Adolescents and youth in developing countries: Health and development issues in context

Journal of Adolescence 33 (2010) 499–508

Contents lists available at ScienceDirect

Journal of Adolescence journal homepage: www.elsevier.com/locate/jado

Adolescents and youth in developing countries: Health and development issues in context Adesegun O. Fatusi a, *, Michelle J. Hindin b a b

Department of Community Health, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

a b s t r a c t Adolescence is a period of transition, marked by physical, psychological, and cognitive changes underpin by biological factors. Today’s generation of young people – the largest in history – is approaching adulthood in a world vastly different from previous generations; AIDS, globalisation, urbanisation, electronic communication, migration, and economic challenges have radically transformed the landscape. Transition to productive and healthy adults is further shaped by societal context, including gender and socialisation process. With the evidence that young people are not as healthy as they seem, addressing the health and development issues of young people, more than ever before, need concerted and holistic approach. Such approach must take the entire lifecycle of the young person as well as the social environment into context. This is particularly critical in developing countries, where three major factors converge – comparatively higher proportion of young people in the population, disproportionately high burden of youth-related health problems, and greater resources challenge. Ó 2010 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Introduction More than 1.5 billion people of the world’s population of 6.7 billon are between the ages of 10 and 24 years. About 70 percent of the young people live in developing countries where social, economic and health challenges are greater than that of the industrialised country (UN, 2009). Today’s generation of young people is approaching adulthood in a world vastly different from previous generations – a world where AIDS, globalisation, increasing urbanisation, electronic communication, migration, economic challenges, among other external forces, have radically transformed what it means to be young. This changed landscape is adding to the challenge of physical, psychological, economic and social transition which ordinarily typifies the lives of adolescents as they move from childhood to adulthood. While the transition from childhood to adulthood is universal in nature, the experiences of adolescence are by no means universal. The onset of the transition is often closely linked with the biological process of puberty, which includes the appearance of secondary sexual characteristics; however, the end point of the transition often differs based on how adulthood is defined in the specific society and community. Societies have role definition and expectations for its young people, including sexual behaviour; these often differ for the two sexes and deviations are attended by sanctions. As such, transition to adulthood is shaped by societal context, including gender expectations and the socialisation process at family levels. Thus, * Corresponding author. Tel.: þ234 703 181 9773. E-mail addresses: [email protected], [email protected] (A.O. Fatusi). 0140-1971/$ – see front matter Ó 2010 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.adolescence.2010.05.019

500

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

it is important to recognise that adolescence and youth are dynamic concepts that may differ from place to place and vary by time period; the universal definition of adolescence, as McCauley and Salter (1995) have noted is best restricted to ‘a period of transition’, in which ‘although no longer considered a child, the young person is not considered an adult’. Young people and transition to adulthood in developing countries: perspectives The concept of adolescence as a distinct life stage is still relatively new in many developing countries. In some societies, adolescence as a unique stage, as it is presently known in modern times, is a relatively new concept. This contrasts with the situation in the developed world where the concept of adolescence as a life stage with legal boundaries has been recognised since the late 1800s/early 1990s (McCauley & Salter, 1995). Historically, G. Stanley Hall’s two-part text of 1904 titled “Adolescence: its psychology and its relations to anthropology, sex crime, religion and education” has been recognised as popularising the use of the term “adolescent” and heralding the recognition of adolescence in the industrialised world as a vulnerable and malleable group deserving of special attention (Knopf & Gordon, 1997). On the whole, adolescence as is currently known in current terms is a product of modernity, influenced mainly by education, industrialisation and urbanisation (Caldwell, Caldwell, Caldwell, & Pieris, 1998; Knopf & Gordon, 1997). Today, many other social forces are yet redefining the notion and lives of young people including the political, economic, educational, technology and religious factors. For many young people in developing countries, the dilemma of their transitory life stage is further complicated by the clashes between the many forces of westernisation, which characterises current global youth culture, and the stricter traditional values of their societies. The impact of these factors reflect not on only on the health and well-being of young people but also on their dreams, aspirations, interests in participation in the political and social lives of their societies, and the overall quality of lives. All these factors – and not just health status – are relevant to the well-being of young people and their ability to transit successfully to healthy and productive adults. While a significant proportion of attention in adolescent health field continues to focus on preventing risky health behaviours which impact negatively on health status, successful passage through adolescence and optimal transition to adulthood goes beyond problem-free adolescence and youth lives (National Research Council and Institute of Medicine, 2002). In the words of Pittman (1991), “adolescents who are merely problem-free are not fully prepared for their future”. Young people need to acquire relevant attitudes, competencies, values and social skills during adolescence to move forward to successful adulthood. Social scientists often view healthy adolescence in terms of successful transition to adulthood, and successful coping and well-being. In contrast, public health practitioners tend to focus more on issues of morbidity, mortality, and health-related behaviours. Both perspectives have invaluable contributions to make in advancing the health of young people, particularly in developing countries where the understanding of health and development issues of young people is still relatively poor and effective interventions comparatively few. In focusing on young people as they move from puberty to young adulthood in developing countries, it is increasingly important to balance the health-related issues and the social dimensions of the lives of young people and to consider the context in which health-related behaviours take place in order to obtain a more holistic picture of issues involved and to inform better evidence-based interventions. Articles in this special edition, which derives largely from presentations made at the International Conference on the Health and Development of Young People, which took place in Abuja, Nigeria in 2008, reflect such balance. The articles focus on different issues relating to the health and development of young people in developing countries. Importantly, these articles provide a broad understanding of some important factors that influence young people’s morbidity and mortality; as Blum and Nelson-Mmari (2004) had noted, such understanding increases the potential to improve the health of young people. Growing through adolescence: social dynamics and context The process of transition from childhood to adulthood involves negotiating through puberty, whereby the individual undergoes changes in various aspects of his/her life – physical, biological, cognitive, psychological, and social. In the process, young people experience rapid physical growth, acquire sexually dimorphic body shape, and develop increasing capacity for abstract thinking They also develop a clearer sense of personal and sexual identity; and a degree of emotional, personal, and financial independence from their parents. The physical changes in puberty – which are driven by a cascade of endocrine changes – include the establishment of adult appearance, increased physical strength, appearance of secondary sexual characteristics, achievement of sexual maturation and acquisition of reproductive capacity. Puberty triggers emotional, cognitive and behavioural change in young people, and influences their relationships with others, including parents and peers. Overall, pubertal changes have profound consequences for health and well-being of young people, and “lie behind the increased mortality and morbidity from accidental and intentional injuries, suicide and mental disorders, substance abuse, and eating disorders in young people” (Patton and Viner, 2007). Health situation of young people in developing countries Historically, adolescence and youth periods have been considered the healthiest period of a person’s life due to low mortality rate; recent trends have, however, given rise to concerns in many quarters. In an article titled “Young people: not as healthy as they seem”, Blum (2009) notes that there has been major shifts in causes of morbidity and mortality among young

