Value adolescents, invest in the future : educational package facilitator's manual

value adolescents invest in the future EDUCATIONAL PACKAGE f a c i l i t a t o r’ s m a n u a l

World Health Organization Regional Office for the Western Pacific Manila, Philippines

WHO Library Cataloguing in Publication Data Value adolescents invest in the future : educational package facilitator's manual

1. Adolescent health services. ISBN 92 9061 069 7

2. Manuals.

(NLM Classification: WS 460)

© World Health Organization 2003 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them - whether for sale or for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P .O. Box 2932, 1000, Manila, Philippines, Fax: +632 521 1036, email: publications@wpro.who.int

Contents Message from the Regional Director Introduction SECTION 1: Adolescent Health and Development A1 Promoting Adolescent Health and Development A2 Who are adolescents? A2a Population Pyramid 2000 A3 Adolescence: Outcome of Development A4 Adolescence: Goals of Development A4a-f Adolescence: Developing Life Skills A5 Why invest in adolescents? SECTION 2: Adolescent Health and Development Issues SECTION 2.1: Nutrition N1 Nutrition during adolescence is important for optimal growth and development N2 Some nutritional issues in adolescence N2a Nutritional issues in adolescence: Undernutrition N2b Nutritional issues in adolescence: Micronutrient deficiency N2c Nutritional issues in adolescence: Overweight and Obesity N2d Nutritional issues in adolescence: Eating Disorders N3 Nutrition and adolescents: What can we do? SECTION 2.2: Tobacco T1 Tobacco and adolescents: Tobacco kills T1a-b Global Youth Survey 1999-2001 T2 Tobacco and adolescents: Tobacco is addictive T3 Tobacco advertising: Adolescents as targets T4 Industry-sponsored smoking prevention programmes T5 Tobacco and adolescents: What can we do? SECTION 2.3: Mental Health MH1 Adolescents and mental health MH2 Mental health problems MH3 Mental disorders MH4 Mental health and adolescents: What can we do? SECTION 2.4: Sexual and Reproductive Health SRH1 Adolescent sexual and reproductive health SRH1a-b Age at first intercourse; percentage of married adolescents SRH2 Sexual and reproductive health risks vii 1 3 5 6 7 8 9 11 13 16 17 18 19 20 22 24 25 26 28 30 32 33 34 35 36 39 40 41 43 44 46 48 49 50

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SRH2a Sexually transmitted infections SRH2b Prevalence of sexually transmitted infections SRH2c Adolescent pregnancy SRH2d Percent of births to adolescents SRH2e Unsafe abortion SRH3 Adolescent sexual and reproductive health: Economic impact SRH4 Adolescent sexual and reproductive health: What can we do? SECTION 3: Five Guiding Concepts in ADH GC0 The Five Guiding Concepts GC1 Link health and development GC2 Unearth the common roots of health and development problems GC2a Adolescent health and development problems have common underlying factors GC2a1 Gender-based discrimination remains a barrier to health and development GC2a2 Poverty undermines health and development GC2b Adolescent health and development problems have common immediate causes GC3 Promote holistic interventions GC3a Create safe and supportive environments GC3b Provide accurate and timely information GC3c Assist in developing life skills GC3d Provide acceptable health services Gc3d1 Provide acceptable health services GC3d2 Provide acceptable health services GC3d3 Provide acceptable health services: counseling services GC3e Create nurturing societies GC4 Adapt to diverse groups and different needs GC5 Empower adolescents to participate and contribute SECTION 4: Healthy Settings for Adolescents HS1 Promoting the healthy development of adolescents: The Settings Approach HS1a-b Safe environments HS2 Healthy setting: Home HS3 Healthy setting: School HS3a Health-promoting schools HS4 Health setting: Health facilities HS4a Models for adolescent-friendly health facilities

51 51 52 54 55 56 57 59 62 63 64 66 68 70 71 73 75 76 77 78 78 79 80 82 84 85 86 90 91 92 95 96 97 98

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HS5 HS6 HS7 HS8

Healthy Healthy Healthy Healthy

setting: setting: setting: setting:

Workplace Community organizations Streets Media and entertainment

99 100 101 103

SECTION 5: Keys to Success in Adolescent Health and Development Programmes KS1 Address both health and development issues KS2 Recognize roots of problems in adolescent health and development KS3 Promote comprehensive and holistic interventions KS4 Adapt to diverse groups KS5 Empower adolescents

104 105 106 107 108 109

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Message from the Regional Director Adolescents are like butterflies. They go through a transition period that is full of potential, yet fragile. They need nurturing and care, and a safe and supportive environment to grow and develop. Like the colours of the butterfly's wings, adolescents too are "colourful." They have boundless energy, ideas, enthusiasm, ambition and potential. They are important assets and resources; they are our future. There have been great improvements in the status of health and development in the Western Pacific Region. Yet, a lot more effort still needs to be made to protect and promote adolescents' needs and rights. Healthy adolescents have a better chance of becoming healthy, responsible and productive adults. Thus, promoting the healthy development of adolescents is one of the most important investments that any society can make. To do that, we must work together to meet their multiple needs. The WHO Western Pacific Regional Office will continue to work in close collaboration with partners, particularly its Member States and other United Nations agencies, to improve adolescent health and development in the Region. Value adolescents. Invest in the future.

Shigeru Omi, M.D., PhD. Regional Director WHO Regional Office for the Western Pacific

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value

Introduction

adolescents invest in the future

This educational package is designed for the use of individuals, groups, and organizations involved in promoting adolescent health and development among a variety of audiences. The main target users are primary health care givers - doctors, nurses and midwives - who deal with adolescents in various settings, and who wish to involve their colleagues in advocacy work for and with adolescents. This package can also be useful for programme managers and policy-makers advocating adolescent health and development programmes and policies. In whole or in part, this package can be used to structure workshops and discussions on adolescent health and development issues. Ideally, adolescents should be invited to participate in these activities in order to achieve heightened understanding of their needs and concerns. The image of a butterfly emerging from its cocoon is depicted many times in this package. This symbolizes the metamorphosis that takes place as adolescents go through development. This image serves to remind us of the need to nurture adolescents as they go through this challenging phase. The image also foretells what adolescents can be, as they transform into the future of their countries. After viewing the full slide presentation, learners should be able to: 1. Explain the concept of adolescent health and development; 2. Determine factors in their own context or community influencing adolescent health and development; 3. Discuss the following key issues in adolescent health and development: nutrition, tobacco, mental health, sexual and reproductive health; 4. Explain the guiding concepts in creating programmes for adolescent health and development; 5. List holistic interventions in adolescent health and development; 6. Enumerate intervention settings in adolescent health and development; and 7. Analyse keys to success in programming adolescent health and development.

Materials This educational package contains: · A slide presentation on adolescent health and development

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·

A Facilitator's Guide (this handbook) which contains: o o o o o Text to be read or adapted by the facilitator Discussion questions for exploring ideas and encouraging audience participation Activities to enhance learning and provide venues for application Explanations of graphs and charts References on adolescent health and development

Methods: How to use this educational package The slides are grouped into five sections. SECTION SECTION SECTION SECTION SECTION 1: 2: 3: 4: 5: Adolescent Health and Development (ADH) Key Issues in ADH Guiding Concepts in Creating Programmes for ADH ADH in Different Settings Keys to Success in ADH Programmes

The facilitator should choose the slides that suit the learning needs of the audience. Each section has a color code to help the user organize a presentation. Each section is divided into main topics and subtopics Each slide has a core message. Additional information is included in the Guide, allowing the facilitator to adjust the depth and breadth of the presentation according to the needs of the audience. This educational package promotes the use of a variety of techniques to elicit audience participation. Discussion questions have been provided for some slides to encourage participants to situate concepts in their own context. Activities are recommended to enhance learning and provide venues for application. These are guides that the facilitator can use to further enrich the audience's learning experience. Play the short animated segment from the CD-ROM (Click the file: metamorphosis.avi). The animation shows a caterpillar encasing itself in a cocoon and after some time, emerging as a butterfly. Use this visual cue to begin the session. “This animation is a fitting metaphor for our topic today - Adolescent Health and Development. You saw a transformation - from caterpillar to cocoon to butterfly. What does this represent?” “What factors in the environment allow the transformation to happen? What similar factors are important in the health and development of adolescents?” “What circumstances might prevent the caterpillar from maturing into a butterfly? Do similar dangers exist for adolescents?” “If the caterpillar is not able to mature into a butterfly, what does nature stand to lose? In a similar manner, if we are unable to recognize the potentials of adolescents, what does society lose?”

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SECTION 1: Adolescent Health and Development These slides define basic terms and establish the importance of promoting adolescent health and development.

Slide Code Number

Title Promoting Adolescent Health and Development

Core Message Promoting adolescent health and development means realizing the full potential of adolescents by addressing their health and development needs and safeguarding their rights. An adolescent is a person between 10 and 19 years of age. As a group, adolescents comprise from 17% to 20% of the population of countries in the Western Pacific Region. Adolescents are more than an age group, however. They are persons in a transitional phase in life. This time of transition varies across individuals and groups, countries and cultures. One in five persons in the world today are adolescents. During this critical period, adolescents go through rapid development. The process allows them to achieve the following: selfworth, safety, structure, belonging, intimate relationships, feeling of accomplishment, responsibility and autonomy, spirituality. Adolescents must achieve development along several lines: physical, intellectual, vocational, social, cultural, emotional and moral. Adolescents can do this by developing Life Skills. Life Skills are abilities for adaptive and positive behaviour, that enable individuals to deal effectively with the demands and challenges of everyday life.

A1

A2

Who are adolescents?

A2a

Population Pyramid 2000

A3

Adolescence: Outcome of Development

A4

Adolescence: Goals of Development

A4a

Adolescence: Developing Life Skills

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Slide Code Number A4b A4c A4d A4e A4f

Title

Core Message Decision making and problem solving Creative thinking and critical thinking

Adolescence: Developing Life Skills

Effective communication and interpersonal relationship skills Self-awareness and empathy Coping with emotions and stress The reasons why we should invest time and resources in ADH lie in the numbers that show the magnitude of the problem and the cost of inaction. Adolescents’ unmet needs have implications on the future of communities and countries. Healthy and developed adolescents have a better chance of becoming healthy, responsible and productive adults.

A5a

A5b Why invest in adolescents? A5c

Protecting adolescents’ rights and working for their welfare can enable countries to deliver on their commitments under various international agreements such as the Convention on the Rights of the Child. Taking care of the health of adolescents would avert future health costs. Promoting healthy choices and preventing risky behaviour today will yield positive health outcomes in the future.

A5d

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SLIDE A1 Promoting Adolescent Health and Development Core Message Promoting adolescent health and development means realizing the full potential of adolescents by addressing their health and development needs and safeguarding their rights. Notes Adolescent health and development are two overlapping concepts. An adolescent's health is very important in development, as much as development strongly influences health. Health and development issues that are not specifically addressed undermine the adolescent's full potential. To encourage healthy behaviour among adolescents, it is important to provide adequately for their development needs. Promoting psychosocial, emotional, and intellectual development of adolescents minimizes their high-risk behaviors, such as substance abuse, smoking, engaging in unwanted/unsafe sex, or unhealthy eating habits. Adolescents are in a crucial stage of development, "no longer children but not yet adults". Discussion Questions "What comes to your mind upon hearing the phrase "adolescent health and development"?" Suggested Activity Ask the audience to write their response to the question on a piece of paper. You may read aloud what they have written, or display the responses on a board. With the help of the audience, pick out the words that are commonly mentioned and build on these words to present the concept of adolescent health and development. This activity can be an opportunity to correct misconceptions and reinforce positive ideas.

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SLIDE A2 Who are Adolescents? Core Message An adolescent is a person between 10 and 19 years of age, comprising from 17% to 20% of the population of countries in the Western Pacific Region. Adolescents are more than an age group, however. They are persons in a transitional phase in life. It is a time of transition that varies across individuals and groups, countries and cultures. Notes The World Health Organization defines adolescents as persons from 1019 years of age. The term youth covers a slightly older population those aged 15-24 years. Together, adolescents and youth are collectively known as young people, with their ages ranging from 10-24 years. But who are adolescents? Adolescents are more than an age group. They are persons in a transitional phase in life. They are living in a critical time of rapid physical, mental, emotional, social, and spiritual development. It is a time of transition that varies across individuals and groups, countries and cultures.

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SLIDEA2a A2a Population SLIDE Population Pyramid 2000 Pyramid 2000 Core Message Core Message One in five persons in the world today One in five persons in the world today is an adolescent. are adolescents.

Adolescents: 1 in 5 persons in the world today! 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Less developed countries More developed countries Total population estimates for year 2000: 6.15 billion

Total adolescents: 1.2 bi llion

600 550 500 450 400 350 300 250 200 150 100 50

0

50 100 150 200 250 300 350 400 450 500 550 600

Source: UNPOP, 1996

Population distri bution in the world year 2000

Discussion Questions Give the audience some time to look at the graph. Ask the audience to describe the shape of this population pyramid. “What is the difference between the two sides of the pyramid that portray less developed and more developed countries?” “Which bars in this graph represent adolescents?” Describe the adolescent population in relation to total world population. Guide the audience in interpreting the graph: · One fifth of the world’s population are adolescents – that’s around 1.2 billion people. · 85% of adolescents live in developing countries

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SLIDE A3 Adolescence: Outcomes of Development Core Message During this critical period, adolescents go through rapid development. The process allows them to gain self-worth, and to experience safety, structure, belonging, intimate relationships, feelings of accomplishment, responsibility and autonomy, spirituality. Notes The adolescent years bring changes in the physical body - increase in height, weight and sexual maturation. Adolescence is also marked by mental, emotional, social and spiritual development. The outcomes of this development process are the following: · Self-worth - feeling that one is valued for meaningful contributions · Safety - meeting the most basic needs food, clothing, shelter, and protection from hurt, injury or loss. · Structure - being part of organized group structures where they can test social abilities, while at the same time working within boundaries imposed by the group. · Belonging - being accepted in an institution, organization or community outside of family. · Intimate relationships - feeling loved by peers; being involved in lasting relationships. · Feeling of accomplishment - achieving clear goals, and being aware of one's progress in life · Responsibility and autonomy - assuming independence, exercising some control over daily events, and taking responsibility for decisions made. · Spirituality - developing values and standing by one's principles.

