Adolescent health and development in the African Region: challenges and opportunities

BRIEFING KIT 2003 ADOLESCENT HEALTH AND DEVELOPMENT IN THE AFRICAN REGION WORLD HEALTH ORGANIZATION Regional Office for Africa Brazzaville AFR/CAH/03/02.2 Challenges and Opportunities Challenges and Opportunities ADOLESCENT HEALTH AND DEVELOPMENT IN THE AFRICAN REGION WORLD HEALTH ORGANIZATION Briefing Kit Regional Office for Africa Brazzaville • 2003 Adolescent Health and Development in the African Region: Challenges and Opportunities Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. 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 Secretariat 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. 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. Printed in the Republic of South Africa © WHO Regional Office for Africa (2003) T1 Table of contents.................................................................................................................1 Acronyms and abbreviations ...............................................................................................2 Preface ...............................................................................................................................3 Introduction .......................................................................................................................5 Developmental processes in adolescence: principles and tasks .............................................7 Changes during adolescence.............................................................................................10 Relationships, sexuality and love .......................................................................................14 Development of competences...........................................................................................17 Common health problems in adolescence .........................................................................19 Pregnancy and abortion ....................................................................................................21 Sexually transmitted infections and HIV/AIDS....................................................................26 Nutritional problems ........................................................................................................31 Personal hygiene ..............................................................................................................35 Alcohol and substance use and abuse ................................................................................36 Violence and crime...........................................................................................................44 Mental health of adolescents .............................................................................................47 Gender and socialization ..................................................................................................52 Adolescents under difficult or special circumstances ..........................................................55 Collaboration and partnership in adolescent health ............................................................58 Programming for adolescent health ...................................................................................69 References .......................................................................................................................76 Briefing Kit - TABLE OF CONTENTS TABLE OF CONTENTS 2Adolescent Health and Development in the African Region: Challenges and Opportunities AADH Adolescent Health and Development AFHS Adolescent Friendly Health Services AFRO Regional Office for Africa AIDS Acquired Immunodeficiency Syndrome ARH Adolescent Reproductive Health AU African Union HIV Human Immunodeficiency Virus HPV Human Papilloma Virus ICPD International Conference on Population and Development IEC Information, Education and Communication MCH Maternal and Child Health MMR Maternal Mortality Ratio NGO Nongovernmental organization OAU Organization of African Unity STDs Sexually Transmitted Diseases STIs Sexually Transmitted Infections UN United Nations UNICEF United Nations Children's Fund UNFP United Nations Population Fund WHO World Health Organization ACRONYMS AND ABBREVIATIONS P3 Young people of today are the adults of tomorrow. They are a very important human resource and make significant contributions to the development of the community. They also have developmental and health needs that must be addressed. Today's world offers remarkable opportunities for adolescents but also exposes them to a variety of health problems and challenges. If their energies are properly channeled, if they are encouraged to realize their full potential, if they are supported through their growing years with knowledge and skill to grow to healthy and responsible adulthood, the world will be the better for it. The WHO African Region has recognized the special health and developmental needs of adolescents. More importantly, it has recognized that young people must be involved in shaping and determining their own destiny and that of others, and that all sectors must collaborate for meaningful results to be achieved. This is evidenced by the adoption of the Adolescent Health Strategy (AFR/RC51/R3) by the Regional Committee at its fifty-first session held in Brazzaville, in September, 2001. As a follow-up to the strategy document, AFRO has prepared this briefing kit on Adolescent Health and Development in the African Region. Its aim is to provide basic information for developing, strengthening and implementing policies and programmes on adolescents/youth. The objectives of this publication are to promote the understanding of the challenges affecting the health and development of adolescents; to strengthen the capacity of countries to meet the health and development needs of adolescents through the active participation of adolescents, families, communities, religious institutions and other relevant organizations; to encourage adolescents' participation in programme activities pertaining to their health; and to promote multi-sectoral actions for holistic adolescent health and development. PREFACE Briefing Kit - PREFACE The health problems and needs of adolescents constitute a challenge to society. They also offer a variety of opportunities to contribute to fostering healthy development of these young people so as to ensure a better future for all. It is hoped that all who are interested in promoting the health and development of adolescents health workers, parents, policy makers, politicians, teachers, religious organizations, youth- serving organizations and, most especially, adolescents themselves will find this document useful. The future is promising for adolescents and youth. While the challenges are evident, the potential is far greater. Concerted effort is needed to enable adolescents to be healthy and to harness their energy and potential for the greater good of all. Such efforts will empower adolescents to be creative, and to shoulder the responsibilities demanded of them in the 21st century. 4 Adolescent Health and Development in the African Region: Challenges and Opportunities IAdolescence is the period of transition from childhood to adulthood. It is the formative period when significant physiological, physical, psychological, and behavioural changes take place in young people. It is also a time of preparation for undertaking greater responsibilities; a time of exploration, experimentation and widening horizons; and a time to ensure healthy all- round development for the adolescent. It is characterized by growing self-confidence, as adolescents transit from childhood dependency, try to assert their independence, and move towards adulthood inter-dependence. Adolescence is the period of life spanning ages 10 to 19 years. The term “youth” refers to individuals aged 15-24 years while the broader term “young people” is used for individuals aged 10 to 24 years. Sub-Saharan Africa has one of the world's youngest populations. At the beginning of the 21st century, about one out of every four persons is 10 to 19 years old. This is the largest group of adolescents ever in the Region. Development, in the context of adolescents, involves all aspects of human development. Young people's health is central to their development and it has a significant impact on national development which, in turn, is critical to addressing problems like poverty that undermine young people's health. Youth are a valuable resource for socioeconomic and cultural development. Unfortunately, their energies and resourcefulness are not yet fully appreciated and reflected in national development policies and programmes. The perception of adolescents as generally healthy has changed due to a better understanding of the adaptation processes that they undergo. It is evident that adolescents are vulnerable and at risk of ill health (morbidity) and death (mortality), as they are exposed to various health INTRODUCTION 5 Briefing Kit - INTRODUCTION problems and challenges associated with their stage of development. The health problems of adolescents are usually caused by unhealthy environments, inadequate support systems for promoting healthy lifestyles, lack of accurate information, and inadequate or inappropriate health services. Adolescents' sexuality and reproductive health are generally not well addressed. As a result, they are exposed to problems like unwanted pregnancies, complications of unsafe abortion, and sexually transmitted infections, including HIV/AIDS. Other common adolescent health problems include malnutrition, injuries and disability as a result of risk-taking activities, and mental illness such as depression and psychosis which can lead to suicide and violence. The health of adolescents is to a large extent determined by family environments that provide the immediate basic needs for shelter, food, education, health care and spiritual values necessary for character building as well as by schools and the work environment. The influence of peers and the wider community can promote health and well being in the adolescents or create unsafe and hostile conditions detrimental to health and development. Preventive health interventions and actions to promote adolescent development can build the adolescents' capacity to develop individual social and life skills and competences to offset negative social influences. This is particularly true of interventions that help them to feel appreciated, have belief in their own worth, know their rights and responsibilities and have a sense of belonging as well as hope in the future. 6 Adolescent Health and Development in the African Region: Challenges and Opportunities DThe second decade of life is a period of rapid growth and personal development during which individuals acquire the competence needed to adapt to a diverse and changing world. During the period, adolescents undergo certain growth and developmental processes that are characterized by physiological, physical, psychological, and behavioural changes and the development of competences. General principles and tasks of adolescent development Principles Development in adolescence and youth follows the general principles underlying all human development. These principles can be briefly stated as: • Development involves the gradual replacement of simple by complex structures and functions. • Development is both continuous and intermittent, that is, some steps are dependent upon previous development, and some attributes and functions develop fairly independently of past experience and established structures. • Development is dependent upon interaction between genetic and environmental factors. • The developmental processes are characterized by periods of rapid change, interspersed with phases of apparent loss of momentum which, at times, appear to be regression to earlier patterns of behaviour. • Development is often uneven. Sometimes, the biologically influenced early/delayed maturation of a young adolescent may lead people to have social expectations of him/her that are out of proportion to the age. DEVELOPMENTAL PROCESSES IN ADOLESCENCE: PRINCIPLES AND TASKS 7 Briefing Kit - DEVELOPMENTAL PROCESSES IN ADOLESCENCE: Principles and Tasks 8Developmental tasks Cultural factors influence the range and performance of the developmental tasks of adolescents. In some cultures, these tasks are taken up in early adolescence; in others, the opportunity to embrace those tasks may be delayed until middle adulthood. Included among these developmental tasks are the following: • Adaptation to the physiological and anatomical changes associated with puberty and the integration of a mature sexuality into a personal model of behavior; • The progressive reduction of earlier forms of attachment to parents and family, and development, through peer relationships, of an enhanced capacity for interpersonal intimacy; • The establishment of an individual identity incorporating a sexual identity and adaptive social roles; • The utilization of enriched intellectual capacity; • Acquisition of a sense of community and a 'world view'; • The development of potentials for occupational and leisure activities with a gradual commitment to those that are relevant to both the individual and the community. Usefulness of the concept of developmental tasks The concept of developmental tasks • Leads to a better understanding of patterns of progressive development in adolescence; • Facilitates comparisons of individuals and groups of adolescents against developmental baselines. • Provides a logical basis for understanding adolescent disorders, disabilities, and problems as being determined by, or shaped through, failures in the developmental process; • Helps adolescents not only to develop but to understand and respond better to explanations of their problems. Adolescent Health and Development in the African Region: Challenges and Opportunities Stages in adolescence When dealing with young people, one must realize that there are recognizable differences between early and late adolescence. Early adolescence (10 – 14 years) During early adolescence, boys and girls: • Develop a capacity to make commitments in personal relationships, in the vocational sphere and in other social contexts; • Begin to feel more or less like adults; • Become concerned about their appearance; • Develop feelings of invincibility (i.e. They feel that they can take risks and no harm can come to them;) • Want to have more freedom and independence from parents; • Become very concerned about what their friends think about them; • Begin to have sexual feelings and a desire to go out and be popular. • In the case of girls, they may experience their first menstrual period. Late adolescence (15 – 19 years) In late adolescence, boys and girls: • Progressively assume greater personal responsibility in relation to parental control; • Actively commit themselves to working with established social structures. • May have experienced most of the changes of puberty by age 16-18. • In the case of boys, they experience sexual stimulation in their dreams, resulting in ejaculation - “wet dreams.” 