K Fritsch

Abstract

Adolescents, having ceaseless energy, ideas, enthusiasm, ambition and potential, are our important assets and resources; they are our future. This presentation will review the challenges adolescents face, including the common causes of mortality among adolescents as well as the contextual factors and underlying causes which place adolescents at risk for ill-health, development problems and premature death. The characteristics and needs of particularly vulnerable and hard to reach adolescents will be highlighted. Analysis of adolescent health and development contextual factors and vulnerability will serve to lay the foundation for a framework for action needed to provide adolescents with the support and opportunities to: (1) acquire accurate information about their health needs; (2) build the life skills needed to avoid risk-taking behaviour; (3) obtain counselling, especially during crisis situations; (4) have access to health services (including sexual and reproductive health services); and (5) live in a safe and supportive environment. Core components of the WHO Western Pacific Regional adolescent health and development framework will be outlined, with focused attention being given to the establishment of adolescent friendly health services and the core competencies required by health professionals and others working with adolescents. Throughout the presentation, participants will be challenged to identify innovative ways for improving adolescent health and development outcomes and facilitating partnerships and interventions targeted at making health services friendly for adolescents and other clients.

Adolescents, those in the 10-19 age group, represent boundless energy, ideas, enthusiasm, ambition, potential and hope. Eighty-five percent of the 1.2 billion adolescents worldwide live in developing countries; the remaining 15 percent live in industrialised countries.¹ Adolescents are important assets and resources; they are our future. Yet many adolescents die prematurely. It is estimated that nearly 1.7 million adolescents lose their lives annually, through preventable and/or treatable events or illnesses including accidents, suicide, violence, pregnancy-related complications and other conditions.¹

Adolescents face many challenges that put them on the path of ill-health. Many are at risk from unprotected sex, dangers of alcohol, tobacco and other substances. Over 150 million adolescents use tobacco; 75 million of these adolescents will die of tobacco-related diseases in later life. Risky behaviours, including unprotected sexual contact, can lead to adolescent pregnancy and sexually transmitted infections (STIs), including HIV/AIDS. Globally, 60 of every 1,000 adolescent girls give birth each year. Infants of adolescent mothers are at twice the risk of dying during the first year of life than infants born to older mothers. Adolescents with HIV represent 50% of all new cases.¹

Some adolescents are at risk from violence and exploitation. In some countries in the region of the Americas, homicide is the most important cause of death among young males. Road traffic accidents are the leading cause of death among boys in many countries. Young people are quite vulnerable to the effects of civil unrest and conflict, as soldiers, as civilians and as refugees.

Life circumstances and lack of a supportive environment leads many adolescents into depression and other mental health problems, including suicide. More than 90,000 adolescents die from suicide attempts each year.

In developing countries under-nutrition and stunting are prevalent in adolescent boys and girls, while obesity is an increasing problem in all societies.

Worldwide, enrollment in secondary schools is about 60 percent and it is estimated that between 300 and 500 million adolescents do not attend school. It is estimated that there are at least 75 million workers between the ages of 10 and 14 globally.¹

Adolescence is a period of rapid physical and mental development when adolescents are confronted with both opportunities for and risks to their health and development. Many adolescents are exposed to health risks because of poverty, exploitation, gender discrimination, war, violence, change in social and economic situations as well as risky behaviour.

Adolescents who are particularly vulnerable and hard to reach include those who:²

• are denied the opportunity to complete their education;

• have no stable homes or support;

• work long hours for little pay and are exposed to hazardous working conditions;

• live in war zones;

• are displaced into camps where traditional values and structures are lacking;

• are vulnerable to sexual abuse or violence or are sexually exploited;

• live as young wives in families which are oppressive or abusive;

• live as ethnic minorities in societies where they and their parents are rejected by the dominant culture; and

• are among the 1 in 10 people affected by a disability and are denied the same development opportunities as their peers.

It is estimated that many premature deaths among adults are largely due to behaviour initiated during childhood and adolescence. Paying attention to the health and development of adolescents, particularly those most vulnerable, will reduce death and disease, including chronic disease in later life, which will promote more productive and healthy future communities and societies.

Although adolescents have distinct needs at different development stages, the underlying causes of adolescent health and development problems are closely connected. The solutions to these problems, though requiring different approaches for reaching adolescents in varying developmental stages and cultures, are also similar and interrelated. WHO, together with its partners, UNICEF and UNFPA, advocate an intensified approach to the health and development of adolescents. This Common Agenda³ outlines the action needed to provide adolescents with the support and opportunities to:

• acquire accurate information about their health needs;

• build the life skills needed to avoid risk-taking behaviour;

• obtain counselling, especially during crisis situations;

• have access to health services (including sexual and reproductive health services); and

• live in a safe and supportive environment.

The WHO Headquarters Adolescent Health and Development (ADH) team is working within the Department of Child and Adolescent Health and Development (CAH) in the following areas:¹

• Prevention and care of illness in adolescents;

• Nutrition in adolescents;

• Development in adolescents;

• Adolescent sexual and reproductive health;

• Adolescent facts and statistics;

• Adolescent boys;

• Adolescent-friendly health services; and

• Measurement of activities and their success.

In the WHO Western Pacific Region, in order to more efficiently and effectively promote the healthy development of adolescents and to reduce mortality and morbidity among them, a regional adolescent health and development framework was developed. The framework provides a common agenda and guide to:

• enhance the effectiveness of existing activities and interventions;

• promote a comprehensive approach to adolescent health and development; and

• prioritise interventions and promote effective use of resources.

The framework's four key result areas for programming and activities are:

• prioritise interventions and promote effective use of resources;

• advocacy;

• building technical capacity;

• developing policies, strategies and integrated interventions; and

• strengthening health systems to improve services to adolescents.

