Overview of Adolescence:

Its M
Dr. Adom Manu

Adolescent and Youth

Reproductive Health eaning,
Uniqueness & Key Concepts

Andamlak Gizaw
(MPH/RH)
Assistant professor
 Session objectives

By the end of this session, participants would be

able to:

 Define adolescence, adolescent, youth, young

people and related age classifications
 Recall the participants' own positive and
negative experiences of adolescence
 Describe how the experiences of adolescents today
compare with the experiences of adolescents 20
years ago
 Identify the important reasons for investing in
adolescent health and development
06/09/2024 2
Slide B1-1
 WHAT IS ADOLESCENCE?
https://www.coursera.org/learn/youth-health/lecture/YSIGO/welcome-from-
susan-and-george

G. Stanley
06/09/2024 Hall – 1846 -1924 3
 Adolescence

Adolescence (from Latin: adolescere

meaning "to grow up")
• It is a transitional period in human
growth and development that
occurs between childhood and
adulthood, from ages 10 to 19 years
• It begins with the onset of (normal)
puberty
• It ends with adult identity and
behaviour
06/09/2024 4
 Adolescence…

06/09/2024 5
 Adolescents: age classification by
WHO/UN

Young People 10 24
Youth 15 24
Adolescence 10 19

06/09/2024 6
 Sub-groups in adolescence

• Early adolescence 10-14 years

• Middle adolescence 15-17 years
• Late adolescence 18-19 years

Other classifications:
• Pre-adolescence 5-9
• Young adults 20-24

 Youth for those aged 15-29 years

(National youth policy of Ethiopia)

06/09/2024 7
 Adolescence… A Transitional Phase
Adolescence is a stage where:
 Young people develop their adult identity.
 Move toward physical and psychological
maturity, and
 Become (relatively) economically independent.
- WHO

06/09/2024 8
 What do you remember about
your adolescence years?

06/09/2024 9
 Adolescence now and then …

 Are the experiences of adolescents today

different from those of 20-30 years ago?

 Please give reasons to support your

answer.

06/09/2024 10
“Adolescence” is really beyond an age issue

06/09/2024 11
 Adolescent development: key tasks to
enable the assumption of adult roles

• Moving from dependency to

interdependency

• Establishing a sense of identity

• Acquiring knowledge base and skills

06/09/2024 12
 Adolescent development: key processes

 Ongoing
 Uneven (within and between individuals)
 Complex
 influenced by the environment
 Mediated through relationships
 Triggered and sustained through participation

06/09/2024 13
 Types of Development
• Physical (biological) development:
– body size, appearance, brain development, motor
development, perception capacities, physical health.
• Cognitive (Intellectual) development:
– thought processes and intellectual abilities including attention,
memory, problem solving, imagination, creativity, academic
and everyday knowledge and language.
• Psychosocial/Emotional development:
– self-knowledge (self-esteem, sexual identity, ethnic identity),
moral reasoning, understanding and expression of emotions,
self-regulation, temperament, understanding others,
interpersonal skills, and friendships.
06/09/2024 14
 Adolescence is special…
 Adolescence is one of the most rapid phases of human
development.
 Biological maturity precedes psychosocial maturity. This
has implications for policy and programme responses
 The characteristics of both the individual and the
environment influence the changes taking place during
adolescence.
 The changes in adolescence have health consequence
not only in adolescence but also over the life-course.
 The unique nature and importance of adolescence
mandates explicit and specific attention in health policy
and programmes
06/09/2024 15
 Adolescence is a special period – the
critical link b/w childhood & adulthood

Sawyer et al, 2012

06/09/2024 16
 WHY FOCUS ON AND INVEST IN
ADOLESCENT DEVELOPMENT?

06/09/2024 17
 Why focus on adolescent health
and development?