9 Briefing Kit - DEVELOPMENTAL PROCESSES IN ADOLESCENCE: Principles and Tasks C10 CHANGES DURING ADOLESCENCE Adolescence is a time for significant changes that include the adolescent growth spurt, in which the size and shape of the body change markedly and the differences between boys and girls become more obvious. This period is also the time when psychological and behavioural development takes place. In particular, it is the age of puberty when the reproductive capacity of the adolescent is established and when moral independence and a questioning attitude emerge. Physiological changes Physiological changes precede and set in motion the physical, psychological, emotional and behavioural changes that occur in the adolescent. During this period, the pituitary gland located in the brain triggers the adrenal gland to produce certain hormones which bring about significant changes in the body of the adolescent person. This is when puberty begins. The changes experienced by young people at this time include: • Rapid growth; • Full growth of the ovary and production of the ovum in the girl; and the growth of testicles and production of sperms in the boy; • The initiation of ovulation in the girl and ejaculation in the boy. In the girl, • Puberty begins. • The ovary begins to produce the ovum around 11 to 14 years, or earlier, once every month; • The ovum produced by the ovary is released and the uterus prepares itself for fertilization; Adolescent Health and Development in the African Region: Challenges and Opportunities • If fertilization does not take place, menstruation occurs. The cycle of menstruation begins; • The vagina starts to produce secretions; • The ovary produces the female hormones, called oestrogen and progesterone, which are responsible for the development of the external manifestations of the feminine sex in the girls (hips widen, the breast and the nipples get bigger and the feminine body shape emerges, etc.) The capacity to conceive is reached before the completion of physical growth and psycho- social maturation. Adolescent girls need to know that, after their first menstruation, they can become pregnant if they have sexual intercourse with a boy or man. Pregnancy is also possible before the first menstruation, as the first ovulation happens before the first menstruation. In the boy, • Puberty usually comes later than in girls; • The matured testicles produce the male hormone called testosterone which is responsible for the development of the external manifestations of the male sex (increase in the size of the genitals, deepening of the voice, the male body shape, etc.) • The testicles produce sperms and seminal fluid. (The release of the fluid containing the sperms, associated with sexual arousal, is referred to as ejaculation.) Physical changes In the girl, • Height and weight increase remarkably. • Hair in the armpit and in the pubic area grows thicker. • Armpit hair and perspiration from sweat glands may cause body odour. • Pimples may develop from increased oils on the skin. • Breasts and nipples get bigger and may become sensitive. • Hips widen, giving a feminine body shape. 11 Briefing Kit - CHANGES DURING ADOLESCENCE In the boy, • Rapid growth occurs. • The voice changes or deepens. • Hair grows on the chin and face, followed by hair on the chest, and increase of hair on the body, including the pubic region. • Pimples may develop • Skin problems may emerge • Muscles increase in size and strength. • The penis and scrotum increase in size. • Sweating increases. • Occasional erection of the penis occurs, particularly early in the mornings. • Occasional wet dreams occur at night due to involuntary ejaculation. The capacity of an adolescent boy to make a girl pregnant is reached before psycho-social maturation (e.g. ability to form lasting emotional attachments) and economic independence are achieved. Once they reach this stage, adolescent boys can impregnate girls if they have sexual intercourse with them. It is important to note that boys can produce sperms constantly and so are able to impregnate girls any time they have intercourse with them. Psychological changes Young people experience marked psychological changes during adolescence. The important change is the development of a sense of identity. This means, to some degree, the adolescent drawing apart from older members of the family, developing more intense relationships with peers, and taking important decisions. He/she also gradually moves from involvement with groups of the same sex (in early adolescence) to mixed groups, and may develop relationships with persons of the opposite sex (in late adolescence). Girls may start experiencing interest in the opposite sex earlier because they mature sooner than boys. 12 Adolescent Health and Development in the African Region: Challenges and Opportunities During adolescence, young people's thinking moves from the concrete to the abstract. They experience wide swings in mood. They also begin to express ideas of their own and to think seriously about who they are and the meaning of life. An orientation and a vision of the future develop progressively in their thinking and they begin to set goals for the future. During this period, young people develop moral awareness and learn to consider alternative courses of action and their consequences. This is also a time when they begin to explore new interests and influences that could mould their thinking, ideas and actions. Support and understanding from family members, the community, teachers and others during this phase is crucial in enabling adolescents to meet the challenges of life. Behavioural changes Adolescence is a time for exploration and discovery of one's own body, capabilities and potential. During this period, young people look beyond their relationships with their parents and families and begin to form other relationships with their peers and other adults in their communities. This exposes them to new influences, experiences, and pressures which encourage them to experiment with new behaviours. Behavior during these years could range from exploring sexual relationships to experimenting with alcohol, tobacco and other substances. Adolescents may be tempted to emulate their role model characters in the media, sometimes with disastrous consequences. Peer pressure may also lead them to practise unprotected sex, drop out of school, drive dangerously or adopt unhealthy eating habits. They can also experience conflict with peers and older persons because of differences in ideas and values. The adolescent years are truly a period of great creativity, empathy and idealism, and a period for acquiring new experiences, ideas and skills. It is the period when young people feel stimulated and get involved in a variety of new activities, physical and artistic. They begin to demonstrate their talents in music, writing, fine art, etc., and participate in competitive sports. 13 Briefing Kit - CHANGES DURING ADOLESCENCE RRelationships Young people develop different kinds of relationships during adolescence. These include relationships with: • Parents, • Other family members and others close to the family, • Peers of the same sex, • Peers of the opposite sex, • Other adults outside the family. Relationships with parents and others in the family begin at childhood. During adolescence, there is a shift from these childhood relationships to new ones with peers and other adults outside the family. This shift may give rise to conflict between the adolescent and the family. However, experience shows that adolescents continue to value their family relationships, even as they cultivate new ones. Parents should recognize these shifts in relationships as normal and be supportive. During this stage, parents should: • Listen to adolescents (They want their views to be heard and need explanations and clarifications). • Respond truthfully to adolescents' concerns. • Offer guidance without being too judgmental. RELATIONSHIPS, SEXUALITY AND LOVE 14 Adolescent Health and Development in the African Region: Challenges and Opportunities • Be understanding • Be sympathetic • Be tolerant • Show confidence and trust in adolescents • Make them feel they are appreciated, respected and loved. Relationships should be characterized by respect for each other and a sense of responsibility. Sex, sexuality and sexual health The terms “sex”, “sexuality” and “sexual health” need to be defined to avoid any confusion in their understanding and usage. Sex refers to the totality of biological characteristics that define human beings as females and males. Sexuality refers to an important element of being human, which includes sex, gender, sexual and gender identity and roles, sexual orientation, eroticism, emotional attachment/love and reproduction. It is experienced or expressed in thoughts, fantasies, desires, beliefs, attitudes, values, activities, practices, roles and relationships. Sexuality is the result of the interplay of biological, psychological, socio-economic, cultural, ethical and religious/spiritual factors. While sexuality can include all these aspects, not all of them need to be experienced or expressed. However, in sum, sexuality is a core aspect of our personality and is experienced and expressed in all that we are, feel, think and do. Sexual health is the experience of the ongoing process of physical, psychological, and socio- cultural well being related to sexuality. Sexual health is evidenced in the free and responsible expressions of sexual capabilities that foster harmonious personal and social wellness, enriching individual and social life. It incorporates freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationship. 15 Briefing Kit - RELATIONSHIPS, SEXUALITY AND LOVE Love There are different types of love: love for parents, love for siblings and acquaintances and love for persons of the opposite sex. It is during adolescence that young people begin to demonstrate interest in the opposite sex. This interest is characterized by intense feelings which they sometimes cannot understand or control. Such feelings usually do not last long. Young people at this time usually confuse love with infatuation. Table 1 highlights the differences between love and infatuation. Table 1 16 LOVE Love grows gradually between two persons. Love is based on knowledge. Love involves the entire personality. Love kindles kindly feelings towards others. It makes the other person happy and improves his/her disposition. Love thinks of the other person. It desires to protect the person and to do things to make the person happy. Love is trustful, calm, secure, hopeful and self- confident. Love says, “We want it forever. We can afford to wait. Nothing can happen to our love for each other.” Love causes one to be proud of the other person and eager to introduce him or her to others, including parents and other adults. In love, physical expression has tender meaning and comes slowly, naturally and sincerely. Each person respects the mind and body of the other person. True love tends to occur in late teens or early twenties or any time after. INFATUATION Infatuation happens suddenly after a casual meeting between two persons. They immediately think they are in love. Infatuation is narrowly based on a few attractive points about each other, not on deep knowledge of each other. Infatuation is superficial. Infatuation is selfish, self-indulgent, and self- centered. A person becomes indifferent and disagreeable towards others who do not understand his/her feelings. Infatuation tends to exploit the other person for personal pleasure, security or selfish satisfaction. Infatuation is insecure, distrustful, jealous and fearful. Infatuation or passion says, “We have only tonight. Let's live it up or let's get married now!” Infatuation is often embarrassed about the relationship and secretive with parents and others. In infatuation, physical contacts are common and tend to be the end. The relationship lacks meaning and it is the thrill of personal gratification that matters. Infatuation tends to be more frequent among young adolescents. Adapted from: Curriculum Guide and Resource Manual for Family Life Education, World Scout Bureau Adolescent Health and Development in the African Region: Challenges and Opportunities DDuring adolescence, young people develop certain competences which are required for coping effectively with the challenges of life. There are two types of such competences – life skills and livelihood skills. Life skills are adaptive and positive behaviours that enable individuals to deal effectively with the demands and challenges of everyday life. The core life skills include: • Decision making • Problem solving • Creative thinking • Critical thinking • Effective communication • Inter-personal relationship skills • Self awareness • Self-esteem • Empathy • Coping with stress • Emotions • Sense of belonging and connectedness • Spirituality • Responsibility and autonomy DEVELOPMENT OF COMPETENCES 17 Briefing Kit - DEVELOPMENT OF COMPETENCES Livelihood skills are practical skills and attitudes which enable individuals to identify and take advantage of opportunities for economic security. Livelihood skills include: • Functional skills • Vocational skills • Practical skills and attitudes • Employability skills • Management of time and money • Understanding career options • Ability to deal with other people in work-related relationships. The family and the community must provide opportunities to ensure that adolescents attain optimal development of these essential competences. 