ISSN 1363-8394<=
/i>
Journal of Adolescent =
Health
and Welfare
Vo=
lume
12 - No 3 - Autumn 1999
In=
corporating
the Newsletter of the International Regional Chapter of the Society for
Adolescent Medicine=
Letter from the Editor
Dear
Colleagues,
The European conference is upon us
already – it is amazing how fast this year seems to be going by! In this issue we report on the Cub=
an
conference and some of the 1998 proceedings.
May I take this opportunity to remi=
nd you
all that we welcome contributions to the Journal, to our conferences, and we
encourage you to join the British Society for Adolescent Health and Welfare
– which as you know, is the ‘grown up’ version of our For=
um.
Conference details are on
Those who are interested in our
assessment and treatment services and particularly our family work will find
this detailed at http://www.familycentre.com
We have had a
&nbs=
p; &=
nbsp; &nbs=
p; Diana
Birch
&nbs=
p; &=
nbsp; &nbs=
p; Director
Youth Support
* CONFERENCE R=
OUND
UP *
Personal views of those
attending recent conferences -
=
Our
two conferences at the Royal College of Physicians in October 1996 and 1998
have now both been published as proceedings books which are available ̵=
1;
see below. Get your personal copy of the proceedings!!
=
=
Extracts
will be printed in the Journal.
Proceedin=
gs of
our conference 1996
Yout= h - Our Resource for the Future
Now avail=
able
from Youth Support -£5 by mail order –
FAX 44 18=
1 325
8647 or E mail us at Lisa@youthsupport.demon.co.uk
Proceedin=
gs of
our International conference October 1998
Youth =
211;
Conserving Our Resource for the Future
Available=
now
Advance o= rders to above address - £8
=
The VIth =
Latin American Congre=
ss
on Paediatric and Adolescent Gynaecology took place in
=
=
Bob
Blum and Gail Slap participated as did Tomas Silber
and several other stalwarts of the Adolescent Medicine community. It is indeed a credit to Jorge
=
=
The articles that follow relate to the conference.
=
=
=
=
=
=
= Early Pregnancy - Myths, Reality and Long = Term Consequences.
Presen=
ted at VIth Latin American
Teenage pregnancy and adolescent sexuality as been dogged by numerous myths and fal= se perceptions - some of which have been extremely deep rooted and difficult to eradicate.
Debunking Myths
The su=
rveys and
long term studies of young parents which we have conducted in the
Myths =
exert most
influence when firmly planted in the belief system of the adolescent and
perpetuated by the peer group - but frequently they are g=
iven
birth and propagated by the media - a powerful force that can quickly spread
misconceptions and endow them with a false legit
Promiscuity
So let= us look at some basic myths regarding teenage couples - the girl is promiscuous - W= ell most of couples had known each other for more than six months, two thirds h= ad been a couple for more than six months and in fact three quarters of them h= ad been friends for more than six months. Most girls became pregnant by their first and only boyfriend. So this debunks two myths - that of the promiscuo= us schoolgirl and that of the fly-by-night, predatory boyfriends who just get = girl pregnant.
Sexual Education
Sexual= education is another mine field - tell them about sex and they will go out and do it. This myth hides a deep prejudice against youth and against knowledge. There= is no other area of life where we attempt to rationalise the withholding of knowledge from young people. Good decisions are made based on accurate fact= ual knowledge - not prejudices and false beliefs. In our survey over 90% of pregnant schoolgirls had not had any significant sex education - 95% had not spoken = to their parents about it, most had missed sex education at school and the commonest source which was also the least accurate was school friends.
Myths = about boyfriends - Are they just interested in sex and abandon their girlfriends when they get pregnant? Well of course some do - but on average this is not the case. Man= y of these baby fathers actually want to support their family, their baby, but they’re not allowed to being marginalised= by the girl’s family or her carers; or they may be too young, schoolboys themselves and they don’t earn money, don’t have jobs. So we are talking about emotional support not financial support and nearly 60% were emotionally supportive of their baby mothers. We do have some cases where t= he boys were not notified about the pregnancy - although 90% were. Some boys w= ho found out eventually were in quite a lot of stress, suddenly finding out th= ey were fathers and not knowing about it, and also feeling guilty because if t= hey had known, they would have wanted to support their family. An interesting fact which came out= of the early part of our study is that 18% of baby fathers we= re actually present at the delivery. Now we have to remember, that fifteen years ago at the start of the longitudinal study, it wasn’t that common for fathers to be in on deliveries.
