Investing in Adolescent Health

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T able of Contents Introduction!"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!#$ C hallenges Faced by A dolescents!""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!#$ W hy Invest in A dolescents!""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!$$ E conomic and Social Benefits of Investing in Adolescent H ealth E ducation!""""""""""""!%%$ E ffective Interventions in A dolescent H ealth and Development!""""""""""""""""""""""""""""""""""!%&$ Interagency Initiatives!""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!%#$ E xamples of Best Practice!""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!%'$ A nnex 1 World Bank Health Projects with A dolescent Components!"""""""""""""""""""""""""!&($ A nnex 2 World Bank E ducation Projects with A dolescent Components!"""""""""""""""""""!&)$ A nnex 3 World Bank Social Protection Projects with A dolescent Components!""""""!&'$ Notes and references!"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""!&*$ $ F igures Figure 1 Adolescent Population (aged 10±19) by Region, 2009 Figure 2 Trends in the Adolescent Population, 1950±2050 Figure 3 Age at which Females are Married or in First Union, Selected Countries Figure 4 Percentage of young people age 15-19 who had higher-risk sex with a non-marital, non-cohabitating partner in the last 12 months in selected countries Figure 5 Global Trends in Youth Employment T able Table 1 Interagency Initiatives Achieving Success Promoting Positive and Healthy Development for Adolescents

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A bbreviations APL CARICOM CCT EFAIDS EHS EPZs FRESH HFLE HNP IATT IFTS LIPW M&E MCH MDGs MEN MOH MSP NGOs SRH STIs SWAp UN WHO UWI

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Adaptable Program Lending Caribbean Community conditional cash transfer Education for AIDS essential health services Export Processing Zone Focusing Resources on Effective School Health Health and Family Life Education health, nutrition, and population Inter-Agency Task Team Inclusive Full Time School Labor Intensive Public Works monitoring and evaluation maternal and child health Millennium Development Goals Ministry of Education Ministry of Health Ministries of Social Protection nongovernmental organizations sexual and reproductive health sexually transmitted infections Sector-Wide Approach United Nations World Health Organization University of the West Indies

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Introduction Adolescence is defined as the period of life from ages 10 to 24 during which individuals make the developmental transition from childhood to adulthood. It is characterized by marked physical, emotional, and intellectual changes, as well as changes in social roles, relationships, and expectations, all of which are important for the development of the individual and provide the foundation for functioning as an adult. Adolescence is also a critical point at which investment can break the cycle of poverty, which can result in social, economic, and political benefits for individuals, communities, and nations. Adolescence also marks the onset of puberty, and is a period during which many adolescents have their first sexual experience. Therefore, promoting and establishing healthy reproductive lifestyles during adolescence could result in the development of healthy lifelong patterns of skills and choices. Investing in adolescents is strategically important for the achievement of the Millennium Development Goals (MDGs 1, 3, 5 & 6) Tackling issues of economic opportunity, the availability of health care, DQG DFFHVV WR VHFRQGDU\ HGXFDWLRQ ZLOO ERRVW DGROHVFHQWV¶ prospects. Lack of educational and employment opportunities, accidents and injuries, early sex, HIV and AIDS, mental health issues, child labor, adolescent marriage, and teenage pregnancy are just some of the risks that can prevent adolescents from realizing their capacities as they transition to adulthood. Global challenges, including climate change, economic uncertainty, globalization, demographic shifts, and humanitarian crises, present an uncertain backdrop for adolescents during the pivotal decade of their lives (UNICEF 2011). Many studies confirm that most health risk behaviors among adolescents are interrelated. Likewise, many protective factors²things that reduce health risks²are interrelated. $GROHVFHQWV¶ substance use, violence, and suicidal behavior FRXOGHDVLO\UHODWHWRIULHQGV¶ substance use, deviance, and suicidal behaviors, respectively. Family dysfunction, social acceptance, and depression can alter the magnitude of the association between peeUV¶DQG DGROHVFHQWV¶ risk behavior. In cumulative risk factor models, rates of adolescent health-risk behavior doubled with each added risk factor. Even though the development of healthy adolescents is a complex and evolving process, it is important to understand how to promote healthy behaviors among youth that will lead to an optimal state of well-being in all areas of life (physical, emotional, cognitive, social, and spiritual). Doing so will require supportive and caring families, peers, and communities; access to high-quality services (health, education, social, and other community services); and opportunities to engage and succeed in the developmental tasks of adolescence. These healthy behaviors mainly start with healthy choices. Good judgment in decision making is probably one of the key aspects to having a healthy life. C hallenges F aced by A dolescents In 2009, there were 1.2 billion adolescents aged 10 to 19 in the world, comprising 18 percent of the world population. The vast majority of adolescents (88 percent) live in

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developing countries. More than half live in either the South Asia or the East Asia and Pacific region, each of which contains roughly 330 million adolescents. India has the largest national population of adolescents (243 million), followed by China (207 million), the United States (44 million), and Indonesia and Pakistan (each with 41 million) (figures 1 and 2). F igure 1 A dolescent Population (aged 10±19) by Region, 2009

