behaviour,adolescence offers a major opportunity to intervene at stages when lifelong behaviour patterns are being established. Another important age-related issue is to ensure that male and female adolescents are comfortable with discussions.This may involve a comfortable,informal environment and an older peer-trained leader to lead the discussions,be a role model and gain the adolescents confidence(51).Many studies have found pairing older adolescents to work with younger ones enhances the intervention.It may be neces- sary,particularly with regard to early adolescence,to separate boys from girls for discussion on sexuality.The two groups can be ad- dressed separately or together based on local culture,and the feelings of parents on the matter. Although generally the approaches should be adapted to different cultures,certain approaches are universal.Young people in early adolescence respond well to active methods that involve games,the arts,and minimal discussion.With cognitive development comes the appreciation of small group discussions and debates.The adolescents' opinion on content and method is an important contribution to the development and adaptation of the interventions. The role of parents in planning interventions concerns age,and it is essential to optimize their contribution to the various stages of adoles- cent development.Cultural expectations of the parents'role in the activities of their adolescent children need to assessed,and for some activities,parental permission may be required by law up to a certain age Adolescent disability Because one in every 10 children is chronically ill or disabled,dis- abled adolescents represent a group whose particular needs must also be considered in planning intervention strategies.Despite the myriad disabilities and chronic illnesses,interventions which are sensitive to adolescents'obvious needs are both necessary and feasible.Interven- tions should be functional and not restrictive.In the United States.for example,eligibility for certain services is based on functional limita- tions,not disease category (52). Adolescence is a time in which various developmental tasks must be completed.The consolidation of identity,reduced dependence on parents,establishment of intimate relationships outside the immedi- ate family,and selection of a vocation are major tasks of adolescence (53).These tasks may take longer to accomplish in young people who are chronically ill or disabled because of deprivations suffered earlier (53-56).Programmes for adolescents can enhance the 0
development process in a variety of ways.Factors that influence the growth and development of young people with disabilities or chronic illness include (52): -family support that is not overprotective; -a network of friends with and without disabilities: -having at least one friend of the same age and one adult to talk to; -domestic and/or community responsibilities; having successfully completed a task; the belief that despite the physical limitation they can accomplish their goals. Concering education about sexuality for physically and mentally disabled adolescents,the information must be appropriate and take into consideration physical limitations.There is also need to explain how one's milieu helps to determine what is appropriate behaviour, especially for those with intellectual limitations,and that the expres- sion of sexuality can go beyond penetrative sex.Emphasis should also be placed on building social skills with the same and opposite sexes (57). Homelessness In 1990,WHO estimated that 30 million children lived or worked on the street (58).According to a report (59)from WHO's Programme on Substance Abuse these young people may be defined by one or more of the following experiences: -living on the streets and concerning themselves primarily with survival and shelter; being detached from families and living in temporary shelters or moving about between friends; remaining in contact with family,but because of poverty,over- crowding,sexual abuse or physical abuse within the family,spend- ing most days or some nights on the streets; living in an institution or in institutional care,but at risk of return- ing to their previous street existence. Continuous exposure to the streets and street life leaves adolescents vulnerable to more difficulties than those typically experienced by other young people.These adolescents must cope with the physical conditions of street life (lack of food,shelter,and sanitation)and the factors responsible for their homeless existence,such as poverty family breakdown,abuse,or armed conflict.Surviving street life and coping with stress may lead to drug use and dealing,commercial sex work,criminal behaviour,violence,and exploitation by adults
An additional consideration in intervening to assist such young people is their lack of access to (and mistrust of)services and re- sources.Adolescents living and working on the street are not a high priority in most countries and are often exploited and viewed as criminals rather than as young people in need of assistance.They may believe that services are merely a ploy by the police or welfare agen- cies to capture them.Such beliefs foster general mistrust among homeless young people of services.This mistrust of potential re- sources is compounded by the inaccessibility of services.Underage adolescents may be denied primary health care in the absence of a parent or guardian to provide the necessary documentation.Some nongovernmental organizations(NGOs)address this problem by as- signing young people an adult to help them fulfil the necessary for- malities to obtain services. Conflict situations In the past decade,an estimated two million children and young people have been killed in armed conflict and three times as many seriously injured or permanently disabled (60).These conservative estimates give no idea of the large number of children whose deaths are concealed or unrecorded.Moreover,many impacts of war and conflict on children and young people are immeasurable.There is no way to measure the emotional and psychological toll on a young person who lives for years with the constant fear of bombings,muti- lation,or death.Between 117 and 138 million young people may be indirectly affected by armed conflict by the year 2000.The most