Improving adolescent
development underlies the
prevention of health problems
during adolescence
WHO Technical Report Series 886, 1998

The sustainable development

goals cannot be achieved without
addressing adolescents.
06/09/2024 18
 Triple Benefits of healthy adolescence

Healthy
Adults

Health
capital of
adolescence

Healthy Healthy
Adolescents Children

06/09/2024 19
 Population of Young People Age 10-24 in Selected Countries Across the World

40
36
35
35 34
33
31 31
30
30
27
26
25 24
23
22
21
Percentage

20
20 19
18 18 18
17
16
15
15 14

10

0
t l
p an any AR ary om tes nds way tes and wai rae orth am xico esh eria ana nda tan pia we
g d
Ja erm g, S un ing mir erla Nor
a a l
S t ea K u Is , N ietn e l ad ig Gh ga ni
s
thi
o
b ab
a M N U a
G n H K E th te
d Z re V ng gh E im
Ko te
d
ra
b N
e n i e w
K o B a A f Z
g ni d A U N
on U e
H t
ni
U

06/09/2024 20
Source: STATcompiler, 2016
 Trends in adolescent population,
1950-2050

Source:
06/09/2024 UNICEF, 2012 21
 Transition to adulthood

Ban Ki-moon, former UN Secretary-General

“Adolescents are the most pervasively

neglected group in global health.”

Richard Horton (Editor-in-Chief of The Lancet)

06/09/2024 22
 The Lancet Commission on
Adolescent Health – Our Future

Big Problem
Huge Opportunity

06/09/2024 23
 Positive Developments
• Increased policy focus in countries: Among the national health policy
documents from 109 countries retrieved in 2013 from the WHO Country
Planning Cycle Database, 84% of the policies included some attention to
adolescents.

• Global advocacy: The new UN Every Woman Every Child Global Strategy
2015–2020 includes adolescent health and, in 2012, the UN Secretary-
General called for the development of a UN system-wide Action Plan on
Youth (Youth-SWAP) to enhance the coherence and synergy of UN system-
wide activities in key areas related to youth development, including health.

• Improved coverage of interventions: Across countries with available data,

there has been a steady increase in young women’s use of modern
contraceptive methods over the past two decades. In eastern and southern
Africa, where the HIV burden is high, the percentage of girls and boys who
was sexually active before age 15 declined, and rates of condom use among
girls increased from 22% to 33%.
06/09/2024 24
 Adolescent Health and the Sustainable
Development Goals (SDGs)

• Adolescent health will shape the future of

the world’s health

• Achievement of the Sustainable

Development Goals (SDGs) related to health,
nutrition, education, gender equality, and
food security depends on adolescent health.

06/09/2024 25
 Adolescent Health and the Sustainable
Development Goals (SDGs)
Some SGDs are directly linked with adolescent health:
• Goal 1: End poverty in all its forms everywhere;
• Goal 3: Ensure healthy lives and promote well-being for all
at all ages;
• Goal 4: Ensure inclusive and quality education for all and
promote lifelong learning;
• Goal 5: Achieve gender equality and empower all women
and girls; and
• Goal 8: Promote inclusive and sustainable economic
growth, employment and decent work for all;
• SDG 10: Reduce inequality within and among countries

06/09/2024 26
 Investment in adolescent health
• Why should we invest in the
health and development of
adolescents?

06/09/2024 27
 Main reasons for investing in
adolescent health and development
 Demographic reasons
 Health benefits: To reduce death and disease, both
now when they are adolescents and in the future when
they are adults, and because of the intergenerational
effects
 Economic benefits: To improve productivity, return on
investments, avert future health costs
 Human rights: To fulfil adolescents’ rights to the
highest attainable standard of health

06/09/2024 28
Slide B7-1
 Guiding principles for working with
adolescents
• Adolescence is a time of opportunity and risk
• Not all adolescents are equally vulnerable
• Adolescent development underlies prevention of
health problems
• Adolescent health problems have common roots
and are interrelated
• The social environment influences adolescent
behaviour
• Gender considerations are fundamental

06/09/2024 29
 What is the status of ARH in Ethiopia?
What do we have?

06/09/2024 30
 NGO Initiatives

• Family Guidance association Ethiopia – is a

pioneer to work with adolescents in Ethiopia
– It has youth centres in different regions of the
country
• Other NGOs
– Has worked with youth
– Particular programs that address young vulnerable
females

06/09/2024 31
 Advocacy

Parliamentarians
NGOs
Government officials
Donors

06/09/2024 32
 Youth Related Policies

• Youth Policy
• Culture policy
• National Adolescent and Youth Reproductive
Health Strategy
• National Adolescent and Youth Health
Strategy

06/09/2024 33
 Services (1)

• Adolescent and Youth health program at the

FMOH
• NGOs have Youth friendly services
• Services are being organized in higher learning
institutes
• Family life education is included in the
curriculum ?

