A conceptual framework for understanding “problems” in adolescence and youth

JOURNAL OF ADOLESCENT HEALTH 1993;14:613-618

CARLOS

V. SERRANO,

M.D.,

Ph.D.

The main objective of this paper is to discuss how the state of youth health and the chances for the psychosocial development of young people depend on assuring a comprehensive approach to adolescent health. Failure to approach adolescent health from a comprehensive perspective based on an understanding of adolescent development will pose ongoing problems for young people. The framework for the paper is developed along the following three lines: a) the significance of comprehensive adolescent health; b) the frame of reference for promoting comprehensive adolescent health; and c) dimension of comprehensiveness of adolescent health care.

The Significance of Comprehensive Ati0k?scc1at

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Comprehensive adolescent health care is a basic element for the social development of young people and hence of the countries of the world in general (1,2). Their health status not only impacts the future potential of a nation but its present capacity as well. To achieve their aspirations of contributing to national development, the health and development of young people is central. Their well-bei.ng will not be attained if quality-of-life issues such as education, nutrition, housing, and good physical and mental health as well as the right to work, recreation, and

From the Pan American Health Organization, Washington, D.C. Address reprint requests to: Carlos Serrano, M.D., Pan American Health Organiznlion, 525 23rd Street NW, Washingfon, D.C. 20037. Based on paper originally deliuered at the Pan American Health Organization Conference on Social Change and Social Dewlopment in Adolescence: A Focus on the Americas, Washington, D.C., March 1618, 2992. Manuscript accepted October 1992.

participation are not addressed. To achieve health, young people need peace, good examples from their elders, and a consistent societal value system. Today, many youths lack well-constitu.ted families and a viable visicn of adequate social performance. All countries of the region of the Americas need to articulate a position and take effective and permanent measures today to promote and preserve the comprehensive health of children, adolescents, and youth. In order to promote comprehensive adolescent health, the following challengesdeserve special attention (3): 1. reducing inequalities in opportunities for health and development among adolescents within each ctiuntry; 2. increasing the levels of prevention services; and 3. strengthening the mechanismc for meeting the biological and psychosocial needs of young people across the teenage years. The mechanismsfor promoting the health, well-being, and development of adolescents can be summarized in four areas: 1. those mechanisms geared to progressively attaining the capacity for self-care; 2. mutual assistance within the group (or peer support) as well as within and between families; 3. acting on the microenvironments of adolescents to make them healthier; and 4. promoting healthy life-styles and behaviors of young people. Finally, the strategies that should be consolidated in a gradual and sustained fashion are: 1. strengthening the participation of communities through the leaders and organizations that work

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First Dimension: The Concept of Comprehensive Health

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Figure 1. Frame of rfference for promotion on comprehensiw health of adolescents.

with young people and with highest priority given to enhancing the participation of youth; of 2. quantitative and qualitative strengthening health services and services of other sectors such as education, recreation, social promotion, and labor; 3. coordination of policies and intersectoral actions;

and 4. the application of approaches that facilitate coordination and interaction such as the concepts of risk, family, community, and intersectoral approaches in the programming of health, wellbeing, and development activities.

The Dimensions ofComprehensive Adolescent Health In this paper, we include the following four dimensions of comprehensive adolescent health and care: a) the concept of comprehensiveness of health; b) the concept of incorporating ecologic and social contexts; cl the application of integrative approaches in the planning and operation of programs for young the incorporation of the chain of prePeQY” ventioh ~1 yrogr amming of health services, research, and training (4).

