Adolescent Health Care: A Collaborative Challenge
The health of young people is of major international concern. Almost a third of the world's population (1.5 billion people) is between 10 and 24 years of age, 80 per cent of whom live in developing countries. Changes in the social, political and economic realities throughout the world are having a major and dramatic impact on adolescents and their families. Manifestations of the difficulties they face are occurring with increasing frequency and at enormous cost. In promoting a comprehensive and shared response to the contemporary health problems of young people, health professionals face a collaborative challenge: to look beyond the obvious in their clinical dealings with young people; to connect with the family and invite them into partnerships in care; to create alliances for health via innovative, interdisciplinary teamwork; and to broaden the horizons of advocacy at local and international levels.
Keyword : Adolescence; Challenge; Collaboration; Health Care
Adolescent health has been increasingly recognised as an important international issue. While mortality and conventional morbidity are relatively low among young people compared to older age groups, it is a mistake to accept these statistical 'realities' uncritically. Over the past three decades, there has been a dramatic worsening across a range of indicators of health and well-being in young people in both developing and developed countries1-3 Drug and alcohol use, teenage pregnancy, increased smoking rates in young women, eating disorders, delinquency & violent crime, stress, depression and suicide are among the more obvious manifestations of the difficulties that young people are facing today. These serious threats to health and life are occurring, not only with discouraging regularity and enormous costs, but also earlier in life than in the past, underscoring the urgency of mounting an effective professional and community response.
A Distinct and Significant Developmental Period
Adolescence is a distinct and significant period of life, the universal aspects of which are largely determined by developmental processes such as maturing sexually, acquiring more adult patterns of psychosocial functioning and achieving relative socioeconomic independence. As noted by Eisen,4"rapidly changing behaviours and inconsistencies in biological status, psychological readiness and social aptitude contribute to the uniqueness of adolescence and make it qualitatively different from all other stages in the life cycle". Gradually, the ebb and flow of developmental progression typical of adolescence are replaced by the relative consistency and coherence characteristic of youth. Usually during the late teens, orientation to outwardly directed tasks and activities such as finding work and establishing a family become the developmental priorities for the young person.
Young people are not a homogeneous group. The needs of boys and girls differ as do those of early, middle and late adolescence. An individual's personal potential, immediate environment and the presence or absence of risk factors create obvious differences. Maturation rates and the expectations of mainstream cultures also vary from place to place. However, the core experiences of adolescence are remarkably similar with major commonalities transcending individual, cultural and social diversity. All young people, for example, have to negotiate a path between pressures to conform and achieve and those to establish a separate, individual identity. Adolescence highlights the inevitable struggle between inner drives and outside expectations.
The term young people has come to mean 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).5 Despite the conceptual and practical constraints involved, chronological groupings such as these offer a reference point for cross-cultural and other comparisons of data and experience and serve as a basis for discussion. In practice, the terms adolescent, youth and young person tend to be used interchangeably.
Young People in a Changing World
Currently one-third (approximately 1.5 billion people) of the world's population are young people aged between 10 and 24 years, 80 per cent of whom live in developing countries. 6 With more than half of the people of the world below the age of 25, the ever-increasing percentage of the world's young people in developing countries has formidable implications for population growth. Worldwide concern about adolescent fertility may be understandable in these terms alone and problems such as malnutrition, unemployment and competing claims for resources such as housing, education and health are considered likely to worsen.3,7
The past four decades have seen technological, social and political changes unparalleled in human history. The world is shrinking! With the information explosion and the global spread of telecommunications, there are few places where young people know nothing about the concerns and aspirations of their peers in other parts of the world. Together with increases in travel, tourism and migration, these trends contribute to a breakdown in cultural boundaries.2
Accelerating urbanisation is taking place, with nearly 50 per cent of the world's population expected to be living in cities by the year 2000.8 Many internal migrants are young people (more young women than young men), often moving to cities in search of work. If successful, their quality of life and prospects for the future may be improved.9 However, it is estimated that nearly one fourth of young people on the move are illiterate and unskilled,10 vulnerable to exploitation, homelessness, unemployment and poverty and the adverse consequences for health that these conditions bring.