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

501

people over the past 25 years. In particular, he highlighted that “what distinguishes the causes of death of young people is that most deaths have behavioural causes exacerbated by national policy or failures of health service delivery systems, or both”. The leading health challenges of young people globally are sexual and reproductive health issues, accidental and intentional injuries, mental health problems, substance use and abuse, and eating behaviour (Blum & Nelson-Mmari, 2004; Tylee, Haller, Graham, Churchill, & Sanci, 2007; WHO, 2002a) A recent comprehensive analysis of population health data by Patton et al. (2009) clearly shows that young people are at substantial risk of mortality, with pronounced rise in mortality rates from early adolescence (10–14 years) to young adulthood (20–24 years) and higher concentration in developing countries. All cause mortality in young adults (20–24 years) in developing countries was 2.4 times higher than in young adolescents (10–15 years). Only three percent of the 2.6 million deaths recorded globally among young people in 2004 occurred in high-income (developed) countries where 11 percent of young people live. On the other hand, 97 percent of these deaths (2.56 million) occurred in low-income and middle-income countries. Strikingly, almost two-thirds (1.67 million) of the global deaths among young people occurred in just two areas of the developing world – sub-Saharan Africa and southeast Asia, whereas only 42 percent of young people live in these areas. The relative risk for death among young people is higher in Africa than in any other region, and nearly seven times higher than in high-income countries. Causes of death vary significantly between the regions of the world, sex, and sub-groups of young people (early adolescence – 10–14 years, late adolescence – 15–19 years, and youths – 20–24 years). The commonest causes of mortality among young people in several developing regions are largely preventable. Communicable diseases and pregnancy-related conditions are the leading causes of mortality among young females, 15–24 years, in sub-Saharan Africa while in southeast Asia injury followed by communicable diseases has the highest contribution in this age bracket. Violence perpetrated by family members contributes substantially to the high rate of injury among females in southeast Asia. Among the males, injury and communicable diseases are the leading cause of death in both sub-Saharan Africa and southeast Asia. HIV/AIDS, tuberculosis, and lower respiratory tract infections are the leading communicable diseases in the two regions. As has been clearly documented in the literature, young people’s health-related issues, concern and needs are different in nature from that of children as well as of adults. Adolescents and other young people need services that are designed specifically to meet their needs in an effective manner, responds to their challenges with sufficient understanding, use approaches that are appropriate and acceptable to them, and set in an environment that is respectful to young people, ensure confidentiality, as well as be receptive and friendly to them – these characteristics are at the heart of adolescent- and youthfriendly health services (Tylee et al., 2007; WHO, 2002b). Such services need providers that are trained in the issues of young people’s health and have the right attitudes and an administrative set up that takes the nature, characteristics and circumstances into account, for example as it relates to location, timing and pricing of services. The multiple changes taking place during puberty often get many young people confused and perplexed, particularly in developing countries where most parents refrain from discussing pubertal-related and sexual issues with their children and exposure to adolescent and youth-friendly information and services poor. In an environment of profound changes that we are witnessing in today’s world, what are the feelings and experiences of young people? What are their concerns and struggles? These questions have significant implications not only for understanding issues of young people in current context, but also for programming for effective impact. Interestingly, while a plethora of scientific publications on puberty exists, those that view the issue strictly from the lens of young people are scarce. Defining adolescence from the perspectives of adolescents Life history interviews – an adolescent-driven, researcher-facilitated qualitative methodology – is a research approach that provides young people opportunities to explore and express in an open-ended manner how they think about themselves, their development, and the people and contexts that contribute to their lives sequence. Using this approach and exploring the data through holistic content analysis coupled with a grounded theory, Bayer, Gilman, Tsui, and Hindin (2010) reported on the lives of Peruvian adolescents in a low-income human settlement outside of Lima, an urban area in Peru. Their study, which is published in this issue of the journal, enabled adolescents in the study setting to narrate their lives and describe the contextual factors that have influenced them. Their results provide significant insight into the struggles and challenges faced by the young people: issues of intergenerational responsibility, family tensions, economic pressures, racism and violence dominated the narrators’ life stories. Some of these issues are hardly focused on by many adolescent health services, implying that services are probably not addressing what matters most to many young people. Unfortunately, most developing countries are lagging behind in terms of services oriented to meet the specific needs of young people and adolescent-friendly health services are inadequate in coverage or even totally absent in most communities despite the rising rates of adolescent and youth problems. The findings of Bayer et al. (2010) also underscore the degree to which adolescents they studied lack access to the supportive individuals and structures that are key to positive adolescent development and highlights “the need for increased attention to the role of families, peers and communities in ensuring that adolescents are able to maintain their well-being and achieve their future expectations”. Without doubt, successful transition from adolescence to adulthood is socially influenced, and depends, to a great extent, on the support young people receive from families, peers, communities and society at large. Despite numerous family tensions that they underscored, adolescents in Lima still identified family and friends as the most important persons in their lives (Bayer et al., 2010). This understanding has increasingly shifted the agenda of adolescent

