This presentation describes the health challenges of adolescents, the approaches to interviewing an adolescent during a clinical encounter and the characteristics of an adolescent friendly health facility.

1. ADOLESCENT HEALTH
Juvenal Nkeramahame, Ajojo Martha, Ojok Micheal,
Ainembabazi Buhamizo
Makerere University College of Health Sciences (MakCHS)

2. OUTLINE
Introduction
Challenges faced by adolescents
STIs in adolescents
The adolescent interview
The adolescent health interview

3. INTRODUCTION
Definitions
Adolescent- a person of age 10-19 years
Young person- one between 10-24 years (UBOS, 2002)
Youth- a person 18-30 years ( Uganda constitution)
Adolescent health- Complete physical, mental, social, spiritual, economic
and cultural well being of adolescents and not just absence of disease
and infirmity generally and matters relating to the reproductive and
sexual health.

4. INTRO..
Uganda has a mainly young population, 52.4% are under 15yrs
adolescents comprise 23.3% (Nat Adol Health Strategy 2011)
Young people comprises 37.43%
Adolescence is a period of transition from childhood to adulthood
during which one undergoes dramatic physical, psychological and
social changes.

5. CHANGES IN ADOLESCENCE
VARIABLE EARLY ADOLESECENCE MIDDLE ADOLESCENCE LATE ADOLESCENCE
AGE 10-13 14-16 17-20 And beyond
SMR I-II III-V V
SOMATIC Secondary sex
characteristics
Height growth peaks Physically mature
Beginning of rapid
growth
Body shape and
composition change
Slower growth
Awkward appearance Acne and odor
Menarche/spermarche
Cognitive and
moral
Concrete operations Emergence of abstract
thought (formal
operations)
Future-oriented with
sense of perspective
Unable to perceive long-
term outcome of current
decision-making
May perceive future
implications, but may not
apply in decision-making
Idealism;absolutism
Conventional morality Able to think things
through independently
Questioning increases

6. VARIABLE EARLY ADOLESECENCE MIDDLE ADOLESCENCE LATE ADOLESCENCE
Self-
concept/identit
y formation
Preoccupied with changing
body
Concern with
attractiveness
More stable body
image
Self-consciousness about
appearance and
attractiveness
Increasing introspection Attractiveness may still
be of concern
Fantasy and present-
oriented
“Stereotypical adolescent” Emancipation complete
Firmer identity
Family Increased need for
privacy
Conflicts over control and
independence
Emotional and physical
separation from family
Increased bid for
independence
Struggle for acceptance
of greater autonomy
Increased autonomy
Peers Seeks same-sex peer
affiliation to counter
instability
Intense peer group
involvement
Peer group and values
recede in importance
Preoccupation with peer
culture
Intimacy/possible
commitment takes
precedence
Peers provide behavioral
example

7. VARIABLE EARLY
ADOLESECENCE
MIDDLE
ADOLESCENCE
LATE
ADOLESCENCE
Sexual Increased interest in
sexual anatomy
Testing ability to attract
partner
Consolidation of
sexual identity
Anxieties and questions
about genital changes,
size
Initiation of relationships
and sexual activity
Focus on intimacy and
formation of stable
relationships
Limited dating and
intimacy
Questions of sexual
orientation
Planning for future
and commitment
Relationship to
society
Middle school
adjustment
Gauging skills and
opportunities
Career decisions (e.g.,
college, work)

8. TANNER STAGING (GIRLS)
SMR STAGE PUBIC HAIR BREASTS
I Preadolescent Preadolescent
II Sparse, lightly pigmented, straight,
medial border of labia
Breast and papilla elevated as
small mound; diameter of areola
increased
III Darker, beginning to curl,
increased amount
Breast and areola enlarged, no
contour separation
IV Coarse, curly, abundant, but less
than in adult
Areola and papilla form secondary
mound
V Adult feminine triangle, spread to
medial surface of thighs
Mature, nipple projects, areola part
of general breast contour