06/09/2024 34
 Services (2)

• Adolescent and Youth Health services are

being organized in the public sector
• Adolescent and Youth-friendly services??
• School RH clubs
• Social marketing
• Safe abortion services
• Health professionals are being trained

06/09/2024 35
 Legal Framework

• Change in age at first marriage

• Stronger penalty for perpetrators of Early
marriage
• Stronger and more efficient penalty for
perpetrators of rape
• Change in abortion law
• Change in contraceptive service provision

06/09/2024 36
Ecological Model of Adolescent
Reproductive Health
 Why Ecological Model (2)

• Research and policy on youth has in the past

focused on behavioral aspects of youth
development
• There is a shift to study the underlying causes
of these behaviors recently
• Risks should always be studied along
protective factors

06/09/2024 38
 Why Ecological Model (2)

• The Ecological Framework helps to breakdown

risk and protective factors at different level
• Risk-taking behaviors are those actions taken
by youth that hinder their personal
development and successful integration into
society
• Adolescent behaviour is influenced by
different inter-related factors

06/09/2024 39
 Factors That Influence Youth Reproductive
Health Outcomes
.

Institution

Family
Youth decision Reproductive
making and health
Peers reproductive outcomes
Individual health behaviour
Partners
Household

Communities

06/09/2024 40
 ADOLESCENT HEALTH PROBLEM

06/09/2024 41
 Risk and protective factors

Risk and protective factors that affect adolescent development and

health are located at 4 levels

Macro-level

Community/School
Family
Adolescent

42
 Risk and protective factors: Individual level
Risk factors Protective factors
• Early physical dev. especially • Positive self-image
girls eg. early menarche
• Average intelligence
• Disability • Religiousity
• Early sex • Perceived importance/
• Intellectual impairment expectation of parents
• Emotional/involuntary • Availability of life skills
impulses
• Career goals
• Stress reactivity
• Lack of life skills

43
Why study risk and protective factors?

Challenges of disability
during adolescence
could undermine their
health dev.

44
 Risk and protective factors: Family level
Risk Protective
• Low parental education • Educated parents
• Single parenthood • 2 parents
• Large family size • Small family size
• Overcrowding • Family cohesion, norms & values
• Family mental illness • Religiousity
• Poverty • Parental support and care
• Influence of siblings with early • Good residence/neighbourhood
sexual experience • Parental high expectation
• Violence at home • Appropriate response to
• Sexual violence at home adolescent’s needs

45
 Risk and protective factors: Community and
school
Risk Protective
• Inadequate support • Social support systems
• Rural-urban drift • Adolescent-friendly health
• Breakdown of community corners
norms and values
• Positive school environment
• Community violence
• Positive peer influence
• Negative peer pressure
• Positive community values
• Lack of positive role models
• Sexual violence at school • Access to role models
& community

46
Breakdown of community norms and values

• Adolescent risky health

behaviours can be linked to
the breakdown in community
norms and values:
• Example:
- drinking and smoking by
minors
- rape and incest
 Risk and protective factors: Macro-level
(National & Global)
Risk Protective
• Negative Media • Good RH Policy
• Inadequate adolescent • Availability of adolescent-friendly
health services eg. RH & health services
mental services
• Availability of supportive
• Imbalance of global stakeholders (counsellors, social
economic order / Poverty workers etc)
• Bad governance • Effective collaboration among
stakeholders (counsellors, social
• Impact of foreign culture workers, religious groups etc)
• Lack of political will to
provide AFHSs
48
 Discussion questions
• Write down things your parents told you that didn’t help you when
growing up

• Write down things other significant adults told you that didn’t help
you when growing up

• Write down things you thought your parents and other significant
adults should have told you to help you but didn’t

• Write down things your peers told you that didn’t help you when
growing up

• Write down things you thought your peers should have told you to
help you but didn’t
49
 Addressing Adolescent Reproductive
Health Issues

06/09/2024 50
 ARH programs in developing
countries/Ethiopia
• Most RH research is school-based
• Programs are more effective in influencing
knowledge and attitudes than behaviors
• Magnitude of effects on behaviors is often
small/modest
• No “magic bullet”
• Multi-component program that target multiple
goals appears to be most promising

06/09/2024 51
 2006-2015 National (ETH)
Adolescent and Youth RH Strategy
Goal 1: Meet immediate and long-term
RH Needs
- Build capacities of health services at all level.
- Develop/revise national guidelines/standards
- Develop outreach programs
- Reviews ANC, delivery and PNC in HF
- Enlist participation of boys, men, gatekeepers, ...
- Develop a HC cadre to provide emergency obstetric
services

