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Adolescent girls’ well-being in resource-poor settings

20 Apr 2015
Caroline Kabiru, Research Scientist at the African Population and Health Research Center’s (APHRC), Population Dynamics and Reproductive Health Research Program
Caroline Kabiru

Introduction

Adolescence is a period marked by rapid physical, emotional and social changes. If young people receive adequate guidance and support, adolescence can be a life phase of immense opportunities with long-term positive impacts. Conversely, adolescence can mark the beginning of a trajectory of risk and poor health and social outcomes if the social, cultural, political and economic contexts in which adolescents live fail to provide them with a ‘structure of opportunity’.[1]

Adolescent well-being is determined by a wide range of factors operating at multiple levels – individual, peer, family, community, policy, etc.[2] At the individual level, for example, adolescents’ awareness, attitudes, perceptions, and self-efficacy, among other personal characteristics can shape their successful transition to adulthood or predispose them to risky behaviors and lifestyles.[3] In Nairobi’s informal settlements, for example, one study showed that adolescents’ involvement in delinquent behavior was strongly associated with a high level of disjunction between their aspirations and expectations for achieving those aspirations.[4] At the macro level, policies around education access, provision of youth-friendly health services, and child protection services can also have a bearing on adolescents’ well-being.[5]

Although adolescence is a critical period universally, adolescent girls growing up in resource-poor settings around the world face unique challenges as they transition to adulthood. In this commentary, I focus on the status of adolescent girls in resource-poor settings, while fully acknowledging that the needs of adolescent boys should also be prioritized. Bearing in mind the complex determinants of well-being, I end the commentary with a reflection on ways in which we can enhance adolescent girls’ well-being through holistic, integrated programs.

The status of adolescent girls in resource-poor settings

Formal education is a critical ingredient for social development.[6] Although many countries have implemented policies and programs to ensure universal access to basic education, a large number of adolescent girls remain out of school and in many low and middle income countries (LMICs) girls have, on average, lower literacy rates compared with boys.[7] Girls’ lower participation in schooling is driven by a wide range of factors, including high rates of early marriage,[8] girls’ greater involvement in household chores, and school-related barriers, such as inadequate sanitation infrastructure and poor teacher attitudes, which impede their full participation in school.[9]

Across many LMICs, young girls begin childbearing early. The root causes of early childbearing include early marriage, sexual and gender based violence, limited access to sexual and reproductive health (SRH) services, and poverty – a factor that leads many adolescent girls to engage in transactional sexual partnerships to meet basic needs.[10],[11] Early childbearing often means an end to formal education and poor life prospects for employment for these girls.[12] Adolescent mothers and their children also have an elevated risk for poor health outcomes compared to older mothers.[13]

The vulnerable status of adolescent girls in resource-limited settings also manifests in poor SRH outcomes—high rates of unintended pregnancies, sexually transmitted infections (STIs), and unsafe abortions. Globally, for example, more than four out of ten new HIV infections among women (15 years and older) occur among adolescent girls and young women aged 15-24 years.[14] Adolescents are also at particular risk for unsafe abortions – the bulk of which occur in LMICs. In Africa, for example, 25 per cent of all unsafe abortions occur among 15-19 year old girls.[15] As with early childbearing, adolescent girls’ poor SRH outcomes are driven, in part, by their heightened vulnerability to sexual and gender based violence,[16] inadequate access to comprehensive SRH information and services, as well as their limited ability to negotiate for safer sex.[17]

Meeting the needs of adolescent girls in resource-poor settings

The plight of adolescent girls has sparked global interest in addressing the factors that affect their health and well-being. Most notable among these efforts is The Girl Declaration, a call to action to prioritize the needs of girls in the post-2015 development agenda (http://www.girleffect.org/the-girl-effect-in-action/girl-declaration/). The increased advocacy around the need for girl-centered programming is a crucial first step in addressing the complex underlying factors that affect adolescent girls’ well-being. The growing political commitment to issues affecting adolescent girls is particularly key to ensuring that adequate resources are channeled into programs that address priority issues for adolescent girls.
 