9. TANNER STAGING (BOYS)
SMR STAGE PUBIC HAIR PENIS TESTES
I None Preadolescent Preadolescent
II Scanty, long, slightly
pigmented
Minimal
change/enlargement
Enlarged scrotum,
pink, texture altered
III Darker, starting to
curl, small amount
Lengthens Larger
IV Resembles adult
type, but less
quantity; coarse,
curly
Larger;glans and
breadth increase in
size
Larger, scrotum dark
V Adult distribution,
spread to medial
surface of thighs
Adult size Adult size

10. WHY STUDY ADOLESCENT HEALTH?
Adolescents make up a significant proportion of the population
Are prone to psychological, social, physical challenges that impact on
their wellbeing.
This is due to their level of activity, willingness to take risk, limited
information
Adolescents have potential to contribute positively to their own
socioeconomic devt & that of the country

11. CHALLENGES FACED BY ADOLESCENTS
Depression
Early pregnancy and child birth
HIV and other infectious diseases
Violence/aggression/trauma
Alcohol, tobacco use and other drugs
Bulimia and Anorexia Nervosa
Sexual abuse
Accidents
FGM
Early marriage
Abortions

12. EARLY PREGNANCY AND CHILDBIRTH
11% of all births worldwide are to girls 15-19yrs. Globally
adolescent birth rate at 49 per 1000 in same group
Decline from 1990 but still a problem
Sexual risk behaviours, lack of information and access to
contraception, early marriages

13. HIV AND OTHER INFECTIOUS DISEASES
More than 2 million adolescents are living with HIV, a reduction from
peak in 2006. Only 10% of young men and 15% of young women
15-24 aware of their HIV status.
Estimated to be 2nd leading cause of death in adolescents globally
More children with HIV surviving into adolescence.
Lack of informaton and access to contraception, drug use, peer
pressure

14. MENTAL HEALTH
Depression is the top cause of illness and disability among adolescents
and suicide is 3rd cause of death
Violence, poverty, social humiliation, feeling devalued can increase
risk of developing mental illness
Half of all mental health disorders in adulthood appear to start by
age 14. Most are undetected and untreated.

15. VIOLENCE
5th leading cause of death
An estimated 180 adolescents die everyday as a result of
interpersonal violence.
Interpersonal violence- one person uses power & control over another
through physical, sexual, or emotional threats or actions, economic
control, isolation, or other kinds of coercive behavior
GBV

16. DRUGS, ALCOHOL ABUSE
Reduces self control, increases risky behavior
Cause of violence, injuries and premature deaths
Harmful drinking among adolescents is a major concern in many
countries.
Lead to health problems in later life
Vast majority of people who smoke today began as adolescents.
Globally 1 in 10 13-15 year olds use tobacco

17. INJURIES
Unintentional injuries are a leading cause of death and disability
In 2012, 120000 adolescents died in road traffic accidents. 60,000
drowned, 2/3 were male.
Secondary to drug use, thrill seeking behavior etc

18. MALNUTRITION AND OBESITY
Many children enter adolescence undernourished leaving them
vulnerable to disease.
Number of overweight and obese adolescents is increasing. Poor diet,
insufficient physical activity
Indulgence in food high in saturated fats, transfatty acids, free sugars,
excess salt.

19. STIs IN ADOLESCENTS
Of the 333M curable STIs, 2/3 live in developing world
Highest rates in ages 20-24 followed by 15-19y
Commonest STI in girls is N. Gonorrhea (9%), T. Vaginalis (8%), C. Trachomatis (4.5%) and Syphilis
(4%).
In boys 4.5%, 5.7%, 0%, 2.8% respectively. (Mulago Skin Clinic)
Adolescents now recognized as a “Gate way to health” (WHO,1998)

20. BARRIERS TO EFFECTIVE STI MANAGEMENT IN
ADOLESCENTS
Asymptomatic nature and lack of suitable detection techniques
Lack of awareness about seriousness of STIs
Lack of availability, accessibility, cost and friendly services.
Consideration that this a health group.