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SLIDE A4 Adolescence: Goals of Development Core Message Adolescents must build upon the knowledge and skills they attain within this period to contribute to, and function within their community. They must achieve development along several lines: physical, intellectual, vocational, social, cultural, emotional, and moral. Notes Adolescents are in a crucial period where they must achieve these goals of development: · Physical development - developing and maintaining a healthy lifestyle; acting in ways that ensure physical health for self and others Intellectual development - gaining basic knowledge, numeracy, literacy; practicing higher order thinking skills like analysing, problem-solving, creative self-expression Vocational development - mastering skills and attitudes that are the foundations of economic security; understanding career options and the steps necessary to achieve goals Social development - forming and sustaining friendships and relationships through communication, cooperation, empathizing, negotiation, patience, taking initiative, and taking responsibility for one's own conduct Cultural development - understanding one's own culture, and respecting the culture of others Emotional development - developing and maintaining a sense of well-being, understanding emotions, and adapting to changing circumstances Moral development - understanding and acting upon the distinctions between right and wrong.

·

·

·

· ·

·

They can best attain these development goals by learning Life Skills -abilities for adaptive and positive behaviour, that enable individuals to deal effectively with the demands of everyday life.

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Discussion Questions "Try to remember the time when you were an adolescent. What was your most significant challenge? How did you deal with it?" "How many of you have children who are adolescents? What are their most significant problems? How do they deal with these problems?" Suggested Activity Ask the audience to form small groups of 3 to 5 persons, and give them time to answer the discussion questions. Encourage the formation of groups with a wide diversity of experience - different age groups, gender, rural/urban origins, country. Ask each group to present a 2-minute summary of their discussion. Alternatively, each group can role-play one member's "most significant adolescent challenge." Discuss the presentations. Invite comments from other groups. Use their specific examples to illustrate the eight important outcomes of adolescent development described above.

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SLIDE A4a SLIDES A4b-f Adolescence: Developing Life Skills Core Message Life Skills are abilities for adaptive and positive behaviour, that enable individuals to deal effectively with the demands and challenges of everyday life. Notes There are innumerable life skills, and these vary across cultures and settings. Below is a core set of skills that adolescents can acquire through learning and practice: Decision-making Problem solving Creative thinking Critical thinking Effective communication Interpersonal relationship skills Self-awareness Empathy Coping with emotions Coping with stress The exact content of life skills education programmes must be adapted to local contexts. However, in general terms, these skills are relevant across cultures. Studies have shown that life skills education programmes can be taught in a wide range of health promotion efforts - on topics such as substance abuse, adolescent pregnancy, and sexually transmitted diseases, including AIDS. Life skills contribute to the development of selfefficacy, self-confidence and self-esteem.

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Discussion Questions Consider this definition of Life Skills: Abilities for adaptive and positive behaviour, which enable individuals to deal effectively with the demands of everyday life. The basic Life Skills are self-awareness, empathy, interpersonal relationship skills, communication, critical thinking, creative thinking, decision-making, problem solving, coping with stress, coping with emotions. "What is your strongest Life Skill?" "How did you develop this skill as an adolescent?" "How did this skill carry you through the challenges of later life?" Use the discussion to establish a connection between the attainment of Life Skills, and the achievement of development goals. Here are some examples: · · Problem solving and decision making skills made possible an early entry into a career in sales (vocational development). Communication skills made it easier to participate in school activities and assume leadership in student organizations (social development).

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SLIDE A5a Why Invest in Adolescents? Core Message The reasons why we should invest time and resources in ADH lie in the numbers that show the magnitude of the problem and the cost of inaction. Adolescents’ unmet needs have implications on the future of communities and countries. Notes Adolescence carries the highest risks of morbidity and mortality from certain causes, including accidents and injuries, early pregnancy and sexually transmitted diseases. Furthermore, many lifestyle diseases (caused by smoking, risky sexual behaviour, alcohol and drug dependency, etc.,) have their roots in adolescence. These statistics show us the magnitude of the problem: Of the 300 million adolescents smoking today, 150 million will die of tobacco-related diseases later in life. 25 % of adolescents aged 15-19 in some Western Pacific countries smoke. In some Pacific Island countries children begin chewing tobacco at age 5. 100 000 adolescents die from suicides every year. Girls under 18 are 2 to 5 times more likely to die in childbirth as women in their twenties. About 50% of HIV infection is among people of 15-24 age group.1 One in twenty adolescents and young people contracts STI each year.2 Promoting the healthy development of adolescents now, is one of the most important investments that any society can make.

UNESCO PROAP Regional Clearing House on Population Education and Communication (1998) Handbook for Educating on Adolescent Reproductive and Sexual Health (online) Available from: http://www.unescobkk.org/ips/arh-web/resources/handbooks/ handbook-1.pdf, Accessed February 28,2003. 2 Ibid.

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SLIDE A5b Why Invest in Adolescents? Core Message Healthy adolescents have a better chance of becoming healthy, responsible and productive adults. Notes If we ignore the needs of adolescents then we put both the present and future of our society at risk. In the long term, our society cannot bear the costs of an unhealthy population and an unproductive workforce. Healthy adolescents have a better chance of becoming healthy, responsible and productive adults, leading to greater skills development, fewer days lost to illness, longer working lives and increased productivity and progress.

SLIDE A5c Why Invest in Adolescents? Core Message Protecting adolescents’ rights and working for their welfare can enable countries to deliver on their commitments under various international agreements such as the Convention on the Rights of the Child. Notes Adolescents have basic rights to health and development. These rights are, on their own, important reasons to invest in adolescents. Protecting the rights of adolescents can enable countries to deliver on their commitments under various international agreements. Articles 5, 12, 17, 19, 24 and 29 of the Convention on the Rights of the Child specify the needs of adolescents for safe and supportive environments, information and skills, health services and counseling.

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SLIDE A5d Why Invest in Adolescents? Core Message Taking care of the health of adolescents would avert future health costs. Promoting healthy choices and preventing risky behaviour today will yield positive health outcomes in the futre. Notes Adolescents are in a critical period of change. They need our support for them to realize their full potentials. Most premature deaths and illnesses in adulthood are largely due to risky behaviour formed during adolescence. Healthy behaviour formed during adolescence continues into adulthood, and can be passed on to future generations. We should look into the needs of adolescents because they are a resource, and when empowered they become a force for change. Adolescents have a wealth of energy, ideas, enthusiasm, ambition and potentials. They can contribute to their own health and to the development of their community. Adolescents are the investments of communities and countries. Their welfare is our future. Discussion Questions “Give some examples of adolescent initiatives in your community (school, organization, etc.). Explain how adolescents can be a resource and force for change.” "If we do not care for adolescents today, what are the implications for tomorrow?”

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SECTION 2: Adolescent Health and Development Issues This set of slides focuses on four key issues: - Nutrition - Tobacco - Mental Health - Sexual and Reproductive Health

The facilitator can choose to discuss all four issues, or only one issue in greater depth. The facilitator can begin by asking participants what they know about the key issues based on their experience. Here are some examples: 1. “What have you observed to be the common nutrition problems among adolescents?” 2. “Why do adolescents smoke?” 3. “What are the common emotional and psychological problems you have among adolescents?” 4. “What are the major sexual and reproductive health concerns of adolescents?”

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SECTION 2.1: Adolescent Health and Development Issues - Nutrition Slide Code Number Title Nutrition during adolescence is important for optimal growth and development Core Message Good nutrition during adolescence is essential for survival, physical growth, mental development, performance, productivity, health and well-being. Twenty percent of total growth in height and 50% of adult weight gain occurs during adolescence. Undernutrition, micronutrient deficiencies, overweight and obesity, and eating disorders are important nutritional issues among adolescents that need to be addressed. Poverty is the major cause of undernutrition. Diseases such as intestinal parasitism and tuberculosis also contribute to the problem. For adolescent girls, gender-based discrimination in distribution of, and access to, food within the family can also be a strong factor. Iron and iodine deficiency are common among adolescents in the Region. Their adverse effects include delayed growth spurt, stunted height, delayed or retarded intellectual development, anaemia and increased risks in childbirth. Lifestyle changes related to high-fat diet and low levels of physical activity have resulted in the rising prevalence of overweight and obese adolescents. These increase the risk of developing noncommunicable diseases during adolescence or later in life. Most adolescents are conscious of the changes in their bodies and want to conform to an “ideal” body image. Eating disorders among adolescents are linked to low self-esteem. Adolescence is the ideal time for nutrition education. Improved knowledge about nutrition leads to healthy food choices and eating practices. Knowledge should be further reinforced by interventions that are comprehensive and holistic.

N1

N2

Some nutritional issues in adolescence

N2a

Nutritional issues in adolescence: Undernutrition

N2b

Nutritional issues in adolescence: Micronutrient Deficiency

N2c

Nutritional issues in adolescence: Overweight and Obesity Nutritional issues in adolescence: Eating Disorders

N2d

N3

Nutrition and adolescents: What can we do?

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SLIDE N1 Nutrition during adolescence is important for optimal growth and development Core Message Good nutrition during adolescence is essential for survival, physical growth, mental development, performance, productivity, health and well-being. Twenty percent of total growth in height and 50% of adult weight gain occurs during adolescence. Notes Good nutrition during adolescence is essential for survival, physical growth, mental development, performance, productivity, health and well-being. Twenty percent of total growth in height and 50% of adult weight gain occur during adolescence. Fifty percent of adult bone mass is achieved during adolescence, resulting in a 50% increase in the calcium requirement. Therefore, adequate nutrition during adolescence is important to support optimal growth and development. On the other hand, poor nutrition during adolescence contributes to death and disability, stunted physical growth and mental development, and increased risk of developing chronic diseases.

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SLIDE N2 Nutritional issues in adolescence

Core Message

Undernutrition, micronutrient deficiencies, overweight and obesity, and eating disorders are important nutritional issues among adolescents that need to be addressed. Notes While there is generally an improvement in the nutritional status of children and adolescents in the Western Pacific Region, there are new problems and issues that need to be addressed. The types of nutritional problems affecting adolescents have changed over the past two decades. Undernutrition, wasting and growth stunting are still reported, but these conditions are on the decline. The prevalence of obesity is increasing due to changes in the socio-cultural and economic life of the community, widespread nutrition transitions to lipid-rich diets and a decrease in physical activity. In the more developed countries in the Region, “malnutrition of affluence” is caused by social pressures to achieve a distorted body image. Adolescents are increasingly confronted with the pressure to have a "perfect" body shape and eating disorders 3 result from their need to conform to this body image.

Schneider D. (2000) International trends in adolescent nutrition. Social Science & Medicine, 51(6): 955-967

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SLIDE N2a Nutritional issues in adolescence: Undernutrition

Core Message Poverty is the major cause of undernutrition. Diseases such as intestinal parasitism and tuberculosis also contribute to the problem. For adolescent girls, gender-based discrimination in distribution of, and access to, food within the family can also be a strong factor. Notes Poverty and lack of knowledge about nutritional needs are contributing factors to undernutrition. Diseases such as tuberculosis and intestinal parasitism further aggravate the problem. Gender-based discrimination in some countries contributes significantly to inadequate nutrition among adolescent girls. This has implications not only on adolescent girls but also on the next generation. Improving their nutrition status and delaying their first pregnancy may effectively change the intergenerational cycle of malnutrition. Suggested Activity: Problem Tree Prepare a poster-sized drawing of a tree, with roots, trunk, stems, but no leaves. (The drawing can also be prepared using digital imaging, and projected on a screen.) Give the participants pieces of paper- rectangular and leaf-shaped. The rectangular pieces represent roots or branches. Begin the activity by writing the word POVERTY on a rectangular piece of paper, and posting this in the root area. Then write the word ANEMIA on a leaf-shaped piece of paper and post this among the branches.

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Ask the participants to also write words related to nutritional problems among adolescents, and the underlying causes of these problems. Have them post the pieces of paper on appropriate spaces in the tree, thereby establishing relationships between their key ideas. Discuss the meaning and implications of your problem tree. Note: Here is an example of how to organize participants’ responses in a problem tree. The facilitator can adapt this activity to other nutritional issues discussed in this section.

Stunting, wasting

Micronutrient deficiency

Poor school performance Anemia

Intestinal parasitism Gender discrimination Lack of knowledge Lack of access to food Poverty

Undernutrition

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SLIDE N2b Nutritional issues in adolescence: Micronutrient Deficiency Core Message Iron and iodine deficiency are common among adolescents in the Region. The adverse effects include delayed growth spurt, stunted height, delayed or retarded intellectual development, anaemia and increased risks in childbirth. Notes Iron and iodine deficiency are common in women, children, and adolescents in the Region. The adverse effects include delayed growth spurt, stunted height, delayed or retarded intellectual development, anaemia and increased risks in childbirth. Iodine Deficiency Disorders The term Iodine Deficiency Disorders (IDD) refers to the wide range of 4 serious adverse effects of iodine deficiency, the most well known being visible goitre and cretinism, a condition characterized by severe brain damage occurring very early in life. Less severe states of iodine deficiency are characterized by more subtle degrees of mental impairment, which occur in apparently normal children or adolescents. The consequences are pervasive and include poor school performance, reduced intellectual ability and impaired work capacity. In the Western Pacific Region, 9 countries, Cambodia, China, Fiji, Laos, Malaysia, Mongolia, Papua New Guinea, Philippines and Viet Nam, have IDD as a significant health problem. These countries have formulated national prevention and control programmes. In most countries, legislation on salt iodization is in place. In Malaysia, IDD is a problem in only part of the country. Besides the 9 countries, Australia and New Caledonia have indicated that IDD might be a problem and have taken steps to assess the situation. New Zealand has recently conducted studies and found that mild iodine deficiency was present in school children. Hetzel, B.S. (1983) Iodine deficiency disorders (IDD) and their eradication. Lancet, 2:1126-1127 4

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Iron Deficiency There are many consequences of iron deficiency and iron deficiency anemia in children and adolescents. These include impaired language development and scholastic achievement, psychological and behavioral effects (inattention, fatigue, etc) and decreased physical activity. In pregnant women, the effects of iron deficiency anaemia include increased maternal morbidity and mortality, increased fetal morbidity and mortality, and increased risk of low birth weight. The key factors responsible for iron deficiency include, diet (low levels of iron, low bioavailability), life cycle (pregnancy, rapid growth), disease states (e.g., malaria and hookworm infection), consequences of low economic status (food insecurity, poor environmental sanitation) and genetic causes of anemia (thalassemia major, other 5 haemoglobinopathies).

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UNICEF (1998). Preventing iron deficiency in women and children. Technical consensus on key issues. New York, UNICEF/UNU/WHO/MI Technical Workshop.

