DL Bennett, M Kang, G Alperstein, M Kakakios

Abstract

The health problems of young people are mostly psychosocial and preventable, result in great personal, social and monetary costs, and contribute to the leading causes of adult morbidity and mortality. Research confirms the benefits of protective factors such as connectedness to families, friends, schools and communities, in the creation of resilience, health and wellbeing. Adolescence is 'a time of second chances' ?with the right opportunities, many negative trends can be reversed. Adolescent health outcomes have multiple determinants, many of which fall outside the domain of health services. Collaborative strategies (cooperative partnerships across disciplines and sectors) are required to achieve a more informed, coordinated and effective approach to the needs and issues of young people. This paper provides a framework for action with health promoting principles including: a life-cycle approach, a population focus on prevention and early intervention, an evidence-based approach, networking and partnership building; and public health advocacy.

Introduction

Adolescent health is at a crossroads. Throughout the Asia-Pacific region, there is a sense of awakening and expectancy. New initiatives are emerging in the areas of service delivery, research and training as well as in the development of professional organisations. Where programs and services have existed for many years, as in the Philippines, Australia, New Zealand, and (more recently) Hong Kong, renewed energy and commitment are in evidence. These are encouraging signs that our field is growing locally and can make a positive difference to the health and wellbeing being of young people.

An innovative and ambitious undertaking in Australia, the Australian Research Alliance for Children and Youth (ARACY),¹ is part of this awakening. ARACY seeks 'to enhance the wellbeing and life chances of children and young people through the establishment of new collaborations across disciplines and sectors for the development and application of useful knowledge'. Over 150 professional stakeholder organisations have already signed up to this wide-ranging initiative, which has the potential to change professional and political landscapes.

The driving force in the Alliance is the notion of collaboration, defined as 'developing cooperative partnerships across disciplines and sectors to achieve a more informed, coordinated and effective approach to the needs and issues of children and young people'. Collaboration amongst researchers, practitioners, policy and political decision-makers is viewed as the most likely means of ensuring that knowledge can be used to inform policy and practice. Our paper presents a case for collaboration based upon accepted principles for promoting, protecting and sustaining the health of young people.

Adolescence - Development and Diversity

The concepts of 'adolescence' are evolving and not all societies view young people in the same way. In traditional societies, adulthood is reached abruptly with a rite of passage at or around puberty. And in societies that have always had a 'youth' category (that time between the end of puberty and the assumption of adult roles and responsibilities), it has not always meant the same thing as it does now. In particular, the age range covering adolescence has changed over time, as have the traits attributed to young people and the nature of their position and function within society.²

WHO has proposed the term young people as referring to individuals aged between 10 and 24 years, an arbitrary age range derived from the overlapping categories of adolescence (10-19 years) and youth (15-24 years).³ Now commonplace in the adolescent health literature, these groupings offer a reference point for cross-cultural and other comparisons of data and experience and continue to serve as a basis for discussion.

Young people are not a homogeneous group. There is enormous diversity, regardless of where they happen to live. For one thing, the expectations of mainstream cultures vary from place to place, reflecting the fact that human development is the unfolding of an individual's full potential within a given cultural context.⁴ The periods of early, middle and late adolescence, for example, are widely recognised in Western countries as corresponding roughly with phases in physical, social and psychological development. But these relationships remain largely unexplored scientifically in developing countries, in the context of cultural, economic and political constraints.⁵

Despite the many differences amongst young people, the core experiences of adolescence are remarkably similar, with major commonalities transcending individual, cultural and social diversity. In many parts of the world, adolescence is a distinct and significant period of life, unique and different from all others. Its universal aspects are largely determined by developmental processes such as growing rapidly, maturing sexually, acquiring more adult patterns of cognitive and psychosocial functioning, choosing ones values and lifestyles and (where possible), achieving relative socioeconomic independence. All young people have to negotiate a path between pressures to conform and achieve and those to establish a separate, individual identity. There is an inevitable struggle between inner drives and outside expectations.

Changing Times and Growing Inequity

The past four decades have seen technological, social and political changes unparalleled in human history. Through the global spread of telecommunications, travel, tourism and migration, the world is shrinking, and the rate of change continues to accelerate. More than ever before, young people know something about the concerns and aspirations of their peers in other parts of the world, particularly through music, television and the Internet. Unfortunately, a growing disparity between those who have technological skills and those who do not is becoming the great divide, with many being left behind.

In this context of change and upheaval, the situation of young people in developing countries is particularly troubling, especially for those living in poor areas. The 'poverty cycle' provides a backdrop of health and social inequalities and social barriers that shape the lives and future prospects of young people.^5-7 The health of most Indigenous young people in all countries with Indigenous populations displaced by invasion and colonisation is far worse than that of non-Indigenous youth.

