Chapter 11: Adolescent Health

Mental Health

- 10 to 20% of all Adolescents suffer from mental health problems. Depression is the leading cause of illness and disability in young people and suicide is third most common cause of mortality. Other common mental health problems include: eating and conduct disorders, anxiety, and depression. Most go unnoticed and or untreated, affecting adolescents' potential and development. - Other risk behaviors include violent behavior, unsafe sexual behavior, and substance abuse. - Risk factors for mental health problems: genetics and the health of the mother, adolescent parent, being an unintended births being born after a short birth interval, having parent who married blood relative, poor physical health and nutritional status, growing up without caregivers, being orphaned, or growing up in an institution, exposure to harmful substances, violence, conflict, or abuse, gender disparity, discrimination, immigrant status, or being displaced. Victims of bullying, family dysfunction, pathological use of the Internet, adolescent pregnancy, and being a child solider. - Suicide is among the five leading causes of death among adolescents 15-19 years in Latin America, Caribbean, Europe and Central Asia, East Asia and Pacific, and South Asia. 8th leading cause of death in Middle East and North Africa region and 11th leading cause in Africa region.

HIV/AIDS and Other Sexually Transmitted Infections

- 2 million adolescents living with HIV/AIDS. Deaths among adolescents are increasing mostly in The Who Africa region. Reason is that they may not be receiving all of the care that they require. 60% of all new HIV infections occur among 15 to 24 year olds. Adolescents girls are at special risks both biologically and socially of becoming infected with HIV. - Adolescents girls (low and middle) face particular risks for HIV and other STI. Includes their immature reproductive and immune systems, gender norms that discriminate against them, age differences with male sexual partners, and pressure in sex or prostitution. - Most STI globally occur in people younger than 25. 340 million new cases of syphilis, gonorrhea, chlamydia, and trichomoniasis.

The Importance of Adolescent Health

- Adolescents are people between 10 and 19 years of age. 1.2 billion adolescents in the world and about one of every 6 people. 90% of all adolescents live in low and middle income countries. - Make up an important share of the population, burden of disease for adolescents is a unique one and needs to be addressed directly (issues of sexuality and reproductive health, mental health, interpersonal violence, and road safety), adolescent is a period during which important health behaviors are set, health of future adult populations will depend on health of adolescents, and MDGs links to health of adolescents.

Other Communicable Diseases

- Adolescents deaths and disabilities from communicable diseases have decreased largely due to coverage go childhood vaccinations. Decrease in Africa by 90%. Communicable disease such as diarrhea, lower respiratory infections, and meningitis are among the leading causes of adolescent mortality. Malaria is a leading cause of DALYs for adolescents. - TB major cause of death for adolescents in parts of Africa where HIV/AIDS and TB have the highest prevalence rates. TB is a major cause of adolescent death in South Asia, which has the highest prevalence rates fo adult TB in the world.

Adolescence as a Transitional and Critical Period

- During adolescent years, children undergo biological, psychological, and social changes: hormonal changes and puberty, rapid increase in cognitive and emotional development (Table 11-3 page 294: physical, cognitive, social, and emotional domains). - Brain develops until people are 25 and as they age the are more in control of their impulses and and make more rational decisions. Adolescents influenced by their peers and as they get older the reduce their dependence on their parents. - Period of adolescent has been getting longer. Puberty comes earlier for boys and girls and they marry and assume mature social roles later.

Additional Comments on Selected Causes of Deaths and DALYs among Adolescents

- Early pregnancy and childbirth (maternal causes) - Anemia - HIV/AIDS and other STI - Other communicable diseases - Noncommunicable diseases - Mental health - Road injuries - Violence

Noncommunicable Diseases

- Fewer than one in four adolescents met the recommended guidelines on PA and in some countries as many as one in three adolescents is now obese. - Obesity exists side by side with a share of children who suffer from underweight, stunting, and micronutrient deficiencies. - Prevalence of cigarette smoking is decreasing in high income, but increasing in low and middle income countries. Increasing share of females smoke. Figure 11.6 page 301 Prevalence of tobacco use among males and females. - Excessive drinking is a major risk factor. Reduces self-control and increases risky behaviors (sec driving, and violence). 5% of all deaths of people aged 15-29 years of age are due to alcohol. - Figure 11.7 page 302 Percentage of current drinkers, former, and lifetime abstainers among adolescents aged 15-19 = shows that alcohol consumption is an important risk factor for Adolescents (except in Med and South East Asia).