502

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

health behaviour and risk research from the narrow focus on the individual to a broadened one utilising an ecological framework whereby the individual is viewed as nested within peer, family, school and community social environments (Mmari & Blum, 2009). Current understanding indicates that research focusing on the identification not only of risk but also of protective factors in each of these adolescent-related environments has greater potentials than others to contribute to effective adolescent- and youth-related programming (Blum et al., 2002; Rink & Tricker, 2003). The conclusion of Bayer et al. (2010) that “the adolescents’ detailed narratives confirm that their lives are incredibly complex and that all of the factors highlighted in their life histories interact in order to influence each individual adolescent” agrees with the perspective. Unfortunately, adolescent research activities utilising the ecological model or/and focusing on risk and protective factors are still considerably few in developing countries: most research in the area of adolescent sexual and reproductive health in developing countries, for example, still focus preponderantly on individual factors (Mmari & Blum, 2009). This situation needs to be reversed; greater exploration of the influence of family, peers, community factors as well as factors in the larger macroeconomic environment on the lives of young people is needed. Biological processes One other shortcoming of the adolescent health research landscape in developing countries is its preoccupation with health problems with very limited focus on normal developmental issues of adolescence, which may well impact considerably on the well-being and quality of lives of young people. One of such issues is menstruation. Without doubt, menarche – the first menstruation – is a landmark attainment in the life of an adolescent female. Menstruation classically defines pubertal development and signals sexual maturity in the female and is closely related to other pubertal processes. Menstrual-related beliefs, knowledge and practices are socio-culturally mediated in developing countries. Studies in various developing countries, including Bangladesh (Dasgupta & Sarkar, 2008), India (Mathew, 2005), Egypt (El-Shazly et al., 1990), Nigeria (AbioyeKuteyi, 2000) and Saudi Arabia (Moawed, 2001), show considerable variation in menstruation-related sociocultural beliefs and practices. Females’ movement, participation in community and social affairs, dietary pattern, and personal hygiene practices such as bathing may be curtailed or altered in some settings during menstruation as a result of myths and inaccurate sociocultural beliefs (Abioye-Kuteyi, 2000; Czerwinski, 2000). Menarche and menstruation particularly have special significance for the health and development of the growing females. Poor menstrual hygiene may predispose to reproductive tract infections, which may impact not only on her present health but may also compromise future reproductive ability and well-being. Restricted movements during menstruation may make her lose valuable school days and learning opportunities. Recently there has been concern about the simultaneous push towards gender equality in school and the lack of toilet facilities in schools for girls in some developing nations. Menstruationrelated nutritional taboos relating to foods high in iron may increase young girl’s risk for anaemia and results in fatigue that may further compromise her capacity for productive school or work-related performances. Thus, appropriate menstrualrelated knowledge and practices are important to the health and development of the adolescent girl. Unfortunately, the picture painted by Ali and Rizvi (2010) from review of research in Pakistan indicating poor attention to this important subject is true for most developing countries. Two of the studies in this issue focus on issues relating to menstrual health: one had its setting in Tanzania, East Africa, while the other was carried out in Karachi, Pakistan. In the Tanzanian study, Sommer (2010) assessed the social and health impact of adolescent girls’ experience of menstruation and schooling. The study, involved girls in both urban and rural areas and multiple research approaches – observation (classroom, public market area, school grounds), archival analysis (policy documents, curriculum, attendance records), semi-structured in-depth interviews of adolescent girls and adults in their daily lives (for example, parents, teachers), secondary data analysis, and participatory activities with girls. The study documented that while young girls have overall positive feelings about growing up, they regarded menstrual onset as a negative of growing up; this implies insufficient guidance for the girls on menstrual issues despite the good coverage of the topic in the school curriculum. With menarche and puberty, more restriction is placed on adolescent girls in many traditional setting by the family aimed at limiting opportunities for sexual experimentation and to protect them from possible sexual violation. Such restriction, however, may also limit the girls’ academic interactions such as group discussion about school assignments. Girls’ experience of menstrual pain and cramps also has tendency to limit their participation in school activities. Significantly, girls face challenges in terms of managing menses en route to and in school particularly as school toilet facilities are inadequate to support optimal menstrual hygiene practices and many could not financially afford the cost of buying sanitary pads. It is possible that this combination of unfavourable factors, as Sommer (2010) highlights, may push girls who are already struggling with their academics or pressures from home to decide to stop attending school. As such, provision of appropriate water and sanitation facilities to better support menstrual hygiene practices could have a role in improving school attendance and completion rate as well as enhance learning and academic performance of adolescent girls. Curriculum-related improvements in terms of content, teacher’s capacity for delivery, and appropriateness of grade for delivery could also add value to the health development of young girls and their ability to gain maximally from their schooling experience. The Pakistani study reported high level of awareness of menarche as part of growing up process and an indication of sexual maturation (Ali & Rizvi, 2010). However, basic knowledge about menstruation, for example, where the bleeding comes from was poor. Less than half of the students have had prior education at the family or household level about menarche and