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SLIDE N2c Nutritional issues in adolescence: Overweight and Obesity Core Message Lifestyle changes related to highfat diet and low levels of physical activity have resulted in the rising prevalence of overweight and obese adolescents. These increase the risk of developing noncommunicable diseases during adolescence or later in life. Notes The key nutrition issue in the Western Pacific is the increase in overweight and obese adolescents. This is mainly due to lifestyle changes related to high-fat diet and low levels of physical activity, particularly in urban areas and in many Pacific island countries. Overweight and obesity during childhood and adolescence tend to continue into adulthood, increasing the likelihood of a range of health conditions such as cardiovascular disease, diabetes and some cancers. Obesity related symptoms also include psychosocial problems such as poor self-esteem and body image. In China, obesity is found to be associated with high income and urban adolescents. In Viet Nam, research among schoolchildren indicates a prevalence for obesity of around 4 percent. In Pacific Island Countries, social ideals (”big is beautiful”) that favor the oversized, physical inactivity and increasing availability of high-fat processed food, are contributing to obesity in the Region. Some of the highest rates of obesity in the world are found in these countries.

Discussion Questions "Why are high-fat meals appealing to adolescents?" “What factors contribute to low levels of physical activity among adolescents?”

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SLIDE N2d Nutritional issues in adolescence: Eating Disorders Core Message Most adolescents are conscious of the changes in their bodies and want to conform to an "ideal" body image. Eating disorders among adolescents are linked to low self-esteem. Notes Most adolescents are conscious of the changes in their bodies and want to conform to an "ideal" body image. Adolescents feel that being thin makes them more attractive and allows them to have more friends. They try to fit into the trendiest clothes modeled by thin fashion models. They want to be the beautiful people they see in magazines, movies, concerts and TV. They may, therefore, try unhealthy diets and engage in unhealthy eating habits that can lead to eating disorders. Anorexia nervosa is a psychiatric disorder characterized by selfstarvation. Bulimia involves patients gorging themselves with food then vomiting or using laxatives. Both are very rare in the Western Pacific Region but have been observed among young women from various social, economic and ethnic backgrounds. The bottom line is, adolescents are under pressure to conform to an "ideal" body image. An adolescent with low self-esteem is more likely to have eating disorders. Discussion Questions "Describe what your society considers as the "ideal body"?" "How does this perception affect the nutritional choices that adolescents make?”

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SLIDE N3 Nutrition and adolescents: What can we do?

Core Message Adolescence is the ideal time for nutrition education. Improved knowledge about nutrition leads to healthy food choices and eating practices. Knowledge should be further reinforced by interventions that are comprehensive and holistic. Notes Adolescence is the ideal time for nutrition education, as young people are in the process of establishing their health-related behaviours. Adolescents are generally adopting new eating habits that they will carry to adulthood. Schools provide an ideal environment for learning about nutrition, and it is easy enough to include nutrition topics in the school curriculum. However, schools can be an avenue for promoting healthy diets and lifestyles in a more comprehensive way, and it is possible to use schools as a springboard for greater multisectoral involvement through a variety of approaches, such as: - Screening for underweight, overweight and nutrient deficient adolescents - Launching and sustaining healthy school lunch and snack programmes - Inclusion of daily physical activity in school timetables - Launching sports events that promote physical activity - Encouraging different kinds of physical activity/exercise as opposed to more sedentary activities like watching television or playing video games - Teaching skills in healthy food selection and preparation - Popularizing nutrition through student-led media marketing campaigns - Subsidizing meals for low-income students - Involving parents in efforts to improve nutrition at home and in school - Using school grounds to grow fruits and vegetables.

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Such an approach to developing comprehensive programmes of action can be used in a variety of specific settings at home, in community organizations, workplaces, for example. Suggested Activity Form small groups of 3 to 5 persons. Encourage the groups to come up with ideas for projects to improve nutrition among adolescents. At this point, you may refer to Section 5: Keys to Success in ADH Programmes, to guide participants in developing their ideas.

Suggested Readings Delisle, H. (1999), Nutrition in Adolescence: Issues and Challenges for the Health Sector, Geneva, WHO Department of Child and Adolescent Health and Development. World Health Organization (2000), Nutrition for Health and Development: A Global Agenda for Combating Malnutrition Progress Report. Geneva, World Health Organization.

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SECTION 2.2: Adolescent Health and Development Issues - Tobacco

Slide Code Number

Title

Core Message Tobacco use is associated with more than 40 life-threatening diseases, not only among smokers but also among non-smokers. More and more adolescents are being exposed to increased risks of developing cancer and cardiovascular diseases in later life. In some countries in the Region, estimates show that the prevalence of current smokers (those who smoke > 6 cigarettes per day) varies from 3.3% to 21.3%. The age at which smoking starts is getting younger. The earlier adolescents start using tobacco, the more likely they will become addicted, and the less likely they will quit. Tobacco companies target adolescents with misleading images of “power” and “glamour” by sponsoring sports events, star athletes, fashion shows and adventure contests, to attract adolescents to smoke. Tobacco industry sponsored smoking prevention programmes target adolescents with messages such as “Youth should not smoke” and “Smoking is an adult decision”. These approaches are ineffective and may actually encourage an increase in youth smoking.

T1

Tobacco and adolescents: Tobacco kills

T1a T1b

Global Youth Tobacco Survey 1999-2001

T2

Tobacco and adolescents: Tobacco is addictive

T3

Tobacco advertising: Adolescents as targets

T4

Industrysponsored smoking prevention programmes

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Slide Code Number

Title

Core Message A comprehensive and integrated approach to tobacco control is necessary, with the following interventions playing a role: (1) educating adolescents on nicotine addiction and the risks of tobacco use; (2) implementing smoke-free schools, public places, vehicles and homes; (3) banning all forms of advertising and promotions; (4) refusing all offers of support, funding or expert assistance on “youth smoking prevention” offered by the tobacco industry; (5) addressing smoking cessation among all smokers, young and adult; (6) campaigning for an increase in tobacco prices.

T5

Tobacco and adolescents: What can we do?

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SLIDE T1 Tobacco and adolescents: Tobacco kills

Core Message Tobacco use is associated with more than 40 life-threatening diseases, not only among smokers but also among non-smokers. More and more adolescents are being exposed to increased risks of developing cancer and cardiovascular diseases in later life. Notes There are more than 4,000 chemicals in cigarette smoke, 60 of which are known or suspected carcinogens. Examples of toxic substances found in tobacco smoke are acetone, ammonia, arsenic, butane, cadmium, carbon monoxide, DDT, hydrogen cyanide, methanol, naphthalene, toluene, and vinyl chloride. Tobacco use is associated with more than 40 life-threatening diseases. It is the primary risk factor for lung cancer and cardiovascular diseases in later life. Smoking is responsible for 90% of all cases of lung cancer, 75% of chronic bronchitis and emphysema, and 25% of ischaemic heart disease. Tobacco smoke causes diseases and death even among non-smokers. Adolescents who do not smoke, but are exposed to secondhand smoke from parents and peers, are also at risk. Pregnant adolescents who expose the unborn child to tobacco are at increased risk of spontaneous abortion, ectopic pregnancy, abruptio placentae, placenta praevia, premature rupture of membranes and premature birth. The infant may be stillborn or may be small for gestational age. Tobacco-exposed infants may also show birth defects. Children of smokers are more likely to smoke as teenagers. Globally, around 300 million young people smoke. Half of them will die of tobacco-related diseases in later life. While adolescents often do not think much of diseases that may afflict them 30 to 50 years later, it is important to inform them that every cigarette they smoke takes away 7 minutes of their lives.

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Discussion Question Ask the audience: “How does smoking harm you?” Use the list below to point out the many ways tobacco adversely affects health.6 HAIR - Smell and staining BRAIN AND MENTAL EFFECTS - Stroke (cerebrovascular accidents) - Addiction / withdrawal - Altered brain chemistry - Anxiety about harm caused by smoking EYES - Eyes sting, water and blink more - Blindness (macular degeneration) - Cataracts NOSE - Less sense of smell SKIN - Wrinkles, premature ageing TEETH - Discoloration and stains - Plaque - Loose teeth - Gum disease (gingivitis) MOUTH AND THROAT - Cancers of lips, mouth, throat and larynx - Sore throat - Reduced sense of taste - Breath smells of smoke HEART - Harms, blocks and weakens arteries of the heart - Heart attack RESPIRATION AND LUNGS - Lung cancer - Cough and sputum, shortness of breath - colds and flu, pneumonia, asthma - Chronic obstructive pulmonary disease and emphysema - Complicates tuberculosis CHEST - Cancer of oesophagus LIVER - Cancer Mackay, J, Erickson, M, (2003) The Tobacco Atlas (online) Available from: http://www.who.int/tobacco/en/atlas9.pdf, Accessed July 18, 2003. 6

ABDOMEN - Stomach and duodenal ulcers - Cancer of stomach, pancreas, colon - Aortic aneurysm KIDNEYS and BLADDER - Cancer BONES - Osteoporosis - Spine and hip fractures MALE REPRODUCTION - Sperm: deformity, loss of motility, reduced number - Infertility - Impotence FEMALE REPRODUCTION - Period pains - Earlier menopause - Cancer of cervix - Infertility and delay in conception WOUNDS AND SURGERY - Wounds take longer to heal - Operation wounds take longer to heal - Longer to recuperate from surgery DIABETES MELLITUS - Complications of Type 2 Diabetes (old names: Noninsulin dependent diabetes mellitus, adult-onset diabetes) LEGS AND FEET - Increased leg pain and gangrene: peripheral vascular disease - Buerger’s Disease BLOOD - Leukaemia BURNS - From fires caused by tobacco IMMUNE SYSTEM - Weakened

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SLIDE T1a-b Global Youth Tobacco Survey 1999-2001 Core Message In some countries in the Region, estimates show that the prevalence of current smokers (those who smoke > 6 cigarettes per day) varies from 3.3% to 21.3%.7

Discussion Questions Ask the audience to view the tables in T1a and T1b. "What is the prevalence of youth smoking in your/our country?" “What is the magnitude of the youth smoking problem in the adolescent community you work with?” Prevalence percentage of students age 13-15 years who used tobacco: Global Youth Tobacco Survey 1999-2001 All students Country Ever smoked cigarettes, even one or two puffs Currently use any tobacco product Currently smoke cigarettes Currently use other tobacco products Ever smokers, smoked first cigarette before age 10 39.2 37.7 20.5 27.3 21.6 31.0 (5.1) (4.9) (7.7) (3.8) (5.0) (4.4) Current smokers, smoke > 6 cigarettes per day

China Changqing 1999 30.1 (3.8) 14.6 (2.3) 6.3 Guangdong 1999 21.6 (1.7) 10.3 (1.2) 4.5 Shandong 1999 16.2 (4.0) 8.6 (1.7) 2.4 Tianjin 1999 21.6 (2.5) 9.7 (1.7) 5.7 Fiji 1999 32.8 (5.6) 15.1 (3.8) 10.4 Northern Marianas 79.8 (6.4) 62.4 (5.5) 39.2 Islands 2000 Palau 2000 61.4 (4.6) 58.5 (3.6) 21.6 Philippines 2000 39.0 (3.3) 23.3 (2.4) 18.2 Singapore 2000 21.5 (1.4) 9.1 (1.1) 9.1 ( )Data presented as 95% confidence intervals (SE*1.96) NA, Not available, question was not asked

(1.5) (1.0) (0.9) (1.6) (3.4) (4.9) (3.5) (2.5) (1.1)

9.6 6.7 6.9 4.9 7.9 52.7

(1.4) (1.0) (1.6) (1.1) (2.2) (4.7)

7.1 19.4 3.3 10.8 6.8 16.0

(3.4) (9.6) (3.6) (7.7) (5.8) (4.5)

53.5 (3.5) 11.1 (1.2) NA

31.9 (6.1) 14.1 (3.0) 22.7 (1.8)

7.2 (4.4) 6.5 (2.4) 21.3 (2.8)

The Global Youth Tobacco Survey Collaboration Group (2002) Tobacco use among youth: a cross country comparison. Tobacco control 11:252-270.

7

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SLIDE T2 Tobacco and Adolescents: Tobacco is addictive Core Message The age at which smoking starts is getting younger. The earlier adolescents start using tobacco, the more likely they will become addicted, and the less likely they will quit. Notes A quarter of all adolescent males have already started to smoke. In some countries, more than half of all young people report having tried smoking and/or chewing tobacco. The age at which smoking starts is getting younger; some begin smoking as early as 10 years old. The earlier adolescents start using tobacco, the more likely they will get addicted, and the less likely they will quit. Cigarettes contain the addictive substance nicotine. The smoking habit results from the need to maintain nicotine levels in the blood. Psychological, social, and physiologic components of addiction are interrelated and often intertwined. Discussion Questions How many of you tried smoking during your adolescent years? What made you start? What prevented you from trying it? How many of you currently smoke? What is your main reason for smoking? How many of you have quit smoking? What made you give up the habit?

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SLIDE T3 Tobacco and Adolescents: Adolescents as targets Core Message Tobacco companies target adolescents with misleading images of "power" and "glamour" by sponsoring sporting events, star athletes, fashion shows and adventure contests, to attract adolescents to smoke. Notes The tobacco industry utilizes an array of strategies to promote its deadly product. There is an attempt to portray cigarettes as "attractive," "trendy," "masculine/feminine," "non-conformist," "fun" and "modern." Tobacco companies sponsor movies, concerts, fashion shows and sports events that cater to a young market, thereby associating smoking with images of attractive role models in the world of sports, music, film and fashion. This reinforces the tendency of adolescents to emulate smoking behaviour in their search for an attractive and glamorous perception of self.

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SLIDE T4 Industry Sponsored smoking prevention programmes Core Message Tobacco industry sponsored smoking prevention programmes target adolescents with messages such as "Youth should not smoke" and "Smoking is an adult decision". These approaches are ineffective and may actually encourage an increase in youth smoking. Notes Tobacco industries are aggressively promoting their "Youth Smoking Prevention" programmes within the Western Pacific Region. This campaign projects smoking as an "adult choice" and therefore "youth should not smoke." These messages may actually encourage an increase in smoking since adolescents aspire to adulthood. These messages also play up the rebellious nature of adolescents who want to be "grown up" and able to make their own choices.