Why Focus on Adolescent Health?

Adolescent health problems result in great personal, social and monetary costs. Although most adolescents are relatively healthy by traditional medical standards, they face a number of significant threats to their health. The most serious, costly and widespread adolescent health problems - unintended injuries, the use of alcohol, tobacco and other drugs, suicide, sexually transmitted infections, unintended pregnancy - are potentially preventable.^8,9 Because of the rapid physical, cognitive and emotional developments that take place during this age period, adolescence is also the time when many health and mental health problems may first emerge. Nearly three quarters of adolescent mortality is due to preventable causes. Moreover, the behaviours that contribute most to the leading causes of mortality and morbidity in adults (for example, tobacco use, poor diet and physical inactivity) are often initiated in adolescence.

As an important stage in the human life cycle (See Figure 1), adolescence is both the receiver and perpetrator of health legacies. The World Health Organization's temporal classification of adolescent health problems acknowledges this reality by recognising: conditions originating in childhood that manifest in adolescence; problems that arise during adolescence; and conditions originating in adolescence that manifest in adult life.³ The broader implications of this continuity of issues and problems, is that the health and well-being of young people has a major impact on the overall social and economic health of the communities in which they live, with enduring effects.

Figure 1 Stages in the life cycle.

Today's youth, as well as having unmet needs now, are tomorrow's workforce, parents and leaders, and their future is shaped by the opportunities we shape for them today. At the World Health Assembly in 1989, behavioural Scientist Professor Richard Jessor described adolescence as '... the crucible for the shaping of health in adulthood and later life'.¹⁰ Whatever the nature of one's beginnings in life, adolescence is a time of 'second chances' and we must work to ensure that our societies make the necessary investment to provide the opportunities that young people need to make a successful transition to maturity.

Social Contexts for Prevention (Figure 2)

Professor Urie Bronfenbrenner, a famous American developmental psychologist, has written about the social contexts in which young people grow up.¹¹ A young person's family, school and neighbourhood (the micro contexts) are the domains that most immediately affect the lives of young people and influence their levels of risky behaviour. The broader macro context, the socioeconomic, cultural and political environments, are also important factors in determining health and health behaviours.

Figure 2 Social contexts for prevention.

There is abundant published evidence demonstrating that children living in families at socioeconomic disadvantage have significantly worse health outcomes, and that those children will grow into adults at greater risk of health problems.¹² The economic and social stress on families resulting from poverty also provides the context in which teenagers are more likely to become involved in crime.¹³

A growing body of research suggests, however, that a wide range of adolescent health problems could be avoided by ensuring that all youth have appropriate support, connectedness, and opportunities. In fact, these factors can have a more profound impact on the life course of children who grow up under adverse conditions than do specific risk factors or stressful life events.^14,15

Some of the most commonly cited protective factors include a strong sense of connectedness to parents, family, school, community institutions, adults outside the family, the development and enhancement of academic and social competence, and involvement in extracurricular activities that create multiple friendship networks. In other words, children and young people who are connected to their families, friends, schools and communities are more resilient (having the ability to bounce back from tough times), more able to make the most of their opportunities, to overcome barriers, and have lower rates of a number of mental health problems and 'at risk' behaviours.^16,17

Wherever they live, as enshrined in the United Nations Convention on the Rights of the Child (1989), adolescents have rights, to information about their health needs, to life skills, to a safe and supportive environment, to youth-friendly services (including reproductive health) and to counselling at times of crisis.¹⁸

In seeking to improve the health of young people, against a background of equity and social justice, a number of guiding principles provide us with a challenging framework for action.

Health Promoting Principles for Adolescent Health

1) A Life-cycle Approach

Research emphasises the critical importance of early life experiences on the growth and development of the child across the life span and has identified the benefits for individuals, families, and communities of focussing on the needs of children in the early years.¹⁹ A 'life-cycle' approach that tackles health needs from conception to adolescence and beyond provides a useful framework for addressing unresolved health problems and emerging challenges in adolescent health. By examining health issues as a continuum of earliest determinants, evolution with age and later outcomes, this approach can integrate training, development and research needs and help find innovative solutions. Such a strategy has yet to be developed as a common approach to training and to the development of a needs-based research agenda.

2) A Population Focus on Prevention and Early Intervention

Health promotion has been defined as 'the process of enabling people to increase control over the determinants of health and thereby improve their health'.²⁰ Adolescence presents a unique opportunity to invest in the health of the entire population. What is required is an approach that addresses the determinants referred to above by promoting universal (population) approaches, not just treatment services targeting young people at risk or already in trouble with their health and behaviour. As illustrated in Figure 3, these population approaches (referred to as 'upstream' interventions) include the modalities of primary prevention, health promotion and early detection and are cost effective.^21,22 However, health improvement is predicated on the balance and effectiveness of what can be achieved across the entire spectrum of interventions.

