By Ninha Silva, MARCH Centre Blog Editor (MSc Public Health Candidate)
Aoife Doyle is Assistant Professor of Epidemiology at the London School of Hygiene and Tropical Medicine and her research focus is primarily on sexual and reproductive health and the evaluation of interventions for young people. Aoife is currently working on the evaluation of the Adolescents 360 and DREAMS initiatives. Aoife is also involved in a research project looking at health services use and access for young people in South Africa.
To celebrate this year’s International Youth Day, I spoke to Aoife about the current areas of concern in adolescent health and some of the research contributions to this field of study.
Could you tell us which are the current areas of concern on adolescent health?
Traditionally it has been almost exclusively sexual and reproductive health (SRH) and that is still one of the biggest issues. Many unplanned pregnancies occur during the adolescent period and the incidence of HIV and STIs can be high. Incidence of STIs can be high in adolescence as this is the time when many young people become sexually active for the first time and, consequently, they start being exposed to these infections.
However, there is now a growing recognition that young people face other health issues, for example, there is an increasing realisation that mental health is an issue for young people. Of course the needs of adolescents vary greatly according to age (early, mid, late adolescence) and the setting. In more developed countries, for example, nutrition and mental health are more of a concern than infectious diseases, because young people are not as exposed to life-threatening infectious diseases as they would be in some parts of Africa or Asia.
Finally, one of the big killers, especially among men, are injuries and violence. If you look at the statistics that WHO recently published in their Global AA-HA report, road injury and interpersonal violence are the top global causes of death in males aged 15-19 years.
Is this because of the increase of conflicts and wars?
Partly that… but partly because events such as road traffic accidents kill a lot of young people. Also, we need to consider suicides and physical fights resulting from alcohol abuse and other social problems. So, sometimes injuries and violence are conflict related, but in general they are a result of conflicts in society, which can be linked to other social problems.
Injuries and violence are one of the biggest issues among men, could you explain how the risks vary in different adolescent age groups and gender?
Among males, road injury is the leading cause of death in 15-19 year olds and the second leading cause of death in 10-14 year olds. Other important causes of death among males are drowning and lower respiratory infections for 10-14 year olds and interpersonal violence and self-harm for 15-19 year olds. Road injury is the third leading cause of death among 15-19-year-old females with maternal conditions and self-harm the leading causes. Among the younger 10-14-year-old females, infectious diseases such as lower respiratory infections and diarrhoeal diseases are still the biggest killers. These are global figures and the picture varies according to region and can vary widely within regions. For example, the leading cause of death among 10-19 year olds in Africa is lower respiratory infections but in high income countries it is road injury.
All these events you have mentioned are preventable. So why are the numbers so high?
In some cases, young people have difficulty accessing services. Either the services are not welcoming to them or they are not at convenient times, for example, outside school hours. Some of the adolescents may simply not understand the importance of using the services, possibly due to a lack of information; possibly because they think they are “young and invincible” and are not at risk… I mean people avoid health services… everybody does that sometimes, but young people may be more likely to do it.
On another hand, in some instances poor health can be linked to a lack of resources. If you take road traffic accidents, for example, accidents are more likely to occur when roads are in bad condition and are not set up for pedestrians.
Education would help but it is not just about education, resources need to be in place to improve adolescent’s health.
One of your research interests is in how to address the broader health needs of adolescent population. From your experience, do you believe that there has been significant improvement in the understanding and development of tools and strategies to address and improve adolescent health?
Yes, I think there has been some progress, but it has been a challenge. I think that adolescents are still underrepresented in many studies, especially the younger adolescents, because they are a bit more of a challenging group to work with. The research and programming communities are now starting to realise that youth participation is very important and they are putting more focus on this, but I am not sure we have worked out how that should be done, especially within the setting of research projects.
Compared to when I first started working in adolescent health, there are now many more resources available for adolescent health. It is likely that over the coming years, there will be more and more evidence emerging which will allow us to better understand what works and does not work in this field.
In the randomised trial on MEMA kwa Vijana you investigate how long term interventions affect behaviours. Can you tell us the findings of the study?
So, that was a long-term impact evaluation of an intervention that started in 1999. The intervention was primarily in-school education for young people at the end of the primary school and participants were in their early teens, because back then people went to school a bit later. The intervention also had condom promotion, youth friendly health services and community mobilization components.
We randomly allocated ten communities to intervention and another ten to the comparison group. At the end of the trial, we went back to do a long-term impact evaluation and managed to find many of the original trial participants. The study found that those that were exposed to the intervention, even though they had left school five or six years earlier, had greater knowledge in terms of sexual and reproductive health, HIV prevention, and pregnancy prevention when compared to the control group. So, that was a very positive finding. Those exposed to the intervention also reported some lower risk sexual behaviours when compared to the comparison group. Unfortunately, there was no real difference between the intervention and comparison communities in terms of attitudes to sex, other reported behaviours or the biological outcomes. The primary outcome, which was HIV, was similar in both groups.
Our conclusion, based on our findings and on qualitative work that took place around the same time, was that this intervention was not a success most likely because there was not enough emphasis on the community aspect, partners and parents. In societies with age and gender-power imbalances, a young person may want to change their behaviour, but may be in no position to do so because there are other external factors.
We presented our conclusions together with the Regai Dzive Shiri project led by Frances Cowan in Zimbabwe, as they had found similar findings when they evaluated their intervention in young people.
What do you think it is needed to translate these findings into effective policies?
I think that first we need to find the right combination of interventions. It is clear that multicomponent interventions are more likely to be effective considering that they have the ability to target families, partners and young people at same time. Second, some of the polices need to be changed to include, for example, condom distribution or sex education in schools.
So, I think there is a lot of work to be done looking at the gap between policy and implementation. We need to really try to think how we can get these policies implemented in resource limited settings.
Do you have any final thoughts you would like to contribute to this year’s International Youth day?
Well, something that needs to keep being repeated is that we need to look at adolescent health more from a health and wellbeing perspective and acknowledge that the most effective interventions will consider all aspects of young people’s lives including education, employment and social support. We need to understand how adolescents’ lives and health can be improved in general and start involving young people more in this effort. Many young people would like to have the chance to make a positive contribution to their lives and lives of others. And as researchers we would like to involve youth more in our research, but sometimes we are not quite sure how to do that in a meaningful way, as opposed to a tokenistic way. So, I think that if people could share good experiences on how they have involved youth in their research, it would help other people working in the field of adolescent health to incorporate those ideas into their future projects.
The United Nations (UN) celebrated the first International Year of Youth in 1985. Ten years later the date was commemorated with the adoption of the World Programme of Action for Youth, which provides a framework and guidelines for national and international actions to improve young people’s situation worldwide. However, the International Youth Day was not celebrated until the 12th of August 2000, when the UN General Assembly passed a resolution endorsing the World Conference of Ministers Responsible for Youth’s recommendation to celebrate this date annually.
Image Copyright: United Nations http://www.un.org/en/development/desa/population/theme/adolescents-youth/index.shtml