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 Goal 2: Increase awareness and Knowledge …
- Community sensitization and dialogue for social
Change
- Engage parents and family members to enhance
family dialogue
- Establish adult-adolescent channels of communication
- Promote targeted messages
- Harmonize and strengthen promotion/education
- Integrate SRH (formal and informal) educ. Sectors
- Strengthen the role of media and edutainment

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Goal 3: Strengthen multi-sectoral partnership and
create an enabling environment
- Advocacy and social mobilization
- Provide information and skills
- Strengthen linkages to referral services
- Advancement of multi-sectoral strategies
- Strengthen collaboration, partnership, and
coordination among policy, research, service, and
training sectors continuum

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 Goal 4: Design and implement innovative and
evidence-based AYRH programs

- Dissemination and utilization of tools, materials,

and best practices
- Sharing of information among youth service
organizations
- Conduct socio-anthropological research
- Collect disaggregated data for all youth programs

06/09/2024 55
 2006-2015 National (ETH)
Adolescent and Youth RH Strategy…
• The strategy laid the foundation for the development of
related policies, strategies, and guidelines on AYSRH,
• Enhanced partnerships between government, non-
governmental, and civil society organizations.
• It also provided a platform for the improvement of knowledge
and attitudes toward AYSRH among adolescents and youth,
parents, health workers, teachers, religious leaders, and
community members.
• To some extent, it has encouraged adolescents and youth to
utilize available health services.
• These in turn improved the environment for implementation
of AYSRH programs and services in the country.
06/09/2024 56
 The challenges/limitations of 2006-2015
Adolescent and Youth RH strategy
• Lack of coordination among implementing partners,
low stakeholder and youth involvement, inadequate
resources, and social and cultural barriers to AYSRH
are faced in implementing the strategy.

• Furthermore, local and global changes have occurred

in the demographic, social, economic and
technological environment that influence policy and
program decisions.

06/09/2024 57
 The challenges/limitations of the
2006-2015 Adolescent and Youth RH strategy
• Ongoing changes in the epidemiological profile of adolescents
and youth health conditions have been driving a shift in
paradigm beyond SRH/HIV towards addressing the full
spectrum of AYH and development problems and their
determinants to design a comprehensive health sector
response strategy.

• Therefore, a comprehensive national adolescent and youth

health strategy was needed.

06/09/2024 58
 National Adolescent and Youth Health
Strategy of Ethiopia (2016-2020)
• The National Adolescent and Youth Health (AYH) strategy, was developed
for tackling the full range of adolescent and youth health and
development issues in Ethiopia.

• The Strategy aims to improve the overall health status of adolescents and
youth in Ethiopia and contribute towards the realization of their full
potential in national development.

• The strategy enhances and sustains the mainstreaming of adolescents and

youth health and rights issues into the country’s growth and
transformation agenda and

• Helps achieve the post-2015 global goals including the Global Strategy for
Women’s, Children’s, and Adolescent’s Health 2016-2030.
06/09/2024 59
 National Adolescents and Youth Health
Strategy of Ethiopia (2021-2025)…

• The strategy aims at:

Reducing teenage pregnancy from 13 percent to 7
percent
Raise the median age at first marriage from 17 to
18 years and;
Reduce HIV prevalence among young people to
0.1 percent.

06/09/2024 60
 National Adolescents and Youth Health
Strategy of Ethiopia (2021-2025)…
• The new strategy goes beyond SRH comprising other
important health dimensions of young people
including:
• Nutrition, youth participation, substance abuse, non-
communicable disease, and gender-based violence.
• The strategy gives special attention to the most
vulnerable and hard-to-reach young people including
those living with HIV, disability, and those living and
working in fragile contexts.

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 Objectives of ARH programs

• Create enabling and supporting environment

for youth
• Improve the knowledge attitude, skill and
behaviours of adolescents
• Increase adolescents’ use of services
• Increase adolescents participation in programs