18 Adolescent Health and Development in the African Region: Challenges and Opportunities CDuring adolescence, young people are vulnerable to a wide variety of problems and challenges, which could have significant consequences for their health and development. These include adolescent pregnancy, abortion and its complications, and sexually transmitted infections. Some health problems of the adolescent result from childhood infections; others originate during adolescence itself and may have lifelong consequences. Problems originating in childhood affecting adolescent health Problems which originate in childhood and affect the health of adolescents include: • Foetal malnutrition and low birth weight which cause health problems throughout adolescence. They can result in stunted growth, low body mass index, micro-nutrients deficiencies and anaemia during pregnancy. • Repeated cases of diarrhoea and respiratory diseases which may also lead to failure to attain optimal adult growth. Adolescent girls who do not achieve their full growth potential are at a greater risk of having low-birth-weight infants and of child-birth complications due to having small pelvis. COMMON HEALTH PROBLEMS IN ADOLESCENCE 19 Briefing Kit - COMMON HEALTH PROBLEMS IN ADOLESCENCE • Infections such as poliomyelitis which may result in permanent disability. Brain damage during delivery (perinatal asphyxia) or as a result of infections, as well as infections of the central nervous system, can result in disorders of sight, hearing, and speech impediments, affecting performance, self-esteem and personality development in adolescents. • Inadequate food and care in infancy, child marriage, sexual abuse or child prostitution which can seriously affect physical, mental and social well-being in adolescence. • Congenital and acquired defects and disabilities. Other problems in adolescence with lifelong health consequences : • Use of tobacco, alcohol, and other harmful substances; • Unprotected sexual intercourse. • Other risk-taking behaviour such as dangerous driving, accidental/intentional injury or violence. • Improperly treated infections, such as sore throat, ear infections, urinary tract infection. • Harmful traditional practices, such as female genital mutilation. • Inadequate social support systems for adolescent mothers, which may make them become social outcasts. Maternal mortality is three to four times higher in adolescents than in adults. Reduction in maternal mortality can only be achieved if the issues of adolescent sexuality and pregnancies are addressed. *Source: Adapted from; The Second Decade: Improving adolescent health and development. WHO/FRH/ADH/98.18 20 Adolescent Health and Development in the African Region: Challenges and Opportunities PPregnancy in adolescence: risks and challenges The problem of adolescents becoming pregnant and having babies is common in sub-Saharan Africa. In many of the countries of the region, at least 30 per cent of 18-year old adolescent girls are already mothers or are pregnant with their first child. Many adolescent girls, however, are not biologically, psychologically, economically and socially prepared for bearing and rearing children. The tradition of early marriage and consequent childbearing among girls which still prevails in many countries of the African Region, therefore, puts the health of young girls at high risk and exposes them to a number of challenges which they may not be prepared to cope with. These risks and challenges include: • Adolescent pregnancy, which is likely to be concealed for as long as possible, jeopardizing both the mother's health and the unborn infant. • Since the subject of adolescent sexuality remains taboo in most societies, there is widespread ignorance among young people of the risks associated with unprotected sexual activity. Sources of accurate information and contraceptive advice are rarely available to them. • Anaemia during pregnancy, retarded foetal growth, premature birth and complications during labour which are all significantly higher for the adolescent mother, as are the risks of her own death during pregnancy or childbirth. PREGNANCY AND ABORTION 21 Briefing Kit - PREGNANCY AND ABORTION • Failure to meet the increased nutritional requirements imposed by pregnancy which may result in stunted growth and damage the adolescent girl's future health. • Some complications of adolescent pregnancy, including abortion, vesico-vaginal fistula and infertility which may result in rejection by husband, family and society. • Motherhood in adolescence which usually means an end to education, training and economic opportunities for the female adolescent. The health of the adolescent mother and the survival of her baby In many African countries, significant numbers of adolescents die as a result of pregnancy or suffer pregnancy-related disabilities. The common causes of death among adolescent mothers include complications of abortion, obstructed labour and pregnancy - induced hypertension (eclampsia). The estimated number of maternal deaths in the world in 1995 was 515,000. Over half of these (272,000) occurred in Africa and majority of them were adolescents due to the immaturity of their bodies, especially their reproductive organs, and their tendency to seek illegal abortion. The babies of adolescent mothers also suffer a similar fate. They have lower survival prospects than the babies of older women. In addition, they face higher chances of serious illness and disability. Adolescent pregnancies are also associated with low infant birth weight that may result in disabilities, such as mental retardation and cerebral palsy. Abortion and complications of abortion Adolescents are more prone to unwanted pregnancies than adult women. This is because they lack information and knowledge on how pregnancy occurs and access to accurate information and services on contraception. Also, pregnancies occur because, more often than not, sexual activity among adolescents tends to be impulsive and unprotected. Abortion One of the results of adolescents' lack of knowledge of and failure to use modern contraception is the practice of induced abortion which is illegal in much of the Region. Studies reveal that illegal, unsafe and induced abortion is now a widespread practice among adolescent girls in sub-Saharan Africa. 22 Adolescent Health and Development in the African Region: Challenges and Opportunities Termination of unwanted pregnancy through induced abortion is a great risk to the health and life of an adolescent girl. Adolescents are often desperate about the consequences of unwanted pregnancy and seek induced abortion from unqualified practitioners in clandestine and dangerous circumstances, even when they might have had legal access to better and safer facilities. All abortions carry a risk. They may result in a range of complications such as: • Bleeding • Shock • Infection • Damage to reproductive organs • Tetanus • Sterility • Death Complications from unsafe abortions can have a devastating impact on an adolescent girl's health and well-being. Studies conducted in the 1980s and 1990s in a number of African countries revealed that up to 68 per cent of women seeking hospital care for abortion-related complications were adolescents. Another study conducted in one of the countries of the Region revealed that 60 per cent of abortion-related deaths occurred among those under the age of 20. Preventing pregnancy among adolescents Pregnancy among adolescents can be prevented through certain measures. Some common ones are: Counseling Counseling can contribute to clarifying for adolescents issues relating to sex and pregnancy and enable them to take more advantageous decisions. Effective counseling may help to prevent pregnancy through appropriate means, such as abstinence and use of contraceptives, including condoms. 23 Briefing Kit - PREGNANCY AND ABORTION Through counseling, young people may also be made to realize that pregnancies during adolescence are very risky and could lead to complications and death. In addition, counseling can help them to understand the social and economic implications; for example, that becoming a mother in adolescence usually means an end to education, training and economic opportunities. All efforts at counseling should, therefore, advocate the avoidance of premature sexual relations and pregnancy in adolescence. In recent times, some cities have begun phone-in help lines where trained counselors answer questions and the anonymity of the caller is assured. Adolescents are finding these resources useful. Education and information Information, education and communication (IEC), if appropriately used, can play an important role in preventing adolescent pregnancies. Adolescents should be encouraged to seek information about sexual issues from their parents, teachers, or any other knowledgeable adult they respect and trust. Various institutions and organizations also need to play a more active role to prevent pregnancies and deaths due to pregnancy among adolescents. Medical professional groups and health workers, in particular, have a duty to provide adequate relevant information on sexual health to adolescents. Schools and educational institutions should give due attention to sex education while libraries should provide good informative books on the subject. Similarly, the media should endeavour to provide accurate information on sexual issues and desist from publishing or broadcasting pornographic material. The role of other community-based organizations, such as religious organizations and relevant NGOs, is also important. They should provide relevant information and education on sexual health to adolescents. Delaying age at marriage Marriage in adolescence often leads to early pregnancies. Therefore, delaying marriage until adulthood will prevent pregnancies, with their associated risks, among adolescents. 24 Adolescent Health and Development in the African Region: Challenges and Opportunities Abstinence Abstinence, that is, abstaining from sexual intercourse, is the most effective way of preventing pregnancy in adolescence. Young people should, therefore, be counseled to ensure that their relationships with the opposite sex do not involve sexual intercourse. Contraception Postponing the first birth or preventing unwanted pregnancies can be done through the use of contraception. Some of the contraception methods suitable for young people are: abstinence, condoms and oral contraceptives (pills). However, adolescents should know that condoms may break or have holes in them and, so, are not effective some of the time. Prevention Measures that can be taken by the authorities at the community and national levels to prevent adolescent pregnancy and its attendant risks include: • Promotion of formal education for the girl-child; • Encouragement of non-formal education for out-of-school girls; • Provision of vocational training for livelihood skills acquisition; • Expansion of accessibility to youth-friendly services; • Creation of awareness at community level on the dangers of child marriage and adolescent marriage; • Enhancing sexual education among boys, especially on the risk of pregnancy; • Counseling boys to avoid physical contact in their relations with girls; • Support for community initiatives geared towards understanding the problems and prevention of adolescent pregnancy; • Encouragement of partnerships between parents, young people, health workers, teachers, etc. • Expansion of job opportunities and support for income-generating activities for adolescent girls and boys. 25 Briefing Kit - PREGNANCY AND ABORTION SA major consequence of unprotected sex in adolescence is the likelihood of contracting sexually transmitted infections (STIs). There are more than 20 STIs. Among the major ones are gonorrhoea, chlamydia, syphilis, herpes, HPV (Human Papilloma Virus) and HIV/AIDS. High-risk groups for STIs Adolescents are especially vulnerable to STIs because of their high-risk behaviour. Among the groups most vulnerable to them are young adolescents of both sexes who engage in unprotected sexual activities. Females naturally run a greater biomedical risk to begin with. This risk is increased in adolescent girls because their bodies are still immature and when they indulge in having multiple partners. Complications and consequences of STIs Complications of STIs tend to be serious and the consequences may last for life. Contracting a sexually transmitted infection during adolescence may cause infertility in future. It also contributes to a high proportion of spontaneous abortions, premature birth and pelvic inflammatory diseases, affecting mostly those in the 15-24 year age group. Pregnancy outside the womb (ectopic pregnancy) is another life threatening consequence of STIs in women. In men, retention of urine due to narrowing of the urethra may occur. Genital herpes, HPV and AIDS are presently incurable and can cause severe psychosocial effects as well as death in the case of AIDS. HPV is largely responsible for both cervical and penile cancers. SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS 26 Adolescent Health and Development in the African Region: Challenges and Opportunities Preventing STIs and HIV/AIDS: Options for adolescents Adolescents are particularly at risk of STIs because of their high-risk behaviour and greater biological susceptibility. The younger the girl is, the greater the risk, especially if she is forced into sexual intercourse. However, a number of simple options are available to adolescents for preventing infections. They include: Abstinence Abstinence means abstaining from sexual intercourse until marriage. It is 100% effective in preventing STIs and HIV/AIDS contracted through sexual intercourse. While it may be a hard decision to abstain from sex, time does prove that it is the best option for any adolescent. Safer sex Safer sex is the term used for close relationships that stop short of sexual intercourse, allowing boys and girls to remain virgins till marriage and marry an uninfected partner. Staying faithful to one uninfected partner for life is safe sex. Avoiding the habit of injecting drugs or sharing needles with drug users also prevents infection. Faithfulness If abstinence is not possible, then each adolescent should try to have a steady, long-term, monogamous sexual partnership in which both partners are completely healthy. This is also called safe sex. (Many adolescents are less likely to have sustained relationships, including sexual relationships. However, faithfulness always pays in the long run.) Condoms Another option for those who cannot abstain from sex is the use of condoms for protection. However, the condoms must be used consistently and correctly with every sexual act. Yet it must be emphasized, that one should not place too much faith in the condom because it is not 100% effective against both pregnancy and STIs/HIV/AIDS. 27 Briefing Kit - SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS Adolescents must always be conscious of the importance of preventing sexually transmitted infections and HIV. While many think that sex is romantic, the truth is there is nothing romantic about STIs like herpes, chlamydia, genital warts and HIV. Adolescents and HIV/AIDS The advent of HIV has added a new and deadly dimension to the problems of STIs and young people in Sub-Saharan Africa. Globally, more than half of new HIV cases occur among young women and men aged 15 to 24. An estimated 1.7 million young people aged 10 to 24 are infected annually. About one quarter of those with HIV are in their 20s and most of these must have contracted the virus during their teens. The rates of HIV infection in Sub-Saharan African countries are among the highest in the world, posing one of the most serious threats to the health and well-being of adolescents throughout the Region. In 1999, 65% of all new cases reported in Africa were among young people. Factors contributing to this gloomy picture include: • Ignorance • Early sexual activity • Breakdown of family structures and social support systems • Influence of the mass media • Inadequate IEC activities • Cultural practices • Poverty • Industrialization • Urbanization • Migration • Alcohol and substance abuse • Wars and conflicts • Myths about cures for HIV/AIDS 28 Adolescent Health and Development in the African Region: Challenges and Opportunities HIV prevalence among adolescent girls In a number of communities, researchers have found that adolescent girls are more likely to be HIV-infected than adolescent boys. Given these patterns, it must be true that many adolescent girls are infected by older men, rather than by boys their own age. A number of factors – social, cultural, and biological – contribute to the greater vulnerability of adolescent girls to HIV infection. Adolescent girls may be at a disadvantage in negotiating condom use or the fidelity of their partners because of age differences, economic disparities, and gender norms. In general, adolescent girls are often more prone to STIs than adult women because of the immaturity of their reproductive organs. HIV transmission is more efficient from men to women, indicating that adolescent girls may be more biologically susceptible to HIV than adolescent boys. As Table 2 shows, estimated HIV prevalence rates among young women aged 15 to 24 range from a low of 0.12 percent in Madagascar to a high of 25.76 in Zimbabwe. These findings suggest that HIV infection is widespread among adolescent girls in different settings. Table 2 HIV Prevalence Rates Among Women and Men Ages 15 24, End of 1999 29 Country Cote d'Ivoire Ghana Kenya Madagascar Mali Mozambique Senegal Tanzania Uganda Zambia Zimbabwe Estimated Range of Prevalence Rates Women (%) Men (%) 6.68 – 12.23 2.10 – 5.47 2.40 – 4.44 0.76 – 1.97 11.07 – 14.98 4.26 – 8.52 0.12 – 0.14 0.02 – 0.06 1.74 – 2.40 1.04 – 1.58 13.36 – 16.11 4.49 – 8.97 1.12 – 2.07 0.39 – 1.02 6.85 – 9.27 2.64 – 5.28 6.65 – 8.99 2.56 – 5.12 16.86 – 18.68 7.08 – 9.32 23.25 – 25.76 9.77 – 12.85 Source: UNAIDS, Report on the Global AIDS Epidemic June 2000. Briefing Kit - SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS HIV threat to boys The threat of HIV to adolescent boys in the Region is equally worrisome. In the case of boys, alcohol and substance abuse can lead to risky sexual behaviour, which may expose them to HIV infection. Boys are also susceptible to sexual abuse by older men and women, which may lead to HIV infection. Adolescents' knowledge of HIV/AIDS prevention Although many adolescents have heard of HIV/AIDS, fewer know of at least one way to prevent sexual transmission of HIV. More adolescent boys know how to prevent HIV infection than adolescent girls. It is, therefore, important to increase knowledge of how to prevent HIV infection among adolescent girls, in particular, and adolescents generally. Adolescents' beliefs and misconceptions about HIV/AIDS Among adolescents who have had sex, substantial proportions believe themselves to be at little or no risk of getting HIV/AIDS, especially adolescent males. Many sexually experienced adolescents wrongly believe that they are safe from HIV/AIDS. The reasons are: • They misunderstand what it means to have only one partner. (To them, this implies having one partner at a time, but having many partners over time.) • Their interpretation of abstinence may be different from its real meaning. • They have false confidence in their partners' sexual history. • They are ignorant of their partners' sexual history. • They use condoms, but do not use them consistently with every sexual act; and, sometimes, they use them incorrectly. References: • School health education to prevent AIDS and sexually transmitted diseases. WHO AIDS Series. No 792. 1990 • The reproductive health of adolescents. A joint WHO/UNFPA/UNICEF statement. 1989 • School health education to prevent AIDS and sexually transmitted diseases. WHO AIDS Series, No.10 1992 30 Adolescent Health and Development in the African Region: Challenges and Opportunities NOne potential source of adolescent health problems is the eating behaviour of young people. In many of the poorest countries of the world, malnutrition results from both shortages of food and inadequate intake of nutritious food. The dietary habits acquired during adolescence have important repercussions on health in both the short term and the long term. For example, insufficiency of minerals and vitamins may cause health problems immediately as well as later in adulthood. During adolescence, average weight doubles and height may increase by more than 15%. The demands of physical growth can only be met by a balanced intake of nutrients, and lack or excess of any element may lead to health problems later. In many low-income and middle- income groups, young people may become economically active before the age of 14 years and may be required to perform heavy manual or domestic labour, compounding the problems of inadequate diet. Poor nutrition is a particularly serious problem for the pregnant adolescent who has to cope with the double nutritional burden of her own growth and her pregnancy needs. There is evidence that the increased risk for very young mothers of having low-birth-weight infants is the result of low calorie intake or strenuous physical work during pregnancy. Another serious diet-related health problem that is just emerging in Africa, is that of increasing consumption of “fast” foods. Young people are often attracted by processed and refined foods which are sometimes advertised as reflecting a modern way of life. Such foods are often high in fats and sugars and low in other essential micronutrients. This behaviour can also result in loss of interest in more complete foods. Prolonged eating of such foods may lead to early physiological changes and diseases which will adversely affect the adolescents' health and development. NUTRITIONAL PROBLEMS 31 Briefing Kit - NUTRITIONAL PROBLEMS On the other hand, in some countries whose populations suffer from under nutrition, there are also problems of over consumption of particular nutrients by some groups. As a result of these abnormal developments in the pattern of consumption, diet-related non- communicable diseases, such as diabetes and heart diseases, which, in the past, were considered to be “diseases of affluence” are increasing rapidly in Africa. Very little is known about young people's food intake generally. However, the evidence that is available indicates that even where intake of calories and protein is sufficient, shortages of other elements such as iron, calcium and some vitamins may be relatively common. Adolescents need additional supplies of iron for the stabilization of haemoglobin while their blood volume expands during growth. Young women, in particular, need more iron to make up for menstrual losses. It has been estimated that adolescents need twice as much iron as adults of comparable weight. Some consequences of shortage of minerals may not be apparent until adulthood. For example, calcium is essential for sound bone formation in adolescence and young adulthood. Insufficient intake during youth could be a cause of osteoporosis (brittle bones) in later life, particularly among women, and it cannot be remedied by increased consumption later. Undernourishment results in low energy which can limit physical activity. It also reduces the ability of young people to resist infection and makes them prone to sickness, low concentration at school, missing school and poor academic performance. Evidence suggests that dietary factors may be responsible for up to half of all deaths due to cardiovascular diseases and between one third and half of non-insulin-dependent diabetes. A decrease in the fat, sugar and salt content of many “modern” diets will have a major impact on the reduction of cardiovascular diseases, hypertension and diabetes. There is also good evidence that such a change in diet will result in reduction in other diseases of adult life, such as cancer of the colon. Obesity is also a risk factor for a range of conditions, including heart diseases, diabetes mellitus, arthritis, gall bladder disease, and some cancers. Concern about obesity is particularly acute among adolescents because of their increased interest in their appearance and the loss of self-esteem associated with poor self-image. 32 Adolescent Health and Development in the African Region: Challenges and Opportunities Poor eating habits can also lead to acne (although these are not the only cause) which is particularly worrying to young people. The importance of the social and psychological aspects of eating behaviour is demonstrated by the increasing prevalence among girls in some countries of compulsive dieting in an effort to lose weight. Another aspect of the problem is its effect on the adolescent's oral health. Unhealthy eating combined with poor oral hygiene can lead to damaged teeth and gums. These are not only health problems in their own right but they are also a source of worry to young people, especially as they may affect the appearance and since they can lead to gum disease and premature loss of teeth in later life. Prevention of nutritional problems The responsibility for preventing nutritional problems among adolescents lies largely with the family, the community and national authorities. At the individual level The adolescent can prevent nutritional problems by: • Eating regularly food that is enough in quantity and is nutritious • Eating food that has balanced content of micronutrients, especially important minerals, like iron and calcium, and vitamins • Avoiding eating too much, which could lead to obesity • Not eating “fast foods” • Reducing the fat, sugar and salt content of their diet • Observing good oral hygiene. Family level At the level of the family, parents have to endeavour to: • Increase the availability of food (household food security); • Encourage adolescents to adopt healthy eating habits; • Address food taboos and gender-based misconceptions which affect adolescents. 33 Briefing Kit - NUTRITIONAL PROBLEMS Community level It is incumbent on the community to: • Support local farmers to improve basic food production, storage and preservation, particularly to ensure adequate supply for local consumption; • Involve the youth in food production; • Strengthen the implementation of nutrition education in schools; • Support community initiatives that offer young people skills for food preparation, preservation and storage. National level Government should develop and implement food policies that take into consideration the needs of adolescents along with the rest of the society. Programmes to combat under nutrition by improving sanitation, education and food availability, particularly for specific vulnerable groups, have contributed to significant decreases in wasting, stunting and death at an early age in various countries. 34 Adolescent Health and Development in the African Region: Challenges and Opportunities PAdolescents need to pay particular attention to personal hygiene because, at this stage of their development, there is increased body secretion and sweating which may make them have unpleasant and embarrassing odours and/or infections. Skin infections are also common in adolescence. Prevention These problems can be prevented through the following measures: • Adolescents should clean themselves daily with soap and clean water, not with corrosive/abrasive substances; • Boys and girls should take their baths daily, and change and wash their underwear and socks. • Adolescents should pay adequate attention to their oral hygiene i.e. clean their teeth at least twice a day (in the morning and before bed), reduce the consumption of sugar and avoid smoking. • Adolescents should wash their hands before eating and after using the toilet. • Adolescent girls should take extra care during menstruation. • Parents should provide adequate sanitary towels, privacy and disposal facilities for the adolescent girls; • The community must ensure adequate privacy, water and facilities for the disposal of sanitary towels, especially in schools, churches, mosques and other public places. PERSONAL HYGIENE 35 Briefing Kit - PERSONAL HYGIENE ASubstance A substance, in this context, is defined as any product that affects the way a person feels, thinks, sees, tastes, smells or behaves when he/she uses it (psychoactive substance.) Such a substance can be a medicine, such as morphine, or an industrial product, such as glue. Some substances are legal, such as approved medicines and cigarettes; others are illegal, such as cannabis, heroine and cocaine. Substance abuse Substance abuse refers to any non-medical use of a drug or any substance used to change the normal operation of the mind. It is also the excessive use of a medicine or an industrial material. Substance and drug use among adolescents The use of a substance or drug is a health hazard to adolescents. It has become particularly associated with the counterculture of the young rebelling and seeking new experiences. The practice has become an epidemic in some parts of the African Region. The following substances are among the common ones abused: • Alcohol • Tobacco • Cannabis or marijuana • Khat (in East Africa) • Petrol • Paints and thinners • Glue ALCOHOL AND SUBSTANCE USE AND ABUSE 36 Adolescent Health and Development in the African Region: Challenges and Opportunities The adverse consequences of drug abuse by the adolescents include dependence, overdose, accidents, physical and psychological damage and premature death. Why young people use or abuse substances There are many reasons why young people begin to experiment with harmful substances. These include: • Availability of such substances • Curiosity • Peer pressure • Experimentation • The thrill of engaging in forbidden activities • Escapism (a way of escaping from the harsh realities of life.) Drinking among adolescents is also associated with a variety of factors, including: • Poor relationships at home and at school • Heavy drinking by parents • Easy access to alcohol • Cultural practices • Active promotion through advertising • Peer pressure • Adolescents see drinking as o a symbol of maturity o a modern and sophisticated way of life o a way of gaining social approval o a sign of toughness, rebelliousness, attractiveness and sociability o a quick way to reduce anxiety o a way of having emotional relief 37 Briefing Kit - ALCOHOL AND SUBSTANCE USE/ABUSE Patterns of substance use and abuse The patterns of substance use and abuse vary greatly among adolescents. Among these patterns are: • Harmful use • Intoxication • Dependence • Withdrawal Harmful use Harmful use is a pattern of substance use that results in damage to physical or mental health. Intoxication Intoxication is a temporary state that follows the use of one or more substances resulting in a change in the person's alertness, thinking, perceptions, decision-making, judgment, emotions or behaviour. An intoxicated person is more likely to suffer from burns, suffocation, seizure, poisoning, overdose, sudden death, etc. Dependence This is a pattern of substance use in which the user always has a strong desire to take the substance and cannot control its use. As a result of it, substance use gains priority over other activities for the user. Tolerance Long-term use increases tolerance. Tolerance requires that larger amounts of the substance be taken for the individual to experience its effects. Withdrawal When a person stops taking a particular substance that he or she has been using regularly, he/she may experience adverse effects known as withdrawal symptoms. Common withdrawal symptoms of various substances are shown in Table 3. 