21. THE ADOLESCENT HEALTH INTERVIEW
HCWs may feel overwhelmed when attending to an adolescent.
It is important to assess the individual to identify high risk adolescents.
This can be obtained using: The HEADSSS Approach
Home environment
Education and employment
Activity (peer-related)
Drugs and other substances
Sexuality
Self-image/suicide
Safety from violence or injury

22. HEEADSSS ASSESSMENT
Home:
Tell me about where you live? With whom do you live?
Who are the adults that are important to you? Do you feel safe at
home?
Education/ Employment:
What class? Favourite subject? What was your average last term?
What do you do in your spare time?
Activities:
What activities, groups, clubs or sports do you participate in?
What do you do after school? Weekends? How much time do you
spend on TV, internet? Do you use facebook or whatsapp?

23. HEEADSSS ASSESSMENT
Drugs:
How do you feel about smoking? About drinking? About use of other
drugs?
Do you now anyone who uses these substances? Does any one use them
in your family?
Have you ever used these substances? When? How? With whom?
Where would you get cigarettes, alcohol or drugs if you wanted them?
sex?

24. HEADSSS ASSESSMENT
Sexuality:
For very young adolescents
Have you noticed any changes in your body recently? How doo you feel about them?
For adolescent girls
Have you began your MPs? If yes, how has that changed your life? Are you still able to
go to school?
For all adolescents
Are you attracted to girls? To boys? Do you have a boyfriend or girlfriend?
Have you ever had sexual intercourse? If yes, how old were you when you first had
sex? If no, how old would you like to be when you have sex for the first time?
Have you ever had sex without a condom?
Have you ever had sex with someone in exchange for money or other things?
Have you ever been pregnant? Have you ever had sex with anyone against your will?

25. HEEADSSS ASSESSMENT
Self-image/ Suicidality
How do you feel about yourself?
On most days, would you say you feel happy or sad? What do you
do when you feel sad?
Have you ever thought of committing suicide? Did you make a plan?
Do you have friends in the community? Which adult can you go to
when you need help?
Is there a difference between school days and the weekend?
Safety/ violence
Are you being bullied at school? How do you settle disagreements?
Do you ever get into a car with a driver who is drunk? Do you always
wear a helmet or a seat belt?
Has any one ever touched you in an unwanted way?

26. ADOLESCENT FRIENDLY HEALTH SERVICES (AFHS)
Provider characteristics
Technical competence/ specially trained staff
All staff oriented
Respect adolescents when interacting with adolescents
Ensure privacy when interviewing adolescents
Peer counsellors/ educators available
Positive attitude towards provision of services

27. AFHS
Health facility characteristics
Location
Privacy and confidentiality
Services free or affordable
Access to services: convenient hours
Client satisfaction
Respect for adolescents
Adequate space and privacy
Adequate supplies and equipment
Sufficient and appropriate IEC materials
Short waiting times

28. AFHS
Programme characteristics
Involve youth in design, implementation and feedback
Involve peer service providers
Parent/ family/ community support
Display services and hours of service
Display guidelines and standards including rights
No overcrowding

29. AFHS
Program characteristics
Short waiting time for clients
Affordable services/ fees
Publicity to inform and reassure youth
Wide range of services available
Functional referral and follow up mechanisms

30. BARRIERS TO PROVISION OF EFFECTIVE
ADOLESCENT HEALTH SERVICES
Individual barriers
Feelings of shame, fear or anxiety about issues of sexuality
Lack of awareness about services
Poor health-seeking behaviour
Poor advice-seeking behaviour
Perception that services will not be confidential
Socio-cultural barriers
Social norms
Stigma surrounding sexually active adolescents
Attitudes of HCWs
Language differences

31. BARRIERS TO PROVISION OF EFFECTIVE
ADOLESCENT HEALTH SERVICES
Structural barriers
Long distance to health facilities
Lack of facilities for adolescents with disabilities
Inconvenient hours of operation
Long waiting times
Charging fees for services
Lack of privacy

32. REFERENCES
1. Ministry of Health. The National Adolescent Health Strategy
(2011-2015), 2011.
2. Adolescent Sexual and Reproducive Health Toolkit for
Hmanitarian Settings. Save the Children and UNFPA
3. Nelson’s Textbook of Paediatrics,18th ed