Figure 3 Health improvement - the balance.

Families First

In NSW, Government initiatives in child health and wellbeing are based on a developmental approach that recognises the particular importance of the early years. Families First is an early intervention and prevention strategy that aims to support families to raise children (aged 0-8) to their full potential. Taking a collaborative, multi-sectoral approach, the program links early intervention and prevention services and community development programs to form a comprehensive service network capable of providing wide-ranging support to families raising children.¹⁹ Families First involves relevant government departments (including health, community services, education & training, housing and disability), non-government agencies funded by the government, and communities, jointly owning and improving the service system. This means having interagency structures and processes for planning, service development, service delivery, evaluation and performance reporting.²³

Better Futures

Better Futures is the NSW Government's health promotion strategy for children and young people aged

9-18 years.²⁴ The key objectives of Better Futures are:

• Keeping young people at school and improving their educational attainment (a population health intervention);

• Supporting the healthy development of young people, for example, through promoting youth involvement and leadership in communities (also enhancing protective factors); and

• Supporting young people at very high risk (realistically-based targeted intervention).

The Gatehouse Project undertaken by the Centre for Adolescent Health in Melbourne, Victoria has convincingly demonstrated the scope of school-based interventions for the promotion of mental health, enhancing protective factors and the lessening of risk behaviours in young people.^25,26 Such studies also highlight the importance of seeking the evidence to inform practice (as discussed below).

As with Families First, Better Futures seeks to create an improved service network that focuses on young people's connection to family, school and community and on their resilience and healthy development. It focuses on the whole population to reduce the number of vulnerable children and families but includes targeted early interventions and efforts to improve clinical services for families and communities at greater risk. Better Futures provides the vision and common goals for multidisciplinary and intersectoral collaboration.

3) An Evidence-based Approach

The Australian Research Alliance for Children and Youth has recently brought together researchers, policy makers and practitioners in a series of focus groups and workshops to achieve a high level of shared understanding about the values, principles and practices that contribute to successful outcomes for children and young people. The interfaces between research and practice, sometimes also linked to a process of policy development, are complex. But there are complementary skills and experience that can be drawn upon to find more effective responses to the social, educational, economic and health issues that create problems for children and young people. The point of the exercise is 'putting knowledge to work', quickly, efficiently and effectively.²⁷

Bridging the research-policy-practice divide (and sometimes, more directly, the gap between research and practice) is a notoriously difficult task. The truth is that "research rarely provides definitive answers to policy questions, and rational decision making rarely lies at the heart of policy processes".²⁸ It has been suggested that policy is derived from the balance between what is: scientific plausible (evidence-based), politically acceptable (fits with the vision), and practical for implementation (existing infrastructure).²⁹

The Access Study

The following example illustrates the relationship between policy, research and practice and the importance of building an evidence base for adolescent health care. The launch of the NSW Health Policy in December 1998³⁰ lead to the establishment of the NSW Centre for the Advancement of Adolescent Health (CAAH). CAAH was commissioned to undertake a program of research and development into improving access to and quality of primary health services for young people in New South Wales - the Access Study (Figure 4).

Figure 4 The access study.

Phase 1 of the study, using qualitative methodology, was conducted between May 2001 and August 2002. The study was a comprehensive needs analysis of the health concerns of and barriers to access for young people from the perspective of young people and service providers.³¹

A multidisciplinary/multi-sectoral reference group provided guidance and support to the chief investigators. Young people highlighted issues of trust and confidentiality and conveyed a lack of knowledge of services and the broad-based skills possessed by service providers.³² Service providers reported a lack of youth-appropriate communication skills, lack of training in specific health issues, and lack of support and back-up from other services.³³

The findings of Phase 1 complemented and enhanced our knowledge from anecdotal reports and published literature and provided a sound base for progressing to Phase 2 of the study, which included these objectives:

• to identify and describe primary health care services for young people across NSW

• to explore and describe elements of quality and accessibility within these services

• to define and describe guiding principles of better practice in youth health which can inform service delivery

In identifying key principles (See Table 1) and preparing a Framework for better practice in youth health, Access Study, Phase 2 has raised some important questions for all concerned ?the researchers, the practitioners delivering services and programs in NSW, and the governmental policy makers. For example, while there are many innovative youth health programs attempting to improve access, youth participation is sometimes minimal, collaboration is often not extensive or in the form of a real 'partnership', professional development budgets are low, sustainability measures are often not considered, outcomes are often assumed rather than measured, and few services have conducted evaluation beyond process measures. These findings point the way to improvements needed for better practice to be more widespread.

