Associated
with greater likelihood of early sexual initiation.
Drugs
• Drug abuse must be discussed frankly with the adolescents.
• More often they do not admit doing drugs when directly asked tell about their
friends.
• Use the CRAFT Questionnaire.
SUBSTANCE ABUSE

1. Have you ever ridden in a Car driven by someone who was high or had been using
drugs or alcohol?
2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
3. Do you ever use drugs or alcohol when you are Alone?
4. Do you Forget things you did while using drugs or alcohol?
5. Do your family or Friends ever tell you that you should cut down your drinking or
drug use?
6. Have you ever gotten into Trouble while using drugs or alcohol? Two or more “Yes”
answers suggest high risk of a serious substance-use problem or a substance-use
disorder .
CRAFT Questionnaire to Detect Substance Abuse

 Promote positive, caring and supportive relationships with families and peers,
teachers, and other adults.
 Ensure that adolescents’ lives are free from neglect, trauma, excessive stress,
violence, abuse, and discrimination.
 Ensure good living conditions including access to sporting facilities.
 Accept diversity among adolescents.
 Help adolescents to develop life skills including communication, decision making,
negotiation, critical thinking, stress management skills.
 Ensure access to educational and vocational training to enhance their abilities and
employment opportunities.
 Integrate mental health promotion and life skills development in the school
curriculum.
PROMOTING MENTAL HEALTH

Mental Health in Adolescence
1. In India, the prevalence of psychiatric disorders among adolescents under 16 years
is 12.5%.
2. Nearly 50% of mental health issues diagnosed in adults have their onset in the
adolescent period.
3. HEEADSSS approach related to mental health can help the clinicians to assess
mental wellbeing and their severity in adolescents.
4. Some of the common mental health problems prevalent in this age group are
substance abuse, violence, depression, suicide, learning disorders, and other
psychiatric disorders.
IN A NUTSHELL

Noncommunicable Diseases in Adolescents
1. Injuries and violence
2. Mental health and substance abuse disorders
3. Chronic respiratory disorders (asthma)
4. Musculoskeletal disorders (low back pain, neck
pain)
5. Neurological disorders (epilepsy, migraine)
6. Dermatological disorders (dermatitis, acne vulgaris)
7. Endocrine disorders (diabetes)
8. Hematological disorders including malignancies
9. Urogenital and digestive disorders
10. Nutritional disorders: Iron deficiency anemia),
overweight, obesity
In 2019, globally,
one in five deaths
among adolescents
were caused by
NCDs and estimated
to cause over half of
the disability-
affected life years
(DALYs).

Noncommunicable Diseases in Adolescence
1. Behaviors responsible for the majority of NCDs in adulthood have their origin in
adolescence.
2. Physical inactivity, unhealthy diet, tobacco use, harmful use of alcohol, and
indicators of metabolic syndrome (high blood pressure, high cholesterol, diabetes)
are some of the important behaviors responsible for the majority of NCDs of adult
life.
3. Injuries and violence including sexual violence is an important cause of morbidity
and mortality among adolescents
IN A NUTSHELL

COMMUNICATION AND COUNSELING
• Integral part of managing adolescent health issues.
• Communication is an exchange of information, knowledge, ideas, or feelings. In a
face-to-face situation, communication is not just exchange of information.
• Conveys one’s feelings, by use of gestures, facial expressions, language, and the
manner of tone.
• Helps in building bridges with the client
• Counseling is not simple advising rather it is helping people to identify problem,
make decisions, and giving them confidence to put their decision into practice.