Lookin= g on at the long term figures again debunks the myth of the unsupportive boy. How m= any stay around for their young families? At two years from first birth about 4= 5% are still involved, but it falls off with time although at fifteen years 20% are still in touch with their kids a fairly high figure really although if = you look at the number of fathers that are still in touch, it’s also very dependent on the background of the young couples. The g= irls who had families, were more likely to have their boyfriends be in touch, so they’re more likely to be stable relationships. Where the girl had be= en in care, when their partners had been in care things were very different. A= nd in fact at fifteen years, 20% of the whole population were in touch, but on= ly 2% of those where the girls didn’t have a family. Of course one could play devilR= 17;s advocate and say - well what about the ones that dropped out - 80% are not there at 15 years - but I think that the most important thing is that if 20% are - it shows potential and willing - so what could we have done to keep t= he 45% who were around at 2 years still available to their children at 15 year= s?
Lookin= g at the number of boys, this was interesting, because just under half of the girls = had multiple boyfriends and were repeating pregnancy. 39% had only one boyfrien= d, one sexual relationship over the fifteen years, which is quite a surprising fact, so these girls are not promiscuous.&= nbsp;
And an= other interesting little myth to debunk - that of the early substitute father - I= am sure we have all seen girls who come to the antenatal clinic and they’= ;re pregnant, and their boyfriend has dumped them. And at the next clinic they bring a new boyfriend saying that he wants to be considered as the father -= most clinic staff shake their head and assume he will also be gone in a short ti= me - but not so this 12% of early substitute fathers are boys who it seems have a real need to be a father. He takes on this ready-made family, the girl and = the baby because he’s the sort of boy who needs to look after people, and= is a carer, and interestingly, these were the boys who were much more likely to stay over the period of time. Of these early substitute fathers they were nearly all still there at fifteen years. They were much more likely to stay than the natural fathers, which I think is very interesting and it just sho= ws the need that some boys have to be fathers is very similar to the need that some girls have to be mothers.
Housing
Let us look at another myth - that of t=
he
girl who gets pregnant to obtain a council flat, better living conditions,
welfare money. One glance at any of our cases shows that to be the lie that=
it
is - but whole papers can and have been written on the ‘culture of
poverty’ that teenage pregnancy is. In the International conference on
adolescent gynaecology in Cuba 1999 we heard over and over about the povert=
y of
girls in Uruguay, Brazil, Chile and it is not a phenomenon limited to Latin
America by any means - London is another example . Housing can be squalid, squats or
families can remain homeless for many years. Poverty and dietary deficienci=
es
perpetuate from one generation to the next as is evidenced in the poor diet=
ary
record of pregnant girls - thirty four percent had very poor diets and no e=
mployed
adult in the home -&nb=
sp;
coupled with low birth weight and premat=
urity
in their children. This factors also associated =
with
high perinatal mortality.
Adoption
So, pe= ople say, why leave children with young mothers? Would they not be better off adopted= or placed with good families and would the girls not do better if unburdened by these children? This myth mus= t be eradicated once and for all in order to make any positive change in the liv= es of young parents and their offspring. Repeatedly it has been show that chil= dren placed in care fare worse than those raised by their parents
Care System
Girls = in the care system had more pregnancies, more boyfriends who stayed around for sho= rter periods, they had more of their children removed into care and fared worse = on every parameter researched. Their children had more problems at five, ten a= nd fifteen years. A perpetuating negative spiral of deprivation and misery.
Father figures
Another misconception here is that the influence of a father figure on the young mo= ther has been emphasised without considering the effect on the boy. It is accept= ed that girls may be predisposed to getting pregnant because they come from si= ngle parent families, they don’t have a father and so they need to go out = and find a boy because they don’t know how to relate to men, they’ve got an absence of a father figure in their lives. What the fifteen year stu= dy showed was how important it was, especially to the first born male children, this absence of father. For example in children of teenage mothers at fifte= en years - behaviour problems in the girls - 20%, in the boys - 70%. More boys bullied than girls, more= boys having minor crime than girls. The relationship with the mother, worse for = the boys than for the girls, as you might expect. Smoking is about the same, al= cohol more in boys, drugs more in boys, sex education - the girls are more likely= to talk to mum so sex education is better. Sexual activities - the boys had mo= re girlfriends, the boys had more sex.