The developmental imperatives of young people compel those who work with adolescents to view the current health status of adolescents as the result, in large measure, of events in childhood that manifest during adolescence (5). At the same time, providers need to consider the influence of physical, mental, and social health during adolescence on later stages of life. The practical implication, for purposes of structuring comprehensive adolescent health care, is the need for the programs to recognize adolescence not as a discrete event but as part of life’s continuum. Thus, in providing health care for mothers and children, emphasis must be placed on enhancing protective factors that reinforce each other and ensure optimal health. Continuities from childhood through adolescence into adulthood should be emphasized in education and health sector programs especially as they relate to health promotion strategies (6). Centra! to this continuum is a fundamental attribute that, despite its profound effect on personality, way of thinking, acting, and feeling, is rarely considered in programming-the attribute of spirituality. Integration of moral principles and values, the respect for one’s self, others, and the environment, as well as the adoption of a religion, all constitute aspects of spiritual development. Adolescence is a time of spiritual questioning and ideniity seeking, yet our failure to acknowledge, support, and facilitate this central aspect of human development is at a high individual and social cost. The research of Werner (71 and others all point to the central role of spirituality in the development of resilience for young people facing adverse circumstances. It is hoped that the aspect of spirituality will be viewed more centrally, as it has a great deal to do with personality structure, mental health, and the future success of young people. In sum, it is assumed that incorporating the concept of comprehensive health into programs targeted to young people will facilitate the processes of so cialization, adaptation, spiritual and social development, and optimal performance during adolescence and beyond. Second Dimension: Incorporating the Concept of Contexts It is important to understand that what happens to individuals with respect to health, well-being, and

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development is not the result of chance nor solely the consequences of one’s own decisions. Indeed, what a country decides about nationnl political and economic deuelapment will have a major impact on the ability of people to achieve personal health objectives (8). At tlGs macro level of decision making,

measures can be taken to ensure better opportunities for young people (8). Improving the opportunity structure for young people will diminish negative social situations which are commonplace in many countries today. For example, for young people in developing countries who have the privilege of obtaining higher education, there are often not the employment opportunities to put their education into practice. It is not enough to achieve one’s potential if the conditions do not exist for using this potential. At the co??tnz~rzitylevel, culture and social changes exert major influences on practices and behaviors passed on from generation to generation. The intense migration from rural to urban areas and from small urban centers to large cities gives rise to the phenomenon of heterogeneity of cultures or acculturation, which is accelerated by the influence of the media. The readaptation to new patterns of behavior may determine new social and health risks especially for the transitional generation. The local factors acting at the microenvironments of famify and individuals exercise great influence-for better or worse-on the health and development of young people. The family structure of and dynamics in Latin America and The Caribbean have been experiencing important changes in recent years (9). Among the more developing nations of our region, these changes include: reduction of birth rates; increase of divorce and nonmarital unions; increase of single and of adolescent mothers; increase of parents and persons living alone; increased age of first or only marriage; and important changes in parental roles; especially loss of fathers’ authority and change of type and intensity of relations of parents with their children. In less-industrialized countries of Latin America and the Caribbean, family expectations are centered around survival and the satisfaction of basic needs: work, housing, basic education of children and women. In the more-developed countries, expectations go beyond basic needs to the psychologic, affective, and gender needs of the family unit. In the Latin American and Caribbean countries, major changes have faced the family during the last four decades: Social and economic changes at the macroeconomic level that impact the plans and opportunities for families; the types of families that co-exist in Latin America; the

changes related to marriage and consensual union; and the trends of fertility. During the same period of 19504989, interrelated phenomena have taken placein the Latin America and Caribbean regions. These include a significant increase of women in the labor force; considerable migration, especially of women, from rural areas to large cities; changes from manual to nonmanual occupations; notable increase of p&ic sector labor force; increment of economical status eclipsed by the increase of population; diminution in the proportion of poor homes but increase of absolute numbers; and diminution of rural poverty with increase of urban poverty. The serious economic crisis provoked by the rise of energy costs during the last decade resulted in restructuring foreign international trade, deterioration of external credit, and escalating national debt for many Latin American countries. Adjustment policies implemented by many countries in response to the economic crisis resulted in the halt of productivity and economic growth. The consequence for a large segment of the population was unemployment for it has been the labor sector of the developing countries of Latin America that has borne the primary burden of debt restructuring. In the countries of the Region, the nuclear family prevails, but a large increase of extended and single parent families is being observed. Another result of the economic crisis of the 1980s has been the fact that one provider (usually the father) was no longer sufficient for satisfying basic family needs; and women and children were compelled to work. Other consequences of the economic adjustment policies were reduction in family income, especially in urban areas, and thus reduction in the quality of life; increases of preventable morbidity and mortality; and in child abuse and abandonment, family violence, social pathology, child and adolescent delinquency, and street youth. With respect to marriage, great differences exist between rural and urban populations and among ethnic groups and social classes. Latin American and Caribbean countries exhibit the highest proporbns of consensual unions in the world. Between 25% and 30% of births are born to girls under 20 years of age. The impact of changes in the family is reflected not only in the structure and type but primarily in family functionmg. In fact, the social, cultural, biological, psychological, economic, educational, and affective functions of the familly are deeply affected by the dynamics of the local, national, and even the international situations. Children, adolescents, and the elderly are, no doubt, the family members most sen-