• G: Greet the person
• A: Ask how can I help you
• T: Tell them any relevant information
• H:V Help them to make decisions
• E: Explain any misunderstanding
• R: Return to follow-up for referral.
Steps of counseling: “GATHER”
Maintain confidentiality and involve parents in care of adolescents
Techniques of good communication
1. Creating a good, friendly first
impression
2. Rapport building during the first
session
3. Nonjudgmental, active listening
4. Providing information in the
simple way
5. Ask appropriate and effective
question

• H: Home living arrangements, relationships, supervision, childhood experiences,
family cultural background/s)
• E: Education, Employment
• A: Activities, Hobbies, and Peer Relationships
• D: Drug Use
• S: Sexual Activity and Sexuality
• S: Suicide, Depression, Anxiety, and Mental Health
HEEADSSS tool for psychosocial assessment

Examining the adolescents is a tactful issue and one must be aware of certain legal
implications as well.
 Explain nature and the purpose of the examination.
 Obtain the consent of the adolescent parent.
 Ideally same sex doctor is preferable.
 The examination should ensure privacy.
 Watch for any signs of discomfort or pain during the examination.
 After doing the examination properly explain the findings and its implications.
Physical Examination

• Encourage the adolescents to adopt health promoting behaviors and to reduce
identified risk behaviors.
• Encourage to participate in activities and remain fit.
• Promoting abstinence or use contraception for sexually active adolescents.
• Reduction of risky behaviors includes smoking cessation, avoiding drinking and
driving and lifestyle changes by Motivational interviewing.
• Efforts to update immunizations. Should occur at each visit.
˗ Adolescents 11-year-old and older should receive diphtheria and tetanus toxoids
(Td), MMR, and varicella vaccine.
˗ Second dose of MMR vaccine if they have not previously had one.
˗ Three doses of hepatitis B vaccine
HEALTH PROMOTION IN ADOLESCENTS

Adolescent Health Checkup
1. Communication and counseling are the integral part of managing adolescent
health issues.
2. Privacy and confidentiality are the important pillars of counseling in adolescents.
3. “HEEADSSS” is a psychosocial screening tool used globally that captures almost all
the domains affecting the psychosocial development of the adolescents.
4. The counseling process should focus on encouraging the adolescents to adopt
health promoting behaviors and to reduce identified risk behaviors.
5. All adolescents should undergo physical examination according to the prescribed
norms.
IN A NUTSHELL

Adolescent Friendly Health Services
1. Availability,
2. Accessibility,
3. Approachability,
4. Acceptability,
5. Appropriateness,
6. Affordability.
Basic Principles: 6 As

1. Screening for health issues (including problem behaviors)
2. Manage and treat illness including other health concerns
3. Prevent and respond to health issues that can endanger young lives
4. Support young people to lead healthy life, by monitoring
5. Interact with adolescents at times of concern or crisis
6. Provide counseling services on wide range of issues
7. Provide health promotional and preventive services
8. Early referral for conditions not manageable at the clinic
Attributes of Effective Adolescent Health Service

• Barrier related to adolescents:
– Discomfort with perceived clinic condition or attitudes
– Concern over lack of privacy and confidentiality
– Embarrassment or shame at needing reproductive health services
• Barrier related to health facility:
– Lack of designated space for adolescents
– Unsuitable timing
– Location and distance
• Barrier related to health providers and policies:
– Untrained providers
– Unempathetic and judgmental attitude of providers and staff
– Discriminatory policies
– Unclear laws and policies
Barriers to Health Seeking Behavior by Adolescents

While dealing with adolescents, the role of health provider is threefold:
(1) To reassure the adolescent that his or her development is normal or identify
problems that may require further evaluation or treatment;
(2) To assess the adolescent and his or her family for factors that may predispose
to or protect against the adolescent’s pursuit of health-risking behavior, and
(3) To promote a healthy lifestyle that will continue throughout adulthood
ROLE OF HEALTHCARE PROVIDER AT THE ADOLESCENT HEALTH CENTER

Adolescent Friendly Health Services
1. Adolescent friendly health service is a form of service delivery system that plays
an important role in helping adolescents to stay healthy and to complete their
journey to adulthood.
2. The basic principles of adolescent health care are 6 “As”— availability,
accessibility, approachability, acceptability, appropriateness, affordability.
IN A NUTSHELL

Adolescent Health teaching tool for UG medical teacher.pdf

Adolescent Health teaching tool for UG medical teacher.pdf

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