Main Messages

- Health of Adolescents is critical to global health because to constitute an important part of the population in all countries. Health of Adolescents central to preserving gains made in child health and laying a foundation for health of future adults. - Specific focus on Adolescent health because they are neither children nor adults and it is a time of rapid biological and psychological change. - Adolescents have a unique burden of disease. Low and middle income countries fall ill and die from from preventable or treatable communicable diseases. More Adolescents face a burden of disease dominated by road injuries, depression, interpersonal violence, and suicide. - Risk factors for communicable diseases include: poor nutrition, inadequate water, sanitation, and hygiene, poor coverage of immunization and other health services. Pregnancy is an important risk factor. Social determinants include poverty, abuse, living in rural areas, poor family educational attainment, and gender discrimination. Peer relationships, living with conflict or aftermath of disasters, and having dew economic options are important determinants of health. - Consequences of poor adolescent health to individuals, and societies are immense. - Promote education to the secondary level for females and males. Investing in water sanitation, and hygiene. Economic policies that encourage job creation and productive employment for large number of adolescents who will enter the job market. - Changes in health systems. - Other specific interventions like improvement licensing requirements for driving, keeping girls in school longer, community based approach to mental health issues.

Violence

- Interpersonal violence is a leading cause of adolescent mortality that results in 180 deaths every day. Among five leading causes of deaths of 15 to 19 year olds in all World Bank Regions (except Africa and South Asia). - Latin America and Caribbean, interpersonal violence is leading cause of death of adolescents 15 to 19 years of age. - For Adolescents males, one in three deaths in low and middle is attributed to violence. 30% of 15-19 are victims of violence by a partner.

Anemia

- Iron deficiency anemia important part of the burden of diseases for 10 to 14 year olds and is among the leading causes of DALYs among males and females in this age group in almost all low and middle income countries. - Suffered undernutrition, stunting, poorer and less food.

Economic and Social Consequences of Adolescent Health Issues

- Maintaining health of adolescents is central to maintaining the gains that have occurred in the health of young children. - Health of adolescents and behaviors in which they engage during adolescent set a foundation for their health as adults (ex. pregnancy and obesity, smoking, alcohol, illegal drugs). - Social and economic costs of HIV and adolescent girls are among the most at risk of being infected with HIV. TB major cause morbidity and death among adolescents in Africa and TB lost of work. Road injuries can lead to substantial and long-lasting disabilities and many years of life lost. Mental health issues go on for much or all of a person's life and have enormous social and economic costs.

Data on Adolescent Health

- Much of the focus on global health has been on children under 5 years of age and most data on child health refers to that age group. - Does not show data on adolescents specifically for low and middle income countries or does not include a separate data for low and middle income countries.

Road Injuries

- Road traffic injuries are number one cause of death globally among 15 to 19 years and second leading cause of death among adolescents 10 - 14 years of age. 330 die everyday and 400,000 young people under the age of 25 die every year from road injury. - 10 to 14 to ages 20 to 25 there is a six fold increase.

Risk Factors and Social Determinants

- Table 11-7 page 298 Key attributable risk factors for deaths among adolescents globally (10 to 14 years and 15 to 19 years): alcohol use, unsafe sex, lack of contraception, iron deficiency, illicit drug use, unsafe water/sanitation/hygiene. - Risks are related to behavior in which adolescents engage. - National wealth, income inequality, and access to education are the most important social determinants of adolescent health. - Health of some peoples are more vulnerable than others: marginalized due to sexuality or ethnicity, those in rural areas, those who live in areas of conflict or natural disasters, and those incarcerated. Differences between males and females can attribute to gender disparities (education). Men greater risks because of war, interpersonal violence, and traffic accidents. - Mortality rate for adolescence males is higher than for females, except Africa. Young men are 3 times than women to get killed don the road. - Families, peers, schools, and exposure to social and other media can influence adolescent behaviors and health.

Broad-Based Measures to Improve Adolescent Health in Low and Middle Income Countries

- Take life-course perspective to it, seeing it as one stage in a series of age categories that people pass through as they go through life. - Collect data specific to adolescents breaking it down to early adolescence 10-14 years and later adolescence 15-19 years. - Importance of social determinants to the well-being of adolescents argues for a broad-based approach to addressing their health needs. Important to integrate interventions at the community, family, and school levels. Enhance educational opportunities and manage the economy that promote employment for large number of adolescents. - Health authorities lack control over factors that concern road traffic injuries and interpersonal violence. Those responsible for road safety and governments must take control. - Measures that health systems can take: adopting universal health coverage to reduce barriers to care, take measures to be more adolescent friendly, health authorities can lead to efforts within countries to enact and enforce laws that reduce risks, expanding focus and address broader range of health concerns. - Health interventions in specific areas need to take into account the particular needs of adolescents. Policies on alcohol and tobacco must be included. Reduce risks, reduce harm, and treat adolescent health problems in specific areas.