Finall=
y let us
consider some of the psychological myths … which could and do take up=
a
whole thesis of their own. Fi=
rstly
linking with the commonly held misconception that contraception is the answ=
er.
Yes, we need better contraceptive services for youth ,<=
/span>
but these are worse than useless if the young people themselves do not see =
the
need or wish to use them. Inability to see the consequences of their action=
s,
concrete thinking, and lack of a future time perspective all impact here.
I have=
described
‘magical thinking’. To explain briefly, young people have a set=
of
belief systems
And th= en there is the myth of ‘the only thing I can do right is have a baby’ - a false solution and a condemnatio= n of youth. Our self esteem study showed that in response to deprivation and particularly sexual traumata -young mother’s self esteem fell - but pregnant teens were protected by their pregnancy from the true impact of th= ese assaults - they believed in themselves while pregnant and this gave them a better sense of self during the early months of the child’s life - bu= t it did not last - hence repeat pregnancies. What we need to do is to give these young people something else to value in themselves - to value themselves as women or as young men and not only as mothers and fathers.
=
The fol=
lowing
article was Jorge Pelaez presentation to the
International Conference in
=
Sexual Practices in Adolescent
Sexual Initiation
We listened previously to speaker talking about some problems that are very co= mmon during adolescence, abortion, sexual exploitation and STD. Now I am going to talk about the first step in sexual behaviours during adolescence, it is se= xual initiation. Risky behaviour in adolescence is very common. We recognise und= er this a precocious first intercourse, poor recognition of the risks with reg= ard to relations, health concerns, in inappropriate circumstances and places, frequent change of couples, ignorance about sexuality, birth control is not considered, Lack of essential knowledge and use of contraception and insufficient knowledge about STDs and their prevention. Today adolescents a= re affected by disproportionately high prevalence of unplanned pregnancies, sex transmitted diseases including AIDS and other STDs that affected their reproductive health. Risky sexual behaviour is considered responsible for almost all of these problems.
Sexual initiation
We are going to talk now about sexual initiation and we define that as the fir= st coitus. An intimate experience of communication of the = signs of affection existing between two human beings which could take part voluntarily. And precocious sexual initiation we define that sexual relationship that begins before the adolescent’s arrival to consolida= tion stage between age 17 to 19 years (Bloch and Erickson classification) To rem= ind you this classification covers four stages. First stage is between 12 and 13 years, second stage between 14 and 15 years - motivation manifestation, thi= rd stage around 16 to 17 and the fourth stage is over 18 years. We consider th= at any relationship that begins before this stage is precocious.
Masters and Johnson said in 1989 that commitment in a couple does not imply only preoccupation about sexual pleasure but includes direct reciprocal responsibility on birth control as a result of such union, in other words pregnancy. That is not common in a couple of adolescents that are below 18 years. That is another reason why we recognise that the relationship that b= egin before 18 years is precocious.
This is the consequence, the popular consequence of precocious sexual initiation: frustrating experience, favouring sexual dysfunction, continuous change is couples resulting in risky sexual behaviour, increased rate of STD, genital infection and their consequences - cervical changes neoplastic and PID, higher risk of abortion, unplanned pregnancy and their consequence and higher risk of PID and in the medium and long-term consequence, we are talking about infertility and ectopic pregnancy.
The main objective of our study is to know the frequency of adolescents attendi= ng secondary school that have initiated intercourse, to determine the course t= hat led them to have a precocious intercourse and to study the adolescent environment, establish risks and protective factors for precocious intercou= rse and to know the characteristic and motivation for the first intercourse.
As you can see we develop a history that include a junior high, technical and = high school institutions from Havana city where they were randomly selected. A self-responding questionnaire was supplied to all the students who went to classes on the day established by the study. A total number of 2713 filled = the questionnaire, 73 were excluded because of incompleteness or mistakes total= ling a sample of 2640 students. This is 1425 females and 1215 males. Informed consent was obtained from each individual and institution.
