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The second article in the Lancet series looks at how social determinants of health (SDH) affect the well-being of adolescents and have important lifelong implications for health. Social determinants of health range from societal factors to individual factors and can be anything from the economic state of the nation in which an adolescent lives to an adolescent’s family group.
The article makes a clear argument for considering how SDH influence the health outcomes of young people – from their peer group to the political context of their country, region, and the world. Figuring out what health outcomes are linked with these different determinants can help us design programs that target these factors, ultimately leading to gains in health for adolescents.
Many of the health outcomes that are affected by SDH are sexual and reproductive health (SRH) outcomes. For example, higher participation in education at a national level is associated with lower HIV prevalence among adolescents and fewer teenage births. Also, peer factors have been found to predict partner communication and negotiation as well as HIV risk.
So, teasing out the most important social determinants of SRH could be a next step in developing effective programs for improving adolescent SRH. An example of this relates to improving parent–child communication about sexual behavior. The article noted the important role that family connectedness plays in adolescent health outcomes, and family norms and attitudes were found to strongly affect a range of sexual behaviors. Interventions that improve communication between parents and adolescents can be used in areas where this type of communication is outside of the norm.
This article argues that we must consider adolescents in the context of their families, peer groups, and communities and understand the impact that national and international factors have on health. Interventions aimed at improving the lifelong health of adolescents should acknowledge both the impact that outside factors have on adolescents as well as the potential adolescents have to play a role in their own health and the health of their peers.
The first article in the four-part Lancet Series on adolescent health, “Adolescence, a foundation for future health,” emphasizes the importance of health interventions during the adolescent years and argues for a “positive youth development approach” to improving adolescent health.
The authors of this article maintain that there are many factors that affect the health outcomes of adolescents. Biological changes during puberty affect health, behavior, and emotional well-being in complex ways. Social factors such as access to education, employment opportunities and family structures also affect adolescent health.
Adolescence is a time when many adopt health behaviors that will not only affect their personal health but also the health of future generations. Yet, adolescents experience many negative health risks. Approximately 15% of the world’s disease burden is among 10-to 24-year-olds. Injuries, accidents, maternal mortality, and disease are the leading causes of death among this population, challenging the widespread belief that adolescence is a healthy time of life.
The authors of this article emphasize the need for a positive youth development approach that targets the health of adolescents as a whole rather than one that targets specific components of health. In closing, the authors make these recommendations:
- Increase the focus on adolescent health within larger health agendas
- Adopt a cross-cutting approach to adolescent health addressing the health of adolescents as a whole rather than in terms of different diseases
- Increase attention to the health of adolescents
- Give adolescents a stronger voice by increasing youth engagement
- Increase the capacity of adolescent health providers
All of the health and development issues raised by the authors of this article are inextricably linked to young people’s sexual and reproductive health. In the same way that social factors influence other aspects of adolescent health, factors such as unemployment and education are also tied to the sexual and reproductive health of adolescents.
For example, the economic disparities that are often associated with unemployment and lack of education fuel the HIV epidemic and contribute to other negative health outcomes among young people, especially adolescent girls. Lower income levels can increase the risk of engagement in intergenerational relationships, early marriage, and sex work, all increasing the risk of HIV infection and early or unintended pregnancy. The reverse is also true: the economic strength of a country suffers when its young people’s sexual and reproductive health outcomes are poor. If young people are sick, are burdened by early marriage, or experience unintended pregnancy, then they will be less able to fully contribute to society.
There is also strong relationship between education and young people’s sexual and reproductive health. Youth who do not attend school or who drop out prematurely miss many of the fundamentals of basic education. They also lose a valuable opportunity to learn about reproductive health and HIV in a stable classroom situation. Young women who become pregnant are more likely to leave school early, have a lower income, and have more children at shorter intervals throughout their lifetime. In contrast, young women who avoid unintended pregnancy are more likely to stay in school, participate in the work force, and have healthier, more educated children.
The authors’ argument for a positive youth development approach to adolescent health is well-founded. Programs cannot effectively address any health or social outcome in isolation; however, in order for such an approach to be effective, young people’s sexual and reproductive health must be at the forefront.
Today the world is home to 1.8 billion young people between the ages of 10 and 24; this is the largest generation of young people in history. Gains in child health and survival, nutrition, and infectious disease have resulted in a burgeoning youth population; however, the health of adolescents has received little attention. In the past 50 years, the health of adolescents has seen far less improvement than that of younger children.
