General Considerations for Adolescent Health Interventions

So far in this article, we have described the major health challenges facing adolescents. We now present a set of general considerations that should inform adolescent public health interventions. The objectives of health pro­grams for adolescents may be seen as helping them to prepare for the transitions they will make into adulthood: completing their education, entering the workforce, form­ing their own family, and participating as a citizen in their community and country (World Bank, 2006). Good health in adolescence is a critical resource for successfully com­pleting these tasks.

Promoting Resilience. As mentioned earlier, the majority of adolescents do not engage in risk behavior or suffer from mental health problems. Indeed, it is even the case that a large propor­tion of those who are exposed to high degrees of adversity do not manifest behavioral or mental health problems in adolescence.

This was demonstrated in a South African birth cohort study (Richter, 2006). Of 2300 children fol­lowed up from birth to the age of 16 years, over 50% lived on less than $1 per day, 20% frequently went to bed hungry, and more than 40% had experience of commu­nity or family violence.

However, only about 5% showed significant behavioral difficulties in their preschool or early school years, had started smoking or carrying a weapon by the age of 14 years, or had been in conflict with the law. An understanding of the factors that confer this resilience in the face of adversity is helpful in inter­vention and program development.

Resilience involves persistence, hardiness, goal- directedness, orientation to success, achievement moti­vation, educational aspirations, belief in the future, and a sense of anticipation, purpose, and coherence (Commission on Positive Youth Development, 2005). Personal resilience cannot be divorced from the social and environmental context.

The context can act synergistically with individual attributes to promote adolescent resilience, or can exert the opposite effect through preventing individual resilience from developing or flourishing. The following are examples of interventions in the individual and social context that promote adolescent resilience (WHO, 1999):

- promoting bonding, the emotional attachment and commitment, to family, peers, school, community and culture;

- promoting skills and competencies in the social, emo­tional, cognitive, behavioral, and moral arenas, for exam­ple, skills to build motivation and persistence, make well-informed and carefully assessed decisions, work in teams, negotiate conflict, and resist peer pressure;

- nurturing a clear and positive self-identity and a belief in the future;
- developing self-discipline and self-confidence, a per­ception that one can achieve desired goals through one’s own action; and

- establishing pro-social norms (those that involve fulfill­ing one’s obligations to others), providing opportunities for pro-social involvement with family, peers, and adults, and recognizing positive behavior.

Promoting adolescent resilience is a worthwhile goal in itself. However, by doing so one is also responding to a range of specific health challenges. Promoting emotional attachment and commitment to family, for example, has been shown to exert positive effects on a range of outcomes such as tobacco use, unsafe sexual behavior, and several aspects of mental health.

The impact of interventions that aim to promote adolescent resilience may have a larger overall impact on morbidity and mortality than discrete interventions, such as a safe sex health promotion pro­gram, precisely because the effects are manifest across a range of outcomes.

Being Comprehensive. Problems result from influences at the following over­lapping ecological levels: individual (for example, self esteem, attitudes, knowledge, self efficacy, genotype, bio­logical factors); interpersonal (for example, family and peer relationships, interactions with health-care provi­ders); community (for example, low level of access to leisure resources, poverty, social norms, and discourses); and public policy (Breinbauer and Maddelino, 2005).

These levels interact in complex manners that are only recently starting to be elucidated. Poverty, for example, can be linked to discourses that support an unequal dis­tribution of sexual power between young men and women (community level). This can be manifest in the power dynamics characterizing romantic and sexual relationships (interpersonal level).

This can result in a young woman having low self-esteem and low self-efficacy (individual level), each of which may, for example, mitigate against her refusing unwanted sexual advances or practicing safer sexual practices within sexual relationships. Richter (2006) draws on several studies to provide the following example of the interaction between factors at each of these levels. Early timing of puberty has been associated with poor attachment, family discord, and low investment in children.

The combi­nation of these stressors and early puberty contributes to conflict with parents, lower self-esteem, and associations with deviant peers. These factors in turn contribute to risk behavior and mental health problems.

A consequence of the complex web of causation of problems in adolescence is that interventions need to oper­ate at multiple levels, thus promoting mutually reinforcing changes. The more traditional actions to strengthen an individual’s capacity to protect their health need to be supplemented by interventions at the interpersonal, com­munity, and public policy levels (Nutbeam, 1997).