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

503

menstruation, with mothers as the commonest source of information among those with prior information. Most of the girls in the study expressed concerns and fear about menarche. Menstrual hygiene knowledge and practices vary by socioeconomic level and schooling experience. A higher proportion of adolescents who were not attending schools in Karachi, for example, have misconception about menstruation compared to those in school. The use of old cloth was the commonest method used to absorb menstrual flow, although a higher proportion of girls from higher socioeconomic class use sanitary pad compared to those from lower socioeconomic settings. While the majority of out-of-school adolescent wash and reuse such old clothes, majority of those in school discard the clothes unwashed. The practice of alternate diet during menses was common among all groups of girls involved in the study as they presumed that some kinds of food may make them ill. Paradoxically, the foods they tend to avoid are those with high iron content such as liver and eggs – which otherwise would have been mostly useful in helping to prevent anaemia in menstruating girls in poor socioeconomic environment. Obviously, these findings provide an appropriate ground for school- and community-based interventions to enhance the menstrual health and overall well-being of adolescent girls, and to equip them as future mothers to pass on accurate information and practices to their own daughters when the time comes. Sex, gender and health risks The sex differential and regional variations in morbidity and mortality pattern among young people are remarkable. Young males died at higher rates than their female counterparts in all age-groups and regions apart from sub-Saharan Africa and southeast Asia. The female preponderance sub-Saharan Africa and southeast Asia is most evident in age group 15–19 with a female: male ratio of 0.68 in sub-Saharan Africa and 0.92 in southeast Asia for 2004. Mortality risk in developing countries compared with developed (high-income) countries was higher for females than for males (relative risk of 5.6 versus 2.8); a major reason for this pattern is the low mortality figure for young females in highincome countries, unlike the situation in many developing countries where maternal mortality and AIDS shortens the lifespan of many young females (Patton et al., 2009). Sub-Saharan Africa, with about 12 percent of the world’s population, accounts for approximately two-thirds of people living with HIV (UNAIDS, 2009). More than three-quarters of young people (15–24 years) living with HIV in sub-Saharan Africa are females (Santosa, 2009). In parts of Africa and the Caribbean, young women (ages 15–24) are up to six times more likely to be infected than young men of similar ages (UNFPA, 2005). HIV transmission in sub-Saharan Africa is mainly through heterosexual intercourses, and high prevalence of risky sexual behaviour among young people contributes substantially to the epidemics. More than 40 percent of sexually experienced adolescent males and up to 10 percent of adolescent females in some sub-Saharan African countries reported having had two or more sexual partners in the past one-year period (Biddlecom, Hessburg, Singh, Bankole, & Darobi, 2007). Age-mixing, resulting from sexual relationship between young girls and much older men, as well as sexual coercion, which are gender-mediated, also contribute to the high HIV infection level in sub-Saharan Africa in addition to predisposing biological factors (Wellings et al., 2006). In Asia, which is the region with the second highest figure of people living with HIV, nearly half of the adult population living with HIV are under the age of 25 years, most of them males (Monasch & Mahy, 2006). Injecting drug use contributes substantially to the picture of HIV epidemics in Asia. Latin America and the Caribbean has the second highest HIV prevalence rate among young people ages 15–24 years after sub-Saharan Africa, and risky sexual behaviour is a major factor in the transmission of the infection (Cunningham, McGinnis, Verdu, Tesliuc, & Verner, 2008). For example, sexually active young people ages 15–19 years in Latin America and the Caribbean are less likely to use condoms in many developing countries compared those of ages 20–24 years as the data from show (Cunningham et al., 2008). Other factors that contribute to vulnerability to HIV during adolescence include poor knowledge about HIV/AIDS, lack of education and life skills, poor access to health services and commodities, early sexual debut, early marriage, sexual coercion and violence, trafficking and growing up without parents or other forms of protection from exploitation and abuse (Dick, Ferguson, & Ross, 2006). While teenage childbearing carries higher risk of maternal and child morbidity and mortality compared to childbirth among older women, the high maternal mortality ratio among young females in many developing countries is as a result of unsafe abortion. Of the nearly 20 million unsafe abortions that took place worldwide in 2003, WHO (2007) estimates that 98 percent occurred in developing countries with restrictive abortion law. In terms of disability-adjusted life years (DALYs), the combined burden of mortality and morbidity per 1000 unsafe abortions is exceptionally high in sub-Saharan Africa; it is 50 percentage points higher than in Asia and 6 times greater than in Latin America (WHO, 2007). An estimated 2.5 million, or almost 14%, of all unsafe abortions in developing countries are among young women under 20 years of age. Young women in sub-Saharan Africa are disproportionately negatively affected by unsafe abortion compared to their peers elsewhere. Almost 60 percent of unsafe abortions in sub-Saharan Africa are among women aged less than 25 years compared to 30 percent in Asia. In Latin America and the Caribbean women aged 20–29 years account for more than half of all unsafe abortions. The unsafe abortion-related mortality ratio is much higher in Eastern, Western and Middle Africa than anywhere else – double that of Asia and more than five times that of Latin America (WHO, 2007). Low contraceptive level contributes substantially to unintended and unwanted pregnancy among young people in developing countries, and subsequently unsafe abortion in an environment of strict abortion law. The contraceptive scenario is worse in sub-Saharan Africa, with only very small proportions of unmarried sexually experienced adolescent girls (age 15–19 years)

504

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

using modern contraceptive. The level is as low as 4 percent in Benin and 5.2 percent Zimbabwe (Bearinger et al., 2007). Contrary to the situation in Latin America where the unmet needs for contraceptives among sexually experienced unmarried adolescent females is in the range of 10–31%, the level is higher than 40 percent in many African countries (Hindin & Fatusi, 2009). Factors associated with low use of contraceptives, particularly condom which could protect against both unwanted pregnancy and sexually transmitted infections, include poor knowledge about sexual and reproductive health issues, myths about contraceptive methods and fear about possible side effect, poor attitude to condom and poor access to contraceptive services. Gender, which refers to socially ascribed role for females and males in a given society, plays a major role in health behaviour of young people in developing countries, particularly as it relates to sexual intercourse. Burnette (2006) defines gender as the social behaviours, lifestyle, and personality characteristics that women and men are expected to exhibit. As children grow into adolescence and young adulthood, gender role differentials widens between males and females (Bruce et al., 1995; ; Hallman & Roca, 2007). Typically, the adolescent male increasingly experiences privileges reserved for men in their society. These include increased autonomy, mobility and access to developmental and economic opportunities. The adolescent female, similarly, experiences the conditions that pertain to adult womanhood in their society. In many developing countries, traditionally, this implies more restricted mobility, reduced interaction with the opposite sex, and more limited social interaction network, and comparatively less developmental opportunities compared to her male counterpart. The work of Pradhan and Ram (2010), which examined the association of perceived gender roles with youth sexual behaviour in a rural Indian setting, provides evidence of differential view of the society as regards notion of acceptable sexual behaviour for male and female youths. Traditionally, societies ascribe youth sexuality-related roles and define the boundaries of acceptable sexual behaviour for males and females. Deviations from these roles are often not tolerated and attract sanctions, particularly in the case of female offenders. This pattern is still evident in many societies in developing countries. There is evidence that whereas the society seriously frown at premarital and extramarital behaviour among females, the same society would often condone such behaviours from young males as an expression of their masculinity. This double standard has potential to encourage risky behaviour among males, which in turn can put their female partners at considerable risk of poor reproductive health outcomes (Hardee, Pine, & Wason, 2004; Tangmunkongvorakul, Roslyn, & Kaye, 2005). Similarly, the notion of male aggressiveness and female submissiveness as part of gender identity also contributes to poor sexual negotiations skills on the part of females and risky sexual and violence-related behaviour among males. Thus, inequitable gender norms contribute to incidences of sexual coercion, gender-based violence, HIV and other sexually transmitted infections, and unintended and unwanted pregnancies (Pulerwitz & Barker, 2008). The findings of Bayer et al. (2010) reflect the notion that “sexual behaviour is an expression of socially constructed sexuality and is largely shaped, conceived and constrained according to norms within different societies.” In their exploration of the concept of ‘real man’ and ‘real woman’, considerable differences in perspectives were recorded between male and female participants as well as for male and female ideal behaviours. Whereas some young men view a man’s ability to attract woman, and sexually satisfy a woman as a measure of ‘real man’, remaining a virgin till marriage, being faithful to her spouse in marital relations, and ability to bear children are some of the elements reported to define a ‘real’ woman. Gender differences were also reported with regards to male and female participation in civil society activities in the article by Acharya et al. (2010). The proportion of males participating in civil society events is about two and a half times that of women. Again, the difference can be linked to the degree of mobility allowed to young males and females. Adolescent females are more likely to report parental restriction compared to males. Schooling, school-based interventions and the health and development of young people A higher proportion of young people in this generation compared to other generation are enrolled in school. In subSaharan Africa, for example, the last two and a half decade has witnessed impressive growth in primary school enrolment and the dramatic narrowing of gender gap across the continent (Hewett & Lloyd, 2005). This development has impacted positively on some reproductive health and development indicators. Among others, schooling has led to delayed marriage and childbearing among young people. On the developmental side, schools offer opportunities for male and female to enhance their intellectual capabilities and increase their potentials to better compete for good employment. Thus, school prepares for young people for productive adulthood, and has potential to contribute substantially to the adolescent transition process. School also provides an enlarged opportunity for peer-relationships, social interaction and opportunity to bond with selected adults in form of teachers and other school staff. School connectedness –feeling that someone in a young person’s school cares about his or her well-being – has significant relationship with many youth-related health and development indices. Among others, school connectedness is negatively associated with poor school performance, school drop-out, early sexual initiation, risky sexual activity, violence and substance use. As such, some have argued that school connectedness is the most important explanatory factor for risky behaviour among school-aged young people (Cunningham et al., 2008). While the positive impact of schools on the health and health behaviour of young people is profound, it is important to note that schooling can have some unanticipated negative consequences, particularly in terms of sexual exposure and behaviour. As schooling provides opportunities for greater social interactions outside the home environment, it advertently increases the opportunity to engage in some practices outside the immediate oversight and protection of parents and other caregivers, including sexual experimentation, substance use and other risk behaviours. Schooling can also increase the exposure of adolescents to sexual coercion, bullying, and violence, among others, in the school environment.

