Frequently, sexuality presents the first challenge to healthy adolescent growth. Often unplanned, and sometimes pressured, adolescent sexual relations occur before young people have adequate knowledge of contraception, sexually-transmitted diseases (STDs) or health services available to them. In developing countries, girls under 18 have a maternal mortality rate that is two to five times higher than women 18 to 25. Between 1 and 4.4 million adolescent abortions occur each year, most of which are unsafe, performed by unskilled practitioners illegally. One out of 20 adolescents contracts a curable STD, excluding viral infections -- at least 111 million cases in persons under 25 each year. STDs often go undetected or untreated among young women, who, embarrassed or stigmatized by the presence of a STD, are reluctant to seek help. Yet STD agents, such as Chlamydia and human papilloma virus, can have dire consequences at later times, such as infertility or cervical cancer. STDs may also facilitate the transmission of HIV.

Although the overall world population living with HIV/AIDS appears to be declining, evidence shows that new HIV infections among adolescents are rising. Worldwide, more than half of all new HIV infections occurs in the 15 to 24 age group. In South Africa, the rate of pregnant teens (15 to 19) with HIV doubled between 1994 and 1996. Although young people may know how AIDS is transmitted and prevented, many believe their risk of infection is minimal. In one study in Malawi, 90% of teenage boys reported having at least one sex partner in the previous year but very few used condoms. Girls appear to have a significantly higher incidence of HIV infection than boys. Statistics from Uganda show girls having six times more HIV infection than boys, even though the rate for teenage girls has dropped 50% since 1990.

Tobacco use is another serious health problem for adolescents. Swayed by images of adult smokers or through advertising, young people perceive smoking to be sophisticated or fun. One third to one half of young people who experiment with cigarettes become regular smokers, half of them within one year. Teens who smoke daily for a number of years develop a habit and addiction level as difficult to reverse as for adult smokers. Although many try repeatedly, very few adolescents actually stop smoking. Studies show that young people who do not use tobacco before the age of 20 are unlikely to start smoking as adults. Studies around the world show that the majority of adult smokers begin tobacco use in their teenage years, sometimes earlier, and that smoking is addictive and dangerous to their health. Therefore, preventing tobacco use in the first place among teens avoids many lifelong and life-threatening health problems.

The INCLEN Role

As a multi-disciplinary network of scientists in 56 medical schools around the world (mostly in the developing world), INCLEN is particularly positioned to consider social issues of clinical importance, to compare such matters across cultural boundaries and to link descriptive studies to interventions. Many INCLEN researchers around the world are involved in projects that address the health problems of adolescents and the unique methodologies necessary to influence adolescents to minimize their risk behaviors.

• In Lucknow, India, INCLEN investigator Dr. Shally Awasthi has studied sexual behavior patterns of adolescent boys in urban slums, finding 10% of boys between 15 and 21 were sexually active, many of whom engaged in sex with commercial sex workers or men. In addition, 5-9% tested positive in urine dipstick tests for leukocyte esterase activity, possibly indicating the presence of urethritis, which can be sexually transmitted. Having poor risk perception and little knowledge of sexually transmitted diseases, the boys rarely used condoms. Dr. Awasthi and her team developed an instrument for reproductive health counseling in the hopes of educating sexually active adolescent boys about sexually transmitted diseases and reducing their risk behavior.

• In Bangkok, Thailand, Dr. Chitr Sitthi-amorn leads a multidisciplinary team of practitioners from medical, educational, public health, policy planning and governmental institutions in developing an adolescent health program. After examining the existing youth services, reasons for nonuse of those services, and unmet adolescent needs, the team will design and institute a pilot adolescent program, integrating hospital-based adolescent health services with community-based youth programs. In monitoring progress, the program will involve youth in identifying indicators of success as well as the ongoing monitoring and evaluation processes.

• In Santiago, Chile, Drs. Jorge Tolosa. Rodrigo Villegas, Cristina Di Silvestere and David Streiner examine risk factors and the decision-making processes of pregnant adolescents receiving late-term prenatal care regarding future use or rejection of modern contraceptives. The fertility among young Chilean women 15 to 19 years old has steadily increased (while the total fertility rate declined between 1960 and 1980), especially for unmarried women. Babies from unwanted pregnancies have higher infant mortality and greater risks to development for those who survive. Although adolescent birth control is offered by the government at no cost, it is underused. This project will study the variables affecting family planning use by young people to design a program that will speak to the cultural, psychosocial needs of this high-risk group.

• In the Philippines and Thailand, Drs. Jorge Tolosa, Mario Festin and Manop Kanato lead a pilot project to analyze youth sexual behaviors, their perceptions of risk for sexually transmitted diseases and their misconceptions and knowledge of effective preventive measures. Thai government data from 1992 states that 47% of STD patients are under 15 years of age. In 1997 half of all Thai HIV cases were from the same age group. This project is studying youth behaviors and knowledge about sexual health issues, designing a school-based intervention program, and testing the effectiveness of intervention methods such as flyers, talks, bulletin boards, posters, role-play, peer discussion, videos and peer counselors.

• In Kenya, Thailand and Uganda, Drs. Dennis G. Willms, Manop Kanato and Nelson K. Sewankambo are implementing a test model of adolescent sexual and reproductive health interventions based on evidence gathered at the three sites. Adolescents at an experimental site will participate in designing, implementing and evaluating intervention programs in order to develop a generic intervention model compelling to young people from a range of cultures. The objective is to enable adolescents to safely navigate themselves through risk situations, making healthier choices.

Other projects include:

• “Tobacco Smoking Among High School Students in Ismailia, Egypt.” A team of researchers at Suez Canal University led by Dr. Fatma Hassan surveyed a cross-section of students at 27 high schools. They found that a significant number of male students persisted in smoking although they knew the harmful effects of smoking. Smoking habits of teachers, peers and fathers contributed to development of their tobacco use.

• “Menarche and Sexuality in Female School Adolescents in Yaounde, Cameroon.” Dr. Francisca Monebenimp and colleagues interviewed 768 schoolgirls ages 9 to 15, finding 13% had already had sexual intercourse. Although 77% knew condoms could protect against STDs and AIDS, 94-95.3% had no idea how STDs and AIDS are transmitted. The girls cited the media as the major source of their information on sexuality.