Here
are some of the results. The majority of the students included in this study
were in the second stage of Bloch and Erickson, between 14 and 15 years. Th=
ere
is significant difference between the no-initiation and initiation and it
represents that the males have a higher proportion of initiation during
Partner in the first intercourse - There is not big difference between male and fem= ale, it was the boy or girlfriend the majority of the partner of the partners in= the first intercourse. The only difference was in the when the partner was a fr= iend more common in females and if the partner was a relative there was no diffe= rence between female and male.
In males the paramount motivation behind first intercourse was group pressure = and family pressure. In women we had the peer and the partner pressure. And the difference was significant.
Where happened the first intercourse? As you can see t= he majority in both sexes were always in park. I had a lot of problems in find= ing a correct word because we found in the dictionary alleys I don’t know= if it is correct, it is small street, dark street, = you know something like this, and parks. But you can see that there is a lot of places, all of them are not good to have a sexual relationship. You can see motel/hotel is very small, beaches, campin= g, party, even a school.
And here the enjoyment by gender concerning the first intercou= rse. When we asked them, How did you fe= el in your first intercourse? And we found also a big difference between male and female. Very pleasant - male always. Female – almost nothin= g. Pleasant – the same, too much male, few female. Fair stresses – more female, indifference – more female, unpleasant, almost every fem= ale.
Contraception
The use of contraception in the first intercourse was also a thing that we want= to know. And we found that only 14% of the students use contraception in their first intercourse. Why they didn’t use contraception? First – unplanned relationship, that’s very common during adolescence. They w= ere surprised by the relations, they don’t plan it, t= hey didn’t know that they are going to have the first intercourse. Ignorance about contraception, ignorance about the risks of unprotected relations. But you can find some other reasons, but for example, here is very important, I call out-drop effects. So of the first intercourse in the adolescence were all these high risk sexual behaviour. <= /span>
Sexual knowledge
Sexuality information errors.= Is it important to prevent and to delay the sexual initiation? – I think so. You see that when there is a very good level of sexual knowledge the percentage= who don’t initiate is bigger. When the knowledge level is very bad or bad= the majority have been initiated. The sexual information level is protection fa= ctor against the proportion sexual initiation.
Peer group
Here is the influence of the peer group in the sexual initiation. We have 2 grou= ps of peers. We divide the adolescents into the peer groups where the majority= are initiated, had sexual intercourse and a peer group in which the prevalence = is not initiated. When the peer group is initiated the majority of the students included in this study will start the sexual relations. When they are not i= nitiated there is a big difference and the majority have not initiated. And when they ignore peer opinion also the majority have not initiated. And we can conclu= de in this case when they adolescents ignore if the peer group have or not sex= ual relations they are free of pressure, of group pressure to start the sexual relation because it is clear that it is not a topic for conversation. Here = is the incidence of abortion in the peer group. When the peer group had a high incidence of abortion almost all the students had been initiated. When ther= e is not intention of abortion this thing changed. And when = they ignore even big the difference.
Family
What about the family? We recognise a very importance to the characteristics in = the sexual practice during adolescence. And as you see when the relationship define very good or good you see that the big percentage of the samp= le have not initiated. When they said that the relations in the family is very= bad or bad almost the majority of adolescents have been initiated even when they say that is regular. The closeness with the parent is also a very important topic. When the adolescent lives with both parents the majority has not been initiated the sexual relations. Even when they live with the grandparents or others the difference is very high and almost always has been initiated the sexual relations.
Finally I would like to show you the life projects and the importance of this in ha= ve a preventing protection factor for sexual initiation. In this study we find t= hat 39% of the sample have a clear and defined life project, 30% - absent and 3= 2% is confused, they are sure about the future. When we connected the life pro= ject and the sexual initiation we found that when they have a clear and defined = life project they majority of the students have been initiated the sexual relati= ons. That is one of most important protection factors. When there is absent almo= st all had been initiated, even when they said that they had a confused life project.