For example, banning advertisements for alcohol that target young people, raising prices, enforcing age-related laws on sales and consumption of alcohol, and banning alcohol at sports events (public policy level) can be accompanied by educational activities (individual level) and efforts to change the social norms around drinking, its desirability and acceptability (community level), and skills in dealing with peer pressure (interpersonal level).

Health services that are networked across government, nongovernmental organizations, private sector clinics, and pharmacies increase the proportion of adolescents who access the services (WHO, 2002). New information tech­nology which especially appeals to adolescents should not be ignored. There are interactive websites around issues of bullying, violence, and power relationships in schools which aim to provide a resource base of approaches, develop a framework for sharing community solutions, and help ensure safe and supportive school environments.

Also, health services that are integrated, for example, providing family planning and treatment of sexually transmitted infections at one site and perhaps by a single health-care provider, are more acceptable and result in fewer missed opportunities for treatment and preventive interventions (Mayhew et al, 2000). Alternatively, an effective referral system is needed, so that those who receive post-coital emergency contraception or termina­tions of pregnancy are referred to family planning ser­vices in an efficient manner.

Intersectorality. A consequence of providing a variety of interventions at different levels is that the involvement of more than one sector is essential. For example, as implied earlier, poverty is a risk factor for risk behavior and mental health problems. This can only be addressed in collabora­tion with, or by supporting the efforts of, government officials in several departments such as economic affairs, development experts, economic planners, and housing authorities, together with nongovernmental organizations (NGOs) working in these fields.

Representatives of other sectors may not initially under­stand the contribution of their area to adolescent health, but through consultation can develop greater insight. For example, fashion executives may come to understand their industry’s contribution to the causation of anorexia ner­vosa in adolescent girls through the employment of very thin fashion models; housing officials and civic planners may realize the relationships between crowded housing and impersonal spatial arrangements and stress, and hence adverse adolescent health outcomes; and the police ser­vices may realize the opportunities that exist for more sensitive and supportive relationships with adolescents who witness or are victims of domestic violence.

Collaborations should be beneficial to all the sectors involved. Improved adolescent health can benefit the jus­tice system through resulting in fewer convictions; faith- based organizations through increased participation in their activities; and the education system by decreased number of dropouts and improved academic performance. If the other sectors do not perceive that they are benefit­ing from their contributions to improving adolescent health, the collaboration will not be sustainable and may even have a negative impact by absorbing energy and time that could have been more profitably used elsewhere.

‘Adolescent-Friendliness’. ‘Adolescent-friendly’ services generally involve well- trained adults who like working with adolescents and treat them as responsible persons, rather than being patronizing or judgmental. The protection of confidenti­ality and privacy, especially around sensitive areas of sex­ual health and drugs and alcohol use, is very important, although this may raise issues of parental notification and consent. ‘Adolescent-friendly’ services should be well pub­licized, accessible by public transport, inexpensive, open in hours when adolescents are not at school or work, and offer a pleasant, secure environment (Graham, 2004).

Involving adolescents in planning and implementation, and obtaining feedback from them, can improve the qual­ity and responsiveness of care. Furthermore, involvement can build adolescents’ skills and confidence in decision making and social participation. Programs for adolescents that actively consult them on their needs and wants, about the content of services and the process of delivery, are more likely to be ‘adolescent-friendly.’

Adolescents place more emphasis on good interpersonal relationships with providers and on confidentiality, than on technical quality of services (WHO, 2002). Such technical quality involves an emphasis on communication skills for providing infor­mation and counseling, and clinical skills for problems that often go untreated, such as menstrual disorders, physical and sexual abuse, and mental problems (WHO, 2002).

Parents (whose permission may be required for some programs), teachers, and youth and religious leaders at the community level, are also needed to provide assistance. Such supportive contacts with adults are crucial to ado­lescents’ health and development, and the involvement of adults increases their ownership and commitment to pro­grams.

The involvement of influential people in the com­munity helps to legitimize the adolescent’s right to have access to services, especially sexual and reproductive health services, where community norms are diverse. A contrary view holds that it is better to quietly engage in activities such as providing contraceptives to unmar­ried adolescents, so that ambivalent community members can ignore these activities and not feel required to react.