1. Adolescent Health Donna M. Denno HServ/GH 544 Photos: http://www.fhi.org/en/Youth/YouthNet/index.htm, WHO website and references, and D Denno

2. Learning Objectives Describe mortality rate trends by age group List common causes of mortality and morbidity among young adults Describe factors during adolescence that impact adult health Describe barriers to health service delivery for youth and strategies for improving delivery

3. 3 Who are we talking about? Neonatal period <28 days Infants <1 year Child <5 years School age children Adolescents 10-19 years Youth 10-24 years Adults >20 years

4. 4 All cause mortality, young people, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

5. 5 Causes of Death, 10-24 year olds, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

6. 6 Causes of Death, 10-24 year olds, females, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

7. 7 As always…causes of mortality vary by region, country e.g. 15% of deaths among 15-24 yo females in India are due to burns. –Unintentional –Self inflicted (related to domestic violence) –Homicide Shangavi et al. Fire-related deaths in India in 2001: a retrospective analysis of data. Lancet. 2009.

8. 8 Should developing countries focus attention on adolescent health? What is the role of the health sector?

9. 9 Beyond Mortality Major contributors to disease burden in youth Sub-lethal injuries  life long disabilities HIV burden STI burden Reproductive health related problems TB burden Malnutrition Mental health problems

10. 10 Impact on Adult Health ~2/3 of premature deaths and 1/3 of the total disease burden in adults--associated with conditions or behaviors that begin in youth Substance abuse including tobacco and alcohol Unprotected intercourse Sexual coercion and force Exposure to violence Eating and exercise patterns

11. 11 Impact on Adult Health ct’d 15-24 year olds account for an estimated 45% of new HIV infections worldwide.

12. 12 Impact on Adult Health ct’d Risk factors in adolescence impact future risk of chronic disease –Hypertension –Diabetes –Cardiovascular Disease –Cancer

13. 13 Impact on Neonatal Health 11% of all births worldwide are among adolescents Stillbirths -- 50% increased risk among under 20 years Neonatal deaths -- 50–100% more frequent if the mother is an adolescent versus older, and the younger the mother, the higher the risk.

14. 14 Continuum of Care Kerber K. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007.

15. 15 Health Sector Response Relatively healthy group Do not need prioritization or special consideration Provide minimum subset of adult (or child) health services Laws and policies may prevent delivery of services to adolescents

16. 16 Health Provider Response Uncomfortable serving youth who are sexually active or engaging in risk behaviors Communication and compliance issues  frustration May not have training to address adolescent concerns/questions about their changing bodies, emotions Bias

17. 17 Adolescent Development Characteristics Influencing Health and Health Seeking Behavior No longer children…yet not adults Physical and psychosocial maturity develop separately Develop at different rates Physically able to reproduce Sense of independence…yet rely on adults Risk taking Invincible

18. 18 Youth response to health services Irrelevant to their needs Distrustful Avoid or use only when desperate

19. 19 Case: Anthony 12 yo Came to town from country side when crops failed Domestic helper in a distant relative’s household, domestic violence Concerned about pubertal changes--is this normal? Case: Florence 16 yo Doing well at school, encouraged by family to continue with education Coerced sex, pregnant, induced abortion, still bleeding a week later Her mom’s friend works at the clinic

20. 20 What are barriers to delivery of effective health services? Youth Cost Lack of services— hours, cost, permission Lack of confidentiality Lack of compassion Distrust Ill treatment Health system Lack of –Data –Training –Supplies –Funding Restrictive laws/policies Vertical programming

21. 21 Youth Friendly Health Services ACCESSIBLE “I can’t go there…I don’t have the money…They won’t see me without registration papers…I cannot understand the forms…They won’t see me without parental permission…They ran out of ___…” ACCEPTABLE “I don’t want to go there…It’s dirty…I have to wait too long…The doctor doesn’t know what she’s doing…The nurse yells at me...They might tell my family…Someone will see me go there, I’ll get in trouble…” EQUITABLE “I get treated poorly because I use ___, I’m poor… a street kid…from a minority group…from the countryside…”

22. 22 What can we do to make services “Youth Friendly”?

23. 23 How do we know if services are “Youth Friendly”?

24. 24 What can we do when youth still cannot or will not come to health facilities?

25. 25 Continuum of Care Kerber K. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007.

26. 26 Intergenerational Cycle of Undernutrition The cycle of poor nutrition perpetuates itself across generations Childhood: Child growth failure, impaired mental development Adolescents : Low weight and height Pregnancy Compromised nutritional status Adult : Small adult woman, lowered productivity Fetal and Infant stages: Low birthweight baby