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

505

With increasing school enrolment, sexual maturation and initiation are increasingly likely to occur while young people are still attending school. As several researchers have noted, the combined effects of higher school enrolment rates and attendant increase in age at marriage result in higher rates of premarital sex than in previous generation (Juárez, LeGrand, Lloyd, & Singh, 2008; Mensch, Grant, & Blanc, 2006). With poor contraceptive behaviour, sexual activities among school-aged adolescent may contribute to increased rates of unwanted pregnancy and other negative reproductive health outcomes. With the restrictive school regulations in many developing countries that prescribe expulsion for pregnant school girls, many pregnant school girls who desire to finish school are likely to resort to abortion. Unfortunately, such abortions are most often than not in most developing countries carried out in medically unsuitable environment and handled by non-medically qualified individuals. With increasing integration of adolescent and youth health-related issues into school settings through both co-curricular and extra-curricular approaches, schools also provide increased opportunity for young people – both males and females – to access essential health-related information, education and skills that can enhance their health and well-being. Indeed, given that majority of males and females of school age young people in most developing countries are in schools, school can serve as a cost-effective platform for reaching a large population of young people with relevant health and related interventions. As such, several programmes have been documented in schools all over the developing world, particularly focusing on leading health problems of young people. In sub-Saharan Africa, a large proportion of such programmes have focused on HIV and other sexual and reproductive health issues given the high burden of these problems. In recent years, attention of such programmes is increasingly focused on primary schools and not just secondary school in many countries; the realisation that impacts are likely to be greater if young people are reached before they initiate sex may be a driving force for this shift. There is now a better understanding of the potential impact of such programmes as the knowledge about “what works” in school-based HIV interventions in terms of impact on behaviour of young people has grown over the years. Gallant and Maticka-Tyndale (2004), for example, have identified characteristics of successful school-based HIV prevention programmes for young people in African setting. Kirby, Laris, and Rolleri (2006) and Kirby, Obassi, and Laris (2006) have also documented 17 characteristics in three domains – programme development, curricula characteristic, and programme implementation – that distinguish school- and community-based sex and HIV education programme that impacts behaviour. Typically, evaluators had impacted the effectiveness of school-based programmes over a short period, usually two years or less. However, as the cohort of young people exposed to school-based HIV interventions at primary school level continue their transition through adolescence and educational system, they are likely to be faced with increasingly challenge regarding sexual decision making. Will the foundation provided at the primary school stage be sufficient for the later and more riskprone late adolescence? How long are the beneficial effects of primary school-based HIV intervention likely to last? Will these benefits, for example, still be maintained during secondary school years? These are important questions particularly in the face of the continuing HIV challenge and the complexity of adolescence transition. Ultimately, to be considered successful, adolescent- and youth-focused HIV interventions programmes must have the capacity for sustained impacts (MatickaTyndale, 2010). This implies a greater emphasis on school-based programmes with beneficial effects extending for several years, and beyond the environment of the school where the programme was delivered. Significant research attention has, however, not been paid to this issue. The research of Maticka-Tyndale (2010) published in this current journal issue provides a lead in addressing this research gap. Drawing on the experience of the Primary School Action for Better Health (PSABH) – a theory-driven school-based HIV intervention delivered in standards 6–8 (equivalent to North American grades 6–8) in Kenyan schools – the paper addressed the question of whether the beneficial effects of a primary school HIV prevention intervention continued once students moved on to secondary schools. The paper specifically addressed the question of “whether secondary school students who attended a primary school with PSABH programming, compared to those who attended a primary school without such programming have greater knowledge about HIV prevention, attitudes that are more supportive of safer sexual activity, condom use and HIV testing, and engage in lower risk sexual behaviours and HIV testing”. The result of this study provides some encouragements for investing more in effective implementation of well-designed school-based HIV interventions. This study should also spur greater research interest in examining the longer-term impact of various school-based interventions, and not just those focusing on HIV issues or those implemented at primary school level alone. Socioeconomic status, poverty and health development of young people Health behaviour and outcomes as well as the developmental trajectories of young people vary by socioeconomic level. A study of young people in Latin America and Caribbean reported that “household poverty is perhaps the strongest and most consistent correlate of risky behaviour for all the countries studied” (Cunningham et al., 2008.). Poverty can be contributory to risk behaviour in several ways. While in some cases, household poverty is a direct factor affecting youth behaviour, such as when a young person had to quit school to get into the labour force to sustain him/herself economically, in many other cases causal relationship is less clear, for example in the case of relationship between poverty, crime, violence or substance abuse. Yet, the possible contribution of poverty to such behaviour cannot be easily discounted. As Cunningham et al. (2008) explain, “poverty and frustration with living in a society with high inequality may lead to greater violence or substance abuse, or there may be other correlates to explain the relationship”. In a study where they tested developmental pathways to risky sexual behaviour among South African adolescents, Brook et al. (2006) reported that family poverty was one pathway; poverty was