38 Adolescent Health and Development in the African Region: Challenges and Opportunities Table 3 Effects of drug or substance use or abuse Drug or substance use/abuse can have a devastating effect on the health and development of adolescents if it is not detected and checked early. • Alcohol Alcohol is a depressant which inhibits or decreases some aspects of central nervous system activity (i.e., activity of the brain, spinal cord, and some other nerves). Alcohol dependence or alcoholism results in negative health consequences and creates social problems for the adolescent. Alcohol use can result in: o Inability to think properly, make correct judgments and exercise self control o Lack of coordination o Accidents o Memory loss 39 Substances Alcohol (beer, wine, spirits, etc.) Nicotine (present in cigarettes and other tobacco products) Opioids (codeine, heroin, opium, morphine) Hallucinogens Cannabis Hypnosedatives Stimulants (cocaine, caffeine which is present in coffee, cocoa, kola nut, etc.) Inhalants (glue, petrol) Withdrawal symptoms Anxiety, tremors, vomiting, sweating, convulsion, delirium, confusion and hallucinations. Nervousness, sleeplessness, abdominal pain, poor concentration, muscle cramps, headaches, cough, changes in appetite. Anxiety, sweating, muscle cramps, runny nose, vomiting, diarrhoea, sleep difficulty No significant withdrawal symptoms No or mild withdrawal symptoms Anxiety, irritability, inability to sleep, muscle cramps, convulsions, delirium Caffeine: headaches, tiredness, aches and pains, anxiety Amphetamines: fatigue, hunger, irritability, depression, suicidal feelings, sleeplessness. Cocaine: fear, depression, nausea, vomiting, tremors, muscle pain, tiredness. No significant withdrawal symptom Briefing Kit - ALCOHOL AND SUBSTANCE USE/ABUSE o Hangovers o Loss of appetite o Liver damage o Heart and central nervous system damage o Sexual impotence • Cigarettes Cigarettes and other tobacco products contain nicotine which is a stimulant that activates, enhances or increases central nervous system activity. It is addictive. Most smokers believe that cigarettes calm their nerves. This is incorrect. Studies have shown that smoking actually creates physiological stress, rather than relaxation. Some of the negative effects of cigarette smoking are: o Loss of sense of smell o Frequent colds o Coughing o Teeth discolouration o Bad breath o Gastric ulcers o Respiratory problems o Heart disease o Cancer of the mouth, throat, lungs, cervix and bladder. Smoking is particularly dangerous for adolescents because their bodies are still developing and changing and the poisonous chemicals in cigarette smoke can adversely affect this process. • Marijuana Marijuana or cannabis is one of the most widely used drugs in many countries and tends to be the first illicit drug adolescents use. Its physical effects on adolescents can be acute. 40 Adolescent Health and Development in the African Region: Challenges and Opportunities Its negative effects include: o Sleeplessness o Impaired or reduced memory o Distortion of vision, perceptions and emotion o Reduced ability to perform tasks requiring concentration or coordination o Dry mouth and throat o Decreased social inhibition o Paranoia, hallucinations o Increased risk of infertility o Diminished or extinguished sexual pleasure o Psychological dependence, with the person feeling like having more and more of the drug to get the same effect. • Cocaine Cocaine belongs to the group of drugs known as stimulants. It tends to give the user a temporary illusion of power and energy and later leaves him/her feeling depressed, edgy and craving for more. It is highly addictive. The negative effects of using any amount of cocaine include: o Violent, erratic or paranoid behaviour o Hallucinations o Confusion, anxiety and depression o Loss of interest in food o Loss of interest in friends, family, sports, hobbies and other activities o Reduction of the body's ability to resist and combat infections o Hepatitis or HIV/AIDS through sharing needles with other users o Brain seizures (convulsions, fits) o Heart attacks, strokes and inability to breathe properly. 41 Briefing Kit - ALCOHOL AND SUBSTANCE USE/ABUSE • Opioids Substances in this group may act as analgesics (pain relievers) and depressants. Such substances include codeine (such as in some cough mixtures), heroin, morphine and opium. • Stimulants This is a group of substances that activate, enhance or increase central nervous system activity. Examples are caffeine (which is found in coffee, tea, cocoa and chocolate), cocaine and amphetamines (found in prescription drugs and some diet pills.) Prevention of substance use and abuse among adolescents It is in the best interest of adolescents, their families and society in general that young people never begin using harmful substances. Measures should therefore be taken by parents, the community and governments to prevent it. Individual level Adolescents should: • Resist the temptation to try using any substance • Resist peer pressure to try using any substance • Avoid the company of those who use any substance • Keep the company of those who do not want to use any substance • In their free time, engage in sports and other recreational activities. Family level Measures that can be taken by parents include: • Providing a safe and supportive home environment for adolescents • Providing adolescents with accurate information on the negative consequences of the use/abuse of alcohol and drugs • Preventing adolescents from having access to dangerous substances • Encouraging adolescents to avoid environments which may expose them to temptation to use these substances • Being good role models by avoiding the use/abuse of substances themselves. 42 Adolescent Health and Development in the African Region: Challenges and Opportunities Community level The community can make a significant contribution to saving adolescents from substance use/abuse by: • Providing community centres with adequate and supervised recreational facilities and activities for adolescents • Providing appropriate youth-friendly counseling facilities with qualified personnel • Providing libraries with up-to-date and relevant literature for adolescents • Supporting the establishment of anti-substance abuse clubs in schools and the community • Encouraging youth participation in the commemoration of international days against substance abuse and of youth days • Involving the youth more in various community activities to give them a greater sense of belonging and responsibility • Creating job opportunities and other productive activities for out-of-school adolescents. Government level Governments' role in preventing adolescents from falling into substance use/abuse includes: • Providing a safe and supportive environment in which the energy of adolescents can be channeled into positive activities • Improving the quality of education to enable adolescents develop their potential fully • Initiation and/or rigorous enforcement of legislation on the use/abuse of substances, especially tobacco and alcohol, in public places • Introducing and/or rigorously enforcing legislation to control advertising of tobacco and alcohol in the mass media. • Establishing youth-friendly rehabilitation centers to help those who may need assistance. 43 Briefing Kit - ALCOHOL AND SUBSTANCE USE/ABUSE VViolence and crime are increasingly becoming problems of adolescents in the Region, both as victims and perpetrators. Sources of violence The sources of violence include: In the home • Domestic violence • Gender-based violence In the community • Student disturbances in educational institutions • Communal clashes/ethnic conflicts • Politically-motivated clashes • Religious conflicts • Crime. At the national level • Wars Causes of violence The causes of violence involving adolescents include: • Vulnerability of adolescents • Misdirected energy on the part of adolescents • Lack of understanding of the causes and consequences of their actions by adolescents VIOLENCE AND CRIME 44 Adolescent Health and Development in the African Region: Challenges and Opportunities • Stress • Peer pressure/gang mentality • Availability of adolescents to be exploited or manipulated by adults • Violence on television • Lack of relevant life skills to cope with stress and resolve conflicts • Unemployment • Lack of recreational facilities. Prevention of violence and crime among adolescents At the individual level Adolescents can avoid being victims or perpetrators of violence by: • Avoiding situations which could lead to violence • Staying away from violent peers • Resisting pressure from adults to take part in activities which could lead to violence • Resisting the urge to be violent or settle disagreements in a violent manner • Being tolerant • Respecting others and self • Exercising self control • Getting involved in sports and other recreational activities • Avoiding watching violent films. At the family level Many behaviours which surface in adolescence stem from childhood experience. The family, therefore, has a key role to play in ensuring that children do not engage in violence and crime when they become adolescents. This role includes: • Purposeful parental guidance • Parents being good role models to their children • Promoting positive family values, e.g., tolerance, respect for others and self • Helping children to develop life skills, e.g., skills for coping with stress and dealing with misunderstandings and conflicts. 45 Briefing Kit - VIOLENCE AND CRIME At the community level Measures that can be taken at the community level to prevent violence and crime among adolescents include: • Reactivating traditional norms, values, and practices which promote non-violence and prevent crime, injuries and accidents • Strengthening institutions for preventing and resolving conflicts, such as elders' councils, disciplinary committees, student welfare committees, guidance and counseling services • Provision of spiritual guidance and moral education by religious bodies • Providing supervised recreational activities and facilities for adolescents At government level What the government can do include: • Re-orientation of rehabilitation and correctional institutions to adopt a more positive approach to the treatment of young people who are in conflict with the law • Promoting youth involvement in initiatives for preventing crime and violence • Improving the quality of education • Providing vocational training for adolescents • Providing employment opportunities • Encouraging the media to de-emphasize violence in their programmes • Implementation of relevant international conventions of the rights of the child in situations of conflict (e.g., the OAU Charter, the International Convention on the Rights of the Child). 46 Adolescent Health and Development in the African Region: Challenges and Opportunities MMental health is important to the healthy development of adolescents. Most adolescents experience normal emotional and mental development. However, mental health problems and disorders are becoming increasingly common among young people. This is because they are vulnerable to the kinds of stress that promote mental illness. It is during adolescence that some mental health problems first appear. Some of the more serious disorders that appear for the first time during this period may have their roots much earlier in life, but they are often not recognized and treated. Mental disorders among adolescents include: • Anxiety • Depression • Psychosis • Eating disorders • Substance abuse. Mental health problems in adolescents often lead to: • Suicide • Risky behaviour, such as unprotected sex and dangerous driving • Disruptive behaviour • Physical inactivity • Poor academic performance • School dropout MENTAL HEALTH OF ADOLESCENTS 47 Briefing Kit - MENTAL HEALTH OF ADOLESCENTS Depression Depression is common among adolescents. It is associated with irritability, fluctuating moods, deep unhappiness, sleeplessness, feeling of hopelessness and thoughts of suicide. These are not 'natural' reactions to the challenges of growing up, but signs of illness. Depression and other unrecognized mental disorders are linked to low self-esteem and stress, and have many seemingly “minor” causes such as: • physical abuse, • problems with parents • pressures related to excessive expectations • anxiety about identity, • pressures related to sexual problems • breakdown of intimate relationships • unwanted pregnancy, • poor academic performance • intense competition at school • unemployment • loss of purpose in life • HIV infection, • social isolation, • urban migration, Depression is also associated with the use of alcohol and illicit drugs, which, in themselves, may increase the likelihood of suicidal behaviour. There is a strong connection between depression and suicide among adolescents. Troubled adolescents usually try to send signals of despair, these often go unrecognized and untreated. Suicide In many countries, suicide rates among adolescents are on the increase. However, suicide is under-reported in Africa. Generally, for every completed attempt at suicide, there are at least 40 unsuccessful attempts. Young men are more likely to commit suicide than young women while more women attempt it. 48 Adolescent Health and Development in the African Region: Challenges and Opportunities It should be noted that some patterns of behaviour, like suicide attempts, drug and alcohol abuse and delinquency, are symptomatic of mental disorders. Also, some young people may be more vulnerable to stress than their peers. They include: • Members of racial, religious or ethnic minorities Those who have experienced significant loss, like bereavement, family disruption or parental rejection • Those subjected to excessive parental pressure • Those in institutional care (hospitals, prisons, orphanages, etc,) • Those suffering from physical or intellectual impairment owing to chronic physical or mental illness • Victims of physical, emotional or sexual abuse • Pregnant adolescents and teenage parents Consequences of mental disorders in adolescents Mental disorders among adolescents have serious consequences for those affected, their families and the community. They can: • Disrupt and distort the psychological, educational and social development of adolescents • Turn adolescents into liabilities to the family and the community • Make them become outcasts • Turn them into violent and criminal elements in society • Increase health costs of the family and the community • Result in premature death (suicide). Prevention of mental disorders in adolescents Mental disorders can be prevented among adolescents by taking appropriate measures, including: At the individual level • Avoiding use of harmful substances, e.g., alcohol, marijuana. • Talking to others, especially parents, about problems • Avoiding trying too hard to achieve goals that may be too high • Avoiding stressful situations. 