Death and DALYs

- Ten leading causes of death globally among adolescents (2012): road injury, HIV/AIDS, self-harm, lower respiratory infections, interpersonal violence, diarrheal diseases, drowning, meningitis, epilepsy, and endocrine, blood, immune disorders. Four leading causes of deaths for adolescents are communicable diseases the tare preventable or treatable. - Leading causes of DALYs is unipolar depressive disorders, iron deficiency anemia, back and neck pain, anxiety discords, and asthma. - Leading causes of death for males: road injury, interpersonal violence, HIV/AIDS, and drowning. Leading causes of death for females: HIV/AIDS, self-harm, and diarrheal diseases. - Leading cause of DALYs in males is road injury, unipolar depressive disorders, HIV/AIDS, and self-harm. For females its unipolar, iron deficiency anemia, road injury, and HIV/AIDS. - Table 11-5 Five leading causes of death globally among adolescents by sex page 297 (ages 10-14 and 15-19 for low and middle income countries and high income countries). For males in low and middle income = leading cause of death road injury; as they age causes move from HIV/AIDS and drowning to interpersonal violence and self-harm. High income = road injury is the leading cause of death for both age groups and self-harm is second. - For females leading causes of death in low and middle in younger age group is communicable diseases and in older age group it is self-harm. Maternal disorders are second leading causes. High income countries are road injury and self-harm in both age group and violence is third leading causes of death in older group. - Table 11-6 page 298 is the Five leading causes of DALYs for males and females aged 10 to 14 and 15 to 19. Road injury more important in low and middle income countries and musculoskeletal issues and conduct disorder are in the leading causes of DALYs in high income countries. Group 15-19 importance of mental disorders and road injuries for both males and females. Violence is prominent in low and middle income countries among males and maternal disorders are prominent in low and middle income countries among females. - Figure 11-3 Leading cause of death globally by age group page 299. Children 5 to 9 leading causes of death are communicable diseases (diarrhea and pneumonia). As they age, die less of communicable disease and more by interpersonal violence, road injuries, and self-harm. Females 15-19 risks of dying maternal causes in low-income. - Figure 11-4 page 299 Leading causes of DALYs globally by age group. Correlation between income group of different regions and the adolescent death rate Africa region has 7 times death rate than European and Mediterranean has adolescent death rat that is twice the rate in Europe. - 1 in 3 deaths among adolescent males in low and middle income in the Americas is due to interpersonal violence. 1 in 5 deaths among adolescent males is low and middle income countries in Eastern Med region is from war and conflicts. 1 in 6 deaths among adolescent females in Asia is from suicide. 1 in 6 death among adolescent Africa is due to HIV. 1 in 5 death among adolescent high income is due to road traffic injuries.

Early Pregnancy and Childbirth (maternal causes)

- Worldwide females age 15-19 among to 11 percent of all births. 16 million females aged 15-19 and 2 million females under the age of 15 give birth every year, an by the age of 18 one fifth of all females have given birth. - Complications from pregnancy and childbirth are leading causes of deaths among females age 15 to 19 in low and middle income countries, where 95% of births occur. Leading causes of death in the Med region and top four causes in the Africa, South East Asia and Americas region. In Africa, females 15-19 are 1.5 times more likely to die compared to male counterparts. 3 million girls aged 15-19 undergo unsafe abortions yearly and some lead to maternal death. - Figure 11.5 Adolescent fertility, ages 15-19, by World Bank Region and Globally 2013 page 300. Adolescent fertility in Africa and Latin America and Caribbean is more than 5 times and more than 3 times higher than in East Asia and Pacific. - High adolescent fertility poses risks to young women because the risks of dying a maternal death are higher when a women with low resources, undernourished, short stature, give birth at young ages, with short birth intervals, and where maternal health services are weak.

MDGs and Adolescent Health

Goal 1: Eradicate poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce chid mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria, and other diseases

Policy and Programs Briefs

HealthWise South Africa: A Life Skills Course for Adolescents Cash Transfer Program for Adolescents Girls in Malawi

Key Adolescent Health Burdens

Key Issues in Adolescent Health Status in low and middle income are on Table 11-4 page 294.

Key Terms and Definitions

WHO defines adolescents as between ages 10 and 19 years. UN defines youth as between ages 15 and 24 years. UN Convention defines child as under the age of 18 years.