Beyond advocacy and political commitments, the complex, multiple, and interacting factors that influence adolescent girls’ well-being mean that key actors must work together to develop integrated programs. These actors must be well informed about the broader determinants of adolescent girls’ well-being. The need for integrated approaches to improve adolescent girls’ well-being also demands investments in complex, often long-term, multi-sectoral programs that require substantial funding and adequate time for design and implementation. Too often, short funding cycles and limited funding both for research and program implementation serve as significant impediments to the development of holistic programs. The result is a plethora of narrowly-defined programs focusing on one or two outcomes that have very limited prospects for scale up and long term sustainability. Although these single-pronged, short-term interventions have their place in advancing knowledge, governments, development partners and donors must be willing to invest in long-term, multi-sectoral programs. Sustainability, potential for scale up, and active involvement of the key beneficiaries – adolescent girls – must also take centre stage in program design and implementation.

On a positive note, there is growing support for multi-pronged interventions targeting adolescent girls, such as the Department for International Development (DfID)-funded Adolescent Girls Initiative-Kenya (http://www.popcouncil.org/research/adolescent-girls-initiative-action-research-program). This randomized, controlled trial, which targets vulnerable adolescent girls, will test the cost-effectiveness of various combinations of initiatives in multiple sectors – health, violence prevention, wealth creation, and education.

In the long run, sustained investments in holistic programs that address the multiple determinants of adolescent girls’ – and boys – well-being will go a long way in helping countries attain their development goals by ensuring that adolescents are sufficiently supported to achieve their full potential. Research will also play a critical role in furthering knowledge on what works in adolescent-centered programming; countries must therefore invest in building local research capacity to support the generation of scientific evidence to inform policies and programs that effectively meet adolescents’ needs.


Acknowledgements

Writing time was partially supported through grants from UKaid from the Department for International Development (DfID) for the Strengthening Evidence for Programming on Unintended Pregnancy (STEP UP) Research Programme Consortium (Subaward Number SR1109D-6) and for the Adolescent Girls Initiative-Kenya (Subaward Number SP1404); and general support grants to APHRC from the Swedish International Development Cooperation Agency (Grant Number 2011-001578) and the William and Flora Hewlett Foundation (Grant Number 2012–7612).

Endnotes

[1]Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. The Lancet 2012;379(9826):1641-1652.
[2]Ibid.
[3]Ndugwa R, Kabiru C, Cleland J, Beguy D, Egondi T, Zulu E, et al. Adolescent Problem Behavior in Nairobi's Informal Settlements: Applying Problem Behavior Theory in Sub-Saharan Africa. Journal of Urban Health 2011;88(Supplement 2):298-317.
[4]Kabiru CW, Mojola SA, Beguy D, Okigbo C. Growing up at the ‘margins’: Concerns, aspirations, and expectations of young people living in Nairobi’s slums. Journal of Research on Adolescence 2013;23(1):81–94.
[5]Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. The Lancet 2012;379(9826):1641-1652.
[6]Okpala A, Okpala C. The effects of public school expenditure and parental education on youth literacy in sub-Saharan Africa. Journal of Third World Studies 2006;23(2):203-212.
[7]PRB 2005 Women of Our World. PRB The World's Women and Girls 2011 Data Sheet (http://www.prb.org/DataFinder)
[8]Erulkar A. Adolescence Lost: The Realities of Child Marriage. The Journal of Adolescent Health 2013;52(5):513-514.
[9]Brock C, Cammish N. Factors Affecting Female Participation in Education in Seven Developing Countries. Education Research Paper. 1997.
[10] Dodoo FN, Zulu EM, Ezeh AC. Urban-rural differences in the socioeconomic deprivation-sexual behavior link in Kenya. Social Science & Medicine 2007;64:1019-1031. 
[11]Kamndaya M, Vearey J, Thomas L, Kabiru CW, Kazembe LN. The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi. Global Public Health 2015:1-14.
[12]Gyimah SO. Cohort differences in women's educational attainment and the transition to first marriage in Ghana. Population Research and Policy Review 2009;28(4):455-471.
[13]Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG : An international journal of obstetrics and gynaecology 2014;121 Suppl 1:40-8.
[14]UNAIDS, The Gap Report 2014. Accessed March 26, 2015 from http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf
[15]Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. The Lancet 2006;368(9550):1908-19.
[16]Decker MR, Latimore AD, Yasutake S, Haviland M, Ahmed S, Blum RW, et al. Gender-Based Violence Against Adolescent and Young Adult Women in Low- and Middle-Income Countries. Journal of Adolescent Health 2015;56(2):188-196.
[17] Joint United Nations Programme on HIV/AIDS (UNAIDS). Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: UNAIDS; 2013.