Strategies to achieve regional objectives are focused on mainstreaming adolescent health and development, establishing partnerships and promoting adolescent participation. These strategies were applied in the WHO Regional Office, through the creation of a cross-divisional adolescent health working group, to promote joint action across regional office foci or programmes. The working group, composed of members representing a variety of technical progammes and areas, meets bi-monthly to discuss programming, activities, joint endeavours and initiatives which directly impact adolescent health and development.⁴

Regional and country advocacy achievements to be noted include the formulation of an advocacy strategy and accompanying materials, which have been adapted for use in China and Vietnam. Country advocacy capacities have also been strengthened.

Technical capacity-building initiatives have included staff appointments in selected countries; their participation in technical meetings and learning through involvement in planning and implementing ADH regional and country projects. Partnerships have been established with other UN agencies, non-governmental organisations and academic institutions.

The development of ADH policies, strategies and interventions has moved forward in a number of countries, including the Philippines, Vietnam and Mongolia, as well as in some Pacific Island countries. Member States have been surveyed regarding the existence of ADH policies, programmes or plans. Adolescent health and development country budget allocations have been established in some countries.

The establishment of Adolescent friendly health services (AFHS) is an important priority area as significant barriers to the use of health services by adolescents exist. Some of the barriers include lack of knowledge on the part of adolescents, unfriendly attitudes and behaviours of health

professionals towards adolescents, legal and cultural restrictions, financial and other costs. Other barriers are a lack of comprehensive services, including sexual and reproductive health services and mental health services, lack of assurance of privacy and confidentiality, inconvenient clinic hours, and non-appealing settings and waiting rooms that may lack appropriate educational materials.

These barriers are stronger for adolescents from poor backgrounds, such as those living in poverty, street children, those living in rural areas, those belonging to ethnic minorities, out-of-school or working adolescents, and adolescent girls.

Identifying core competencies needed by health professionals caring for adolescents has been undertaken regionally and globally. A detailed description of the related process of competency formulation and assessment is found in the publication entitled A Framework for the Integration of Adolescent Health and Development Concepts into Pre-service Health Professional Curricula in the WHO Western Pacific Region.⁵ The process included a regional survey of pre-service nursing and medical curricula for ADH content and institutional preparedness. Adolescent health and development curricular modules are being written in collaboration with the Hong Kong Polytechnic University School of Nursing. WHO Headquarters ADH Orientation modules have been field-tested in the Region and ADH programme managers and health professional educators from Malaysia, the Philippines, Vietnam and Mongolia trained in their use. The modules have been adapted and/or translated for use in Mongolia and the Philippines.

A training manual and accompanying CD-Rom on STI and HIV Communication and Counselling in Pacific Island countries has been produced in collaboration with the University of the South Pacific. Techniques appropriate for adolescents have been integrated in the manual. A module on poverty, gender and adolescent health is being produced, as part of a Regional Poverty, Gender and Health Tool-Kit.

Adolescent friendly health service initiatives have been given priority in a number of countries in the Region (Mongolia, Kiribati, China, Vietnam), aimed at setting adolescent friendly health service standards, for health care providers and facilities, based on assessments and analysis of services currently provided. These activities, undertaken in collaboration with WHO Headquarters, are focused on a quality improvement process, involving the identification of issues, setting of standards, criteria and means of verifying actions taken towards meeting the standards. Improving health services for adolescents involves increasing the awareness of health planners and providers regarding the concept of adolescent friendly health services and facilitating their identification of ways to overcome the barriers to accessing health services and enhancing the friendliness of the services provided to adolescents.

It has been demonstrated that provision of appropriate health services has positive health outcomes for adolescents, including reduction in the incidence of early and unwanted pregnancy and complications during pregnancy and childbirth, STIs, and use of tobacco, alcohol and drugs. Responding to adolescent health and development needs must also include the establishment of a supportive legal and social environment as well as the provision of support and education for parents, families, teachers, religious leaders and friends.

Investing in health service improvements to make health services friendly for adolescents can pave the way for changes for the whole population.

Although we have made significant progress in addressing ADH issues and needs in the Region and within selected countries, many challenges remain, including strengthening the evidence base to address ADH; addressing mental health problems of adolescents; focusing on interventions which affect the determinants of the health and development of adolescents; establishing mechanisms to promote the healthy development of at risk and

vulnerable adolescents; measuring outcomes and effectiveness; and, procuring necessary funding. The First Asia-Pacific Regional Adolescent Health Congress will promote a commitment to continue adolescent health and development work and will strengthen partnerships among all of us for the benefit of adolescents in the Region.

References

1. Overview of Child and Adolescent Health: Adolescent Health and Development. World Health Organization, 2000-2002. (http://www.who.int/child-adolescent-health)

2. Programming for Adolescent Health and Development - What Should We Measure and How? Risk and Protective Factors Affecting Adolescent Health and Development. Report of a Technical Consultation. World Health Organization, 1999.

3. Action for Adolescent Health: Towards a Common Agenda. World Health Organization, 1997. (WHO/FRH/ADH/97.9). (http://www.who.int/child-adolescent-health/New_Publications/ ADH/WHO FRH ADH 97.9.pdf)

4. Growing in Confidence: Programming for Adolescent Health and Development: Lessons From Eight Countries. World Health Organization, 2002. (WHO/FCH/CAH/02.13). (http://www.who.int/child-adolescent-health/New_Publications/ADH/WHO FCH CAH 02.13.pdf)

5. A Framework for the Integration of Adolescent Health and Development Concepts into Pre-Serviced Health Professional Educational Curricula. World Health Organization Western Pacific Region, 2002.