1. Adolescent Health 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 List and explain the elements of adolescent friendly health services

3. 3 Who are we talking about? A range of social and economic factors have created a distinct group in most societies, who are no longer children and not yet adults Age only one of the factors defining the period between childhood and adulthood, but a good proxy

4. 4 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

5. 5 Who are we talking about? In reality it is a biologic and developmental phase

6. 6 Adolescents 1 in 5 people 85% live in developing countries 1/3 of the population in developing countries

7. Adolescents are a diverse population group. Different needs Gender Soc-econ Culture Changing needs…

8. Changing Needs Phase of rapid physical, psychological, emotional development A time of new opportunities, new capacities, new experiences and new challenges Changing roles, responsibilities, influences and expectations: moving towards family formation, economic security, citizenship

9. 9 How healthy are adolescents? 2.6 million deaths per year

10. 10 All cause mortality, young people, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

11. 11 How healthy are adolescents? Reductions in adolescent mortality rates have been ~half that compared to reductions in child mortality rates Viner, et al. 50-year mortality trends in children and young people: a study of 50 low-income, middle-income, and high-income countries. Lancet 2011

12. 12 Causes of Death, 10-24 year olds, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

13. 13 Causes of Death, 10-24 year olds, females, 2004 Patton GC et al. Global patterns of mortality in young people. Lancet. 2009.

14. 14 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.

15. 15 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

16. 16 Continuum of Care Kerber K. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007.

17. The Health and Development of Adolescents has an Impact throughout the Life Course…for example… Health Problems During Adolescence Age when Health Problem has its Major Impact AdolescenceAdulthoodChildhood (next generation) Accidents and Violence ++++ Adolescent Pregnancy +++ Human Papilloma virus ++++ Tobacco use +++++ HIV ++++++

18. 18 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

19. 19 Impact on Adult Health ct’d 15-24 year olds account for an estimated 45% of new HIV infections worldwide.

20. 20 Impact on Adult Health ct’d Risk factors in adolescence impact future risk of chronic disease –Hypertension –Diabetes –Cardiovascular Disease –Cancer

21. 21 Impact on Neonatal Health 11% of all births (16 million) 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.

22. 22 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

23. 23 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

24. 24 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

25. 25 Youth response to health services Irrelevant to their needs Distrustful Avoid or use only when desperate

26. 26 What have been your experiences in observing, receiving, or providing health care for adolescents in resource limited settings (or anywhere)? What are barriers to delivery of effective health services?

27. 27 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