We arrived to these conclusions that there is high percentage of adolescents t= hat initiate precociously their sexual relationship more frequently males. The majority of adolescents start their first intercourse voluntarily, also thr= ough a high degree of pressure from their counterpart and group. The patterns to= a group in which the majority have begun sexual relations as well as to belon= g to a dysfunctional family behaved as a risk factor of precocious sexual initiation. A big majority of adolescents had their first intercourse in inappropriate places and circumstances, did not = use contraceptive methods. A high percentage of female referred to a non-pleasant experience during their fir= st intercourse and living with both parents as well as a clear definition of t= heir life plan behaved as a protective factor of the precocious sexual initiatio= n. As recommendation we can say that an intensive work should be developed aim= ed to elimination, modification of control of reproductive risk factors of relations with special attention to the precocious sexual initiation. The following aspects to be considered: gender perspective, education in sexual health, project for development of youth, psychological and social pressure= .
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News of the International
Regional Chapter (IRC) of SAM
(Society for Adolescent Medicine)
Co Chairs - Diana Birch Gustavo Girard Treasurer Aric Schichor
&=
nbsp;
&=
nbsp;
=
=
Our 1999 Chapter workshop “When
is a family dysfunctional? - A cross cultural view.R=
21;
Will be printed in the next issue of the Journal.
Int= ernational Seminar on Violence and Adolescence
A s= eries of workshops run by international experts will examine the factors that determine the presence of violence , preventive measures to reduce its incidence and the provision of mental health care for the victims of violence. = Among the speakers will be
*D =
Birch
Det=
ails
from – ISAS -
Tel= 972 2 6520574 F= ax 972 2 6520558
SAM
2000 - IRC Workshop
PLEASE PREPARE IDEAS AND SEND IN CONTRIBUTIONS
SUBJECT
Proposal for SAM meeting March 2000
‘Institute’ - International Regional
Chapter (IRC) SAM
‘Yo=
uth in a
Violent Age – The Challenge of the new millennium?’<=
/b>
As we enter a new millennium, part of
Our modern age has brought continents and cultur=
es
closer together, air travel, the media and now the internet has bridged the=
gap
between social groups disseminating not only knowledge and information but =
also
spreading cultural challenges and ‘unhealthy̵=
7; behavioural patterns. Youth=
learn
to mimic gangs, gun carrying school boys, and violent cultures – the =
peer
group has become worldwide. The International community can no longer regar=
d certain
patterns of disorder as relating to ‘other cultures’ – we=
are
fast becoming uniform in the problems we deal with and hence need to find
common solutions.
In this institute we will examine some key areas=
of
universal international interest focussing on issues of Youth and violence.=
Just for fun …
Our
Mum in
The ne= rvously dressed official holds up a placard with my name, scanning the arrivals lik= e a bird searching for a worm. Beamingly deferential she ushers me to a VIP sui= te whilst a worried looking boy attempts to find my luggage. No good trying to help or do it myself - would cause too much loss of face. Eventually, two coffees later he triumphantly appears and we whisk through immigration and customs at record speed - quite a change from the almost painful, long slow perusal of self and documents which is the norm - using mirrors to make sure nothing is concealed behind you and attempting to reconcile faces with a stranger’s image in a passport photo - can’t help looking shifty trying hard to be relaxed.
Then the taxi. I reach behind=
me for
the seat belt only to be reassured - no don’t worry, you don’t =
need
to do that. I politely agree not to be inconvenienced by safety precautions=
and
the cab ploughs it’s way towards
Major = junction - no road signs as usual - turn left at the thirteenth bridge! The Police man sternly waves down = the car in front - what now? He jumps in for a lift back to the city! Anti imperialist slogans almost obscure the level crossing - the car screeches t= o a almost stop peering right and left to look for train= s - at least they are slower than the cars. At least a semblance of slowing for the traffic - more than can be s= aid for the red lights - which we just shot straight through.
Funny = how you forget about the decay, the rubbish in the street, the dust and fumes, some= how it is all too much to take in. Depressing tall blocks of flats, ragged wash= ing hanging on balconies. Imperialist once palace like constructions covered in stucco ornamentation now crumbling beyond repair. Buildings defying logic in staying up - hollow empty shells, missing ceilings, floors, windows, roofs = and yet there are families living in every inconceivable ledge.
