Strengthening health care worker engagement with early adolescence in low- and middle-income countries: an overdue area for action

Introduction

In 2009, the Society for Adolescent Medicine published a position paper called “Health care reform and adolescents – an agenda for a lifespan” articulating five principles essential to meeting adolescents’ health-related needs (Table 1) [1]. Although the paper focused on improving health care for adolescents within the USA, the five principles for promoting adolescent health are broadly applicable and useful as a framework for reviewing current approaches to adolescent health care globally. Specifically, the principle promoting improved engagement between healthcare workers and young adolescents could have a substantial impact globally but particularly in low- and middle-income countries (Table 1, Principle 3).

There are many reasons for focusing on the importance of a “broad range of health care professionals” who are mandated and whose capacity is strengthened to work with adolescents (Table 1, Principle 3), including: 1, adolescence is a phase of life during which young people’s lives and health behaviors are profoundly shaped by family, school, neighborhood factors, (social) media and other influences [2], [3]. Building the capacity of a range of health care professionals, either in schools, clinics or beyond, to address adolescent health and wellbeing issues is therefore essential [4]. 2, Many adolescents are sensitive to interpersonal exchanges during the period of life when their bodies are rapidly changing [5]; assuring health care professionals appreciate this dynamic, along with building their abilities to engage effectively with adolescents is essential. 3, In many low- and middle-income countries, the field of Adolescent Medicine is nascent; yet, having competent adolescent health and medicine experts enables the generation of resources, both financial and intellectual, to guide a national response to meeting young people’s needs [6].

By “adolescent” we refer to the United Nations (UN) definition of ages 10–19 years, and early adolescence as ages 10–14 years [7]. In this paper, we are proposing that particular attention is warranted during early adolescence, a period of immense physiological and social change, but one that is frequently overlooked by health care workers, given the perception that early adolescence represents a healthy window of time between childhood vulnerability to disease, and the risk-taking behaviors of older adolescents. This misperception however leads to missed opportunities as will be explained.

While this paper focuses on Principle 3 (Table 1), all five principles are essential for adolescent health care, and critical synergies exist between them. Competent health care professionals who are supported in their work are more likely to follow Principle 4 (protecting confidentiality), and Principle 5 (address the specific needs of special groups of adolescents), although additional strategies and investments would be needed for both, and to address Principles 1 and 2. For protecting confidentiality in particular, which is often compromised by health workers living in the same geographic and social catchment area as adolescents, actions must be taken to transform mindsets and to modify practices.

The importance of intervening in early adolescence

The global adolescent population is large, with over 1.2 billion adolescents (aged 10–19) today, the vast majority residing in low- and middle-income countries [8]. Proportionally, this population represents 15–25% of the population in countries in low- and middle-income countries. As the Global Early Adolescent Study (GEAS), conducted in 13 countries and other studies such as the Young Lives Project have documented, early adolescence represents a transitional period during which gendered vulnerabilities to health risks intensify [9], [10], [11]. This includes, for example, the biological and societal related vulnerabilities girls face during adolescence to sexual violence, [12], [13] pregnancy, and infection with human papilloma virus (HPV) or HIV and AIDS; and boys becoming more vulnerable to injuries related to income-generating activities [14] and violence [11]. However, while adolescents’ access to health services has begun to improve in countries such as Ethiopia and Chile, which have more recently focused on this population [15], in many other places, their access to health care, both preventative and treatment, remains patchy. For example, HPV vaccine has been piloted in a handful of low resource countries but rolled out nationally in very few, such as recently in Kenya [16], [17], [18]. However, early adolescent access to services for preventing pregnancy [5], [6], [19], and for those experiencing sexual violence, remains insufficient; child protection programs, for example, may overlook early adolescents [20]. In addition, half of all mental health disorders begin by age 14 [4]; yet access to mental health services for this population in many low- and middle-come countries remains extremely limited and stigmatized [21].

Almost a decade ago, a World Health Organization (WHO) consultation on the sexual and reproductive health of young adolescents in low- and middle-income countries emphasized the need to engage with young adolescents around their sexual and reproductive health [22]. In addition, Dixon-Mueller [23] provided an argument for improved age-specific variations when studying and addressing the sexual, marital, and reproductive transitions of adolescents, separating 10- to 19-year-olds into three categories (early/ages 10–14, mid/ages 15–17 and late/ages 18–19 adolescence). In analyzing adolescents’ physiological development, cognitive abilities for making “safe, informed and voluntary” decisions, and institutional concepts of being “old enough” to make sexual and reproductive health decisions, she articulated that 10- to 14-year-olds were particularly vulnerable, and in need of attention [23].

The onset of puberty during the early adolescent window in particular provides urgency for attention to Principle 3, and the need for a broad range of health professionals (clinic, school-based, community health workers) to focus on this age group. During early adolescence, of which puberty is an integral part, tremendous physiological, cognitive and social changes occur in a person’s life [24], [25]. Having competent and empathetic healthcare workers in, for example, clinics, schools, and community health units, who understand healthy developmental processes and the potential for young people to have many questions as their bodies mature, is essential [26]. In societies where engagement with healthcare workers during early adolescence is less common, parents and caregivers may not appreciate the potential benefits of such interactions. A review by Kim and White [5] identified the barriers that caregivers – including parents – may create for young adolescents intentionally engaging with health workers, for example, concerns that their confidentiality would not be maintained, and/or a sense of lacking autonomy over their own health information. Alongside this, the review pointed to concerns of caregivers, for example, wanting their young adolescents to be heard while also wanting to be engaged in the process. Importantly, Bundy et al. [27] recently proposed two packages of interventions that overlap the window of early adolescence and present potential pathways for increased engagement between health care workers and this population [5], [27]. The first is focused on ages 5–14, and includes, for example, HPV vaccines, deworming, and vision screening, while the second targets ages 15–19, and adds, for example, sexual and life skills education and mental health counseling [27]. The second package in particular is relevant for the gendered roles in relation to sex and sexuality that begin to become established for young people during early adolescence, and so healthcare worker awareness of this continuum is essential. Capable and empathic health workers are key to the delivery of these interventions.