Throughout the world, rapid social changes that challenge traditional attitudes, values, standards and behaviour are occurring, leading to a deterioration in the stability of the family and impacting significantly on the lives of young people.11,12 The World Health Organization had observed with increasing concern that 'family and family values are noticeably in decline'. The extended, multi-generational family of traditional societies is giving way to the single parent family and, increasingly, to the no-parent families of street children.12 Single parent families account for about 15 per cent of all families in Asia and the Pacific, 20-30 per cent in Africa, Latin America and the Caribbean and up to 35 per cent in parts of Europe. Approximately 90 per cent of all such households are headed by women. Street children constitute one of the major tragedies of the modern world with an estimated 40 million in Latin America, 25-30 million in Asia and 10 million in Africa. Poverty affecting more than half of the world's population, the emergence of family violence (mainly directed towards women and children) and the threat to many families of the spread of HIV/AIDS are additional major trends of global concern. It is not surprising that adolescents have been described as 'casualties of change'.13
Adolescent Health - A Risky Business
Changing conditions and new influences have lead to different patterns of behaviour and new health problems for young people. With a reduction in the passively acquired childhood infections of earlier times through public health measures such as immunisation, cleaner water supply and better sanitation, there has been a shift from biological to social causes of mortality and morbidity. In today's world, the vast majority of deaths in young people are related to behavioural aetiologies: unintended injuries, suicide and homicide. Apart from juvenile losses due to war and strife in the world's notorious trouble spots, these are the major killers of young people.3,11
Adolescent mortality trends in the second decade of life show a remarkable similarity in both developed and developing countries, with external causes of death predominating. However, while accurate figures are elusive, maternal mortality (frequently attributable to lack of prenatal care and illegal abortion) remains among the top three causes of death in young women in developing countries.14 AIDS is also now taking an increasing number of young lives throughout the world.
International trends in youth suicide represent a particular cause for concern. For most countries where data are available, young males have at least twice the risk of dying from this cause as their female counterparts, tending to choose more lethal methods of self harm. However, there appears to be a narrower gender differential for youth suicide in some Asian countries. In Hong Kong, for example, the male to female ratio is 1.3:1,15 rather than between 1.8:1 to 3.0:1 as seen in many Western countries. In 15 to 24 year olds, Australian figures for completed suicide are amongst the highest in the Western world,16 increasing by over 40% between 1982 and 1992 to account for almost a quarter of all deaths in this age group.17 While risk factors for completed suicide (a previous attempt, depression or other psychiatric disorder, alcohol and drug abuse, recent losses and ongoing family problems) are becoming better known amongst clinicians, a clear understanding of underlying causes remains elusive. Societal changes which marginalise young people appear to be significant.13,18
Trends in adolescent mortality are linked to trends in morbidity. A massive literature now exists on the nature and implications of adolescent risk-taking and the ways in which problems are often linked.19-20 For example, experimentation with alcohol and other drugs is part of growing up for many young people, but has the potential for severe harm in the form of medical illness, compromised social function, trauma linked to road accidents and death. Young people who experience significant mental health problems are at greatest risk of homelessness, risk taking behaviour, substance abuse and suicide. Globally, the addictive nature of tobacco and the harmful long term consequences of its habitual use are being increasingly recognised. While cigarette smoking rates among young people have been far greater in developed than in developing countries, those statistics are changing.21 The World Health Organization estimates that 50 million children in China and 330 million children and young people in Europe will die prematurely of tobacco-related causes if its use remains unchecked.22
In addition to the traditional problems of early marriage and child-bearing, still prevalent in many societies, there appears to be a global trend towards earlier sexual relationships in both sexes.2-3,11 The associated problems of unwanted pregnancy and childbirth, induced abortion (often in hazardous conditions) and a wide range of sexually transmitted diseases represent another major category of concern in adolescent health.
Concepts of Health and Well-Being
The WHO definition of health, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"23 still seems to need its advocates. At the most basic level, health is closely dependent on the availability of adequate nutrition, clean water, sanitation and shelter. Health is also linked to the availability of education, employment, transport, recreation and welfare services.