And not just families - businesses also dicing with perilous
conditions. The restaurant on the fourth f=
loor
reached by groping up decayed marble staircases through derelict floors
populated only by large bats - a security man pretending to challenge at the
door in case the visitor should be ‘official’. Families are all=
owed
to have a restaurant and serve meals in their homes as long as no more than
twelve people sit around the table. We ate an illegal meal squashed into a =
room
which had been used as set for a famous Cuban film - hence the popularity -=
at
least the food matched the reputation. Unusually for
At the=
hotel
they were trying hard but the smell of paint could not quite mask out the m=
usty
mildew odour of drains and the cockroaches seemed quite at home in the
bathroom. Memories of the Rossia in
So many incongruities - looking up from the swimming pool, with the peacock strutti= ng on the grass beside, my vision carried through cracked dirty glass to naked children perched on the edge of a tottering balcony of their overcrowded tenement. The historical room with photos of long dead film stars who graced the place in bygone decades, mixed with revolutionary texts and memorabilia. Old Hollywood style elevators with bronze dials indicating the floors - you could just imagine Fred Astaire dancing out of one - except that he would n= ot know what floor he was on - the indicators had a life all of their own.
On rou=
te to the
hospital, it’s been three days since I could get through to home on t=
he
phone, th=
e
car radio played a plaintive ‘don’t cry for me
Feeling
I’m travelling through the set of&nb=
sp;
‘Twelve Monkeys’ the Bruce Willis ‘destruction of a
civilisation’ film with echoes of Planet of the Apes - the scene where
Charlton Heston turns a corner on the beach and sees the statue of Liberty
jutting out of the sand. Weird - it’s as if everything has been destr=
oyed
but somehow the people are left behind - teeming masses of people peeping o=
ut
through every crevice. Everyo=
ne in
a fifty year time warp - time to move on - away from the
At the= Floridita you can eat Hemmingway - drink his daiquiris - sample his prawn cocktail - = eat fish the way he liked it. My bottle of water sat incongruously in a champag= ne style ice bucket tended by three waiters.&= nbsp; Who cares about Hemmingway in the slum streets where children wait to get their water out of a truck in plastic buckets.
It doe= sn’t feel quite safe walking the streets alone - maybe because of the poverty making us feel guilty for what we have - but it’s more than that. Set= ting aside the unnerving ‘sexual undertones’ in many of the ogling men’s eyes in old Havana - undressing you and more with their eyes; t= here remains a sort of desperation, a feeling of being almost at the end of civilisation … maybe because people are apparently living passively oblivious of the decay around them. You walk avoiding gaping chasms in the street, dodging piles of dust and rubble, picking your way through roads th= at can one moment be a main highway and suddenly peter off into a slum alley.<= /span>
I go i=
nto
survival mode - dress down, blend in, memorise the map in my head and
don’t look at it, keep walking purposefully and confidently - I’=
;m
sure it’s when you’re nervous that you give off vibes that attr=
act
street crime. It’s afternoon, my shadow=
217;s
in front of me, so I must be walking east (not so easy on a cloudy day!).
What o=
f the new
generation - what hope for the future is there for youth? My mission in
The
The following article was presented by =
Gail
Slap at the International conference in
What I= want to do today is talk about adolescent reproductive health and I’d like to= do it in a variety of ways. We’ll talk some about clinical service, but really what I’d like to do is consider with you where we’ve gon= e in terms of our research efforts in adolescent reproductive health and where I think we need to be heading as we move into the next century. Well, first I think it’s fair to a ask a question why adolescent. Firstly, and I th= ink you all know this, 20% of the world population is 10 to 19 years old, there= are 1.5 billion teenagers between the ages of 10 and 24, 50% of the world’= ;s population is under 25 and this is climbing, 86% of youth now live in developing countries and further more if we look at youth around the world living in urban environments,= a youth is three times as likely to live in a city in a developing country as= in a city in a developed country. These youths face the highest risk, they face the least support. And even more than that group is the 70% of the world’s urban migrants who are youths.