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I

Figure 2. A model fbr understanding risks and thrir e&cts.

sitive to crisis and probably more responsive to positive change. It is important to recognize that youth are exposed to multiple environments daily: thus, the risks to which they are exposed may potentiate each other. For millions of young people in the Region, “the street” is where they spend most or all of their time (10) confronting all conceivable risks and dangers. Most serious, however, is that “the street” environment holds children and adolescents responsible for their own plight and stamps them with a seal of guilt and criminality which legitimates abuse and mistreatment. Every environment and setting where young people can be found has its opportunities to enhance health and development as well as its health limiting risks. To develop effective interventions, it is necessary to understand and act within the context adolescents’ experience in order to identify the risk factors to which they are exposed and to determine which activities and strategies can be developed with greatest success in each situation. Indeed, effective programs cannot wait for the spontaneous demand for services by adolescents and young people for some are too disenfranchised to ever make such demands. Third Dimension: Application of Integrative Appmach in the Planning of Programs for Comprehensive Adolescent Health The risk approach is based on the following premises: Persons, families, and groups have different de-

grees of likelihood of having deficient health and well-being. This means that the distribution of effort and resources should be proportional to needs (equity). The factors that determine the levels of health, well-being, and development of children and adolescents are many; they are often interrelated. Their control (risk factors) and promotion (protective factors) require the participatory effort of sectors, disciplines, professions, and the persons themselves. The risk approach, if applied appropriately, constitutes an effective methodology for adapting organizational and institutional requirements and for making optimal and appropriate use of technologies in accordance with adolescents’ health and welfare needs. The risk approach is grounded in a concept of probability that an undesired event increases when the individual (or group) is exposed to one or more risk factors; and that health will improve when people are exposed to one or more protective factors. Control of the risk factor (by suppression or compensation) diminishes the probability of damages or when the protective factors reinforce one another the likelihood of good health increases (primordial prevention). Schematically, the degree of vulnerability of an adolescent is a function of his or her prior history coupled with the susceptibility and/or fortitude which is the consequence of the profound changes (biological and psychosocial) particular to this phase of development. In addition to the degree of vulnerability are the protective or risk inducing effects that macro and micro-environment policies, family and community norms, culture, and socioeconomic policies have on young people (see Figure 2). The family approach. The family context is particularly important for adolescent health owing to the strong positive influence that a functional family and, conversely, the strong negative influence that a dysfunctional family can exercise on the adolescent’s past, present, and future health. Indeed, the interrelations and interdependencies of the various family members and the social role of the family unit in preserving and transmitting values and cultural identity are extremely valuable for the health, wellbeing, and development of children and adolescents, A healthy family is one in which each member functions well biologically, psychologically, and socially. It is, moreover, a family in which each member functions well in relation to the others. Finally, it is a family that fun&ions well in relation to other families in the community. Conversely, a family with one

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for youth to come. It requires deliberate activities.

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Fourth Dimension: e Incorporation of the Chain of Prevention in Programming of Health Services, Research, and Training

Figure 3. Primordial prevetltiotl-promotion

of protective factors.

or more problem adolescents posqLj a risk for adolescents of other families in the community. From the point of view of policies and standards, measures geared to strengthening the family functioning are most Laluable for a society and for its individual members.

The community approach. The effectiveness

of social and intersectoral participation is essential at the local or community level where support networks exist or can be built (11). Implementation of policies of decentralization of resources emphasize local health and social services development and aim to potentiate the community and intersectoral participation (12). There appears to be wide agreement concerning the contribution that youth can make to ward attaining comprehensive health for themselves and for all. This requires introducing effective techniques of communication and participation, as well as proper use of the mass media, to attain the educational objectives. Also, there is agreement that effective youth participation requires their involvement in designing the methods and messages that are effective in advancing the health of their peers. The community resources located in areas where adolescents and young people live should be identified, supported, and used to promote health and well-being. To be effective requires more than opening the doors of such institutions and waiting