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SLIDE T5 Tobacco and adolescents: What can we do? Core Message A comprehensive and integrated approach to tobacco control is necessary, with the following interventions playing a role: · Educating adolescents on nicotine addiction and the risks of tobacco use · Implementing smoke-free schools, public places, vehicles and homes · Banning all forms of advertising and promotions · Refusing all offers of support, funding or expert assistance on "youth smoking prevention" offered by the tobacco industry · Addressing smoking cessation among all smokers, young and adult · Campaigning for an increase in tobacco prices Notes Start by knowing the evidence on what works and what doesn't work to protect young people from tobacco. Evaluate your existing programme against a set of parameters that will distinguish more from less effective interventions. Adolescents should be educated on nicotine addiction and the risks of tobacco use. Create "safe environments" for adolescents that are tobacco-free. Tobacco advertising and promotions targeting young people should be banned. At the same time, positive role models should be brought forward for adolescents to emulate. Families, teachers, peers and health services can be tapped to assist adolescents in smoking cessation. Adolescents and their advocates must campaign for increases in tobacco prices via taxation and other means. "The most effective way to deter children form taking up smoking is to increase taxes on tobacco." World Bank, 1999

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It is important to remember that the tobacco industry offers funding support, assistance, and/or expert consultations to help schools and organizations design and implement tobacco control programmes. Turn down these offers and require all prospective donors to disclose possible links with the tobacco industry. A comprehensive and integrated approach to tobacco control is necessary to make sure that adolescents don't smoke. Suggested Activity Form small groups of 3 to 5 persons. Encourage the groups to come up with ideas for projects to address the problem of smoking among adolescents. Here ! ! ! ! ! ! are some examples of projects: Smoke-free schools School-wide media-marketing campaign (e.g., Posters) "No to Tobacco" peer counseling Classroom workshops and supplementary subject matter activities No cigarette sales in school canteens Parental involvement in creating smoke-free homes

At this point, you may refer to Section 5: Keys to Success in ADH Programmes, to guide participants in refining their ideas. Suggested Readings World Bank (1999) Development in Practice: Curbing the Epidemic; Governments and the Economics of Tobacco Control, USA. World Health Organization (1998) Adolescent Health and Development Programme, Family and Reproductive Health, The Second Decade: Improving Adolescent Health and Development, Geneva.

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Further Activity Evaluate your programme on youth smoking prevention by doing this quick test: YES or NO: ! Does it clearly mention that youth smoking prevention ! ! ! ! interventions should be framed within a comprehensive tobacco control programme? Does it support cigarette price increase through taxation? Does it support total advertising bans? Does it deal directly with nicotine addiction as a major cause for compelling people to continue smoking? Does it talk about the risks associated with smoking?

If you answered "NO" to any of these, and… YES or NO: ! Does it advocate any of the following messages: "Youth should not smoke" "Smoking is an adult decision" "Only adults should smoke" "It's the law: obey the law" "Just say no" Does it stress peer pressure as the most important reason for teen smoking without acknowledging the role of environmental cues, especially from advertising and promotions? Does it emphasize restricting access by youth to tobacco products through the use of ID cards, signs prohibiting sales to minors, policies to raise the age limit for tobacco sales and "voluntary cooperation" of tobacco retailers? Does it involve a "partnership" between the tobacco industry and government, educators' groups, parents' groups or civic institutions? Is the tobacco industry promoting the programme as part of its "responsible marketing" policy?

! !

! !

If you answered "YES" to any of these… Then the "Youth Smoking Prevention Programme” you are considering is likely to be ineffective. Rather than protecting youth from tobacco, it may actually encourage an increase in youth smoking.

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SECTION 2.3: Adolescent Health and Development Issues - Mental Health

Slide Code Number

Title

Core Message Adolescents need good mental health to experience normal emotional and mental development, to develop their potential, to have fulfilling relationships, and to deal with the challenges of everyday life. Adolescents living in extreme poverty, exposed to violence or abuse, rapid social change and school pressure can experience mental health problems, which include emotional, behavioural, thinking/studying, and identity problems. Mental disorders are not uncommon among adolescents, but are often unrecognized and untreated. Globally, each year, 4 million adolescents attempt to take their own lives. At least 100 000 die in these attempts. Some common mental disorders are depression, anxiety, substance abuse, psychosis and eating disorders. Mental health promotion has the potential to improve the overall development of adolescents and reduce the impact of risk factors for mental health problems and disorders.

MH1

Adolescents and mental health

MH2

Mental health problems

MH3

Mental disorders

MH4

Mental health and adolescents: What can we do?

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SLIDE MH1 Adolescents and mental health

Core Message Adolescents need good mental health to experience normal emotional and mental development, to develop their potential, to have fulfilling relationships, and to deal with the challenges of everyday life. Notes The World Health Organization (WHO) defines mental health as a state of emotional and social well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively or fruitfully, and is able to make a contribution to his or her community. This definition clearly implies that mental health is fundamental to a healthy life. Adolescents need good mental health to experience normal emotional and mental development, to develop their potential, to have fulfilling relationships with other people, and to deal with the challenges of everyday life. Majority of adolescents experience normal emotional and mental development, and they have a good sense of well-being. Still, adolescents may develop mental health problems and disorders that are more than just the "ups and downs" of what is considered "normal".

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SLIDE MH2 problems

Mental health

Core Message Adolescents living in extreme poverty, exposed to violence or abuse, rapid social change and school pressure can experience mental health problems, which include emotional, behavioral, thinking/studying and identity problems. Notes There are large numbers of adolescents who are less able to cope with anxieties brought about by rapid changes in themselves and their immediate environment, resulting in mental health problems. Specific groups of adolescents at higher risk are those who live in extreme poverty, who have survived violence or abuse, those experiencing family problems, or are under extreme pressure to do well in school, and those experiencing rapid social change such as urbanization. Mental health problems include: ! Emotional problems such as sadness (or grief), anxieties (or worries), anger or stress. Stress arises from having to cope with rapid physical, psychological, social and sexual changes. Adolescents also face new challenges as they are expected to assume more responsibility and achieve greater independence. Behavioural problems are manifested as risky behaviour (unsafe sex, hazardous/drunk driving, smoking), self-harm, disruptive behaviour, physical inactivity, educational failure and school dropout. Behavioural problems also include aggressive behaviour towards parents, teachers, siblings, and peers. These types of behaviours are expressed either individually or in a group. Thinking and studying problems arise from lack of skills in critical thinking, creative thinking, decision making and problem-solving. As a result, some adolescents are unable to make objective judgments about choices and risk. They have

!

!

41

difficulties generating new ideas, making difficult decisions and finding solutions to difficult problems. Academic difficulties often arise from inordinate pressures placed on adolescents to do well in school. These pressures can cause headaches, eyestrain, difficulties concentrating and sleep problems. Adolescents who are not able to show academic achievements can become frustrated, and feel inadequate. They may also be less confident in relating with their peers. ! Identity problems can arise as adolescents struggle to define their individuality and sexuality, even as they hope to conform and "belong" with their peers. Adolescents need to develop self-awareness - recognition of self, character, strengths and weaknesses, desires and dislikes. Adolescents need to understand their uniqueness as a person.

Discussion Question "What are some examples of social pressures on adolescents in your community that can cause mental health problems?" "What are some examples of protective factors that can prevent the development of mental health problems?" Suggested Activity Divide the audience into four groups. Ask each group to focus on one type of mental health problem (emotional, behavioural, thinking/studying, or identity problems) they encounter in their community. Discuss the following questions then have each group present their discussion outputs to the audience. Alternatively, the group may role-play the problem they are describing. ! ! ! ! What are the major causes of this mental health problem? How is the problem manifested by adolescents? What kind of support do adolescents get when they experience these problems? Are these support systems adequate? If not, how can these be improved?

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SLIDE MH3 Mental disorders Core Message Mental disorders are not uncommon among adolescents, but are often unrecognized and untreated. Globally, each year, 4 million adolescents attempt to take their own lives. At least 100 000 die in these attempts. Some common mental disorders are depression, anxiety, substance abuse, psychosis and eating disorders. Notes When mental health problems go on for long periods of time and interfere with an adolescent's cognitive, emotional or social abilities, these are called mental disorders. Some common mental disorders among adolescents are depression, anxiety and substance abuse. Psychosis and eating disorders may also affect adolescents. Often, mental disorders are not recognized and go untreated. Mental illness and associated disorders in adolescents are associated with high-risk behavior that can be destructive to themselves and others: academic failure, substance abuse, eating disorders, physical inactivity, sexual promiscuity, disruptive behavior and suicide. Mental illness and associated disorders are linked to 90 percent of all suicides. Globally, each year, four million adolescents attempt to take their own lives and at least 100 000 adolescents die in these attempts (http://www.who.int/child-adolescent-health/OVERVIEW/AHD/ Adh_sheer.htm).

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SLIDE MH4 Mental health and adolescents: What can we do? Core Message Mental health promotion has the potential to improve the overall development of adolescents and reduce the impact of risk factors for mental health problems and disorders. Notes It is important to have an integrated approach to promoting mental health, which include: ! ! ! ! Encouraging positive, caring and supportive relationships between adolescents and their families, peers and other adults; Providing safe and nurturing environments; Developing life skills such as communication, decision making, negotiation, critical thinking, and stress management; and Ensuring access to education and training opportunities to enhance their abilities and employment opportunities.

Adolescents must have access to quality mental health services. If adolescents can easily access services that are sensitive to their needs, then many of these mental health problems and disorders can be dealt with at an early stage. Cooperation with different sectors in society is also important. Many factors that contribute to the development of mental health problems require interventions at the community and country level, involving various groups and sectors. Mental health promotion is also a key strategy. Assist adolescents in developing life skills: social, interpersonal, cognitive and emotional coping skills that will enable them to deal effectively with the demands and challenges of everyday life. Mental health can be promoted in various settings: schools, community centers, and the workplace. These efforts can be built into existing organizational structures that can reach adolescents.

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Suggested Activity Form small groups of 3 to 5 persons. Encourage the groups to come up with ideas for projects to address the problem of mental health among adolescents. Here are some examples of projects: Peer counseling Classroom workshops and supplementary subject matter activities to enhance life skills Workshops for parents and teachers on adolescents and mental health

At this point, you may refer to Section 5: Keys to Success in ADH Programmes, to guide participants in developing their ideas.

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SECTION 2.4: Adolescent Health and Development Issues - Sexual and Reproductive Health

Slide Code Number

Title Adolescent sexual and reproductive health

Core Message Sexual exploration and expression during adolescence are common and normal. Attitudes toward sexuality are changing rapidly. Unwanted and unprotected sex can have lifelong health and economic consequences. Within the Western Pacific Region, data from selected countries show that average age at first intercourse ranges from 14 to 18. The percentage of married females 15 to 19 years of age ranges from 1% to 19%. The percentage of 15 to 19 year olds who have given birth by age 20 varies from 2% to 22%. Adolescents are at high risk for sexual and reproductive health problems, such as sexually transmitted infections (STIs), including HIV, unwanted pregnancies and abortions done in dangerous circumstances. Both adolescent boys and girls are at risk of contracting STIs. However, for adolescent girls, untreated STIs can lead to cervical cancer, pelvic inflammatory disease, ectopic pregnancy, infertility, and increased risk of HIV infection and mother to child transmission.

SRH1

SRH1a

Age at first intercourse; percentage of married adolescents Percentage of adolescents who have given birth

SRH1b

SRH2

Sexual and reproductive health risks

SRH2a

Sexually transmitted infections

SRH2b

Prevalence of sexually transmitted infections

Young people have the highest infection rates of STIs.

SRH2c

Adolescent pregnancy

Adolescent pregnancy puts both mother and child at higher risk for morbidity and mortality. Pregnant adolescents are more likely to experience difficult labor, which can lead to injury for both mother and child.

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Slide Code Number SRH2d

Title Percent of births to adolescents

Core Message The percent of births to adolescents in selected countries in the Western Pacific Region ranges from 6.1% to 13.3%. There are adolescent girls who seek abortions for unwanted pregnancies, often late in pregnancy and in dangerous circumstances. Unsafe abortions can result in complications, such as haemorrhage, septicemia, injuries, infertility and death. An abortion may also have psychological consequences, such as depression. The los of young people to maternal mortality and AIDS leads to a reduction in productive years of life, and a decline in national productivity. Adolescent pregnancy and motherhood significantly limit adolescent girls’ educational and economic opportunities, thus reducing their productivity and contribution to the economy. Complicated pregnancies, STIs and HIV-related morbidity increase expenditure on health care. Promoting sexual and reproductive health of adolescents requires a variety of responses: providing adolescents with information, developing life skills, making comprehensive promotive, preventive and curative services available, and creating a supportive environment that advocates sexual and reproductive health.

SRH2e

Unsafe abortion

SRH3

Adolescent sexual and reproductive health: Economic impact

SRH4

Adolescent sexual and reproductive health: What can we do?

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SLIDE SRH1 Adolescent sexual health and development Core Message Sexual exploration and expression during adolescence are common and normal. Attitudes toward sexuality are changing rapidly. Unwanted and unprotected sex can have lifelong health and economic consequences Discussion Questions Introduce the topic with a general question such as: "Compare this generation of adolescents with the older generation. What are the main differences in their attitudes toward sexuality?" Notes During adolescence, sexual exploration and expression are common and normal. Sexual relationships may begin in adolescence either within or outside marriage. Attitudes of young adults toward sexuality are changing rapidly worldwide, without exception in the Western Pacific Region. Cultural factors, peer group pressure, the breakdown of traditional family structures, migration and urbanization are some of the social factors that increase the desire and opportunity for sexual activity. Images from mass media also play a significant role, as film, television, and music show explicit sexual dialogue, lyrics and behaviour. All these contribute to how adolescents perceive sexual and reproductive issues. As a result of these changing sexual behaviours, adolescents face several public health risks: sexually transmitted infections including HIV, unwanted pregnancies, abortions done in dangerous circumstances, and mental health problems.

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SLIDE SRH1a-b Age at first intercourse; percentage of married adolescents; percentage of adolescents who have given birth Core Message ! In the Philippines, average age at first intercourse is 18; in Malaysia, between 15 to 18; in Mongolia, 14 years. A recent survey among high school students in New Zealand revealed that 12% of the group had first sex at 12 years or younger.

!

Among the 15 to 19 age group, the percentage of married females ranges from 19% in Papua New Guinea to a mere 1% in Australia, Japan, Republic of Korea, and Singapore. The percentage of 15 to 19 year olds who have given birth by age 20 varies greatly among countries in the Region 2% in Japan, 8% in China, 19% in Viet Nam, 21% in the Philippines and 22% in Mongolia.