Beginning sexual experience<=
o:p>
So why adolescent
reproductive health. Well, whether youR=
17;re
married or you are unmarried, people are most likely to begin their sexual
experiences during the adolescent years. 50% of African women and 30% of
Individuals
But ad= olescent reproductive health means more than the risks, it means more than the pregnancies, it means more than the sexually transmitted disease. It also m= eans looking at individuals - take some examples - three girls, all aged 12, best fri= ends, birthdays within one month of each other, and helping them cope with the differences in their pubertal development, but also trying to understand wh= at controls these difference in development. If you consider the first 12-year old, she is 10-0-4, she is 50th percentile for height and weight, note that= she is not smiling. Why is she not smiling? She is wearing braces. Look at this teenager on the left. She is also 12 years old. What was the first thing she did when I asked to take her picture. She kicked= off her shoes. Why did she kick off her shoes? She is worried about being too <= span class=3DGramE>tall . She is barely 10-0-2. And this 12 year old, 10-= 0-2 notice= what she is doing, when I asked to take the picture. She is standing on her toes because she is fearful of being too short. So they all = have their own difficulties and differences to deal with and yet they are all entirely normal.
Now le= t’s look at this 14 year old. This too is adolescent reproductive health. She h= as delayed puberty, markedly delayed puberty. She is in the hospital constantly for her sickle-cell disease. And let’s look at this 16 year old father who’s hospitalised after a gun-shot wound out on the street. This you= ng man has 2 children. We cope not just with the violence of the inner city, n= ot just with the medical complications of his gun-shot wound, but we cope with= the difficulties that this young family faces.
Now wh=
at we do
know about risk behaviours is that they increase dramatically during
adolescence and yet I think there is a tendency to say all risks at all tim=
es.
Data from the
But th= e WHO asked us to do something else and that was to identify the positive indicat= ors for adolescent health what I would consider the good adolescents, as well as the bad adolescents. I think we’ve done a good job and are working ha= rd on this. I don’t think we’ve done as much here. Yes, we’ve identified the negative indicators, we’re getting much better in identifying which adolescents are at risk. But we do= n’t really understand is what makes a teenager resilient. They ask that we expl= ore the perceptions of teenagers regarding their health needs and problems and again I do think we’ve made headway here. Now our job is to truly exp= lore the perceptions of teenagers rather than giving teenage= rs instruments that are developed by adults that force them to respond to what= our preconceived notions of their perceptions are. And finally we were asked to evaluate the effect of interventions and programmes and again I think we are moving steadily in this direction.
Critical research issues
When I= thought about what are the critical research issues in adolescent reproductive heal= th this is what me list would look like:
· what is the access around= the world to reproductive health care;
· how do we modify risk behaviours for HIV and other sexually transmitted diseases;
· how should we screen for STDs and how shall we treat for STDs; no= t just in terms of what is the best treatment, but also what is the most realistic treatment, given the environment.
· Contraceptive counselling= and compliance;
· pre-natal care, content, quality and utilisation;
·
gender roles and
responsibilities, which I don’t think we’ve done enough with;
· physi= cal and sexual abuse, and I’d like to point out here I am t= alking not just about girls but also about boys.
Access to services
Now,
I won’t have time to go through all of these, but what I’d like=
to
do is walk with you through at least two of them. Let’s take a look at
what’s happening to access, how teenagers present and who they presen=
t to
at least in the
First utilisation. Data from =
the
Now let’s look closer what happens to visit numbers by age and sex. What = you see is that during childhood and into the early adolescence years girls and boys are seeking physician offices about equally. We begin to see some chan= ge in the mid-adolescent years and look at what happens by late adolescence 18= to 21, girls are over twice as likely to seek care in off= ices as are boys.
Now let’s keep going. Well you might say how does all= this relate to non-insurance. And I think we begin to see something very telling. When we look at the non-insurance rate, What you see is that males= are far more likely by late adolescence 18 to 21 to be uninsured as females,= well why is this, And here we begin to get some indicator of what’s going = on . Look at what happens to public insurance at age 18 to 21 for girls, look at what happens with boys, remains absolutely stable . So what’s going on here? Why are the girls suddenly receiving so much pu= blic health insurance while the boys are remaining quite low and flat. And the answer is adolescent reproductive health problems as you might expe= ct.
Looking at the percent visits to various specialist by a= ge. What you can see at age 11 to 14 is that about 40% of the office care is to paediatricians and that about 25% is to family practitioners. A very small number are to obstetricians /gynaecologists. Now let’s look at what happe= ns at 18 to 21. Adolescents are as likely to see an obstetrician /gynaecologist as they are to see a family practitioner. And this is not 25% of female visits, this is 25% of all visits. What’s happen= ing is that males by and large in the late adolescent years simply are not seeking care at the rate that females are and females are seeking care primarily for reproductive health issues.