The continuous prmenfion approach. The concept of prevention chain is basic for understanding: First, that preventing certain factors or circumstances in early stages of life makes possible improvements of health at later stages of life. Second, at any moment, in good health or in ,he presence of morbidity, it is possible to a) avoid damage by preventing specific risk factors; b) prevent complication of existing damage; c) prevent a sLrious condition from ending in death; and d) avoid sequelae and disability. The first level, primordial prevention, is the most important for any primary health-care strategy for it aims at building resilience and resistance to risk through healthy bodies, strong and well-oriented personalities, attitudes, and practices through desirable life-styles and behaviors; protective social and physical environments; sense of responsibility and spiritual development. A second, more-focused level of prevention is aimed at reducing the effect of specific causal factors or agents, that is primary preventim. Examples include immunizations to prevent diseases, safety measures (improved traffic signals, use of seat belts and bicycle helmets) or legislation (increasing the minimum age for consumption of alcohol or for obtaining a driver’s license, etc.) to reduce injuries. When primary prevention is combined with promotion of protective factors described above, the result is more effective and there is a greater opportunity for young people to participate. Minimizing existing damage is secondary prevention. Knowledge of the prevalent problems of youth, as well as of the risk factors, allows for early rec-

ognition of individuals with problems, and early initiation of treatment at the primary care level. In relation to risky behaviors, it is necessary to determine the risk factors associated with their appearance. Identifying initial cases and starting early intervention with the participation of peers and other support networks is essential for preventing the problems from advancing and becoming complicated with other more serious forms of risky behavior. Finally, if the various forms of prevention are absent or not sufficiently effective, death or grave sequelae may be final result of the “casual” chain. To

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prevent these results, it is necessary to have services of high levels of technical complexity and with complete social azd intersectoral support. This is fertiury peneMion. What is evident as one progresses aIong this chain is that services become increasingly technologic, expensive, and exclusive when limited resources will restrict the number of beneficiaries. Prevention of disease, sequelae, and death should begin with education, training for self-care, optimal use of protective factors, and in programming for health and well-being. In this sense, it is important to consider the chain of prevention as a continuum. Its fragmentation is highly unadvisable for both physical and psychosocial health (see Figure 3).

World Health Organization (WHO). Forty-Second World Health Assembly, Technical Discussions on the Health of Youth. Background Document. Geneva, WHO, 1989 (E and Sl. World Health Organization (WHO). Forty-Second World Health Assembly, Report of the Technical on the Health of Youth. Geneva, WHO, 1989 (E and Sl. Achieving Health for AU-A Frame for Health Promotion. Ministry of Health and Welfare, Canada, 1986, Working Document (El.

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4. Serrano CV. A Conceptual Framework for Care of Comprehensive Adolescent Health. Washington, D.C.: Pan American Health Organization, 1991 (E and S). 5. Pan American Health Organization. Report of Consultation Meeting on “Health Priorities in Adolescent Health and Strategic Interventions.” Washington, D.C., Jan. 1989 (S). 6. Serrano CV. Infant, childhood and adolescent mortality in developing countries. In: Wallace H, Kanti Giri, eds. Health Care of Women and Children in Developing Countries, Chapter XXVI. Oakland, CA: Third Party, 1990 (El. 7. Werner E. Overcomine: thr odds Hieh risk children from birth to adulthood. Itha’ca, NY: Comell%niversity Press, 1992. 8. Bibeau G, Pedersen D, Puentes C. Life-styles, Health and Medical Technology. Report of Consultation. Washington, D.C.: pan American Health Organization, 1985 (E and S). 9. The Family in Latin America and The Caribbean. Review article presented in the workshop on Family, Development and Population Dynamics in Latin America and The Caribbean CEPAL-CELADE, Santiago, Chile, Nov. 1991. CEPALCELADE database (E and Sl. 10. Florenzano R. The Adolescent Health Situation in Latin America-Bases for a Regional Plan of Action. Report of Consultation. Washington, D.C.: Pan American Health Organization, 1987. 11. Pan American Health Organization Fertility in AdolescenceCauses, Risks and Options. Technical monograph No. 2 prepared by Monroy A, Morales N, Velasco L, Washington, D.C.: 1988. 12. Social Participation in Local Health Systems. Technical Report of a Consultation. Washington, DC.: Pan American Health Organization, 1989 (S and El.