“Surely we do not want to save children in their first decade of life only to lose them in the second.” –Anthony Lake, Executive Director, UNICEF
A growing youth population means a growing work force, and higher rates of unemployment. Poverty, lack of education, migration, natural disasters and political unrest lead to social situations that can devastate the health of adolescents. Adolescents face increasing health disparities; childbirth-related complications are the number one cause of death among adolescent girls ages 15-19. Road traffic accidents, suicide, and infections such as HIV are the leading causes of death among this age group.
“Irrespective of region most adolescent deaths are preventable and thus strongly justify worldwide action to enhance adolescent health.”—Lancet
Now, more than ever, greater attention to the health needs of this growing and unique population is needed. In April, the Lancet released its second series on adolescent health. This series includes four papers, “Adolescence: a foundation for future health,” “Adolescence and the social determinants of health,” “Worldwide application of prevention science in adolescent health,” and “Health of the world’s adolescents: a synthesis of internationally comparable data.”
This landmark series emphasizes the urgent need to increase attention to adolescent health. Join us over the next few weeks as we share the key messages from these articles and discuss their implications for the sexual and reproductive health of young people.
Every year, lack of access to family planning services contributes to approximately 7.4 million unintended pregnancies among adolescents. The unmet need for contraception among adolescents is as as high as 68% in some regions, such as sub-Saharan Africa, South-central Asia, and Southeast Asia. Although young people might not be accessing family planning services, youth are increasingly using HIV testing services.
Young people who use voluntary counseling and testing (VCT) services likely engage in sexual behaviors that that put them at risk for both HIV and unintended pregnancy. Globally, there has been a push to integrate contraceptive services at HIV testing sites; however, little is known about the effectiveness of providing contraceptive services at VCT centers.
In 2009, researchers from FHI 360 set out to determine the factors associated with contraceptive uptake among young people visiting VCT centers. The study was conducted in Kenya at both youth VCT clinics and general VCT clinics. At each facility, researchers conducted baseline and follow-up client interviews, provider interviews, and clinic observations to determine which client-, provider-, or facility-based characteristics were associated with same-day uptake of contraception, intention to use contraception, and use of contraceptives three months after a VCT visit.
Before visiting the VCT center, 72% of youth participants reported sexual activity in the past three months, and 37% of all participants were currently using contraceptives. Only 18% were using a modern contraceptive method other than the male condom and only 18% always used a condom. One-third of the clients reported they did not want to get pregnant, were not using a method and did not intend to use a method. Seventy-eight percent of providers reported ever counseling VCT clients on contraceptive use in the past week, and only 17% reported always asking female clients about whether they wanted to get pregnant.
After visiting the VCT center, many clients reported they were never screened for family planning need, were not given contraceptives by the VCT provider and/or did not intend to follow up on a provider referral for contraceptive services. Youth who had a current partner, higher levels of education, more children, and a desire to delay pregnancy were significantly more likely to begin using a contraceptive method at the time of their visit. Young people who intended to use family planning before visiting the clinic, and who were provided with contraceptives at the time of visit, were more likely to use contraceptives at the three month follow-up.
Youth who visited VCT centers that had higher scores of HIV /family planning integration were more likely to begin a contraceptive method at the time of their visit. Clients of providers who were younger or who had received training in family planning were more likely to use contraceptives at the three month follow-up. Youth clinics (compared to general clinics) received better scores on integration and youth friendliness but clients were less likely to use contraceptives after visiting; however, youth clinics might be serving a higher-risk group of youth.
The research results demonstrate that young people visiting VCT centers have a high risk for unintended pregnancy. However, very few clients who attended the clinics were counseled on contraceptive methods other than condoms, received contraception at the time of visit, or were referred to other family planning services. Further research is needed to better understand the specific factors that influence contraceptive uptake among young people so that programs integrating VCT and family planning can best meet the needs of their clients. Because young people might be more likely to visit VCT centers than family planning clinics, programs must ensure there are no missed opportunities in meeting the contraceptive needs of young people attending VCT centers.
To learn more about this issue, read the full study “Service delivery characteristics associated with contraceptive us among youth clients in integrated voluntary counseling and HIV testing clinics in Kenya.”
This post originally appeared on the Women Deliver website on April 30th, 2012 and can be accessed here.