49 Briefing Kit - MENTAL HEALTH OF ADOLESCENTS At the family level • Providing a caring and supportive family environment • Promoting positive relationships with siblings and peers • Ensuring that life for them is free of excessive stress, trauma, abuse, violence, neglect and discrimination. • Providing good living conditions • Accepting diversity among children and allowing them to be themselves. • Enabling them to develop life skills, such as critical thinking, coping with stress, communication, and negotiation • Providing them with accurate information and counseling on issues that may confuse them or that they have difficulty in understanding • Recognizing signs and symptoms of mental disorders early and having them treated • Providing appropriate care for physically and mentally challenged adolescents At the community level • Promoting positive relationships with peers, teachers and others • Providing them with opportunities to acquire education and vocational training • Providing employment opportunities • Providing adolescent-friendly health services and competent health personnel for the treatment of mental disorders • Providing appropriate facilities to enable physically and mentally challenged adolescents to live an active and fulfilling life. At the national level • Including the needs of adolescents in national mental health policy • Providing adolescent-friendly mental health services and workers • Improving the quality of education and access to it by adolescents • Integrating mental health promotion and life skills development into the school curriculum • Providing appropriate employment opportunities • Improving social and economic conditions for adolescents and their families 50 Adolescent Health and Development in the African Region: Challenges and Opportunities • Reducing violence and discrimination against adolescents • Initiating and implementing policies and laws that cater to the needs of physically and mentally challenged adolescents. References: • Accidents in childhood and adolescence. The role of research. M. Manciaux and C.J.K. Romerr, eds. 1991 • Prevention in childhood and youth of adult cardiovascular diseases: time for action. Report of a WHO Expert Committee. WHO Technical Report Series, No.792, 1990 • Young people's health – a challenge for society. Report of a WHO Study Group on Young People and “Health for All by the year 2000” WHO Technical Report Series, No. 731,1986 51 Briefing Kit - MENTAL HEALTH OF ADOLESCENTS GGender is used to describe those characteristics of women and men which are socially constructed, while sex refers to those which are biologically determined. People are born female or male but learn to be girls and boys who grow into women and men. This learned behaviour makes up gender identity and determines gender roles. Gender roles Society usually prescribes different roles for adolescent boys and girls and this practice affects their health and development in many ways. It results in differences and unfairness in the provision of opportunities and resources for them and in their ability to make decisions and exercise their human rights, including the rights to protect their health and seek care when they are unwell. Gender roles and unequal gender relations, plus other economic and social factors, result in different and, sometimes, unfair patterns of exposure to health risks and unfairness in access to and use of health information, care and services. These differences have a notable impact on the health of adolescents. In most African societies, adolescent girls are more at risk since more restrictions are placed on their behaviour and activities than in the case of boys. They may also be victims of societal discrimination, violence, sexual abuse or early marriage. The fact that external signs of maturity usually become apparent in girls earlier than in boys has been used to make them get married even when they are not yet physically or psychologically prepared for it. However, the mean age of marriage has been rising generally, especially among those attending school, while the age of puberty in both sexes appears to be falling. As a result, there is now a longer period during which premarital sexual intercourse may occur. GENDER AND SOCIALIZATION 52 Adolescent Health and Development in the African Region: Challenges and Opportunities Consequences of differences in gender roles The differences in the roles ascribed to boys and girls in the family and society influence how they are perceived by the rest of society and how they perceive each other. The consequences include unequal opportunities: • In education • In employment • In access to credit • In rights concerning inheritance • Before the law The practice of bringing up boys and girls differently and ascribing different roles to them is usually to the disadvantage of the adolescent girl, making her vulnerable and undermining her health and development. Such roles demand of the girl, among other things: • Submissiveness • Dependence on men for decision making • Subjection to certain food taboos • Accepting a lower status than the boy. Another aspect of the problem is the tendency of families in the Region to prefer sons to daughters. This always has adverse effects on the health and development of the adolescent girl because it results in discriminatory practices, such as: • Neglect of girls when they are sick • Girls being given less food than boys • Girls being made to do a lot of housework from a very young age • Less attention being paid to the education of the girl than that of the boy. In addition, boys and girls experience intense pressure during puberty, but the girl experiences greater pressure during this period. Usually, the movements and activities of girls are more restricted than those of boys and the boys are subjected to less guidance in sexual matters than girls. 53 Briefing Kit - GENDER AND SOCIALIZATION Boys and gender issues Most gender-related programmes have focused on the girl-child while the problems and needs of young males have been largely ignored. However, it is now being realized that the traditional practices are also having adverse effects on the boy-child and that he is also vulnerable. Adolescence is a particularly confusing period for boys, especially since little deliberate effort is made by parents to inform or educate them about sexuality and its implications. Boys receive ambiguous and confusing messages and are subjected to intense pressure “to be men” without being psychologically or economically prepared to bear the attendant responsibilities.They are also vulnerable to ill-health as a result of being exposed to risky behaviours, such as staying out late at night and experimenting with alcohol, smoking and sex. Prevention of gender inequalities The chances of adolescents growing up to become healthy, responsible and productive adults can be greatly enhanced if boys and girls are given equal opportunities, especially at home, at school and in the community, while recognizing their individual capacities. Girls and boys must be given equal access to: • Education • Opportunities to acquire life and vocational skills • Employment • Health services • Opportunities for self-expression • Protection under the law. 54 Adolescent Health and Development in the African Region: Challenges and Opportunities AIn the African Region, a substantial number of adolescents are living under difficult or special circumstances which affect their health and development negatively. In order to provide opportunities and services to adolescents equitably, there is a need to make deliberate efforts to reach the very vulnerable and disadvantaged ones who are forced to live under special or difficult circumstances and to ensure that their problems are understood and their needs met. Existing programmes and interventions do not adequately address these problems. Such adolescents include: • Street children, • Refugees, • Displaced persons, • Orphans, • Adolescents who are physically and mentally challenged, • Adolescents in conflict with the law, • Out of school adolescents • Sexually and physically abused adolescents Predisposing factors The factors which create these situations are social, economic or political. They include: • Civil strifes/armed conflicts which result in mass displacement of people, disruption of family life, and dislocation of social support systems. ADOLESCENTS UNDER DIFFICULT OR SPECIAL CIRCUMSTANCES 55 Briefing Kit - ADOLESCENTS UNDER DIFFICULT/SPECIAL CIRCUMSTANCES • Poverty, which denies adolescents opportunities to develop fully their intellectual potential and acquire vocational skills. It breeds environments where drugs and alcohol, crime, rape, violence and sexual exploitation thrive. It also denies adolescents access to health and educational services, while exposing them to ill health. • Family Discord (Disharmony) due to • Marriage breakdown • Violence in homes, • Single parents • “Busy” or absentee parents • Disintegration of the extended family system • HIV/AIDS • Economic migration • Natural disasters and complex emergencies. Consequences If the predisposing factors and their effects on health and development of these adolescents are not addressed, the negative effects will be experienced both during adolescence and in adult life. Health consequences • HIV/AIDS • STIs • Substance abuse • Malnutrition • Sexual abuse • Mental ill health (such as Suicide and Depression) • Poor hygiene • Unwanted pregnancy • Infant ill health and death • Abortion and its complications • Injuries 56 Adolescent Health and Development in the African Region: Challenges and Opportunities Social consequences • Sexual exploitation/Prostitution • Rape • Crime/Violence • Lack of education and livelihood skills • Poor sanitation and housing • Lack of food Economic consequences • Unemployment • Poverty • Additional burden on the economy It should be noted that these consequences go beyond the affected individuals; they also affect national development negatively. Preventive approaches 1. Governments preventing situations that expose adolescents to difficult circumstances. 2. Adolescent Health and Development policies and programmes taking into account adolescents under difficult circumstances. 3. Governments taking into consideration and assessing the magnitude and causes of the problem of adolescents under difficult circumstances and introducing appropriate interventions to deal with them. 57 Briefing Kit - ADOLESCENTS UNDER DIFFICULT/SPECIAL CIRCUMSTANCES CEffective solution to the problems that threaten the health and development of adolescents in the African Region requires a multi-sectoral approach, involving collaboration and partnerships at various levels. It calls for the active participation of the adolescents themselves; their families; the ministries of health, youth affairs and education; non-governmental organizations, the private sector, the mass media; other stakeholders; Member States; WHO/AFRO; and other UN and international agencies. The role of adolescents Involving adolescents in primary health care, as a strategy for improving their own health and that of their communities, is gaining increasing recognition. More than half the world's people are under the age of 25 years, and they constitute a formidable potential resource for health action. There are a number of other reasons why adolescents should be involved in the promotion of their own health and that of others: • Adolescents have always helped their families and communities. • Adolescents are contributing to the general welfare of their family or community, experiencing the rewards of helping others, working alongside adults and achieving social recognition. • Adolescents are often generous, open and willing; their enthusiasm and pleasure add tremendous impetus to any project in which they are involved. • Adolescents are physically, emotionally and intellectually ready to respond - in certain ways, more than adults; they have a freshness of approach, idealism, creativity and boundless energy. COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH 58 Adolescent Health and Development in the African Region: Challenges and Opportunities • By virtue of their numbers, adolescents are not only a tremendous resource for health care activities in the community, they are also a potentially influential group whose cooperation and good will is essential to cultivate. In some countries, adolescents' contribution to the health and welfare of their communities is already substantial. They contribute their labour to the family economic unit at an early age through: • Working in the fields or in a small family business, • Taking care of younger brothers and sisters while their parents work. • Managing households and providing care for siblings where parents have died (war situations, AIDS, accidents, etc). In this role they have considerable responsibility for the health and welfare of children younger than themselves, and sometimes for the elderly. Where traditional family structures are still intact, adolescents also help members of the extended family and their community in tasks which are undertaken cooperatively. Also, national and international youth organizations have involved adolescents in formal health care programmes and projects in many countries. For the effective participation of adolescents in the provision of health care it is recommended that: • Two-way channels of communication should be set up to permit full access by adolescents to relevant information and give them the opportunity to contribute their own ideas. • In all matters relating to their health, adolescents should have a say in decisions about the objectives, policies, the nature of activities and the allocation of resources in governmental and non-governmental organizations at the local, national and international levels. • Adolescents should be involved in the planning, design and implementation of all relevant research undertaken in the field of health, including studies to identify young people's awareness, knowledge, attitudes and behavior related to health. 