At a more philosophical level, there are important political and spiritual dimensions of health.24 Powerlessness can be viewed as a basic cause of ill health in that it renders individuals and communities more vulnerable, less able to command resources and services to protect their health. In any community, the young and the old lack political power and can therefore be considered at greater risk. For a human being, the concepts of wellness and well-being are also related to one's ability to be aware of oneself, "to know that one knows". From this perspective, health can be viewed as a state of awareness, the promotion of which is essential to efforts to improve people's health. These concepts are embodied in the Ottawa Charter which defines health promotion as "the process of enabling people to increase control over the determinants of health and thereby improve their health".25 Health promotion is thus directed towards strengthening the knowledge, skills and capabilities of individuals and influencing the impact of economic conditions, physical and social environments. Health promotion aims to increase the capacity of people to act on their own behalf and to maximise the chances that their efforts will be successful.
The prevailing view of adolescent health, which takes these matters very seriously indeed, incorporates the unique physical, psychological and social developments of adolescence and the implications for health of social environments, lifestyle and behaviour. In the words of Peter Franzkowiak, "Only by a change in the way we view adolescents, and the way we manage their health awareness, can they be engaged in personal preventive health as a lifestyle priority".26 Adolescent health recognises the profound link between these issues and the disease patterns of adult life, together with the enormous burden this places on the individual society. In every sense, "Adolescence is the crucible for the shaping of health in adulthood and later life",27 a powerful rationale for providing and facilitating access to appropriate services for young people and for advocating on their behalf in the broader arena of the community.
Access to Care - A Unifying Concept
Compared with other age groups, young people have received little medical or psychological attention. While there is evidence to suggest that this situation is slowly changing in parts of the world, a planned and systematic approach is rare and obstacles exist at many levels. In practical terms, progress in adolescent health care is hindered by a widespread lack of specific data about their needs and concerns, a lack of adequate training for health professionals and a lack of accessible and appropriate health services.11 The underpinning issues, however, are the perceptions, attitudes and behaviours, both on the part of adult care givers and young people themselves, which represent major impediments to care.
Concern and consternation about adolescent behaviour are not new. Almost three thousand years ago, a Greek poet called Hesiod despaired for the future of his people, if they were to be dependent on the frivolous and reckless youth of his day. Long before that, an Egyptian priest carved sadly in stone: 'Our earth is degenerate - children no longer obey their parents.28 What society seems to know about adolescence today hasn't changed much since ancient times, particularly a prevalent crisis mentality which misguidedly views adolescence as inevitably tumultuous and problematic. Such misconceptions often have the power of myths29,39 and involve stereotypes so negative, we would find them offensive were they racial, religious or ethnic. Equally inappropriate is the common misconception among health professionals, and the populace at large, that adolescence is a transitional and basically healthy time of life requiring minimal intervention. This mindset of benign neglect belies the reality that many of the difficulties facing this age group do not simply abate with the passage of time. The significant continuity of adolescent behavioural and mental health problems into adulthood is well recognised.31
At a broader level, obstacles to promoting adolescent health include territoriality among the various disciplines and service sectors involved and, often, a lack of real political will on the part of governments to take effective action.32 Throughout the world, policy and legislation often lack coherence and rarely provide an adequate basis to meet the needs of young people for information (especially information about sexuality and sexual health), education, guidance, counselling and clinical services 2,33
On the other hand, adolescents are low consultors of health care and have made few demands. Typically, they are shy of taking their problems to 'members of the establishment', are concerned about issues of confidentiality and privacy, and particularly sensitive to the attitudes of those who care for them.11 Confidentiality and the consent of minors, controversial maters in all countries, appear particularly problematic in developing nations where health services tend to be more oriented to parental needs and the concept of 'the adolescent as the patient' is less accepted.
Given their reticence to seek help and their notorious under-utilisation of mainstream services, young people present us with the important goal of providing accessible, responsive and effective services for them, and the task of determining where, how and by whom this can be done. The Society for Adolescent Medicine has urged that proposals to improve access to care be evaluated for their effects on adolescents using seven criteria34 (see Table I). Universal access to a basic level of health care for all young people is viewed as 'a timely and essential goal'.
