All too often, health-care providers overlook the psychological and social characteristics of their clients. For young adults, addressing such concerns can be crucial. Understanding the psychological and social influences that bring adolescents to clinics can be especially useful and effective in serving this age group.
Some problems young adults face are psychological. Many adolescents are afraid, embarrassed or unwilling to take the precautions against sexually transmitted diseases (STDs) or to prevent an unintended pregnancy. For example, some adolescents may have multiple partners, yet rarely use condoms. These young adults may be prone to such risk-taking because they do not yet have a mature sense of the hazards involved or an appreciation for the long-term implications.
Pressures from society also affect adolescents and their reproductive health. Cultural expectations, such as a prime value on marriage and motherhood, may encourage girls to bear children at an early age or to begin sexual activity at a young age, exposing them to unintended pregnancy. Traditions of polygamy or sex with older partners in some African countries can increase the risk young women face of contracting HIV or other STDs. Poverty may lead boys or girls into prostitution for money to buy food. Social taboos on discussing sexuality or teaching children about reproductive health issues can leave many adolescents poorly prepared to protect themselves against STDs or unintended pregnancy.1
Self-esteem
Few studies have examined how psychological and social values affect adolescents and their reproductive health, and some public health policy-makers may question whether notions of "self-esteem" and "self-confidence" are even relevant in developing countries. Yet feelings of insecurity, fear and self-doubt can interfere with good reproductive health behavior in any culture, says Dr. Cynthia Waszak, an FHI research scientist who specializes in adolescent health. Without confidence, young adults may not seek reproductive health services, or be capable of saying "no" to unwanted sex.
"Yes, there are differences in how people see themselves as part of a community, depending on the country and culture," she says. "But I cannot think of a culture where feeling good about yourself is not important. People still have feelings about themselves, and perceptions about whether they like themselves that determine how they are going to behave, no matter where they are. Self-esteem is a relevant concept everywhere."
Dr. Bené Madunagu of Girls' Power Initiative in Nigeria, echoes this view. "If young women do not believe in themselves, and they do not believe they have the capacity to address reproductive rights at all, then they will be unable to assert their rights in [high-risk] situations," says Dr. Madunagu, whose program offers an after-school discussion group for girls and young women from 10 to 18 years old.
Sponsored by the Ford Foundation and New York-based International Women's Health Coalition, Girls' Power holds weekly meetings to help adolescent women build confidence and talk openly about many areas of their lives. The program also teaches a variety of job skills, including such male-dominated vocations as carpentry and money management. "Without becoming empowered through an educational program, they would not realize their capacity to cope with their own prejudices, and gender prejudices in society," Dr. Madunagu says.
Lack of self-confidence is a problem forº many adolescents, especially girls. "At early stages of life, the problems for boys and girls are the same," says Muhammad Ibrahim, director of the Adolescent Girls Program in Bangladesh, an educational effort for rural girls throughout the Asian country. "But when it comes to the teenage years, girls are doubly disadvantaged. It is not just poverty, but also social values that prevent girls from developing in a healthy way. Girls and boys are treated differently. While boys are able to go on with their training, their freedom to move about and to play sports, girls are taken out of circulation."
In Bangladesh, she says, girls typically are not allowed to leave their homes, go to the marketplace alone or ride a bicycle, especially in rural areas, after puberty begins. They often leave school at age 13 or 14 to get married.
For health-care providers who see young adults infrequently, helping their young clients build self-respect and esteem may seem difficult. Providers, however, can contribute to improved esteem by establishing a caring relationship with adolescent clients.
"Providers should treat clients with respect, and a lot of them do not do that with adolescents," says Dr. Waszak, who has recently evaluated women's and girls' skills-building programs run by the World Association of Girl Guides and Girl Scouts (WAGGGS) at refugee camps in Zimbabwe, Uganda and Kenya. "When clients are not treated with respect, it certainly has an impact on a person's self perception. It never makes anyone feel good to be treated judgmentally, rudely or condescendingly, or just turned away."
Simply having access to an adult counselor can help young adults to practice safer sex. A Baltimore, MD, family planning clinic provided individual and group counseling at two high schools during school hours, and at the clinic after school. Free services included contraceptive counseling, pregnancy testing and referrals. Students who did not need these services could still visit to discuss issues or watch films. During the three-year program, the pregnancy rate among girls at the two schools declined significantly while pregnancy rates at other high schools increased.2 Experts attribute the program's success to the accessibility of trained staff who treated their young clients respectfully.
"Why did this program work? Because it offered practical services, but also treatment by caring providers," says Dr. Laurie S. Zabin, professor of population dynamics at Johns Hopkins University in Baltimore, who studied the school program. "Teenagers care very much whether their providers are caring. The identification of a teenager with a provider in a loving relationship over time is a wonderful way to build motivation. All these factors appear to have created an atmosphere that allowed teenagers to translate their attitudes into constructive preventive behavior."
Building skills
Once a sense of trust is established between a young adult and a provider or counselor, specific skills should be taught. Some of the skills that sexually active adolescents should learn include the ability to obtain and use condoms, as well as to be able to communicate about contraceptive use and STD prevention with a partner. All young adults should be capable of saying "no" to sex, but may need help in learning to assert themselves.