59 Briefing Kit - COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH • Governments should support the involvement of adolescents in the promotion and protection of their own health, particularly in such areas as family life, sex education and the avoidance of risk-taking behaviour. • Governments should recognize that the health of adolescents is fundamental to overall development and that their participation is a valuable resource for the promotion and protection of health. Prerequisites for effective adolescent participation To enable adolescents participate effectively in programmes relating to them, the following basic conditions must be met : • Selection of motivated adolescents • Sound training (skills development) • Open communication • Clearly presented information • A non-judgmental atmosphere • Recognition that much can be learned from adolescents themselves • Sensitivity to the feelings and views of adolescents It is important to ensure that: • channels of communication permit the full access of the adolescents to accurate information in order to make decisions and to give them an opportunity to provide feed back; • adolescents have an opportunity to strengthen their organizational skills by participating in services and management of programmes; • adolescents have a say in decisions on the objectives, policy and the nature of activities that affect their well-being; • adolescents share in the responsibility for the economic, social, and political consequences of their activities. 60 Adolescent Health and Development in the African Region: Challenges and Opportunities The role of the family The child is born to a family and develops from childhood through adolescence to adulthood, normally within the family circle. Adolescence is the time when young peoples' growing capabilities are most affected by family influences. At this period, they are like raw materials for human development that can be moulded and shaped by those around them. It has been found that the ways young children are loved, nurtured, supported and encouraged by the family, are important determinants of success in their adolescent years. Likewise, the values that they imbibe during their formative years have a bearing on whether they are able to enjoy fulfilling relationships with other members of the community. However, in today's changing world, the status, values and roles of the family are also in a state of transition in some cultures the traditional security of multi-generational extended families has given way to the limited security of nuclear families and even single-parent families and the 'non-families' of street children. The migration of families to urban areas with unfamiliar, or even hostile, environments may mean a significant reduction in the amount and quality of time parents have for adolescents. Another notable problem is that parents can misinterpret what constitutes fairness between the sexes. In many cultures children grow up in a discriminating environment to the disadvantage of the female child. This inequity may begin before birth and may run through the entire life of the girl, harming her health and development. Grown-ups can also provide to their children correct information and advice on matters relating to sexual and reproductive health. They can become friends with their offsprings and ensure that the adolescent does not engage in harmful practices or develop dangerous behaviour. Adults can do this by • Passing on sound traditional values to their children and adolescents, • Being good role models for their children, • Setting an example by abstaining from harmful substances like drugs and alcohol, • Demonstrating respect for each other, and • Refraining from violence and abuse of any form. 61 Briefing Kit - COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH The role of the Ministry of Health While a holistic approach to adolescent health is advocated, with every effort made towards a functionally integrated approach across sectors and disciplines, the health ministry in every country has to take a leading role. It must seek out and encourage multi-sectoral partnerships and design specific need-based programmes to address the problems of adolescents. The Ministry of Health should: • Make concerted efforts to remove obstacles and barriers to accurate information for adolescents and adults about healthy behaviour, development and services. • Create linkages with other sectors such as education, employment, social welfare and criminal justice as well as NGOs to enhance adolescent health programmes. • Strive to provide youth-friendly health services that are accessible, confidential and flexible. This can be done through modification of existing service-delivery systems. • Coordinate with school systems and provide counseling services for health and sexuality, responsible reproductive behaviour and healthy relations. • Take the lead role in providing training on aspects of adolescent health and development and develop inter-personal communication skills in those responsible for providing information or counseling to young people. • Give emphasis to conducting operational research as well as social science and behavioural studies. Such studies can provide additional information on sensitive issues which are helpful for the designing and promotion of youth-friendly services. • Strongly advocate coherent policies and legislations supportive of health and development of young people and undertake research on the status and impact of such policies and legislation. • Provide fora for orientation of media personnel on adolescent health and develop a briefing kit for the use of all stakeholders. Source: Adolescence: the critical phase: the challenges and potential. WHO, 1997 62 Adolescent Health and Development in the African Region: Challenges and Opportunities The role of the Ministry of Youth Affairs The ministry responsible for youth affairs has a central role to play in the promotion of adolescent health and development. It should: • Develop and implement policies, laws and programmes in support of adolescent health and development; • Provide training in vocational skills for adolescents; • Monitor, evaluate and constantly respond to the growing and changing needs of adolescents; • Provide and supervise recreational facilities for adolescents. The role of IEC Information, education and communication (IEC) are essential for the promotion of the health of adolescents, but the appropriate messages will not get across if transmitted only through conventional mass media channels. Some channels are often dull and identified with the established authorities of the adult world. It is important to give information on the developmental processes and problems of adolescence to young people, using communication media they can identify with and messages they can understand. It is equally important that adults should be informed of what adolescents want to know and what they perceive as their problems. All methods of communication, the old as well as the new, should be used to inform young people, as long as nothing is forced on them. Information must be proposed, not imposed, through the greatest possible number of channels to which adolescents have easy access. Peers, when trained, are often the best conveyors of health information, since adolescents will more readily listen to them. In order to get adolescents to listen to and appreciate their advice, adults should, while remaining firm, learn to sympathize and empathize with them and avoid trying to communicate with them in a condescending manner. Adolescents need to have their own questions answered before being given information society thinks they need. The messages given by adults to the young must be clear and without ambiguity. It is essential that communication be two-way so that adolescents can express their own experience, as well as being the recipients of information adults wish to convey to them. Effective communication requires a non-judgmental atmosphere marked by mutual respect and honesty. 63 Briefing Kit - COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH The role of other stakeholders Adolescent health and development pose a challenge not only to families but also to societies and to nations everywhere. This is because the health and development of adolescents depend on many inter-linked factors such as living conditions, the way those around them cope with the challenges of growing up and the effectiveness of the community level infrastructure. Also affecting adolescents are the policies and laws that can enhance or deter health and development, the ways they are implemented or enforced and the relevance of programmes to the health of the young. The following sectors can make positive contributions to the health of the adolescent population: School environment Adolescence is the period when most young people are in school. The school environment therefore plays a crucial role in their development. It is important for the authorities and parents to ensure that this environment can • provide family life education that includes sexuality and sexual health; • enhance knowledge and skills about healthy behaviour and relationships; • promote healthy social interactions; • develop relevant extra-curricular activities • advocate equal and expanded education for both sexes; • establish close liaisons with other key sectors. Workplace Many young people start to work during adolescence. To ensure the continued health and development of the adolescent, the workplace should • provide vocational skills and training for both sexes • advocate and provide equal opportunities for both sexes • ensure safe working conditions • liaise with health services and schools 64 Adolescent Health and Development in the African Region: Challenges and Opportunities Community The community is the overall environment in which adolescents live and grow up and it has an enormous impact on their development. The community should • r e c o g n i z e e q u a l r i g h t s a n d responsibilities for all adolescents • give due concern and attention to the needs of adolescents • encourage positive adult attitudes and behaviours towards adolescents • provide adolescent-friendly health services that include trained counselors. Mass media In this age of information and cultural globalization, the mass media is having tremendous impact, for good or ill, on the development of adolescents in the African Region. It is, therefore, imperative to ensure that they • provide programmes that will have a positive impact on adolescent health and development • involve adolescents in creating programmes for themselves • encourage less violence and abuse on entertainment programmes • discourage advertising of harmful substances and behaviours Social welfare institutions The relevant institutions for promoting the social welfare of adolescents should • promote their rights, responsibilities, and positive culture • ensure training of staff to work with adolescents • reach the adolescents in difficult circumstances. Religious institutions Adolescence is the period when young people develop spirituality and form ideas that influence their behaviour for the rest of their lives. Religious institutions therefore should 65 Briefing Kit - COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH • provide spiritual and moral guidance • provide opportunities for constructive activities • cooperate with other sectors to enhance adolescent health and development The criminal justice and law enforcement agencies For one reason or the other, some adolescents are brought into contact or conflict with the law at this delicate stage in their lives and such encounters could influence the kind of citizens they develop into in later life. It is therefore absolutely essential for law enforcement agencies, the law courts and other institutions involved in the exercise of justice to: • provide proper orientation for their staff on how to deal with adolescents • make appropriate laws for adolescents and ensure their proper implementation • ensure separation of juvenile offenders from adult criminals • offer rehabilitation services for juvenile offenders. The role of the Member States of the WHO African Region In Resolution AFR/RC51/R3 of the fifty-first session of the WHO Regional Committee for Africa (September 2001), ministers of health from the 46 countries resolved to accord adolescent health and development priority in national social and economic development agenda. The approved regional strategy on adolescent health urges Member States to: • accord adolescent health and development priority in their national economic development agenda; • review, develop, implement and evaluate national policies and programmes on adolescent health and development; • reorient and build the capacity of the health sector to provide basic services to meet the special needs of adolescents, including those in difficult circumstances, through the active participation of young people, families, communities, religious leaders, local NGOs and other relevant partners; • build multisectoral partnerships and strengthen collaboration to increase resources for adolescent health and development; 66 Adolescent Health and Development in the African Region: Challenges and Opportunities • equip young people with the requisite skills to enable them to participate meaningfully in the development and implementation of adolescent health policies and programmes. The role of WHO Regional Office for Africa On its part, the Regional Office for Africa resolves to: • continue to advocate for adolescent health programmes and to mobilize adequate resources for their implementation; • provide technical support to Member States for the development and implementation of national policies and programmes on adolescent health; • mobilize governments, agencies of the United Nations, NGOs and other stakeholders to organize youth seminars and conferences to discuss the problems and challenges of adolescents in order to improve their health and development; • support institutions and national experts to carry out research on the health problems and needs of adolescents. During the last decade WHO has developed manuals on counseling techniques and research, which are being used widely by countries. In many countries there have been several successful experiences in promoting some aspects of adolescent health, but these have been on a small scale and mostly in the non-governmental sector. Regional strategies and resolutions related to adolescent health and developments are: • The Regional Committee resolution AFR/RC45/R7 which raised concern for the health and well-being of adolescents. • The Regional Strategy for mental health 2000 2010, which addresses the prevention of substance abuse, especially among young people. • The Reproductive Health Strategy for the African Region 1998-2007, which spells out the reproductive health needs and problems of adolescents. • Adolescent Health: a Strategy for the African Region (AFR/RC51//R3) which identifies and responds to the health needs of adolescents, as well as promotes their health and holistic development throughout the Region. 