Adolescent health – A developing international discipline

Half of the world's population are younger than 25 years of age and it is estimated that youth (10 to 24 years of age) number 1.8 billion. The percentage of the population that is adolescent or youth varies from region to region, and the issues they face vary both quantitatively and qualitatively (1). The phenomenon of adolescence is a universal one in which major developmental tasks are constants and the impact of risky behaviours and lifestyle overshadow the traditional medical needs of this age group. However, there are youth populations that are at greater risk of communicable diseases, malnutrition, complications of pregnancy and the effects of wars. Adolescence is a challenging phase of the life cycle. It is a phase that begins with a clear biological marker, but which ends within a socially defined, culturally variable context that blurs the boundaries between adolescence and adulthood. In the authors' experiences, adolescents in developing and in developed nations tell similar stories about their issues and concerns. These include their concerns over mental health, substance abuse, violence and discrimination, and family disruptions. They seek a greater say in what happens to them, more educational and vocational opportunities, and assurance of safe housing and access to youth-friendly, competent health services. In most regions they must learn to deal with world changes such as globalization, urbanization and emerging technologies. Some must deal with negative experiences such as sexual exploitation, abuse and parental illnesses or addictions. Chronic conditions such as asthma or diabetes and the occurrence of injury, addiction and obesity have an impact on adolescent development and can affect the process of transition into adulthood. On balance, adolescence is a phase of life that has more positives than negatives and youth the world over symbolize the energy and joy of this most precious time. In the present commentary the authors outline the international context within which the field of adolescent health has emerged. A more detailed analysis of the health status and health concerns of adolescents in developing nations will be addressed in a later paper. The United Nations Convention on the Rights of the Child covers up to the 18th birthday but lacks explicit language about adolescence (2). Similarly, most nations, Canada included, lack formal youth-specific national policies and programs. In separate documents the Pan American Health Organization (PAHO), World Health Organization (WHO), and United Nations Children's Fund (UNICEF) have addressed the possible frameworks for such policies (3–5). At the country level there are adolescent-oriented programs, especially regarding reproductive health care, but the accessibility and quality of these programs varies considerably (especially on the African and Asian continents). Many involve partnerships with external agencies or foundations (eg, Kellogg Foundation has a special interest in working in Latin America or Africa). Recently the WHO has sponsored a number of initiatives that have an impact on adolescent health. These include major working groups on tobacco, obesity and the effect of urbanization on substance abuse. Several of these working groups are adolescent-specific and focus on topics such as the needs of boys, adolescent friendly health services and child soldiers. PAHO has taken a particular interest in the role of resiliency in adolescent development while other international agencies have become active in the struggle against child-adolescent sexual exploitation and the concerns and/or needs of young sex trade workers. Greater attention is now being paid to the adolescent dimensions of global problems such as AIDS, mental health, and chronic illnesses and disabilities. Issues of sexual orientation, as they affect adolescents, remain inadequately addressed internationally. This increased awareness of adolescent health is encouraging, but it must be acknowledged that direct benefits of these initiatives to individual adolescents remain hit and miss. In many countries youth health is linked strongly to school health programs. In some instances these programs include direct services, but in most situations they are disease prevention and health promotion entities. School programs are less available in developing countries and fail to reach the many children and youth who are not in school. Where offered, they usually address issues such as eating disorders, sexuality, suicide, bullying, discrimination or abuse. Their effectiveness remains a matter of controversy. In some situations (eg, tobacco use or drinking and driving) the main approach is via media campaigns or legal restrictions. More recently, interest in addressing adolescent health promotion via peer counselling, youth participation and youth empowerment strategies has become more popular. Adolescent-oriented research has a long history but in most regions it remains under-funded and underdeveloped. Disciplines such as developmental psychology, social psychology, anthropology, and clinical medicine based in academic centres have been the major contributors. Most of these centres are in the developed nations but exciting partnerships between these centres and researchers in developing nations are beginning to appear. WHO has pioneered the use of narrative research techniques in developing nations. These research efforts have emphasized reproductive health issues. Population-based research on adolescents continues to grow as each country awakens to the need for sound epidemiological information on its youth populations (6). In some instances, these efforts include cross-national studies such as those regularly conducted under the auspices of WHO (7). The field of adolescent health is multidisciplinary in nature but much of its origins are derived from adolescent medicine in the United States (8,9). Canadian physicians have played a leadership role in this evolution (10–12). In 1987, the International Association for Adolescent Health was founded and both authors of this paper have played important leadership roles in its subsequent development (8). This international body brings together individual adolescent health professionals and national associations for adolescent health from over 30 countries. Its membership strength is in North America, Europe, Oceania and Latin America but new interests are beginning to emerge on the African continent and in a number of countries in Asia. However, there remains a global dearth of adolescent health services and properly trained adolescent care workers. As the needs of adolescents become better understood and more carefully documented it is clear that our approaches must shift. We must address the realities of poverty, regional conflicts, illiteracy and exploitation that many adolescents confront on a daily basis. However, we must build a foundation that is less reactive, less crisis driven and more developmentally appropriate. We can do this by focusing on asset building, promoting resiliency, and offering programs that are less problem focussed and offer a better balance between risk and protection. We must recognize the importance of paying attention to the real needs of youth and of developing our skills in offering opportunities for them to participate in meaningful ways. Whether in developing nations or the developed ones, we should be encouraging programs that foster adolescents' feelings of strong, healthy connections with family, school, community and caring adults. The needs of boys, global access to quality reproductive health care, timely intervention in early adolescence, mental health services, provision of youth-friendly health services and access to better training in adolescent care for health professionals are needed in all regions and all countries. The life skills approach being advocated by PAHO holds promise and signals the need to promote healthy child and adolescent development (13). The universality of the basic needs of adolescents is acknowledged and each nation is challenged to make a commitment to make the investments required to meet them (14,15).

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