"Self-esteem without skills is hollow," says Dr. Susan Newcomer at the National Institute of Child Health Development (NICHD), a federal research agency in the United States. "If you tell teenagers to feel good about themselves when they do not have any substantive reason to feel good about themselves, you are not helping them. Real self-esteem comes from being able to do something well."
Such skills can be introduced through a variety of exercises. These include values clarification, decision-making practices and behavior reinforcement through role modeling and positive feedback. School and clinic programs can enable students to talk about their personal feelings, including how they feel about sexual activity and safe sex behavior, in order to identify which components of preventive behavior may be difficult for a particular individual, and why.
Such programs may address students' specific sexual histories, their skill levels for HIV and pregnancy prevention, and communication strategies. Sex education programs in the United States that offered values clarification and skill-building exercises were more likely to be successful than those that did not, according to one study.3 Learning the ability to protect oneself against sexual risk is especially important for an adolescent, says Dr. Newcomer.
Even when motivation exists, obtaining contraception is not always easy for young adults. A study in Ghana found that 18- and 19-year-old unmarried women were discouraged from using family planning by providers. One woman who visited a health clinic to get a contraceptive reported, "Because I was young and not married and was not sure when I would be getting married, I was told it would not be advisable to be taking the pills."4
Even when adolescents have better access to contraception, some may not take precautions. Adolescents in the U.S. city of New Orleans, LA, were not more likely to use contraception just because they knew about it and where to get it, according to a study. Of 228 pregnant adolescent women, 86 percent said they knew about contraception at the time they became pregnant, but only 16 percent reported using a method. Increasing knowledge, without addressing the underlying psychological needs of young adults, will not necessarily lead to safer behavior, the study authors concluded.5
Social norms and other cultural influences also play a role. "Too much emphasis on self-esteem makes it sound as if you're saying, 'If teenagers only thought right, they wouldn't have any problems,'" says Dr. Zabin of Johns Hopkins. "They have to face poverty, violence and a harsh reality. An individual's social world is the setting in which the risk behavior is taking place. It is our responsibility as providers to help change that environment, not simply to blame a teenager's self-image for her failures."
When pregnancy occurs
Adolescents who do become pregnant often face a variety of psychological or social barriers to good reproductive health. Pregnancy may be a time when an adolescent's self-esteem is at its lowest. This makes it difficult not only to plan wisely for the pregnancy, but may also affect a woman's attitudes about future pregnancies or her willingness to protect herself from STDs.
For young married women in their first pregnancies, addressing emotional concerns can help promote a safer, more successful pregnancy. When pregnancy is out of wedlock or unplanned, the emotional consequences can be severe. An unmarried pregnant adolescent often faces her dilemma without the support of her family, partner or peers. In some cultures, she may be scorned or may have difficulty obtaining adequate services for pregnancy counseling or prenatal care.
Receiving support from others can be important. A study in Baltimore found that pregnant adolescents receiving support in their decisions from a parent or another adult, and those few who did not consult a parent, were more satisfied with their decisions to continue or terminate their pregnancies than adolescents whose parents did not support them.6
An FHI study of 519 adolescents, ages 12 to 18, who sought prenatal care or abortion-related emergency services at a hospital in Fortaleza, Brazil, is examining such issues as self-esteem and the relationships the women have with family and partners. When asked in separate questions if they wanted to get pregnant when they did or would have preferred to delay pregnancy, about one woman in every five answered "yes" to both. These contradictory answers may indicate the ambiguous feelings many women have, researchers say.
Preliminary findings also show that many adolescent mothers do not receive emotional support from their families. Some 58 percent of the pregnant girls said their mothers reacted positively to the news of their pregnancy, and only 45 percent reported support from their fathers. By contrast, 71 percent of the pregnant women's partners were supportive of the pregnancy, says Dr. Patricia Bailey of FHI.
"For young women, becoming pregnant will change their lives dramatically," says Donna McCarraher, an FHI evaluation specialist working on the study. "They will be less likely to go back to school, they will earn less money, and their situation can be a source of tension with their partners and family."
-- Sarah Keller
References
- Ankrah ME. Adolescence: HIV and AIDS in sub-Saharan Africa. Presented at Workshop on Adolescent Reproductive Health in Sub-Saharan Africa, The Centre for Development and Population Activities, Feb. 13, 1996.
- Zabin LS, Hirsch MB, Smith EA, et al. Evaluation of a pregnancy prevention program for urban teenagers. Fam Plann Perspect 1986;18(3):119-26.
- Kirby D. Sexuality education: A more realistic view of its effects. J School Health 1985;55(10):421-24.
- Stanback J. The impact of family planning services delivery guidelines dissemination in Ghana. Unpublished paper. Family Health International, 1997.
- Landry E, Bertrand JT, Cherry F, et al. Teen pregnancy in New Orleans: Factors that differentiate teens who deliver, abort, and successfully contracept. J Youth Adolesc 1986;15(3):259-74.
- Zabin LS, Hirsch MB, Emerson MR, et al. To whom do inner-city minors talk about their pregnancies? Adolescents' communication with parents and parent surrogates. Fam Plann Perspect 1992;24(4):148-73.
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