506

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

associated with difficulty in the parent–child relationship, which in turn was associated on the one hand with vulnerable personality and behavioural attributes and, on the other hand, with deviant peers, and ultimately relates to risky sexual behaviour. There have been strong suggestions regarding relationship between household poverty and risky sexual behaviour in several other scenarios. A young girl in a situation of abject poverty and in situations where employment opportunity is low and social support lacking may turn to sex work to sustain herself. In a study carried out in Mexico and Chile by Cunningham and Bagby (in press) and cited by Cunningham et al. (2008), household poverty was strongly correlated with risky sex and early initiation of sexual intercourse, even after controlling for young people’s connection with their parents, connection with institutions, abuse in the household, and social exclusion. A recent study from the Health and Behaviour of School-age Children (HBSC) involving analysis of the data of 33 countries shows an association between a range of self-reported health behaviour and family economic level (Richter et al., 2009). In many developing countries, adolescent pregnancy rates are higher among girls from poor families compared to those from better economically endowed families, , although the precise role of poverty in this outcome is not clear. In Latin America and the Caribbean, for example, pregnancy rates have been reported to be three to five times higher among poor adolescents than among non-poor adolescents (Cunningham et al., 2008). Pregnancy rates are also higher in rural areas where poverty is more prevalent than in urban communities. Young women with no education are also generally at higher risk of teenage pregnancy compared to those who had a minimum of secondary education. Many of the studies presented in this issue, in various ways, illustrate the effect of poverty as a contextual factor that impacts adolescent and youth development. For example, Acharya et al. (2010) reported that household economic status was positively associated with participation in voting behaviour among women in India, while adolescents studied by Bayer et al. (2010) indicated that socioeconomic factor plays an important role in their lives. Ali and Rizvi (2010) as well as Sommer (2010) indicate that one of the concerns of young girls regarding menstruation is the issue of buying sanitary pads. Girls from poor homes are less able to afford such and therefore have to recourse to other choices such as old clothes. Youth participation The World Programme of Action for Youth to the Year 2000 and Beyond (United Nations, 1997) identifies “full and effective participation of youth in the life of the society and in decision making” as one of the ten priority areas of action aimed at improving the situation and well-being of young people. Research has actually shown that participating in organised activities, such as community-based activities, is associated with both short- and long-term indicators of positive development among young people. It has also been shown to be positively correlated with achievement, educational aspirations, selfesteem, ability to overcome adversity, and leadership qualities among young people. As Barber, Stone, and Eccles (2005) have explained, constructive organised activities facilitate healthy development of young people in at least three ways. First, organised activities provide a developmental forum for initiative and engagement in challenging tasks, and allow young people to express their talents, passion, and creativity. Second, organised activities help young people meet their social relatedness, providing a broad range of opportunity for social development. Third, participation in organised activities may also promote the development of assets such as social, physical, and intellectual skills, meaning roles and empowerment, positive identity, constructive peer networks, and clear expectations and boundaries. Yet, the importance of political participation has been vastly understudied as part of the experience and obligations of youth. While many countries have Ministries of Youth Development, and some countries allow for youth to participate in the political process, the meaning and type of this participation, as well as barriers to participation have been largely ignored. It has been suggested that the transition to adulthood must include civic rights and responsibilities and that these rights and responsibilities are crucial for individual development, socialisation, as well as investing in larger community and national concerns (National Research Council and Institute of Medicine, 2005). It is also noted that whether a young person engages in civil society or not, in most developing countries, is dependent on their status within their families and communities. Acharya et al. (2010) explore the role of youth participation in India’s civil society. As reported in this issue, they found that for many young people, engagements in political life or civil society are limited – especially for young women. Factors associated with political participation included age, marital status and residence. Conclusion Young people are critical to shaping the future of the world. As parents of tomorrow they provide the biological link to the future and they constitute the workforce for the future. Constituting a significant proportion of the world, there is a need to address their health, well-being and development issues from a holistic perspective. As they transit from childhood through adolescence to young adulthood, young people need to be provided with support to accomplish their transition successfully and to cope adequately with the changing dimensions of their own personal development in a world of unprecedented changes. This calls for effective programming informed by relevant research evidence. This goal also needs to be accomplished in a cost-effective and sustainable way. In the light of available evidence, programmes must not address young people just as individuals, but consider them in the context of their overall environment. Studies that have examined such environmental context, although mostly based in developed countries, have found that most important influences on whether young people will engage in risky behaviour are

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

507

their relationships with their parents/families, and schools, followed by a host of other individual characteristics, household influences, and peer and community influences (Cunningham et al., 2008). Thus, relevant factors in the microenvironment of families, peers and schools as well as factors in the larger macroenvironment must be identified in the context of developing countries and factored into policies and programmes. This article has argued for a holistic perspective to the issue health development of young people, and drawing from some of the papers presented at the International Conference on the Health and Development of Young people (which are published in this edition), had highlighted the importance of gender, schooling and poverty in the health development of young people. It is important to note that while each of such factors can, on its own, increase risk or protect against it, ultimately and in reality they are cumulative in nature (Cunningham et al., 2008). Furthermore, the co-relationship between different risk behaviours must be recognised, and taken into account in programming for maximum impact and costeffective results. Approaching the health and development issues of young people must not be from the viewpoint of young people as problems to be solved and health problems to be addressed; rather, young people must be recognised as whole persons with great potentials whose needs must be recognised as a matter of rights and supported to achieve their maximum potential as they transit through adolescence to become healthy, productive adulthood. Issues relating to their pubertal development, such as menstrual attention, and not just health problems must be accorded priority at household, community, national and global levels. Research evidences highlighted in this paper provide some ground for strengthening policies and actions to further healthy development of young people in line with the “research that improves policies and programs” philosophy of the Abuja conference (Abuja Call to Action: Increase Investments for Young People’s Health and Development, 2008).