!

Suggested Activity Ask the audience to form small groups of five. Have them discuss the following questions: ! ! What are some common misconceptions that adolescents have about fertility and sexual and reproductive health? How do adolescents normally find out about sexual and reproductive health? What / who are their sources of information? How do you promote fertility awareness among the adolescents you work with?

!

Have the groups present their discussion outputs to the rest of the audience. The facilitator can encourage them to make a creative presentation through artwork or role-play.

49

SLIDE SRH 2 Sexual and reproductive health risks Core Message Adolescents are at high risk for sexual and reproductive health problems, such as sexually transmitted infections (STIs), including HIV, unwanted pregnancies and abortions done in dangerous circumstances. Notes Sexual and reproductive health are key issues to adolescent health and development because the health risks they bring are life threatening: ! ! ! Adolescent pregnancy puts both mother and child at high risk of morbidity and mortality. Unsafe abortion often results in complications such as haemorrhages, septicaemia, injuries, infertility and even death. Sexually transmitted infections (STIs) can lead to cervical cancer, pelvic inflammatory diseases, and ectopic pregnancy, among others. HIV infection results in death.

!

Discussion Questions Encourage participants to answer these questions in a holistic way, mindful of physical, psychological, cognitive, emotional, social, and economic factors. "In what ways are adolescents vulnerable to STIs and their consequences?" "Why should adolescent pregnancy be a priority public health concern?" (These questions will be answered in subsequent slides.)

50

SLIDE SRH2a-b Sexually transmitted infections (STIs) Core Messages Both adolescent boys and girls are at risk of contracting STIs. However, for adolescent girls, untreated STIs can lead to cervical cancer, pelvic inflammatory disease, ectopic pregnancy, infertility and increased risk of HIV infection and mother to child transmission. Young people have the highest infection rates of STIs. Notes Both adolescent boys and girls are at risk of contracting STIs. However, adolescent girls are more susceptible because of immature defense mechanisms (inadequate mucosal secretion, immature lining of the cervix, thin lining and low acidity of the vagina). For adolescent girls, STIs, if untreated, can lead to cervical cancer, pelvic inflammatory disease, ectopic pregnancy, infertility and increased risk of HIV infection and mother to child transmission. · · · Young people ages 15 to 24 have the highest infection rates of STIs. About half of the 35 million new cases of STIs each year occur among young people (10-24 years). Around 7000 young people (10-24 years) are infected with HIV daily.

Within the context of a supportive environment, adults should be able to explain safe sex to adolescents. Health services should introduce sexually active adolescents to the use of condoms.

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SLIDE SRH 2c Adolescent pregnancy Core Message Adolescent pregnancy puts both mother and child at higher risk for morbidity and mortality. Pregnant adolescents are more likely to experience difficult labor, which can lead to injury for both mother and child. Notes Adolescent pregnancy puts both mother and child at higher risk for morbidity and mortality. Lack of physical maturity of the pelvis can lead to obstructed or prolonged labor, which in turn can lead to complications such as haemorrhage and even death for both mother and child. The risk of dying among pregnant women aged 15 to 19 is double that of women in their 20s. Young adolescent girls, those under 15 years, are also more likely to experience premature labour, spontaneous abortion and stillbirths than older adolescents and women. Pregnancy-related illnesses, such as hypertension and anaemia, are also more common among adolescents than among adult women. Children of adolescent mothers have a higher risk of being low-birth weight, which predispose them to higher infant morbidity and mortality. In many countries, the risk of death in the first year of life is 1.5 times higher for babies born to women under age 20, than for those born to women aged 20 to 29. Young mothers also lack resources for, and knowledge about, child rearing. As a result, their children are unlikely to receive adequate care.

52

Suggested Activity Form small groups of 3 to 5 persons and ask them the following questions: Would you hand out condoms as part of an educational campaign on fertility and reproductive health? Would you prescribe oral contraceptive pills to an adolescent without parental consent? Participants should approach their answers from different perspectives, mindful that social, cultural, religious and political issues greatly influence the conduct of reproductive health campaigns. In general, health service personnel should weigh their responsibility to meet the needs of adolescents, against their responsibility to inform guardians/parents of the adolescents' needs. At the same time, adolescents need to receive advise about safer sex practices, how to avoid risky circumstances, and the need to seek adult support when they find themselves in situations they cannot handle alone. 8

Bennet, D. and Kang, M. (2001) Adolescence. In: Oates, K., Currow, K., Hu, W ., Cameron, I., Ed. Child health: A practice manual for general practitioners. Sydney, MaclennanPetty.

8

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SLIDE SRH2d Percent of births to adolescents Core Message The percent of births to adolescents in selected countries in the Western Pacific Region ranges from 6.1% to 13.3%

Percent of births to adolescents (15-19 years) 9 in selected countries in the Western Pacific Region Vietnam Samoa Philippines Mongolia Laos Fiji Discussion Question “What are the factors that lead to adolescent pregnancy?” 6.1% 7.6% 7.7% 11.9% 13.3% 12.2%

9

Population Data Sheet (2001). Bangkok, United Nations Economic and Social Commission for Asia and the Pacific.

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SLIDE SRH2e Unsafe abortion Core Message There are adolescent girls who do seek abortions for unwanted pregnancies, often in late pregnancy and in dangerous circumstances. Unsafe abortions can result in complications, such as haemorrhage, septicaemia, injuries, infertility and death. An abortion may also have psychological consequences, such as depression. Notes Globally, an estimated 4.4 million 15-19 year olds undergo unsafe, illegal abortions performed by unskilled practitioners. In the Western Pacific Region, data on adolescent abortion are scarce. However, despite cultural restrictions, adolescent girls do seek abortions for unwanted pregnancies, often in late pregnancy and in dangerous circumstances. Unsafe abortions can result in complications, such as haemorrhage, septicaemia, injuries, infertility and death. An abortion may also have psychological consequences, such as depression.

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SLIDE SRH3 Adolescent sexual and reproductive health: Economic impact

Core Message The loss of young people to maternal mortality and AIDS leads to a reduction in productive years of life, and a decline in national productivity. Adolescent pregnancy and motherhood significantly limit adolescent girls' educational and economic opportunities, thus reducing their productivity and contribution to the economy. Complicated pregnancies, STIs and HIV-related morbidity increase expenditure on health care.

Notes Pregnancy- and STI/HIV-related morbidity increase expenditure on health care. Children born to adolescent mothers are at higher risk of morbidity, thus would require more medical care. Loss of young people to maternal mortality and AIDS leads to a reduction in productive years of life, labour force and a decline in national productivity. Adolescent pregnancy and motherhood significantly limit adolescent girls' educational and economic opportunities; thus making it difficult for them to realize their full potential.

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SLIDE SRH4 Adolescent sexual and reproductive health: What can we do?

Core Message Promoting the sexual and reproductive health of adolescents requires a variety of responses: providing adolescents with information, developing life skills, making available comprehensive promotive, preventive and curative health services, and creating a supportive environment that advocates sexual and reproductive health. Notes Promoting the sexual and reproductive health of adolescents requires a variety of responses. The main responses include: · Providing adolescents with information about their bodies, sexuality, reproduction, consequences of sexual behaviour, use of contraceptives, family planning, and safe sex. Developing their self-esteem, decision making and negotiating skills to help them make better choices, and thereby prevent early pregnancy, unsafe abortion, sexually transmitted infections and sexual abuse and violence. Making health services available and accessible to adolescents. These services should have adolescent-friendly and non-judgmental service providers. These should be accessible, and have opening/closing hours that consider the needs of adolescents. Health services must also be able to provide adolescents with condoms and oral contraceptive pills, if indicated. Personnel should be able to explain the pros and cons of different contraceptive methods. Creating supportive environments that will allow adolescents to ask questions about sexual and reproductive

·

·

·

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health, where adults respond openly to their reactions, and are non-judgmental without condoning risky behavior. · Enhancing multisectoral cooperation in promoting adolescent sexual and reproductive health. Programmes should take into account the needs of the whole person and their relationships with partners, rather than to focus on a specific condition such as pregnancy or STI. Integrating sexual and reproductive health education and life skills development into the school curriculum.

·

Suggested Activity Form small groups of 3 to 5 persons. Encourage the groups to come up with ideas for projects to address sexual and reproductive health issues among adolescents. Here are some examples of projects: ! ! ! ! Peer counseling Classroom workshops and supplementary subject matter activities on sexual and reproductive health Telephone hotline Parental involvement in promoting adolescent sexual and reproductive health

At this point, you may refer to Section 5: Keys to Success in ADH Programmes, to guide participants in developing their ideas. Suggested Readings Bennet, D. and Kang, M. (2001) "Adolescence" in Child Health: A Practice Manual for General Practitioners, Oates, K., Currow, K., Hu, W., Cameron, I., (eds.), MaclennanPetty, Sydney. Visit the website of the United Nations International Conference on Population and Development (ICPD) http://www.fpa.org/icpd Note the ICPD Programme of Action Paragraph 7.46: Countries, with the support of the international community, should protect and promote the rights of adolescents to reproductive health education, information and care. Refer to http://www.fhi.org for a more detailed presentation on adolescent sexual and reproductive health. The site was developed by Family Health International.

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SECTION 3: Five Guiding Concepts in ADH This set of slides presents Five Guiding Concepts that can aid in planning and evaluating programmes for adolescent health and development.

Slide Code Number

Title

Core Message In promoting adolescent health and development: 1. Link health and development 2. Unearth the common roots of health and development problems 3. Promote holistic interventions 4. Adapt to diverse groups and different needs 5. Empower adolescents to participate and contribute A combination of health and development targets is needed to ensure that adolescents have the necessary competencies, knowledge, opportunities, and support to choose health and improve their well-being.

GC0

The Five Guiding Concepts

GC1

1. Link health and development

GC2

2. Unearth the common roots of health and development problems Adolescent health and development problems have common underlying factors Gender-based discrimination remains a barrier to health and development

Adolescent health and development problems have common roots. These roots must be targeted directly, in order to address all other problems connected to them.

GC2a

Underlying factors, such as genderbased discrimination, poverty, and rapid social changes are fundamental causes of adolescent health and development problems. Gender-based discrimination is a barrier to the ability of adolescents, particularly adolescent girls, to exercise their right to develop their capacities and to have access to services and opportunities.

GC2a1

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Slide Code Number

Title Poverty undermines health and development

Core Message Poverty undermines the right of adolescents to grow up in safe, stable, and nurturing environments. Poverty is a critical barrier to accessing education, healthy diets, health care and good employment. ADH programmes should target directly the immediate causes of adolescent health development problems. These include inadequate education and skills, poor access to health information and services, unsafe and unsupportive environments, exploitation and abuse. If health and development problems have common roots, then these can be addressed most effectively by combined interventions. Adolescents need an environment that protects them from excessive stress, abuse and violence (or the fear of violence); provides positive, close relationships with family, adults and peers; and gives them opportunities to reach their full potential. Adolescents need accurate information that will help them understand their own process of development, risks to health, requirements for health, and available services. Adolescents need to develop social and interpersonal skills, cognitive skills and emotional coping skills to deal with the demands and challenges of life. Adolescents need comprehensive promotive, preventive and curative health services that are adolescentfriendly, guarantee confidentiality, and are staffed by nonjudgmental service providers with good counseling skills.

GC2a2

GC2b

Adolescent health and development problems have common immediate causes

GC3

3. Promote holistic interventions

GC3a

Create safe and supportive environments

GC3b

Provide accurate and timely information

GC3c

Assist in developing life skills

GC3d

Provide acceptable health services

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Slide Code Number

Title

Core Message Services should include growth and development monitoring, assessment of health problems or risky behaviour, counseling, health education, and access to vaccinations, nutritional supplements and contraceptives. Prompt diagnosis and management of health problems should be provided, with referral to the next level of service delivery, if indicated. Adolescents do not have the naivety of children nor the awareness of adults. Counseling sessions take more time and must be conducted with sensitivity. Counseling helps adolescents understand and manage challenges experienced during adolescence, and to support them in their decisionmaking. Health-enhancing behaviour and outcomes are primarily the responsibility of adolescents themselves. However, the knowledge, skills, and opportunities they need to develop and to make healthy choices are influenced by the larger social, political, economic and cultural context in which they grow and change. Adolescents are a diverse group, and while they have a common need for education, life skills development, health services and livelihood skills, interventions should address specific needs of specific groups. Meaningful participation can only happen when adolescents are empowered with necessary life skills, and given opportunities to express their needs, and make healthy decisions for themselves.

Gc3d1

Provide acceptable health services

Gc3d2

GC3e

Create nurturing societies

GC4

4. Adapt to diverse groups and different needs 5. Empower adolescents to participate and contribute

GC5

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SLIDE GC0 The Five Guiding Concepts

Core Message In promoting adolescent health and development: 1. Link health and development 2. Unearth the common roots of health and development problems 3. Promote holistic interventions 4. Adapt to diverse groups and different needs 5. Empower adolescents to participate and contribute Notes Adolescence is a time of rapid development: physical emotional, intellectual, social, moral, spiritual, and aesthetic development. This is a period when they need safe and nurturing environments to promote behaviours that foster health and development. An understanding of these five guiding concepts will aid in promoting adolescent health and development. These concepts must be taken into consideration when planning programmes for adolescents.

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SLIDE GC1 Link Health and Development Core Message A combination of health and development targets are needed to ensure that adolescents have the necessary competencies, knowledge, opportunities, and support to choose health and improve their well-being. Notes Promoting healthy adolescent development and preventing/responding to health problems are two major goals that are inextricably linked to each other. Enhancing the overall development of adolescents helps not only to forestall problems but also to improve health and well-being. Healthy behaviour among adolescents can only be expected if development needs are met. Answering the development needs of adolescents will help answer their health needs. Solving health issues requires a developmental approach. A combination of health and development targets are needed to ensure that adolescents have the necessary competencies, knowledge, opportunities, and support to choose health and improve their wellbeing. In an analysis of over 100 US-based programs on delinquency, preventing pregnancy, drug use, and dropping out of school, six common themes related to development emerged as vital to successful outcomes: ! Skills building ! Participation of adolescents in the community ! Membership in groups and organizations ! Norms and expectations (and developing new norms acceptable to groups where they belong) ! Adult-youth relationships ! Accurate information

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SLIDE GC2 Unearth the common roots of health and development problems Core Message Adolescent health and development problems have common roots. These roots must be targeted directly, in order to address all other problems connected to them. Notes Adolescent health and development problems and issues have common roots and are closely connected.10 They can be divided into underlying factors and immediate causes. These are likely to lead to high-risk behaviour, and subsequently to health and development problems. Underlying factors: gender-based discrimination, poverty, unemployment, urbanization and migration, social values and norms, wars and emergencies Immediate causes: inadequate education and skills, poor access to health information and services, unsafe and unsupportive environments, exploitation and abuse

Even as programmes focus on the prevention of particular health problems in high-risk groups, it is important to view adolescent health issues from a wide perspective. Programming and policymaking that deals directly with underlying causes and basic needs will benefit various aspects of adolescent health.