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 Characteristics of Successful ARH
Programs (1)
• Accurately identify and understand the group to be
served and meet their need;
• Age appropriate sexual education for in school and out of
school youth
• Gender-specific services
• Involve adolescents in a meaningful way in the
design of the program;
• Work with community leaders and parents;
• Remove policy barriers and change providers'
prejudices;
06/09/2024 63
 Characteristics of Successful ARH
Programs (2)
• Help adolescents rehearse the interpersonal skills
needed to avoid risks;
• link information and advice to services;
• offer role models that make safer behavior
attractive;
• invest in long-enough time frames and resources
• Reach underserved adolescents
– Street adolescents
• Meet the need of married adolescents
06/09/2024 64
 Common Adolescent Reproductive Health
Programs (1)
• Youth friendly clinic services
Services are said to be ‘youth friendly’ if they have
 policies and attributes that attract adolescents to the
facility or program
 provide comfortable and appropriate setting for youth
 meet the needs of adolescents and are able to retain
their adolescents for follow up and repeat visits
Senderowitz, 1999

06/09/2024 65
Common Adolescent Reproductive Health
Programs (2)
• Providing information and services to
adolescents
– Mass media, interpersonal communication and
community mobilization
• Contraception for adolescents
“Adolescents have the right to clear and accurate
information about contraceptive methods, including
correct use, side effects, and how to reach a health
care provider with their concerns”
ICPD 1994
06/09/2024 66
Common Adolescent Reproductive Health
Programs (3)
• HIV and STI services
– One third of new STI cases and half HIV infections
occur in under 25 age worldwide yearly
• Prevention of early and unintended pregnancy
• School based sexuality education
– Doesn’t address the need of out of school
adolescents
• Developing life skill

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Common Adolescent Reproductive Health
Programs (4)
• Mass media based behaviour change and
social marketing interventions
• Programs to make RH services more youth
friendly
• Community based non formal education
programs

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 Common Adolescent Reproductive Health
Programs
• Youth club/ organizations
• Livelihood programs to generate economic
opportunities for youth
• Advocacy campaign to influential political and
cultural leaders ( adults in general)

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 Program areas

• Advocacy and awareness creation program: National

Adolescents and youth health forum
• Youth-responsive facilities through the
implementation of youth-friendly health service
packages
• Empowering younger adolescents through life skill
education
• Access to quality health services
• Meaningful youth engagement
• Multispectral coordination and collaboration
06/09/2024 70
Measuring Youth and Adolescent Health Programs
 Ethical Issues

• Measurements that involve adolescents’

participation in data collection may have ethical
issues
• Ethiopia law
– Adolescents below the age of 15 are non consenting
minors (they can’t give consent by them selves)
– Adolescents between 15-18 are consenting minors
(they may not be able to consent in sensitive issues
that may harm the adolescents in any way)

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 Methodological Challenges of Evaluating
ARH Programs
• Adolescent behavior is affected by a number
of confounding factors.
– They are more susceptible to contextual and
environmental factors as compared to adults
• The intended effects of ARH interventions are
long term for some interventions
• Measuring the quality of ARH programs
requires an understanding of cultural
constructs in the local setting
06/09/2024 73
 Methodological Challenges

• ARH programs are often quite complex, multi

component initiatives
• ARH programs produce effects at more than one
level
• ARH programs and issues of adolescent sexuality
measurements are sensitive in many settings
• Overlap of indicators with other areas of RH
– Interventions in other RH programs also affect
adolescents
06/09/2024 74
 Common ARH Indicators

• The existence of ARH policies

– How does the policy environment supports ARH
services?
• Adolescents are meaningfully involved in the
design and implementation of programs
– A yes/No indicator

06/09/2024 75
 Staffing

• Percent of program staff trained to work with

or provide services to adolescents
(#of program staff who have received specific
training to provide education or counseling or
adolescent health care/ total # of program
staff working with adolescents)*100

06/09/2024 76
 Awareness

• Percent of adolescents aware of the program

The service will be specified based on the program
(#of adolescents aware of the program/
Total # of adolescents)* 100
• Percent of adult in community who have a
favorable view of the program
(#of adults who have a favourable view of the
program/ total # of adults)
06/09/2024 77
 Integration

• Sexual RH Education curriculum conformity

to best practices
– A Yes/No indicator

06/09/2024 78
 Target Group
• Number/ percent and characteristics of
adolescents served or reached by the
program
– Socio demographic characteristics of adolescents
• Sexual and reproductive health knowledge
– measures adolescents’ knowledge of key sexual
and RH topics and issues.

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 CONCLUSION

06/09/2024 80
 “Adolescence is a key phase of human
development. The rapid biological and
psychosocial changes during the second
decade affect every aspect of adolescents’
lives. These changes make adolescence a
unique period in the life- course in its own
right, as well as an important time for laying
the foundations of good health in adulthood.”
- WHO, 2014

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