References Abioye-Kuteyi, E. A. (2000). Menstrual knowledge and practices amongst secondary school girls in Ile Ife, Nigeria. The Journal of the Royal Society for the Promotion of Health, 120(1), 23–26. Abuja Call to Action: Increase Investments for Young People’s Health and Development. (April 27–29, 2008). Investing in young people’s health and development: research that improves policies and programs. Abuja, Nigeria. http://www.jhsph.edu/gatesinstitute/policy_practice/conferencesmeetings/adolhealth/calltoaction.html. Acharya, R., Singh, A., Santhya, K. G., Ram, F., Jejeebhoy, S., Ram, U., et al. (2010). Participation in civil society and political life among young people in Maharashtra: Findings from the Youth in India – Situation and Needs Study. Journal of Adolescence, 33(4), 553–561. Ali, T. S., & Rizvi, S. N. (2010). Menstrual knowledge and practices of females adolescents in urban Karachi, Pakistan. Journal of Adolescence, 33(4), 531–541. Barber, B. L., Stone, M. R., & Eccles, J. S. (2005). Adolescent participation in organised activities. In K. A. Moore, & L. H. Lippman (Eds.), What do children need to flourish? Conceptualisation and measuring indicators of positive development (pp. 133–146). New York: Springer Science þ Business Media Inc. Bayer, A. M., Gilman, R. H., Tsui, A. O., & Hindin, M. J. (2010). What is adolescence?: Adolescents narrate their lives in Lima, Peru. Journal of Adolescence, 33(4), 509–520. Bearinger, L. H., Sieving, R. E., Ferguson, J., & Sharma, V. (2007). Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet, 369, 1220–1231. Biddlecom, A. E., Hessburg, L., Singh, S., Bankole, A., & Darabi, L. (2007). Protecting the next generation in sub-Saharan Africa: Learning from adolescents to prevent HIV and unintended pregnancy. New York: Guttmacher Institute. Blum, W. B. (2009). Young people: not as healthy as they seem. Lancet, 374, 853–854. Blum, W. B., McNeeley, C., & Nonnemaker, J. (2002). Vulnerability, risk, protection. Journal of Adolescent Health, 31S, 28–39. Blum, W. B., & Nelson-Mmari, K. (2004). The health of young people in a global context. Journal of Adolescent Health, 35, 402–418. Brook, D. W., Morojele, N. K., Zhang, C., & Brook, J. S. (2006). South African adolescents: pathways to risky sexual behaviour. AIDS Education and Prevention, 16, 259–272. Bruce, J., Lloyd, C., & Leonard, A. (1995). Families in focus: New perspectives on mothers, fathers, and children. New York: Population Council. Burnette, M. M. (2006). Gender, gender identity and sexuality. In R. D. McAnulty, & M. M. Burnette (Eds.), Sex and sexuality. Sexuality today: trends and controversies, Vol. 1 (pp. 185–201). Westport, CT 06881: Praeger. Caldwell, J. C., Caldwell, P., Caldwell, B. K., & Pieris, I. (1998). The construction of adolescence in a changing world: implications for sexuality, reproduction, and marriage. Studies in Family Planning, 29, 137–153. Cunningham, W., Bagby, E. Factors that predispose youth to risk in Mexico and Chile. Background paper for “youth at risk in latin america and the caribbean regional study”. Washington DC, World Bank. in press. Cunningham, W., McGinnis, L., Verdu, R. G., Tesliuc, C., & Verner, D. (2008). Youth at risk in Latin America and the Caribbean: Understanding the causes, realising the potential. Washington: The International Bank for Reconstruction and Development/The World Bank. Czerwinski, B. S. (2000). Variation in feminine hygiene practices as a function of age. Journal of Obstetric, Gynecologic, Neonatal Nursing, 29(6), 625–633. Dasgupta, A., & Sarkar, M. (2008). Menstrual hygiene: how hygienic is the adolescent girl? Indian Journal of Community Medicine, 2(33), 77–80, Available at: http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf Pakistan Demographic and Health Survey 2006–07, accessed on May 20, 2010. Dick, B., Ferguson, J., & Ross, D. A. (2006). Young people, HIV/AIDS and the global goals. In D. Ross, B. Dick, & J. Ferguson (Eds.), Preventing HIV/AIDS in young people: A systematic review of the evidence from developing countries (pp. 2–4), UNAIDS interagency task team on HIV and young people, Geneva: World Health Organisation. El-Shazly, M. K., Hassanein, M. H. A., Ibrahim, A. G., & Nosseir, S. A. (1990). Knowledge about menstruation and practices of nursing students affiliated to university of Alexandria. Journal of the Egyptian Public Health Association, 65(5–6), 509–523. Gallant, M., & Maticka-Tyndale, E. (2004). School-based HIV prevention programmes for African youth. Social Science and Medicine, 58, 1337–1351. Hallman, K., & Roca, E. (2007). Reducing the social exclusion of girls. Promoting Healthy, Safe, and Productive Transitions to Adulthood Brief (no. 27). Available at: http://www.popcouncil.org/pdfs/TABriefs/PGY_Brief27_SocialExclusion.pdf. Accessed 15.05.10. Hardee, K., Pine, P., Wason, L. T. (2004). Adolescent and youth RH in the Asia and near east Region: states, issues, policies and programmes. Washington DC: Policy, Working Paper Number 9. Hewett, P. C., & Lloyd, C. B. (2005). Progress towards ‘education for all’: trends and current challenges for sub-Saharan Africa. In C. B. Lloyd, J. Behrman, N. P. Stromquist, & B. Cohen (Eds.), The changing transitions to adulthood in developing countries: Selected studies (pp. 84–117). Washington, DC: National Academies Press. Hindin, M. J., & Fatusi, A. O. (2009). Adolescent sexual and reproductive health in developing countries. An overview of trends and interventions. International Perspectives on Sexual and Reproductive Health, 35, 58–62. Joint United Nations Programme on AIDS (UNAIDS). (2009). Report on the global AIDS epidemic. Geneva: UNAIDS.