10

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886).

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Example 1 Poor access to information and services promoting sexual and reproductive health, coupled with unsafe and unsupportive environments, make it difficult for an adolescent to deal with an unwanted pregnancy. Early child-bearing and parenthood, social stigma, and loss of educational opportunity, may all impose considerable stress on adolescent mothers and can lead to mental health problems or disorders. This is particularly true in societies where adolescent sexuality is taboo, and adolescent pregnancies are met with shame and isolation.

Example 2 A programme on preventing HIV/AIDS should focus not only on dissemination of information about the disease, but also on the development of self-esteem and mastery of assertiveness skills among adolescents. These skills allow adolescents to negotiate safe sex, in the process preventing sexually transmitted infections, and also preventing early and unwanted pregnancy. These same skills also help adolescents refuse the lure of drugs, or resist peer pressure to abuse alcohol. If a programme focuses on an underlying factor (in this case, self-esteem and assertiveness), then the program targets many health issues and the benefits that can be expected from it expand greatly.

With this guiding concept in mind, programs and policies for adolescents can enhance, complement, and strengthen each other. Suggested Activity Think of a particular issue in adolescent health and development and draw a problem tree identifying its immediate causes and underlying factors. Guide the participants in representing the problem in terms of roots (underlying factors and immediate causes) and branches (diverse problems associated with the main issue.) Ask the participants to attempt problem trees on such issues as tobacco, adolescent pregnancy, adolescent suicide, eating disorders. (Recall that a similar activity was introduced in the discussion on Nutrition.)

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SLIDE GC2a Adolescent health and development problems have underlying factors Core Message Underlying factors, such as genderbased discrimination, poverty, and rapid social changes are the fundamental causes of adolescent health and development problems. Notes Underlying factors § Gender-based discrimination § Poverty § Unemployment § Urbanization and migration § Changing social values and norms § Wars and emergencies Gender inequities determine the pace and quality of adolescent health and development. Gender-based discrimination is a barrier to the ability of adolescents, especially adolescent girls, to exercise their right to develop their capacities and to have access to services and opportunities. For example, girls in some societies are not given adequate formal education or training. Poverty undermines the right of adolescents to grow up in a safe, stable and nurturing environment. Poverty increases the likelihood of illhealth, and is a critical barrier to access shelter, adequate nutrition, education, health care and employment opportunities. Poverty forces a significant proportion of adolescents in the region to drop out of school and contribute to family income by taking up jobs that are frequently low-end, low-skilled, insecure and with low benefits. Poverty limits employment opportunities for adolescents, as these adolescents are less likely to have skills and thus are less likely to get good employment. Unemployment is also common among parents of poor adolescents, and this has a negative impact on the adolescents.

66

Urbanization and migration bring about changes in values and norms, behaviour and lifestyles. These changes could lead to adolescents adapting risky behaviour because of peer pressure, and temptations such as easy access to tobacco, drugs and sex. Some social values and norms such as early marriage among adolescent girls, serve as negative influences on healthy development. War and other emergencies put adolescents at risk of mortality and morbidity and limit development opportunities.

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SLIDE GC2a1 Gender-based discrimination remains a barrier to health and development Core Message Gender-based discrimination is a barrier to the ability of adolescents, particularly adolescent girls, to exercise their right to develop their capacities and to have access to services and opportunities. Notes There are gender differences in adolescent morbidity and mortality rates. Health data show that boys generally have higher levels of mortality while girls have higher rates of morbidity. Boys have higher rates of mortality and morbidity from injuries due to violence, accidents and suicide, while girls have higher rates of morbidity and mortality 11 related to reproductive tract and pregnancy related causes. Adolescent boys are treated differently from adolescent girls. In most societies, boys are preferred to girls, and given more attention, opportunities and resources. Girls generally have fewer opportunities than boys. For example, girls often have less education than boys, which denies them the opportunity to develop their full potential. In settings where early marriage is common, early childbearing puts adolescent girls' health and survival at risk and curtails their education and economic opportunities. Nutrition is another area where male preference puts adolescent girls at higher risk for undernutrition and micronutrient deficiency. On the other hand, adolescent boys face discrimination in their access to some services, such as reproductive health services. This is a result of over-emphasis on the reproductive role of women to the extent that the needs of men and adolescent boys are neglected or given little attention. Encouraging “macho" behaviour may expose adolescent boys to greater risk of violence and injury.

11

WHO (2000) What about boys? A literature review on the health and development of

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Gender-based discrimination is a barrier to the ability of adolescents, particularly adolescent girls, to exercise their right to develop their capacities and to have access to services and opportunities. Thus, interventions must be gender-sensitive to ensure that the needs of both girls and boys are met. Discussion Question "What are some specific examples highlighting gender-based discrimination in your local setting?”

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SLIDE GC2a2 Poverty undermines health and development Core Message Poverty undermines the right of adolescents to grow up in safe, stable, and nurturing environments. Poverty is a critical barrier to accessing education, healthy diets, health care and good employment. Notes Poverty undermines the right of adolescents to grow up in a safe, stable and nurturing environment by increasing the likelihood of ill-health, and is a critical barrier to access shelter, adequate nutrition, education, health care and employment opportunities. Some adolescents who are living and working on the streets are especially vulnerable due to physical conditions of street life (lack of food, shelter, and sanitation) and the factors responsible for their homeless existence, such as poverty, family breakdown, abuse or armed conflict. Surviving street life and coping with stress may lead to drug use and dealing, commercial sex work, criminal behaviour, violence, and exploitation by adults.

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SLIDE GC2b Adolescent health and development problems have common immediate causes Core Message ADH programmes should target directly the immediate causes of adolescent health and problems, such as inadequate education and skills, poor access to health information and services, unsafe and unsupportive environments, and exploitation and abuse. Notes Immediate causes ! Inadequate education and skills ! Poor access to health information and services ! Unsafe and unsupportive environment ! Exploitation and abuse The underlying factors (discussed in the previous slide) bring about the immediate causes of adolescent health and development problems. Studies and programme experiences around the world have shown that the problems among adolescents are caused by a set of immediate causes, including: Inadequate education and skills With lack of information, adolescents may pursue a lifestyle marked by risky behavior (e.g. experimentation with tobacco, alcohol, drugs, and sex) largely due to misinformation and misconceptions. Although proper information is not the sole deterrent to risky behavior, it makes adolescents stop and think about the consequences of the choices they make. Poor access to health information and services Adolescents need information and services that are more tailored to their needs and wants. Access pertains to physical access as well as the ability of these services to answer adolescents' special needs.

71

· Unsafe and unsupportive environment A safe and supportive environment makes it easier for adolescents to make healthy choices. "Safe" means absence of violence (or fear of violence), accidents and trauma. "Supportive" means an environment that provides a positive and close relationship with family and peers. Policies and legislation work towards helping adolescents achieve their full potential. The media offers good role models. · Exploitation and abuse Exploitation and abuse may occur in several forms (sexual, physical, psychological) in various settings such as the home, schools or the workplace. A safe and supportive environment would help in keeping adolescents safe from exploitation and abuse. Adolescents will thus be able to focus their energies toward development rather than on coping with physical, emotional, and social trauma or threats.

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SLIDE GC3 Promote holistic interventions

Core Message If health and development problems have common roots, then these can be addressed most effectively by combined interventions. Notes Adolescent risk-taking behaviour and health and development problems have common roots and are interrelated. Thus, they can be addressed most effectively by a combination of interventions that promote healthy development. Addressing adolescents' issues requires selecting, adapting and combining interventions. There are many issues involved in each problem and therefore solutions need to be comprehensive. These interventions should consider specific situations of adolescents to ensure that they address relevant concerns and needs. The type of intervention should vary according to gender, age, marital status, state of health, home and social situations. Interventions should be focused on two aspects: ! The individual - the development of identity and self-esteem; achieving competence in certain skills, and applying those skills in service to others ! The social environment ! Family - a sense of connectedness to parents and family, parental presence in the home, shared activities, and parents' bright expectations for their teens, are all positively associated with healthy behaviour ! School - a feeling of connectedness to a school, (where they are treated fairly, are part of a community, and are able to form relationships with peers and caring teachers), is associated with healthy behaviour ! Community - youth-serving institutions or organizations increase the quality and quantity of relationships formed by adolescents

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Promoting holistic interventions means addressing the key needs of adolescents, which include: ! Safe and supportive environments ! Accurate and timely information ! Life skills ! Counseling ! Acceptable and affordable health services

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SLIDE GC3a Create safe and supportive environments Core Message Adolescents need an environment that protects them from excessive stress, abuse and violence (or the fear of violence); provides positive, close relationships with family, adults and peers; and gives them opportunities to reach their full potential. Notes Adolescents need a safe and supportive environment that motivates and supports healthy development and positive behavioural choices, and protects adolescents from engaging in risky behaviours. Safe and supportive environments offer: · Minimal risk of injury, exploitation, or disease · Meaningful relationships with adults, peers and partners · Peers who have pro-social attitudes and behaviour · Structure and boundaries for behaviour · Encouragement of self-expression · Educational, economic and social opportunities · Opportunities for participation with their contributions being valued · A positive school environment Studies in both developed and developing countries have found that such an environment motivates and supports the healthy development and positive behavioural choices of adolescents. It also protects adolescents from engaging in risky behaviour. Adolescents who live in these environments are less likely to initiate sex too early, less likely to use substances, and less likely to experience depression.12 This evidence presents a link between the social environment and health outcomes for adolescents, and thus the need for our responses to focus not only on the adolescents, but also their environment. 12

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886).

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SLIDE GC3b Provide accurate and timely information Core Message Adolescents need accurate information that will help them understand their own process of development, risks to health, requirements for health, and available services. Notes Adolescents need information that can help them choose health, protect themselves, and stay healthy. Adolescents need to be provided with accurate and complete information about: ! Growth and development (physical, emotional, mental, sexual, and social development) to help them understand the processes going on in their minds and bodies, the implications of these developments, and how to successfully manage them. ! Health issues such as nutritional requirements, physical activity, sexual and reproductive health, substance abuse and mental health. ! Potential risks to their health from behaviour such as early and unprotected sex, use of tobacco, alcohol abuse and drug abuse, and how to avert these risks. ! Opportunities and available services, related to health, education, vocational and recreational opportunities in order to optimize the use of resources available to them. Lack of information and knowledge limit adolescents' ability to recognize their health problems. This is one of the reasons why adolescents so often fail to seek health services for their health problems. If adolescents are not provided with accurate information, they will seek information from a variety of sources including peers, magazines, books, mass media, and the Internet. However, the information from these sources may be incomplete, incorrect or misleading and could pose a danger to adolescents.

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SLIDE GC3c Assist in developing life skills

Core Message Adolescents need to develop social and interpersonal skills, cognitive skills and emotional coping skills to deal with the demands and challenges of life. Notes Life skills are abilities for adaptive and positive behaviour that enable adolescents to deal with the demands and challenges of everyday life. These challenges including negative peer pressure, risky situations related to sexual behaviour, substance abuse, and violence. There are several life skills that adolescents must develop: · Social and interpersonal skills (including communication skills, refusal skills, assertiveness, and empathy) · Cognitive skills (including decision making, critical thinking, problem-solving and self-evaluation) · Emotional coping skills (including stress management and an internal locus of control). Research on life-skills programming13 noted, among others, positive changes in self-reporting of health behaviour, improvements in mental health status, improved relations and more open communications with parents, improved teacher-pupil relationships and classroom behaviour. (A more in-depth discussion of Life Skills development can be found in Section 1.)

13

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886).

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SLIDE Gc3d Provide acceptable health services

Core Message Adolescents need comprehensive promotive, preventive and curative health services that are adolescentfriendly, guarantee confidentiality, and are staffed by nonjudgmental service providers with good counseling skills. Notes Adolescents need comprehensive promotive, preventive and curative health services, including sexual and reproductive health services. Without such services, adolescents are left in the dark as how to prevent and manage health problems and health risks. Addressing adolescents' barriers to utilization of health services is part of providing health services. Barriers to adolescents' utilization of health services can be due to adolescent factors or health services factors. Adolescent factors in recognizing health problems/ risks include: ! Limitation in recognizing health problems/risks ! Lack of awareness of consequences ! Not wanting to draw attention to self ! Lack of information on health services Health service factors that hinder adolescents' utilization of services include issues such as: ! Long waiting time, parental consent required ! Distant location, inconvenient office hours, high cost ! Lack of confidentiality, insensitivity when asking difficult questions, conducting physical examinations or tests that are deemed unpleasant. Adolescents want services that are friendly, with emphasis on confidentiality, non-judgmental attitude of service providers, accessibility and convenient hours. Adolescents need to know about the types of health services provided, the costs, and the way in which these are delivered. Adolescent-friendly services encourage adolescents to participate in maintaining their own health.

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SLIDE GC3d2 Provide acceptable health services Core Message Services should include growth and development monitoring, assessment of health problems or risky behaviour, counseling, health education, and access to vaccinations, nutritional supplements, and contraceptives. Prompt diagnosis and management of health problems should be provided, with referral to the next level of service delivery, if indicated. Notes Basic health services should include: · Monitoring growth and development · Assessing possibility of health problems and/or risky behaviours e.g. unsafe sex and sexually transmitted infections, drug use, depression · Providing vaccinations, nutritional supplements, contraceptives · Providing information on key issues · Providing counseling services In addition, health services should be capable of: · Promptly diagnosing health problems · Managing common health problems · Referring to the next level of health service delivery and/or to other services (e.g. welfare, rehabilitation), if necessary School health services should have these basic services, including routine checks for detection of visual and auditory disorders, and administration of vaccines. School health services should be able to provide treatment for common illnesses and refer adolescents to the next level of health service delivery when needed. Government health centers and clinics usually cater to adults and children, but there can be special days when they provide special services for adolescents, which usually include health education on sexual and reproductive health.