In Phase 3 of the study it is envisaged that the evidence base for different models of youth health care will be further strengthened as part of a program for systemic change in youth health practice (See Figure 4).

An Evidence Base for Training

A complementary strategy is to improve the abilities of health workers to respond to young people more effectively and with greater sensitivity. The training of general practitioners in adolescent health care now has a strong evidence base, with a randomised controlled trial in Australia showing that gains in knowledge and skills are significant and sustained.³⁴

By providing a comfortable, confidential environment and asking relevant questions (for example, the HEADSS exam³⁵), clinicians can identify adolescents who are at risk for, or currently engaging in health-compromising behaviours. This type of encounter allows clinicians to educate adolescents about the risks of such behaviours and potentially modify the behaviours and their related outcomes. Studies show that adolescents and their parents want clinicians to address risk-taking behaviours and prevention and that adolescents see their physicians as credible sources of health information,³⁶ especially those they know and trust.³² Most clinicians also acknowledge the importance of incorporating preventive care into their practice. Together, these factors create a unique opportunity for open discussions of sensitive topics such as reproductive and mental health behaviours, symptoms and needs.³⁷

However, training in adolescent health care, while desired by increasing numbers of doctors in the Asia-Pacific Region, is a long way off being properly planned and coordinated. WHO's Western Pacific Office has explored the issue of integrating adolescent health and development concepts into pre-service curricula in medicine and nursing.³⁸ Raising awareness among health professionals and promoting such education and training opportunities remains a worthy and important challenge for adolescent health advocates.

4) Networking and Partnership Building

The late Dr Herbert Friedman of the World Health Organization stated that "The key to successful health promotion is partnership ?partnership between young people and adults, between the health sector and other key sectors, between government organisations, and within the United Nations system itself".³⁹ He is referring to 'alliances for health', the raison d'etre of centres for adolescent health within the Asia-Pacific Region and organisations like ARACY. Strategies for advancing the health of young people will increasingly focus on links and partnerships with all relevant stakeholders, including those with universities and academic centres of excellence.⁴⁰

In the field of adolescent health and medical care, there is little doubt that broad-based models of service delivery cater best to the contemporary needs of young people.⁴¹ A comprehensive and integrated approach makes it possible to go beyond the more obvious problems, to deal with causes and contexts and to explore the special growth dimensions of young people as well. In such environments, the talents, creativity and active involvement of young people can be called upon.⁴² Youth participation, particularly at the primary care level, provides significant gains for both the individuals involved and the community at large. Youth participation epitomises the concept of 'interactive roles for a healthy society'.

An innovative program involving youth participation, networking and partnerships has been initiated in affiliation with CAAH. Based upon the concepts of creativity, collaborative protocols, sustainability and working on a continuum, Creatively Linking Community through its Arts (CLACIA) connects artists and arts facilitators with community groups in interactional projects and activities.⁴³ This cross-generational program is supported by the Australia Council's Community Cultural Development Unit and epitomises the growing appreciation of the importance of creative collaborations within communities for enhancing the health and wellbeing of all age-groups (Figure 5).

Figure 5 Creatively linking a community through its arts.

5) Public Health Advocacy

Improving the overall health and wellbeing of young people, particularly in developing countries, requires more effective advocacy directed towards influencing the social, economic and environmental determinants of health. Adolescent health promotion is political and clinicians need to be aware that public health advocacy is an important part of adolescent health promotion, at least as important as day-to-day work with individual young people and families.⁴⁴

It is important to strategically build a climate of public interest and responsiveness. This means actively working to counteract the predominantly negative media coverage that young people receive in many countries, and finding ways to convey to the public and to political decision makers, research information about adolescence, the health issues and problems of young people, and helpful ideas based upon solutions that work. For example, 'authoritative' parenting (parenting that is: warm, nurturing and responsive; firm, strict and demanding of maturity; and that fosters and encourages psychological autonomy) is becoming a topic of great interest.^45,46 The research shows that adolescents from authoritative homes achieve more in school, report less depression and anxiety, score higher on measures of self-reliance and self-esteem, and are less likely to engage in anti-social behaviour including delinquency and drug abuse.

Conclusion

Adolescent health is complex, falling '...outside biological paradigms, clinical medicine and its usual classifications, and (outside) the classic distinctions between physical and mental health, between medical and social aspects of health, and between curative and preventive care'.⁴⁷ It therefore requires the participation of many disciplines and organisations. In our efforts to improve the health of young people, fortunately, there is a host of collaborative strategies that make a difference.

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