508

A.O. Fatusi, M.J. Hindin / Journal of Adolescence 33 (2010) 499–508

Juárez, F., LeGrand, T., Lloyd, C. B., & Singh, S. (2008). Introduction to the special issue on adolescent sexual and reproductive health in sub-Saharan Africa. Studies in Family Planning, 39, 239–244. Kirby, D., Laris, B. A., & Rolleri, C. (2006). The impact of sex and HIV education programs in schools and communities on sex behaviour among young adults. Washington: Family Health International. Kirby, D., Obassi, A., & Laris, B. J. (2006). The effectiveness of school interventions targeting HIV and aids prevention at young people in developing countries. In D. A. Ross, B. Dick, & J. Ferguson (Eds.), Preventing HIV/AIDS in young people: A systematic review of the evidence from developing countries. Geneva: WHO. Knopf, D., & Gordon, T. E. (1997). Adolescent health. In J. B. Kotch (Ed.), Maternal and child health: Programs, problems and policy in public health (pp. 173–175). Maryland: Aspen Publishers. Mathew, K. M. P. (2005). Attitudes of adolescent students in Thiruvantaapuram towards gender, sexuality, sexual and reproductive health and rights. Trivandrum: Achutha Menon Centre for Health Science Studies. Maticka-Tyndale, E. (2010). Sustainability of gains made in a primary school HIV prevention programme in Kenya into the secondary school years. Journal of Adolescence, 33(4), 563–573. McCauley, A. P., & Salter, C. (1995). Meeting the needs of young adults. Population Reports, Series Journal, 41, 1–39, Baltimore: Johns Hopkins School Public Health, Population Information Program. Mensch, B. S., Grant, M. J., & Blanc, A. K. (2006). The changing context of sexual initiation in sub-Saharan Africa. Population and Development Review, 32, 699–725. Mmari, K., & Blum, R. (2009). Risk and protective factors that affect adolescent reproductive health in developing countries: a structured review. Global Public Health Journal, 21, 1–16. Moawed, S. (2001). Indigenous practices of Saudi girls in Riyadh during their menstrual period. Eastern Mediterranean Health Journal, 7(1–2), 197–203. Monasch, R., & Mahy, M. (2006). Young people: the centre of the HIV epidemic. In D. Ross, B. Dick, & J. Ferguson (Eds.), Preventing HIV/AIDS in young people: A systematic review of the evidence from developing countries (pp. 15–17), UNAIDS interagency task team on HIV and young people, Geneva: World Health Organisation. National Research Council and Institute of Medicine. Committee on Community-Level Programs for Youth. (2002). Personal and social assets that promote well-being. In J. Eccles, & E. D. Gootman (Eds.), Community programs to promote youth development. Board on children, youth and families, division of behavioural and social sciences and education (pp. 66–85). Washington DC: National Academy Press. National Research Council and Institute of Medicine. (2005). Growing up global: the changing transitions to adulthood in developing countries. Panel on transitions to adulthood in developing countries. In B. Cynthia, & Lloyd. (Eds.), Committee on population and board on children, youth and family. Division of behavioral and social sciences and education. Washington DC: National Academy Press. Patton, G. C., & Viner, R. (2007). Pubertal transitions in health. Lancet, 369, 1130–1139. Patton, G. C., Coffey, C., Sawyer, S. M., Viner, R. M., Haller, D. M., Bose, K., et al. (2009). Global patterns of mortality in young people: a systematic analysis of population health data. Lancet, 374, 881–892. Pradhan, M. R., & Ram, U. (2010). Perceived gender role that shape youth sexual behaviour: evidence from rural Orissa, India. Journal of Adolescence, 33(4), 543–551. Pittman, K. (1991). Promoting youth development: Strengthening the role of youth serving and community organisations. Washington DC: Center for Youth Development and Policy Research, Academy for Educational Development. Pulerwitz, J., & Barker, G. (2008). Measuring attitude towards gender norms among men in Brazil: development and psychometric evaluation of the GEM Scale. Men and Masculinities, 10, 322–338. Richter, M., Erhart, M., Vereecken, C. A., Zambon, A., Boyce, W., & Nic, G. S. (2009). The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Social Science & Medicine, 69, 396–403. Rink, E., & Tricker, R. (2003). Resiliency-based research and adolescent health behaviors. The Prevention Researcher, 10(1), 3–4. Santosa, R. F. (2009). Young people, sexual and reproductive health and HIV. Bulletin of the World Health Organisation, 87, 877–879. Sommer, M. (2010). Where the education system and women’s bodies collide: The social and health impact of girls’ experiences of menstruation and schooling in Tanzania. Journal of Adolescence, 33(4), 521–529. Tangmunkongvorakul, A., Roslyn, K., & Kaye, W. (2005). Gender double standards in young people attending sexual and health services in northern Thailand. Culture, Health and Sexuality, 7, 361–373. Tylee, A., Haller, D. M., Graham, T., Churchill, R., & Sanci, L. A. (2007). Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet, 369, 1565–1573. United Nations. (1997). The world programme of action for youth to the year 2000 and beyond. Available at: http://www.un.org/events/youth98/backinfo/ ywpa2000.htm Accessed 7.03.09. United Nations Population Fund (UNFPA). (2005). HIV/AIDS: what does gender have to do with it? Chapter 13. State of the world population 2005. Available at: http://www.unfpa.org/swp/2005/english/ch4/chap4_page1.htm Accessed 17.05.10. United Nations. (2009). Young people. Available at: www.icpd2015.org/assets/pdf/Young%20People.pdf Accessed 15.05.10. Wellings, K., Collumbien, M., Slaymaker, E., Singh, S., Hodges, Z., Patel, D., et al. (2006). Sexual behaviour in context: a global perspective. Lancet, 368, 1706– 1728. World Health Organisation (WHO). (2002a). Growing in confidence: Programming for adolescent health and development. Geneva: WHO. WHO/FCH/CAH/02.13. World Health Organisation. (2002b). Adolescent friendly health services – An agenda for change. WHO/FCH/CAH/02.14. Geneva: World Health Organization. World Health Organization (WHO). (2007). Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003 (5th ed.). Geneva: WHO.