Adolescent Health Care - A Collaborative Challenge
As doctors and allied health professionals seeking to make a positive difference to the health and well-being of young people, we face a number of collaborative challenges:
Challenge 1: To Look Beyond the Obvious
There are tools to help a medical or health practitioner make the most of the opportunity, for example, the Children's Hospital of Los Angeles Adolescent Risk Profile Assessment, the so-called HEADSS (Home environment, Education, peer Activities, Drugs, Sexuality, and Suicide! depression) Exam.35 Properly administered, this 'psychosocial biopsy' provides an opportunity to develop rapport, a clinical impression of risk profile and a guide to intervention. 'Tuning in' to an adolescent patient's circumstances, lifestyle, interests, feelings and health behaviours is not necessarily a long, drawn-out process, but it does require the confidence to engage a young person in a clarifying, reassuring and direction-finding discussion. 36-37
The identification of health issues and interventions for young people must be made within a holistic model of aetiology. A model of health care for high risk youth developed by Dr Richard MacKenzie38 depicts the multiplicity of human needs that may exist beyond the presenting complaint. (See Fig.). He reminds us that "focussing on one problem behaviour or on a single symptom ignores the complexity of interaction and feedback, and leads to intervention with a high probability of failure and subsequent recidivism." As discussed below, improving the fit between the contemporary social health problems of young people and the system of response designed to address those needs requires innovative approaches. Initially at least, these depend on a willingness on the part of clinicians to engage effectively with adolescent patients and to take the time and effort to 'look beyond the obvious'.
Challenge 2: To Connect with the Family
The family is also the first emotional and social support we experience, our first teacher and our first health care provider.40 Family is perhaps best defined by the quality of relationships between members and the sense of belonging that these relationships provide. Family relationships are an essential ingredient in an adolescent's developing sense of self and sense of 'being' - a cornerstone of the mental health continuum.41
Health is the outcome of dynamic organism-environment transactions.42 There is now a large and growing body of evidence that families can be the first line of defence against illness and the environment in which we learn our health behaviours43 : patterns of diet and exercise are set down in childhood and sustained by the family; smokers tend to many smokers and are more likely to smoke than the children of non-smokers; alcohol abuse as well as spouse and child abuse are learned in the family; illness, particularly chronic illness, often waxes and wanes in sync with family emotional processes.
Families are not optional. Sociological research has also confirmed the protective function of caring relationships between young people and adults and of an ongoing positive connection to family (and school) as important factors in the development of resilience in young people.44 Our professional responsibility, therefore, is to support the interface between young people and their families, to promote adolescent independence and autonomy rather than separation and to work to strengthen effective family functioning.45 We need to engage the young person's family in a spirit of cooperation and trust, including them as 'members of the treatment team' and as partners in care rather than ...as objects of care'.46
Challenge 3: To Create Alliances for Health
The guiding principle for what is required is that a comprehensive and integrated approach, involving all (or many) of the young person's needs and circumstances, 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.48 There is now little doubt that broadbased models of service delivery cater best to the contemporary needs of young people.49-50 While services need to have the capacity 'to deal with a host of co-morbidities', the ethical philosophy needed is one based on respect, care and belonging.
Few health care providers feel equipped to meet the complex needs of young people by themselves.51 Interdisciplinary care thus represents the hallmark of best clinical practice with adolescents and their families, providing the necessary building blocks for successful intervention and care. Effective teamwork enables a comprehensive approach, fosters flexibility and responsiveness, encourages creativity and innovation and incorporates support for team members. Beyond these clinical dimensions, the establishment of teams also opens the way to interdisciplinary training in adolescent health, a major collaborative challenge in itself.52
Calling upon the talents, creativity and active involvement of young people in their own care is an important challenge for health professionals. Youth participation, particularly at the primary care level, provides significant gains, both for the individuals involved and the community at large. When the appropriate adult support is provided, young people can contribute in a wide variety of ways (See Table II) and generally respond enthusiastically to the challenge. Youth participation epitomises the concept of 'interactive roles for a healthy society'.53
One of the special alliances for health involves the incorporation of arts workers within multidisciplinary adolescent health care teams. When artists and musicians enter into stimulating relationships with ill or troubled young people, working comfortably alongside their more traditional (but often equally creative) health care givers, magic is in the making. For example, hospitalisation can represent a major crisis point during adolescence, particularly in the context of chronic illness where repeated or lengthy admissions are required. The facilitation of creative expression and active participation within an institutional environment in these circumstances can have profoundly positive effects on a young person's confidence, self-esteem and healing processes.54
Creativity and youth participation make a major contribution too to the care of angry, despairing and disaffiliated youth, particularly those who are homeless. For this vulnerable group in societies everywhere, integration and comprehensiveness are viewed as the sine qua non of service delivery.55-56 Experiential evidence in a variety of centres around the world also confirms the benefits of integrating health care and the creative arts to foster the strengths, talents and abilities of homeless at at-risk young people.57 The challenge is to link with the human spirit by creating environments that allow a reconnection with warmth, caring and love.