67 Briefing Kit - COLLABORATION AND PARTNERSHIP IN ADOLESCENT HEALTH The role of other UN agencies Most UN agencies give high priority to adolescent health and development programmes among their many activities. Landmark conferences and resolutions urging Member states to plan and develop frameworks for country programming for adolescent health and development include: • The 1985 International Year of the Youth (UN General Assembly) • In 1989, UNICEF and UNFPA joined WHO and issued a joint statement on the Reproductive Health of Adolescents. • The 1990 Convention on the Rights of the Child and the OAU African Charter on the Rights and Welfare of the Child which discouraged customs, traditions and cultural or religious practices inconsistent with the rights, duties and obligations of young people. Both draw attention to the right of every child to enjoy the best attainable state of physical, mental and spiritual health. • The 1994 International Conference on Population and Development (ICPD) • The WHO/UNICEF/UNFPA Study Group on Programming for Adolescents Health emphasized the need for the three agencies to provide complementary support to countries to strengthen and expand the activities aimed at promoting adolescent health in a more programmatic manner. UN agencies should: 1. Support Governments to implement adolescent health programmes. 2. Support the Ministry of Health to establish adolescent-friendly health services. 3. Support joint reviews on programming and measuring adolescent health programmes. 4. Continue to monitor and highlight adolescent issues through supporting research and international fora on them. References : • Laws and policies affecting adolescent health. J.M. Paxman, R.J. Zuckerman, 1986 • Programming for adolescent health and development Report of a WHO/UNFPA/UNICEF study Group on Programming for adolescent health. WHO Technical Report Series, 886 • Coming of age. From Facts to Action for Adolescent Sexual and Reproductive Health. WHO/FRH/ADH/97.18 68 Adolescent Health and Development in the African Region: Challenges and Opportunities P69 Programming for adolescent health poses a challenge in that adolescents are undergoing progressive changes from childhood dependence to adult interdependence. They are a heterogeneous group, even within the same country. Specific interventions should take account of this situation, in particular, help them to develop competences, skills, values, etc. to become well-adjusted members of the society. Key challenges to adolescent programme development include how to: • promote a greater understanding of adolescents' needs among adults and a recognition that they are people, not problems, with an exceptional capacity to respond well when those needs are met. • provide for adolescents educational information, knowledge, skills and care that lead to positive actions and constructive lifestyles appropriate to their age. • preserve cultural values, yet permit greater autonomy in enhancing the health of adolescents. • reduce the spread of substance abuse, including tobacco, alcohol and other drugs among adolescents. • prevent problems of violence and sexual abuse among adolescents and provide them with advice and help when in need. • involve adolescents in designing youth-friendly programmes to improve their health and institute interventions. • collect and analyze data by age and sex. • ensure tracking of the quality and coverage of adolescent programmes • ensure documentation of best/good practices • provide life skills (social competences) PROGRAMMING FOR ADOLESCENT HEALTH Briefing Kit - PROGRAMMING FOR ADOLESCENT HEALTH 70 Determinants of adolescent health problems Knowledge and understanding of the major aspects of the economic and social environment which determine adolescent health are a prerequisite to preparing effective programmes for its achievement. Such determinants include: • Relationships with families and significant others; • Social norms and cultural practices; • Mass media and entertainment; • Availability of vital opportunities and resources; • Social security • Policy and legislation. • Poverty Approaches that would help to positively influence the above aspects for the health and development of adolescents would include the following mechanisms: • Informing, raising awareness, advocating and mobilizing activities through community- awareness sessions, group meetings and discussions, and creative use of the media in support of selected adolescent health issues. • Equipping adolescents with life skills and livelihood skills to deal effectively with the demands and challenges of everyday life. • Providing safe school environments, shelter and health services for adolescents. • Providing for adolescents in difficult circumstances in all adolescent health and development programmes. • Encouraging collaboration between organizations and groups in society involved in adolescent health and development. • Monitoring and evaluating activities dealing with adolescent health and development. Adolescent Health and Development in the African Region: Challenges and Opportunities Guiding principles of interventions Adolescents need environments that offer them nurturing, guidance, rules, clear expectations and consistent limits. They need opportunities to explore, excel, contribute, learn, and receive high-quality instruction to enable them to meet the demands and challenges of everyday life. Most important, they need people who can inspire them to aim high and who are committed to their well-being. Such people would have to take the following principles into consideration as they work with adolescents: • Adolescents must be recognized as a priority target group and should be reflected as such in national programmes. • Despite myths that sexual knowledge may promote promiscuity, evidence suggest that it makes adolescents more, and not less, responsible. • Adolescents have a right to accurate information relating to their health and development, including issues believed to be sensitive. • Promoting the health and development of adolescents is a tremendous task. However, they are an important potential resource which is inadequately tapped. Involving them in the implementation of prorgrammes will make the task easier. • A positive attitude among the adults interacting with adolescents results in a relationship of trust and confidence. • A holistic approach in responding to underlying causes and issues of the problems of adolescents will yield better results. • The families of adolescents are most crucial in shaping adolescent behaviour and values; however, other social interactions and relationships outside the family also play an important role (peers, school, religious associations, recreational and sports centres, etc). • Societies need to promote equity between boys and girls to ensure healthy relationships among adolescents. Intervention settings • Home • School • Health facilities • Workplace • Street 71 Briefing Kit - PROGRAMMING FOR ADOLESCENT HEALTH • Community recreation centres • Residential centres • Media/entertainment places • Youth clubs • Political institutions and legislative systems • Rehabilitation/Correctional Institutions • Vocational training centres • Other community based facilities Policy programmes and strategies Meeting adolescents' needs for health information and services is vital to the future of adolescents and other young people. Recent consensus documents emerging from United Nations conferences have clearly spelt out the importance of addressing the health needs of adolescents. The Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development, underlines the need “to protect and promote the right of adolescents to the enjoyment of the highest attainable standards of health, provide appropriate, specific, user-friendly and accessible services to address effectively their reproductive and sexual health needs, including reproductive-health education, information, counselling and health-promotion strategies.” It also urges countries to “ensure that programmes and attitudes of health-care providers do not restrict the access of adolescents to appropriate services and the information they need, including for the prevention and treatment of sexually transmitted diseases (including HIV/AIDS) and sexual violence and abuse.” The Consensus statement at the close of a regional consultation on strengthening the provision of adolescent-friendly health services to meet the health and development needs of adolescents in Africa (October 17-21, 2000) held in Harare, spells out the basic adolescent health needs as follows: • information and counseling on development during adolescence and healthy lifestyles, including sexual and reproductive health • Access to quality health services • asic livelihood skills and opportunities 72 Adolescent Health and Development in the African Region: Challenges and Opportunities • Functional education • Supportive environment, including facilities for recreational activities • Good nutrition The statement proposes the following strategies for meeting the identified needs: • Advocacy and awareness creation • Policy guidelines • Participation/involvement of adolescents, parents and communities • Health education • Adolescent friendly health services • Socio-economic empowerment • Partnerships/Networks • Multi-sectoral collaboration • Gender mainstreaming • Mentoring and fostering • Resource mobilization • Research • Supervision, monitoring and evaluation Promoting a safe and supportive environment A safe and supportive environment is part of what motivates adolescents to make healthy choices. By a safe and supportive environment is meant an environment that includes a positive, close relationship with the family and other adults and peers. Such relationships can provide guidance for the adolescents, set limits when appropriate, and challenge certain assumptions, risky behaviours and beliefs. A safe and supportive environment is particularly significant for the adolescent's health and development. Such an environment would include: • Relationship with families and other people • Family values • Positive social norms and cultural practice • Communication 73 Briefing Kit - PROGRAMMING FOR ADOLESCENT HEALTH • Positive mass media and entertainment • Vital opportunities and resources • Adolescent-friendly policies, legislation and services. Programmes to promote the healthy development of adolescents should aim at achieving the following: • A supportive environment over a long period, with graded steps towards autonomy, enhancing self-esteem and promoting a healthy life style. • Good communication between adolescents and adults and peers in their lives. • A sound understanding of adolescents' beliefs and behaviour within a given culture. • Services by people who respect adolescents, have a sound knowledge of their needs, and are trained in communication skills. • Focusing on holistic programmes that include the total lifestyle of the adolescent. • An intersectoral approach to programmes that include the school, the family, the health systems, religious and community leaders, and community organizations. • Close links between community and complementary school-based programmes for adolescents in and outside school. • Involvement of adolescents in the planning and implementation of programmes. Communication One of the most fundamental problems of adolescence is the inadequacy or ineffectiveness of communication between young people and their peers and adults, especially their parents. Adolescents want explanations and answers on a wide variety of issues as they try to understand and master the changes going on in their bodies and minds, in their status and in their relationship with others. At the same time, parents, teachers and others may be anxious to ensure they do not go wrong. In the process, lack of communication may lead to misunderstanding which, in turn, could lead to conflict. Effective communication would definitely make things easier for all concerned and ensure healthy relationships. 74 Adolescent Health and Development in the African Region: Challenges and Opportunities Parents and teachers of adolescents, in particular, have a duty to ensure effective communication in their relationships as a way of contributing to providing a supportive environment. They should: • Let adolescents say what they want to say. • Show genuine interest in them. • Try to understand their feelings. • Speak with, not at them. • Speak to them in a way that makes them feel important (or enhances their self-esteem). • Listen to them in a way that makes them feel they are being taken seriously. • Respect their point of view, even when you disagree with them. • Avoid being judgmental. • Give honest answers to their questions while being sensitive to their feelings. • Work at achieving mutual understanding. • Let them know they are appreciated and loved, but be firm. References: • The health of young people: a challenge and a promise. WHO, 1993 • Young people's health – a challenge for society. Report of a WHO Study Group on Young people and “Health for all by the year 2000 WHO Technical Report Series, no 731,1986 75 Briefing Kit - PROGRAMMING FOR ADOLESCENT HEALTH 1. Action for Adolescent Health: towards a common agenda; recommendation from a joint study group. (WHO/FRH/ADH/97.9). WHO, 1997. 2. Adolescent reproductive and sexual health: a guide to conducting a situation analysis (Draft for field-testing). WHO, 1997. 3. Adolescence: the critical phase: the challenges and the potential. WHO, 1997. 4. A picture of health: A review and annotated bibliography of the health of the young people in developing countries. (WHO/FHE/ADH/95.14). WHO, 1995. 5. Boys in the picture: Oh, les garcons!: Los muchachos en la mira: Em foco, os rapazes. (WHO/FCH/CAH/00.8). WHO, 2000. 6. Why should we invest in adolescents? Burt, Dr. Martha R (1998). W.K. Kellogg Foundation. 7. Comprehensive school health education: suggested guidelines for action. (WHO/UNESCO/UNICEF/92.2). WHO, 1992. 8. Counseling skills training in adolescent sexuality and reproductive health: a facilitator's guide. (WHO/ADH/93.3) WHO, 1993. 9. Injectable contraceptives: what health workers need to know (WHO/FRH/FPP/97.31). 76 RREFERENCES Adolescent Health and Development in the African Region: Challenges and Opportunities 77 10. Intra-uterine devices: what health workers need to know. (WHO/FRH/FPP/97.32). WHO, 1997. 11. L i f e s k i l l s e d u c a t i o n i n s c h o o l s : D i v i s i o n o f M e n t a l H e a l t h . (WHO/MNH/PSF.93.7A.Rev.1). WHO, 1997. 12. Accidents in childhood and adolescence: the role of research. WHO, 1991. 13. Laws and policies affecting adolescent health. Paxman, John M. and Zuckerman, R.J. (1987) WHO, 1987. 14. Programming for adolescent health and development. (WHO Technical Report Series No. 886). WHO, 1999. 15. Programming for Prevention in childhood and youth of adult cardiovascular diseases: time for action: Report of a WHO expert committee. (Technical Report Series No. 792.) WHO, 1990. 16. 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