Now let’s take a look at what the leading diagnoses are. By 18 to 21 near= ly a third are coming in for prenatal reasons. At 11 to 14 adolescents come in f= or routine care, pre-school, pre-camp kinds of check-ups. How many 18 to 21 ye= ar olds do you think are coming in for, check my ears and listen to my heart, = no. What they are coming in for is pre-natal care.
Let’s
move on now to talk about sexually transmitted diseases. In 1997 the
Prevention
And
finally prevention in the
We’ve seen other successful interventions. But once again the implementation =
has
been markedly delayed. So whether we look at individual counselling or coup=
les
counselling or programmes for high risk groups or peer leader education, or
mass media campaigns they have been shown to work, and yet have they been
implemented broadly, for the most part - no. One of the things that these
studies have done is look not just at the ability of interventions to impro=
ve
knowledge but also the ability of the intervention to change behaviour. I t=
hink
our next step is to look, yes, at knowledge, yes, at behaviour, but also to
look at health outcome.
When
we think about STD surveillance strategy most surveillance strategies, no
matter what country you look at, use passive reporting rather than active c=
ase
finding. What that means, is that no matter how bad the numbers sound they
probably still an under-estimation. Secondly the
surveillance data are difficult to interpret when we consider that 8 new
pathogens have appeared in the last 18 years, that we
have new syndromes, and we have new tests, such as LCR. Periodic behavioural
health surveys are very important, they’ve been underdeveloped and
they’ve under utilised and they’ve often been blocked in many
countries, including at times in the
Provider performance measures. And I think this is very important. Increasingly certainly in the United States we have seen measures of the doctors doing what they should be doing, what are called performance strategies or screening strategies typically these have = not included STD screening, they’ve included things like our mammograms b= eing done at the appropriate rate in some cases our PAP smears being done at the appropriate rate. Several of larger managed care organisations are now beginning to include chlamydia screening as a performance measure and I think it is a very important step in improving care.
Well, if we think about what the current focus for adolescent risk research has b= een certainly over the 80s and much of the 90s we’ve tended to look at selected problem behaviours, at youths in difficult circumstances, we’= ;ve looked at the deficits, the problems, the risks of individual adolescents a= nd we’ve looked at family and peer characteristics. What are the limitat= ions to this kind of approach? I think the biggest problem is rights of the yout= h, it imposes a deficit model. What that means it will not help us identify the predictors of success. Why is it that in adolescent who’s impoverishe= d, who’s on the streets, who has minimal supp= ort may still do well. And there are adolescents who despite very adverse circumstances do do well.
I think the second thing it does it de-emphasises the study of neighbourhood influence in youth development, yes, we’ve looked at the individual, = yes, we’ve looked at the family and the immedia= te peers. But we really have not used the kind of sophisticated and often qualitative research methodologies that are needed to look at neighbourhood. And I am not talking here just about the neighbourhood where the adolescent lives, think about the adolescent’s day: they may wake up in one neighbourhood, go to school in another neighbourhood, play basketball in a third neighbourhood, go to movies in a fourth neighbourhood, they are very = very mobile, and all of those neighbourhoods can have influence and impact on the adolescent’s development.
And finally I think this approach encourages fragmented services that really are aimed at the crisis, at treating rather than preventing the sequelae of problem behaviours.
Now what I’d like to do is take you through a case example of why I think this approach is a problem. Consider here two 18 year old men, both have HI= V. Both are good candidates for triple chemo therapy. Both live in urban slums. Both are uneducated, unemployed and poor. Both rely on local hospital clini= cs for their health care. Both have families that want them to take medicine y= et neither has done so. Why? Two situations sound very similar.
One
man lives in Punei?,=
Now
consider the second man. He lives in
The new direction then in reproductive behavioural health research that I would= see are to define what are the societal realities and expectations regarding reproductive behaviour and health care, to identify the neighbourhood norms= and expectations for sexual behaviour, to begin to remove neighbourhood barrier= s to help the behaviour and to try to define programme effectiveness as more than improve knowledge, more than better behaviour
The Journ=
al of
Adolescent Health and Welfare
is published
by:- Youth Support,
Tel No 01=
81 325
8162 =
Charity No 296080 =
Fax No 0181 325 8647