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SLIDE Gc3d3 Provide acceptable health services: counseling services Core Message Adolescents do not have the naivety of children nor the awareness of adults. Counseling sessions take more time and must be conducted with sensitivity. Counseling helps adolescents understand and manage challenges experienced during adolescence, and to support them in their decisionmaking. Notes Adolescents need to talk to peers and/or adults when they have concerns about themselves or events surrounding them or when they need help to deal more effectively with problems. Counseling helps adolescents by enabling them to understand their situation better and to make sound decisions. Counseling is commonly provided for reproductive health issues, substance abuse, and depression as a complement to the other major interventions. It is usually conducted on an individual basis, although group methods are sometimes employed. Adolescents can carry out basic counseling with their peers. Peer counseling can be successful in efforts to prevent pregnancy, sexually-transmitted infections, smoking, alcohol abuse, and drug abuse.

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Here are some scenarios where counseling can be valuable: ! Adolescents need counseling to help them appreciate the positive aspects of sexuality and reduce their anxiety about feelings that arise naturally in adolescence. They need to be counseled about self-respect, the risks of early or unprotected sex, and the importance of developing lasting and fulfilling relationships. Adolescents need counseling to help them deal with impulses that lead to violence. Adolescents need to gain an insight into how they deal with stressful situations and the destructive consequences of violent behaviour. The counselor can assist in finding outlets for these destructive impulses and channel the adolescent's energies into more productive pursuits.

!

Suggested Activity Visit (or cite examples of) organizations or agencies that offer counseling services. ! What are the most common problems brought forward by adolescents? ! What features of the counseling service make it acceptable to adolescents?

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SLIDE GC3e Create nurturing societies Core Message Health-enhancing behaviour and outcomes are primarily the responsibility of adolescents themselves. However, the knowledge, skills, and opportunities they need to develop and to make healthy choices are influenced by the larger social, political, economic, and cultural context in which they grow and change. Notes The key areas in the social environment include: Social attitudes and norms Social norms that value adolescents, their health and development will promote the healthy development of adolescents. On the other hand, social norms that value early marriage among adolescents, for example, serve as negative influences on their health outcomes as well as educational and economic opportunities. Policies Policies that support adolescent health and development are very likely to significantly influence the healthy development of adolescents. For example, a reproductive health policy that allows adolescents, regardless of their marital status, to access contraceptive services, will enable adolescents to protect themselves from early, unwanted pregnancies and sexually transmitted infections. Relationships with the family, friends and other adults Adolescents who have positive relationships with their parents, friends and other adults (e.g. teachers) are less likely to initiate sex too early, less likely to use drugs and alcohol, and less likely to 14 experience depression.

14

WHO (2001) Broadening the horizon: Balancing protection and risk for adolescents. Geneva, World Health Organization.

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Mass media and entertainment The media can help promote adolescent health and development, by: ! providing accurate information on health and development issues; ! communicating and mobilizing community support for promoting adolescent health and development; and ! addressing aspects of the social environment such as social norms and policies that have a negative impact on adolescent health and development.

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SLIDE GC4 Adapt to diverse groups and different needs Core Message Adolescents are a diverse group, and while they have a common need for education, life skills development, health services and livelihood skills, interventions should address specific needs of specific groups. Notes Adolescents are a very diverse group, coming from and living in equally diverse backgrounds and environments. Some adolescents go through their adolescent years smoothly. But there are adolescent populations, such as those adolescents living in poverty and street children, who are more vulnerable and need more support than others. Different groups of adolescents have different needs, and types and levels of support they would require. Gender and age considerations are important when providing interventions. For example, it is important to adapt interventions to age and developmental stage when providing information on contraception, pregnancy, and disease prevention. There is evidence that introducing basic information on sexuality, emotions, and the new physical sensations experienced at puberty is highly beneficial in early adolescence, before many adolescents become sexually active.15 All adolescents need basic interventions, such as education, life skills, health services, and livelihood skills that will contribute to their health and development. However, special interventions may be required to meet the needs of more vulnerable adolescents.

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886). 15

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SLIDE GC5 Empower adolescents to participate and contribute Core Message Meaningful participation can only happen when adolescents are empowered with necessary life skills, and given opportunities to express their needs, and make healthy decisions for themselves. Notes Adolescents have rights. These rights are clearly stated in various international conventions, especially the United Nations Convention on the Rights of the Child (CRC). (Full text available at http://www.uncrc. info) The CRC ! ! ! ! states that adolescents have rights to: Information and skills (Article 17) Education and health services (Articles 23, 24, 28, 31) Safe and supportive environment (Articles 2, 3, 4, 5, 16, 18, 19, 22, 24, 25, 27, 32, 33, 34, 35, 36, 38) Participation (Articles 12, 13, 14, 15 23)

These rights constitute the legal framework within which efforts to promote adolescent health and development should be embedded. (Find out whether the country where you give this presentation has ratified and reported on the CRC. If so, you may want to point this out to the audience.)

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SECTION 4: Healthy Settings for Adolescents These slides describe the settings approach in planning and implementing interventions supportive of adolescent health and safety.

Slide Code Number

Title Promoting the Healthy Development of Adolescents: The Settings Approach

Core Message Promoting the healthy development of adolescents means reaching them “where they are” - in their homes, schools, health facilities, parks and malls, youth centers, clubs and organizations, workplaces, bars and cafes, and even in the streets. Adolescents have a right to live in an environment where they are safe from injuries.

HS1

HS1a Safe environments HS1b

Violence is among the leading causes of death and morbidity of young people. The home should be a supportive and nurturing environment because of its many influences in adolescents’ lives: in promoting moral development and a sense of responsibility; providing adult role models; establishing a cultural identity; setting expectations for behaviour; providing basic services, information and opportunities; and counteracting or filtering negative influences from the environment. The home is an entry point for early interventions. Efforts to create nurturing environments in other settings must outreach to the home.

HS2

Healthy Setting: Home

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Slide Code Number

Title

Core Message The school provides an environment for formal education and skills building. It is often where adolescents learn to establish relationships with peers, and with adults outside of their families. The school is therefore an important venue for health interventions, particularly health promotion and life skills development. The school is also an access point for primary health care services. A health-promoting school is a healthy setting for living, learning and working. It strives to improve the health of students, school personnel, families and community members. It fosters health and learning, and offers services such as physical education and recreation facilities, counseling, social support, and primary care services. It nurtures adolescents by respecting their self-esteem, providing opportunities for success, and acknowledging good intentions and personal achievements. Health facilities, from small clinics to tertiary care centers, provide a setting for the delivery of information on health and development, counseling services, clinical/medical services, and for the development of life skills. Health facilities must be adolescent-friendly, accessible, affordable, non-judgmental, must provide accurate and timely information, encourage communication, and involve adolescents in self-care.

HS3

Healthy Setting: School

HS3a

Health-promoting schools

HS4

Healthy Setting: Home

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Slide Code Number

Title

Core Message There are several models for adolescent-friendly health services: a health center specializing in adolescent health; a communitybased health facility which targets adolescents in the context of providing services to all segments of the population; a community-based center that forms part of a network of service providers; and organizations that emphasize outreach work to provide information and services. Workplace health programs should address the special needs of adolescents for accurate and timely health information, promotive, preventive and curative services, and safe working conditions. Community organizations help adolescents attain their full potential by providing social support, guidance, and constructive alternatives to negative influences in their environment. These organizations create opportunities for adolescents to contribute meaningfully to the community through skills training. Through interaction with supportive adults and peers, adolescents develop a sense of structure, safety, status and belonging. Community organizations help adolescents develop self-confidence and self-esteem by encouraging them to take responsibility for themselves and assume a role within a group. Community organizations that have gained the trust of adolescents are important entry points for many health interventions.

HS4a

Models for adolescent-friendly health facilities

HS5

Healthy Setting: Workplace

HS6 Healthy Setting: Community Organizations

HS6a

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Slide Code Number

Title

Core Message In many places in the Western Pacific Region, the street is the center of everyday living - from markets in urban areas to communal water sources in rural areas. For street children and out of school adolescents, the street is home, and perhaps the only setting to reach this population. Health interventions can be done effectively in the street. It can be a venue for providing information on health and related issues using a variety of techniques, from distribution of printed materials to street theater. Mobile clinics provide promotive, preventive and curative services, and can be the entry point to a network of health centers. Successful programmes among street children emphasize skills building (life skills, vocational skills), informal education, and linking to a network of support systems such as health facilities and welfare programmes. The media and the entertainment world can be advocates and partners for the promotion of adolescent health and development. They can create awareness for issues concerning adolescents, communicate health information, contribute to the promotion of positive societal norms, and advocate support for programmes and policies for adolescents.

HS7

Healthy Setting: Streets

HS7a

Interventions on the street

HS8

Healthy Setting: Media and Entertainment

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SLIDE HS1 Promoting the Healthy Development of Adolescents: The Settings Approach Core Message Promoting the healthy development of adolescents means reaching them "where they are" - in their homes, schools, health facilities, parks and malls, youth centers, clubs and organizations, workplaces, bars and cafes, and even in the streets. Notes The Settings Approach reaches clients "where they are" - in places or spaces where people live, learn, play, travel, relax and work, such as homes, schools, health facilities, clubs and organizations, workplaces, cafes, and even in the streets - in an effort to: Introduce interventions The interventions could include education and services (including health education and services), and skills building. The targets could include adolescents, parents, teachers and health providers. There is a need to assess the appropriateness of interventions depending on the settings. Some interventions have a natural affinity with particular settings. For example, health services can be found mostly in health centers. Likewise, peer education is usually given in schools and youth clubs or organizations. Improve the environment This could include improving school facilities like playground safety, or by developing recreational facilities (e.g., parks, youth centers) in residential areas. The existing environment could also be improved by introducing policies such as smoke-free areas (e.g., in internet cafes, malls, schools). Efforts to improve adolescent health and development require a combination of actions that aim to improve existing settings and reach greater numbers of adolescents in various settings.

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SLIDE HS1a-b Safe Environments Core Message Adolescents have a right to live in an environment where they are safe from injuries. Violence is among the leading causes of death and morbidity of young people.

Notes Adolescents are at risk for injuries, both unintentional and intentional. Examples of unintentional injuries are road traffic accidents, drowning and falls. Examples of intentional injuries are suicide, bullying, harassment, assault, sexual abuse, rape, homicide, and organized violence due to gang wars or armed conflict. Unintentional injury is the leading cause of death among young people, especially traffic accidents among boys. Suicide in young people is increasing and is a major cause of death, especially of adolescent males. Interpersonal violence is increasing among young people, with girls especially victimized.16 It is possible to address this issue by looking at the risk-taking behaviour of adolescents and addressing closely interrelated problems such as alcohol and drug abuse. However, some of these risks arise simply as a result of the young person being in an unsafe environment where they cannot feel secure. Reducing both types of risks can significantly lower high rates of associated mortality and morbidity.

16

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886).

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SLIDE HS2 Home

Healthy Setting:

Core Message The home should be a supportive and nurturing environment because of its many influences in adolescents' lives: in promoting moral development and a sense of responsibility; providing adult role models; establishing a cultural identity; setting expectations for behaviour; providing basic services, information and opportunities; and counteracting or filtering negative influences from the environment.

! ! ! ! ! !

The home is an entry point for early interventions. Efforts to create nurturing environments in other settings must outreach to the home. Notes The home is the center of family life. The family plays a major role in the lives of adolescents, including: The home is a good contact point for an assessment of adolescents' needs, especially in the family context. It is also a central place to improve relationships between adolescents and parents, and other significant members of the family. Adolescents get information and adopt behaviour through interaction and observation at home. The home, therefore, offers an entry point for early interventions in areas such as improving nutrition, and enhancing school performance. The home is an important setting for helping adolescents with high-risk behaviour and also helping high-risk families. Results of programmes have shown that outreach to the homes of high-risk families have improved health outcomes and school performance of adolescents.

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Suggested Activity Ask the participants to form small groups of 3 to 5 persons, and answer this guide question: "In your experience, what are the factors in the home that affect, either positively or negatively, the health behaviour of adolescents?" Give each group one or more of these health-related behaviours to discuss: · · · · · · · · · · · · · Diet Physical activity Health-service use Morbidity Injury Violence Sexual behavior Contraception Sexually transmitted infections Pregnancy Suicidal intentions/thoughts Substance use/abuse Runaway history

Ask the participants to present the results of their discussions. Relate the participants' observations with the following statements, which are based on the findings and conclusions of Add Health, the National Longitudinal Study on Adolescent Health, is the largest, most comprehensive survey of US-based adolescents to date, involving 90,118 students from 134 schools. 17,18

The study was designed to explore the causes of healthy and unhealthy behaviours, and in the process considered the extent by which families, friends, schools and communities exert a protective influence on adolescents.

Blum, R. and Reinhart, P. (1997) Reducing the risk: Connections that make a difference in the lives of youth. Minneapolis: University of Minnesota, Division of General Pediatrics, Adolescent Health. 18

17

Resnick, M., Bearman, P ., Blum, R., Bauman, K., Harris, K., Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., and Udry, R., (1997). Protecting adolescents from harm: Findings from the National Longitudinal Study on

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! For all health-risk behaviours, across all socioeconomic levels, family structures, races and ethnicities, when adolescents feel connected to their families, and when parents are involved in their children's lives, teens are protected. ! In the following domains violence, substance use/abuse and sexual behaviour researchers found that parents do, indeed, matter. ! A major overall family protective factor was parental expectations regarding school achievement. Higher expectations for completing high school and college were associated with lower levels of health-risk behaviours. ! Parent-family connectedness was a protective factor vs. suicidal thoughts and behaviour. ! Adolescents are protected from alcohol, tobacco and other drug use by the following factors: parent and family connectedness (physical presence of a parent in the home at key times), parent-adolescent activities, parental presence (having general access to a parent), and parental school expectations. Negative factors included family suicide or suicide attempts, and household access to substances and guns.

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SLIDE HS3 School Core Message

Healthy Setting:

The school provides an environment for formal education and skills building. It is often where adolescents learn to establish relationships with peers, and with adults outside of their families. The school is therefore an important venue for health interventions, particularly health promotion and life skills development. The school is also an access point for primary health care services. Notes The school provides an environment for formal education and skills building. It also has the potential to improve the health and development of adolescents, especially in places where adolescent enrolment in schools are high, through: ! Health education and prevention activities, including physical and mental health, nutritional and food safety, and physical education Healthy and safe environment combining good nutrition and food safety with clean water and sanitation Health services including growth monitoring, primary health care services and referral to appropriate health and/or other services Sports and recreational skills and facilities Life skills development

! !