F igure 2 T rends in the A dolescent Population, 1950±2050

There are several key factors that put adolescents, both unmarried and married, at sexual and reproductive health risk stemming from early, unprotected, and unwanted sexual activity. These factors are the vulnerability of their personalities; peer pressure; lack of access to sexual and health education and to accessible, affordable, and appropriate contraception; social pressure to marry and bear children early; and inability to refuse unwanted sex or to resist coerced sex (National Research Council«2005). The number of sexually active adolescents is increasing globally, and the level and context of sexual activity among adolescents varies widely by gender and location. In 2010, there will be more 10-to-19-year-olds on the planet than ever before²approximately 1.25 billion (McCauley and Salter 1995)²83 percent of whom will live in developing countries and will be most vulnerable to a range of reproductive health problems, including too-early pregnancy and childbearing; infertility; genital mutilation; unsafe abortion; sexually transmitted infections (STIs), including HIV; and gender-based violence, including sexual assault and rape (WHO 2008). Marriage and coercive sex: About 14 percent of adolescent girls in developing countries are married by age 15 and as many as 30 percent are married by age 18. Adolescents who are married or are in a formal union need contraceptive services. However, social norms usually lead to women becoming pregnant soon after marriage. Sexually active adolescents who are not in a formal union also have an unmet need for contraceptives. Moreover, substantial proportions of adolescents experience coercive sex or have transactional sex, and in such situations have limited opportunities to protect themselves (WHO 2002). About 16 million adolescent girls aged 15 to 19 give birth each year (WHO 2002). It is crucial that adolescents receive the guidance of parents, teachers, and health care providers to

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assure better health and sexual health outcomes. Figure 3 displays the age at which females are married or in their first union in selected countries. F igure 3 Age at which F emales are mar ried or in F irst Union, Selected Countries

Adolescent mortality and morbidity: Young adolescents are more likely to experience complications during pregnancy and childbirth than adult women and are at greater risk of pregnancy-related death. Infants of adolescent mothers are also at higher risk of mortality and morbidity. The adolescent fertility rate (births per 1,000 women aged 15 to 19) is highest in the World Health Organization (WHO) African Region (118 per 1,000) and in low-income countries (110 per 1,000) compared with a global average of 47 per 1,000 during 2000±08. In the WHO African Region, fertility is high at all ages and adolescent pregnancies are common, mostly because marriage occurs at young ages. By contrast, in the WHO Region of the Americas, many adolescent pregnancies occur outside marriage.1 Unwanted pregnancies: There are 87 million unwanted pregnancies and 46 million abortions each year, of which 21.6 million are unsafe abortions and 98.33 percent of which are performed in developing countries. Thirty to 60 percent of adolescent pregnancies end in an abortion. Young women (aged 15 to 24) account for an average of 46 percent of these deaths. The percentage of young women dying from unsafe abortion varies by region: 33 percent in Latin America and the Caribbean, 39 percent to 72 percent in Africa, and 9 percent to 23 percent in Asia (Arrows for Change 2006; Shah and Ahman 2010; WHO 2007). Domestic and sexual violence: The issue of domestic and sexual violence needs to be addressed in both developing and developed countries. Although the victims of rape and sexual abuse are overwhelmingly young women, men can also be subject to sexual victimization and violence and be forced to perpetrate sexual violence against others. Social problems such as alcohol and drug consumption, unemployment, and social discrimination can generate and perpetuate domestic violence among partners, children, parents, and family members.

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STIs and HIV: There are an estimated 100 million STIs every year, and two of five new HIV infections occur in adolescents or young people (aged 15 to 24) (UNFPA 2008). Figure 4 shows that young males in late adolescent are more likely to engage in higher risk sex than female, and also it presents that not only the Sub-Saharan countries have a higher percentage, there are countries in the Caribbean and East Europe regions with high percentages as well. F igure 4 Percentage of young people age 15-19 who had higher-risk sex with a non-marital, noncohabitating partner in the last 12 months in selected countries

Mental health: An estimated 20 percent RIWKHZRUOG¶VDGROHVFHQWVhave a mental health or behavioral problem. Depression is the largest contributor to the global burden of disease for people aged 15 to 19, and suicide is one of the three leading causes of mortality among people aged 15 to 35. Globally, an estimated 71,000 adolescents commit suicide annually, while up to 40 times as many attempt suicide. About half of lifetime mental disorders begin before age 14, and 70 percent begin by age 24. The prevalence of mental disorders among adolescents has increased in the last 20 to 30 years, an increase attributed to disrupted family structures, growing youth unemployment, DQGIDPLOLHV¶XQUHDOLVWLFHGXFDWLRQDODQG vocational aspirations for their children (UNICEF 2011). Education and work: Global net secondary school attendance is roughly one-third lower than primary school attendance.2 $OPRVWKDOIWKHZRUOG¶VDGROHVFHQWVRIWKHDSSURSULDWH age do not attend secondary school, and when they do attend, many of them fail to complete their studies or finish with insufficient skills. For those who are employed, decent work is scarce. In 2010, young people aged 15 to 24 accounted for around one-quarter of the ZRUOG¶VZRUNLQJSRRU (ILO 2010). In a recent World Bank survey, more than 20 percent

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