Late Friday, 27 April 2012, at the 45th Session of the United Nations Commission on Population and Development (CPD), member states issued a bold resolution in support of young people’s sexual and reproductive health and human rights.
This victory comes on the heels of a UNICEF report released this week highlighting the challenges that the largest-ever generation of young people face—including HIV/AIDS, violence, and unintended pregnancy—and reaffirms long-standing international agreements including the 1994 United Nations International Conference on Population and Development Programme of Action.
“This CPD is one of the most important events to take place – to talk about young people, for young people and with young people,” said Kgomotso Papo, speaking on behalf of the South African Delegation during the closing plenary. “We must remove all barriers that compromise the health, well-being and development of youth; and ensure the right of every individual to autonomous decision-making in regards to their bodies, their health and their sexual relationships. On these points, there can be no compromise.”
Key points of the final resolution include:
- The right of young people to decide on all matters related to their sexuality
- Access to sexual and reproductive health services, including safe abortion where legal, that respect confidentiality and do not discriminate
- The right of youth to comprehensive sexuality education
- Protection and promotion of young people’s right to control their sexuality free from violence, discrimination and coercion
Much has changed since the landmark International Conference on Population and Development (ICPD) in 1994. Shifting global health funding, a maturing HIV epidemic, and the rise of the largest-ever generation of youth have all affected the current sexual and reproductive health and rights landscape. Similarly, several key global processes—a 20-year review of global sustainable development goals (Rio+20), a 20-year review of progress towards achieving the Cairo Programme of Action (ICPD+20), and a review of the Millennium Development Goals—are happening within the next few years, all with implications on the future of the global sexual and reproductive health and rights agenda.
“At this time of global uncertainty, there is no more important investment to be made,” said Janna Oberdorf, Director of Communications at Women Deliver. “Only healthy young people whose human rights are protected can be fully productive workers and effective participants in their country’s political processes. When young people are healthy and empowered, they can contribute to building strong communities and vibrant nations.”
In closing the session, Commission Chairperson Ambassador Hasan Kleib (Indonesia) called on member states to realize these agreements at the national level, stating that “we now have to walk the walk.”
This is an excerpt from a post written by Suzanne Ehlers, president of Population Action International; the post originally posted on the Huffington Post Impact blog. The original post can be accessed here.
Next week, I head to the United Nations to attend the 45th session of the Commission on Population and Development (CPD). The Commission’s work is to “monitor, review and assess the implementation of the ICPD Programme of Action at the national, regional and international levels.”
The 2012 CPD outcome document will serve as a foundation for major upcoming international negotiations on sustainable development and population, so we’ve deemed it a strategic investment of time and energy. We’ll travel the 95-North corridor later this week and monitor the proceedings on behalf of the world’s young people in particular, because this year’s theme is “Adolescents and Youth.”
Sounds simple, but it’s a tinderbox.
The number of adolescents and young people in the world today is at an all-time high. Along with food, water and safe shelter, this huge share of the world’s population needs access to contraception and a range of sexual and reproductive health services.
There will be many at the CPD who to choose to deny that young people are sexually active. These same deniers are so out of touch with the reality of young people that they don’t consider their human rights. It’s as if they don’t have rights, or that those rights aren’t under threat. They equate access to comprehensive sexuality education with a rise in sexual activity, when sex ed actually delays sexual initiation.
These deniers also conflate the basic tenets of good health care — such as privacy, confidentiality, and informed consent — with undermining cultural, religious and familial values. The opposite is true. Young people are sophisticated enough to explore and define their values, and make informed decisions that help safeguard their well-being.
As we head into a week of tense negotiations, let’s huddle to make sure our offensive game is primed and ready:
- We will be prepared to respond to emotionally-charged untruths about young people and their vulnerabilities with emotionally-charged facts and strong evidence.
- We will maximize a unique and isolated circumstance (UN conference rooms) for the benefit of young people around the world, whose lives literally depend on the success of our efforts.
- We will hold the line and reaffirm past commitments, but we will also seek to advance a visionary agenda for the full realization of young people’s sexual and reproductive health and rights.
To read more of this post, please click here.
More posts on the CPD coming soon! Look for “Why Are Youth Voices Important at CPD?” this week, as well as an overview of the key points from the United Nations Landmark Resolution on Adolescents and Youth next week.