In some contexts, parents and caregivers may also be uncomfortable, too busy, or culturally prohibited from discussing puberty with their children [28]. This reality underscores the potential value of the involvement of other adults, including healthcare workers during early adolescence, be it in school-based delivery, community health worker outreach, or clinics, that enable them to fill this gap, providing information and support, and helping to build girls’ and boys’ confidence about their changing bodies [29], [30], [31]. The delivery of the HPV vaccine, for example, as an intervention targeting early adolescents, creates opportunities for promoting positive interactions with healthcare workers, such as the simultaneous delivery of colorful, story-filled puberty books for girls (and boys) who come into clinics [32]. A recent special issue of the Journal of Research on Adolescence [33] highlighted the under-addressed areas of puberty education as a global health issue [33]. Health workers have a role to play in delivering such education, within a clinical context and potentially through the use of digital technologies [34].

Early adolescence within the adolescent health care agenda

The global adolescent health community has made important strides in the last two decades to promote attention to adolescent health and wellbeing. These efforts have not focused on very young adolescents in the past, but are beginning to do so now, for example, with the arrival and roll out of the HPV vaccine and male circumcision programs. Multiple organizations have developed program support tools, built capacity and supported countries to make health services more adolescent friendly. The HIV and AIDS epidemic has led to interventions being deployed across many sub-Saharan African countries focused on incorporating older children and early adolescents – infected vertically – into, and assuring adherence to, treatment [48]. Efforts to roll out the delivery of HPV vaccine have identified mechanisms for reaching young adolescent girls in particular [49], [50]; and select school systems in low- and middle-income countries have included vitamin or micronutrient fortification programs, such as the delivery of iron supplementation to early adolescents [51], [52]. Most of these responses have focused on young adolescents in non-humanitarian contexts. In humanitarian response contexts, there have for many years been interventions focused on more effective delivery of child protection services, which in particular incorporate psychosocial health care [53], [54]. In both protracted and acute emergency contexts, child protection services provide ready populations for health care worker attention.

Despite such efforts, as noted earlier, there continue to be many barriers to the provision and use of health services by and for adolescents in low- and middle-income countries and a particular gap in attention to promoting engagement of healthcare workers with very young adolescents [24]. There are many reasons for this including higher rates of morbidity and mortality among older adolescents, and the possibility that they may interact more frequently with the healthcare system in comparison to younger adolescents [55], [56], although not unmarried girls or older adolescent boys. In addition, the inclusion of attention to early adolescents in universal health care strategies, and the primary health care agenda, may not yet be adequately delineated in many countries. However, as evidence accrues for the benefits of preventative intervention in early adolescence as part of promoting an “agenda for a lifespan” [1], building the capacities (including through training and sensitization) of health care workers to intentionally engage during early adolescence in such contexts, be it through schools, community health outreach, health clinics or using new technologies, is essential [7], as part of a package of actions to improve and sustain improvements in their performance [57]. Important to note is that “adolescent friendly health services” approaches have not been universally successful in meeting the five principles amongst other limitations, and have often focused on older adolescents, overlooking the critical early adolescent period of growth and development [24], [58]. Thus, going forward, there is a need to identify effective approaches for incorporating young adolescents in such services.

The potential for improving healthcare worker engagement with early adolescents

There are both opportunities and potential benefits in applying Principle 3 to a framework of response in low- and middle-income countries that promotes healthcare worker attention to early adolescence. As noted already, there are a broad range of health professionals who could address the needs of this population, ranging from those based in clinics, to those who are school-based, to those who serve as community health workers, and those who are involved in outreach education work at schools and elsewhere, such as through youth clubs or the provision of puberty books at health clinics [3].

Underscoring the value of applying Principle 3 to healthcare worker engagement with young adolescents, examples already exist of countries that are strengthening school-based delivery of health services to this population, and community outreach programs that target out of school adolescents. However, a larger shift is still required within countries and the global community beyond targeting interventions to prevent poor health outcomes among young adolescents and extend the “lifespan of health” per the Society of Adolescent Medicine’s framework. By referring to a “lifespan of health,” the society articulates the critical importance of investing in adolescence, given the implications for later life, highlighting, for example, how substance abuse in adulthood is often ingrained through adolescent behaviors. The necessary shift calls for more positive and trusting relationships that may develop between young adolescents and health professionals. Such relationships have shown to be more difficult to build when initiated in later adolescence, for example, as young people encounter healthcare worker biases against adolescent use of contraception [59], [60], [61]. Some studies have shown that training health care workers in topics such as the menstrual cycle, contraception and the stages of adolescence, increases the youth friendliness of service provision [58], [62], [63]. This however raises a key final point. Investments in improved training of healthcare workers will need to occur to enable their ability to perform well under Principle 3, ranging from friendly delivery of puberty education to strengthening their expertise in understanding menstruation as a vital sign for reproductive health. In addition, there are multiple other health preventative topics about which healthcare workers can engage this age group more sensitively, including the mental health and nutritional needs that may arise during this developmental period.