Challenge 4: To Broaden the Horizons of Advocacy
Raising public interest and awareness of the health status and problems of young people is an appropriate starting point. This means being willing to tell 'the other side of the story', the positive and redeeming features of the age-group, and actively seeking to counteract the predominantly negative media coverage that young people attract.59 The effective communication of research information about adolescent health issues and potential actions to support adolescent health also helps build a climate of public interest and responsiveness.
Health care providers, particularly doctors, can also advocate for young people by communicating directly with decision-makers and politicians to build a constituency of support for action. The existence of a 'youth health policy' focuses the attention of service providers on the needs of young people, identifies them as a priority group requiring accessible and appropriate health services and provides a framework for improvements in health by outlining key issues and desired outcomes.60 Calling for and participating in the development of youth health policies is thus an important advocacy role. In this context, assisting young people to act as advocates for themselves is a particularly powerful way to work.
Other 'alliances for health' result from creating colaitions between health, education, welfare, juvenile justice & religious sectors. Young people often fall between the cracks, rarely experiencing seamless service delivery or coordinated and integrated care. The practice of intersectoral collaboration clearly holds the seeds of effectiveness where intervention and prevention are concerned. Facilitated links with academic and community organizations also provide many indirect benefits to young people through mobilising expertise, coordinating research and training efforts, bridging the gap between research and practice, and reaching a broad audience for health promotion.61
Finally, on the world stage, international collaboration enables a sharing of knowledge, energy and inspiration with colleagues across the globe. The World Health Organization has played a special role over three decades in focussing world attention on the health needs of young people.4,62-65 Through high level meetings, policy formulation, publications, advocacy and direct funding of projects, WHO has encouraged action at all levels, with a particular emphasis on health promotion, primary health care and youth participation. The Technical Discussions on the Health of Youth during the 1989 World Health Assembly,66 the Joint Statement by WHO/UNFPA/UNICEF on the reproductive health of adolescents67 and the creation, in 1990, of the WHO Adolescent Health Programme, have provided additional impetus.
International interest in adolescent health issues has also been boosted by a number of non-government organizations.68 The Society for Adolescent Medicine was established in the United States in 1968 to improve the overall quality of health care for adolescents. In 1987, the International Association for Adolescent Health was created as a multidisciplinary umbrella body with a commitment to "the enhancement of adolescent health through education, research, the advancement of health promotion and the provision of high quality health care for adolescents in all regions of the world".69 Organizations such as these, and others (for example: Rotary International; International Pediatric Association; International Youth Foundation), work collaboratively in support of youth health. Since the mid-1970s, international conferences and seminars on adolescent health have brought together diverse audiences of concerned health professionals together, at times, with young people themselves. There has been a proliferation of such events in the past 10 years with more to come.
Responding to the health needs of young people requires both professional and political responses. While governments and communities need to take action to create healthier environments for young people in which healthy life choices are easier to make, health professionals need to become not only more effective service providers but also more effective advocates for youth. The overarching goal is to promote an ethical philosophy of adolescent health care and identify approaches that enhance resilience and self esteem among young people and their families to the benefit of the community at large.
This paper is based on a keynote address presented at the 9th Asian Congress of Paediatrics, Hong Kong, 23-27 March, 1997.
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