affected areas will be South-East Asia,where 50 million children and young people could be at risk,followed by Africa where 20-30 million young people may be vulnerable. According to global estimates,the proportion of war casualties who are civilians has surged from 5%to over 90%in recent decades. Likewise,a very large number of children and adolescents are victims of human rights violations. Many of today's conflicts last through an individual's childhood,ado lescence and early adulthood.War and conflict disrupt the social networks and primary relationships that support a young person's physical,emotional,moral,cognitive,and social development and consequently have far-reaching physical and psychological implica- tions.The effects of armed conflict on youth development are cumu- lative and correlated.The well-being of young people is best ensured through family and community-based efforts to address armed con- flict and its aftermath.Such efforts are most effective when they are 33
based upon local cultures and on an understanding of adolescent development.Young people should be seen as survivors and active participants in creating solutions,not just as victims or problems (61). While thousands of children and young people die every year as a direct result of fighting,many more die from malnutrition and disease associated with armed conflict.The interruption of food and clean water supplies,destruction of food crops and agricultural infrastruc- ture,disintegration of families and communities,displacement of population,destruction of health services,sanitation systems and public health programmes all take a heavy toll on young people. Many of today's armed conflicts take place in the world's poorest countries where there is greater incidence of malnutrition and dis- ease,and the onset of armed conflict can increase the death rate by up to 24 times (61) Population movements,sexual violence and the breakdown of estab- lished social values dramatically increase the spread of STDs,includ- ing HIV.Reduced access to reproductive health services increases the vulnerability of adolescents in particular.Transmission is also in- creased by the breakdown of health services and by blood transfusion services unequipped to screen for HIV. Landmines and other explosives (bombs,shells,and grenades)pose a tremendous threat to children and young people.Young people in at least 68 countries are exposed to over 110 million landmines that can maim or kill (61).Even without injuring,the presence of landmines causes psychological and emotional distress.If a family member is disabled,the family economy may crumble.Three times more young people are seriously injured or maimed by armed conflict than are killed by it(61).The lack of basic services and the destruction of health facilities mean that disabled children and adolescents get little support.Only 3%of these victims in developing countries receive adequate rehabilitative care (61). The destruction of educational infrastructure is one of the greatest development setbacks for adolescents and their communities.Years of lost basic education and vocational skills take an equivalent length of time to replace,and the loss further strains society's ability to recover from wars.The conflict in Mozambique led to the destruction of approximately 45%of the primary school networks(61).During the crisis in Rwanda,more than two-thirds of the teachers either fled or were killed.Education is particularly important during times of armed conflict.It provides a sense of stability and connection in a time of chaos.At school,adolescents have the benefit of regular contact 34
with peers and teachers who help them develop new knowledge and coping skills on such issues as conflict resolution,avoiding landmines, and health education.Appropriate educational activities for adoles- cents have helped to bolster their psychological well-being and ex- empt them from military service. Traditionally,the focus of any response to the needs of adolescent refugees primarily concerned their most obvious material needs. However,the inevitable loss,grieving and fear that adolescents also face in these situations where they may witness extreme brutality deserve serious consideration.The horror and perpetuation of armed conflict curtail crucial adolescent identity development.The feeling of being let down and even betrayed by adults distorts adolescents perspective and makes them distrustful.Of the 3030 children sur- veyed by the United Nations Children's Fund(UNICEF)in Rwanda in 1995,almost 80%had lost immediate family members,and among these,more than a third had actually witnessed the family members' murders (61).The adolescents'response to such traumatic events is governed by personal factors(age,sex,personality type,personal and family history and sociocultural background),and the frequency and length of exposure to the traumatic event. Selecting interventions In addition to the particular needs of adolescent populations as illus- trated above,selecting,adapting and combining interventions to address a wide range of issues involves several essential steps closely related to the assessment of priorities (see section 8).Therefore, these activities can be viewed as an intrinsic part of the entire pro- gramming cycle more comprehensively described in sections 7-10 Ultimately,all adolescent programming is concerned with how inter- ventions affect individual adolescents and the people who interact with them.Programming towards this aim may be accomplished at many different levels:individual,group,community and district,and national levels.An understanding of how the various interventions can work together to promote health will help inform the program- ming actions needed at the different levels. Information collected through the assessment process can be used at each level of programming to better understand the needs and concerns of young people and the capacity of the systems that serve them to respond to those needs.Although four levels of programming are recognized,the first two levels (individual and group)are most relevant to the selection,adaptation and incorporation of interven- tions that directly involve young people.The second two levels(dis- trict or community and national)involve assessment on a wider scale 35