! !

The school also plays a role in dealing with issues in the social environment, such as identifying and addressing factors that contribute to adolescents dropping out of school and using illicit drugs.

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SLIDE HS3a Healthpromoting schools Core Message A health-promoting school is a healthy setting for living, learning and working. It strives to improve the health of students, school personnel, families and community members. It fosters health and learning, and offers services such as physical education and recreation facilities, counseling, social support, and primary care services. It nurtures adolescents by respecting their selfesteem, providing opportunities for success, and acknowledging good intentions and personal achievements. Notes The World Health Organization recognizes health-promoting schools as an approach to improve the health of children and adolescents. A healthpromoting school can be characterized as a school that is constantly strengthening its capacity as a healthy setting for living, learning and working. It is a comprehensive strategy that involves children and adolescents, their families, the school and the community. A healthpromoting school: ! Strives to improve the health of school personnel, families and community members and students ! Fosters health and learning with all the measures at its disposal ! Engages health and education officials, teachers, students, parents and community leaders in efforts to make the school a healthy place ! Strives to provide a healthy environment, school health education and school health services along with school/ community projects and outreach, health promotion programmes for staff, nutrition and food safety programmes, opportunities for physical education and recreation and programmes for counseling, social support and mental health promotion ! Implements policies and practices that respect an individual's self-esteem, provides multiple opportunities for success and acknowledges good efforts and intentions as well as personal achievements.

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SLIDE HS4 Healthy Setting: Health Facilities Core Message Health facilities, from small clinics to tertiary care centers, provide a setting for the delivery of information on health and development, counseling services, clinical/medical services, and for the development of life skills. Health facilities must be adolescent-friendly accessible, affordable, non-judgmental, must provide accurate and timely information, encourage communication, and involve adolescents in self-care. Notes Health facilities, from small clinics providing a limited range of health services to hospitals that provide a wide range of services, are settings for providing: ! Information on health and development ! Counseling ! Clinical/medical services or interventions ! Skills building (e.g. decision-making, self care) Health facilities need to understand the needs of adolescents and the barriers to the delivery of services to adolescents. Health facilities need to consult with adolescents, their parents and the community to find ways to remove barriers and to deliver adolescent-friendly health services.

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SLIDE HS4a Models for adolescent-friendly health facilities Core Message There are several models for adolescent-friendly health services: a health center specializing in adolescent health; a community-based health facility which targets adolescents in the context of providing services to all segments of the population; a community-based center that forms part of a network of service providers; and organizations that emphasize outreach work to provide information and services. Notes There are several existing models for providing adolescent-friendly health services. These include: ! A health center specializing in adolescent health. This model is often linked to a medical school or a teaching hospital ! A community-based health facility that strives to provide adolescent-friendly clinical services to adolescents, within the context of health service provision to all segments of the population ! A community-based center (not a health facility) that offers services to adolescents, either through its own programmes and/or linkages with health facilities or NGOs ! Organizations such as NGOs that seek to improve adolescents' access to health services. The emphasis is mainly on outreach work to provide information, and very limited clinical services, if any. Discussion Question “What are the pros and cons of adapting each model of health service in your setting?” “What model does your health facility follow?”

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SLIDE HS5 Workplace Core Message

Healthy Setting:

Workplace health programs should address the special needs of adolescents for accurate and timely health information, preventive and curative services, and safe working conditions. Notes In some countries in the Western Pacific Region, the workplace is a setting where a large number of adolescents can be reached. Workplaces for adolescents include factories, markets, small shops, and others. The streets are workplaces for adolescents who shine shoes, sell food, or provide street entertainment. In rural areas, they work in farms (including poultry or fishing farms). Providing health information and services in workplaces can be done through: ! Establishing a clinic at the workplace, especially in workplaces with a large number of workers ! Regular visits by health providers to the workplaces ! Health insurance schemes for adolescent workers ! Health campaigns Health initiatives for workers benefit both the workers as well as the management by ensuring a healthier workforce and workplace. Providing health information and services at the workplace requires linkages and collaboration between the health sector and the business sector. Such linkages could be facilitated by appropriate policies. It is also necessary to assess conditions in the workplace, to help improve working conditions, and to avoid abuse and exploitation of adolescents. In Article 32 of the United Nations Convention on the Rights of the Child: States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development.

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SLIDE HS6 HS6a Healthy Setting: Community organizations Core Message Community organizations help adolescents attain their full potential by providing social support, guidance, and constructive alternatives to negative influences in their environment. These organizations create opportunities for adolescents to contribute meaningfully to the community through skills training. Through interaction with supportive adults And peers, adolescents develop a sense of structure, safety, status and belonging. Community organizations help adolescents develop selfconfidence and self-esteem by encouraging them to take responsibility for themselves and assume a role within a group. Community organizations that have gained the trust of adolescents are important entry points for many health interventions. Notes Community organizations such as youth clubs, often have the overall aim of helping adolescents develop their full potential. They do so by: ! Providing adolescents with social support and guidance, skills training, positive and constructive alternatives to negative influences that adolescents might encounter in their environment ! Creating opportunities for adolescents to contribute meaningfully to the community ! Meeting the developmental needs of adolescents -- sense of structure, safety, status and belonging ! Instilling positive values and attitudes, ! Developing life skills, self-confidence and self-esteem, and taking responsibility for themselves and to assume a role within a group The health sector should collaborate with these organizations to introduce and/or strengthen health and development activities.

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SLIDE HS7 Streets Core Message

Healthy Setting:

In many places in the Western Pacific Region, the street is the center of everyday living from markets in urban areas to communal water sources in rural areas. For street children and out of school adolescents, the street is home, and perhaps the only setting to reach this population.

Notes Globally, an estimated 30 million children live or work on the street. The street setting may be the only way to reach them. The following interventions in the street have the potential to reach a large number of people, including adolescents: ! ! Street theater and outreach work providing information on health and related issues Mobile clinics providing preventive and curative services as well as referral services

Successful programmes for street children have carried out interventions in these areas: ! ! ! Skills building (life skills, vocational skills) Informal education Linking street children with existing support systems such as health facilities and welfare programmes

Life skills important on the street include decision-making and taking responsibility for oneself, and interpersonal relationship skills that include dealing with peer pressure and being assertive.

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It is also important to remember that young people living on the street need to earn money to survive. They do a variety of jobs, many of which pose serious health hazards. There is need for programming interventions that do not compromise their ability to earn, yet attempt to decrease the risk of health problems associated with street activities. Programming can aim to engage adolescents in activities which will help 19 them move away from such work to less risky ways of earning a living. Adolescent participation is particularly important in planning interventions in the street setting. Their involvement promotes the development of socialization and communication skills, and helps to develop their self-esteem. Discussion Questions “Name some health risks faced by adolescents living on the streets.” “Given the harsh demands of surviving in the streets, what do you perceive to be these adolescents’ attitudes towards their own health and development?”

19

WHO (1999) Programming for adolescent health and development: Report of a WHO/UNFPA/ UNICEF study group on programming for adolescent health. Geneva, World Health Organization (WHO Technical Report Series, No.886).

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SLIDE HS8 Healthy Setting: Media and entertainment Core Message The media and the entertainment world can be advocates and partners for the promotion of adolescent health and development. They can create awareness for issues concerning adolescents, communicate health information, contribute to the promotion of positive societal norms, and advocate support for programmes and policies for adolescents. Notes The media and entertainment world could be advocates and partners for the promotion of adolescent health and development. They can influence adolescents, adults, and the social environment by: ! Communicating health information ! Influencing attitudes and contributing to positive societal norms regarding adolescent health and development issues through public dialogue ! Influencing the attitudes and health behaviour of adolescents and also influencing the attitudes and behaviour of adults towards adolescents ! Contributing to the creation of a safe and supportive environment by promoting healthy behaviour, advocating policies that support adolescent health and development ! Highlighting the conditions that affect the health and development of adolescents Suggested Reading Resnick, M., Bearman, P ., Blum, R., Bauman, K., Harris, K., Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., and Udry, R., (1997) Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association, 278, 823-832.

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SECTION 5: Keys to Success in Adolescent Health and Development Programmes These slides describe the measures of success in planning and implementing adolescent health and development programmes.

Slide Code Number

Title

Core Message Address both health and development issues of adolescents. Interventions that focus only on specific health issues are less effective because most health problems that beset adolescents are related to development issues. Programmes should recognize the underlying and immediate causes that influence adolescent health and development, such as: gender and poverty issues, inadequate education and skills, poor access to health information and services, unsafe and unsupportive environment, and exploitation and abuse. Programmes should promote comprehensive and holistic interventions, such as: creating nurturing environments, providing accurate and timely information, developing life skills, and providing acceptable health services. Programmes should adapt to diverse groups and different needs. Programmes should involve and empower adolescents to participate and contribute.

KS1

Address both health and development issues

KS2

Recognize roots of problems in adolescent health and development

KS3

Promote comprehensive and holistic interventions Adapt to diverse groups Empower adolescents

KS4

KS5

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SLIDE KS1 Address both health and development issues Core Message Address both health and development issues of adolescents. Interventions that focus only on specific health issues are less effective because most health problems that beset adolescents are related to development issues. Notes Addressing fundamental developmental needs of adolescents promotes healthy behavior. For example, a programme that aims to enhance the self-esteem and confidence of adolescents increases their ability to resist the peer pressure to take drugs. The same self-esteem and confidence also helps a teenager resist early sexual activity. By addressing a more basic issue, several health problems are tackled. The need for accurate information on health issues must be communicated to adolescents so that they will develop the appropriate skills to deal with them. Together with enhancing self-esteem (an overall strategy), information and education regarding drugs and reproductive health (a targeted strategy) are needed. Discussion Questions: “Give some examples of how to address/enhance/strengthen self esteem among adolescents.” "How do these worthwhile activities enhance self-esteem?" - Team sports activities - Theatre productions - Art activities - Summer/ part-time jobs “Give examples of health problems that can be prevented if adolescents have self esteem.”

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SLIDE KS2 Recognize roots of problems in adolescent health and development Core Message Programmes should recognize the underlying and immediate causes that influence adolescent health and development, such as: gender and poverty issues, inadequate education and skills, poor access to health information and services, unsafe and unsupportive environment, and exploitation and abuse. Notes Many health problems of adolescents have common antecedents. These underlying and immediate causes reinforce each other. If we take risk-taking behaviour as an example, we find that there are factors that predispose adolescents to engage in this behaviour. To name a few, these are: low self-esteem, underdeveloped interpersonal and decision making skills, lack of interest in education, inadequate information on health, low perception of opportunities, absence of dependable and close human relationships, and meager incentives for delaying short-term gratification. Addressing these factors that predispose to risk-taking behavior would target not just one single health problem, but many problems sharing the same underlying causes. Programmes for adolescent health and development must incorporate this principle for these to achieve a wider reach and purpose without needing to draw on more resources.

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SLIDE KS3 Promote comprehensive and holistic interventions Core Message Programmes should promote comprehensive and holistic interventions, such as: creating nurturing environments, providing accurate and timely information, developing life-skills, and providing acceptable health services. Notes A supportive and caring environment is an essential requirement of healthy adolescent development. The family, schools, community organizations, health care services and other institutions working for and with adolescents can together ensure that today's adolescents will grow into responsible, and competent adults. The synergistic influence of these institutions will make a difference. Together, they have the potential to address the underlying factors that undermine adolescent health and development It would best for adolescent health and development advocates to create networks and organize referral systems. Community groups, health clinics, and schools can all be maximized as information and referral centers for adolescents' problems and needs. Fundamental adolescent needs can be answered by involving several sectors in programmes for adolescents. For example, setting up programs that provide jobs for students during their vacation may be organized through the private sector. Sports associations may host sporting events. Adolescents interested in theater may be provided exposure in local theater groups. These efforts should be coordinated with schools, health clinics, and community organizations. Program planners must therefore: ! Review and assess existing programmes related to adolescents, ! Build upon resources of existing programs; do not re-invent the wheel, ! Form partnerships and alliances among advocates, ! Ensure that specific strategies reflect inputs from stakeholders, and describe what each sector is willing to do and is accountable for.

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SLIDE KS4 groups Core Message

Adapt to diverse

Programmes should adapt to diverse groups and different needs. Notes Cultural identity and adolescent development are linked. Understanding one's culture is an important part of exploring personal identity. This is integral to the development process. Adolescents' understanding of who they are and where they fit in their surroundings and social environment, compounded by an awareness of culture can greatly enhance a sense of belonging. If respect for culture and the differences that occur across them are present in adolescent health and development programmes, a feeling of safety and trust is enhanced. Programming which demonstrates respect for diversity validates the personal worth of all participants, and develops a sense of belonging. When cultural diversity is respected, the potential for interventions to be effective with adolescents is enhanced because: ! When people feel their traditional cultural values are regarded as important, parents, family, and other members of the community are more likely to be responsive and supportive of new approaches. Adolescents who feel that their subjective experience of culture is respected are more likely to contribute to the programming process not only as recipients of programming, but as planners and leaders as well. Understanding why young people are at risk for certain behaviours improves the ability of programming to design effective interventions. Assessment of risky behavior and related health problems is more complete when cultural factors that influence behavior are considered.

!

!

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SLIDE KS5 adolescents Core Message

Empower

Programmes should involve and empower adolescents to participate and contribute. Notes The involvement and participation of adolescents from conceptualization to implementation is the key principle towards successful programming. Their participation ensures several aspects crucial to sustainability and success: § Relevance of the program - working with adolescents puts program objectives, strategies, and evaluation schemes in a realistic perspective. Commitment to program objectives - commitment is stirred when adolescents themselves are involved; adolescents commit to a program because it is for their own sake; adults who work with them become more involved because their work becomes more meaningful and real. Reassurance of self-esteem - young people involved in programs are given the opportunity to develop in various ways; they discover their own strengths and get recognized for them.

§

§

Suggested Activity There are several examples all over the world showcasing success stories of programs where young people themselves are the core planners and implementers. Publications that document these successful programmes may be available in your local library or on the Internet. In one program for tobacco use prevention, around 3,250 teenagers are the main teachers on issues of tobacco prevention. (http://www.kdhe.state.ks.us/tobacco) Discussion Questions “How can we ensure that adolescents are able to participate and contribute in health and development programs?”

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