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Cultivating Connectedness and Equity: A Call to Action for the Global Adolescent Health Community

      The Society for Adolescent Health and Medicine (SAHM) is the most influential and largest organization of multidisciplinary, professional adolescent and young adult providers in the world. Each of us has our own inherent value, unique skills, and undeniable talents to improve the physical and psychological health and well-being of all adolescents and young adults; to share and learn from each other methods of improved clinical care, health promotion, education, and research; to advocate for all adolescents and young adults; and to support, connect, collaborate, and cultivate our relationships and friendships, and care for each other. We are also here to reaffirm our commitment to stand against discrimination, intolerance, violence, and hatred directed at any group regardless of their race, ethnicity, culture, sexual orientation, nationality, age, religion, gender, or gender identity both in the United States and around the world [
      Adolescent Health
      SAHM Issues Statement on Orlando Tragedy.
      ]. It is through this commitment, our mission, and advocacy, we can improve the psychosocial and physical health and well-being of all adolescents and young adults. To our members who are not able to be with us at the annual conference this year, we miss you, we support you, and we remain connected to you.
      The theme of this year's conference is “Cultivating connections: the importance of relationships in adolescent and young adult health.” We are privileged that one of the pioneer experts on connectedness is SAHM's immediate past president, Dr. Michael Resnick. Connectedness refers to a sense of interpersonal closeness with the broader social world or with other individuals and is characterized by feelings such as caring, belonging, trust, value, and respect [
      • Resnick M.D.
      Protective factors, resiliency and healthy youth development.
      ]. This definition encompasses the nature and quality of connections both within and between multiple layers of the social ecology and includes an adolescent and young adult's relationships to family members, friends, school, community, institutions, and society. Dr. Resnick also states that connectedness includes close connections to moral and spiritual meaning [
      • Bernat D.H.
      • Resnick M.D.
      Connectedness in the lives of adolescents.
      ].
      Why do adolescents and young adults need connectedness to other individuals, families, community, and society? It is through these connections and relationships, our adolescents and young adults discover, develop, and define their social, cultural, and moral identities. Thus, it is a critical time for communicating messages of altruism, inclusion, acceptance, and optimism. Connections, including spiritual connections, are also important because they are key determinants of their health and well-being and can be protective against an array of health risk behaviors [
      • Resnick M.D.
      Protective factors, resiliency and healthy youth development.
      ,
      • Bernat D.H.
      • Resnick M.D.
      Connectedness in the lives of adolescents.
      ]. Supportive connections are associated with better physical and mental health outcomes resulting in improved overall health and resistance to stress and disease. Connectedness of individuals and their families to community and society can also increase a person's sense of belonging or “mattering” to a group [
      • Bernat D.
      • Resnick M.D.
      Healthy youth development: Science and practice.
      ]. Unsupportive connections or social environments may encourage maladaptive coping behaviors, stress, and disease [
      • Resnick M.D.
      Protective factors, resiliency and healthy youth development.
      ,
      • Bernat D.H.
      • Resnick M.D.
      Connectedness in the lives of adolescents.
      ,
      • Whitlock J.
      • Wyman P.A.
      • Moore S.R.
      Connectedness and suicide prevention in adolescents: Pathways and implications.
      ]. While peer-peer connections are of great importance in adolescence, parent-adolescent and family connectedness still have a prominent impact on adolescents [
      • Bernat D.
      • Resnick M.D.
      Healthy youth development: Science and practice.
      ]. Although adolescence can be a time of independence, many adolescents still want close relationships with their parents and other caring adults, like their health care providers, and rely on them for support and guidance.
      The importance of family connectedness is demonstrated at an exhibit at the Red Cross Museum in Geneva, Switzerland, called Restoring Family Links. It states that human beings are social beings who are defined by their links with each other. When those links are broken, they lose part of their identity and bearings. Giving and receiving news and finding one's loved ones again are elements of stability that are even more essential during crisis situations. We see loss of connections through the crises of mass incarceration and immigration policies. Both of these issues have been expressed concerns of SAHM members.
      Mass incarceration is increasing in the United States. The United States is home to 5% of the world's population, but 25% of the world's prisoners [
      • Guerino P.
      • Harrison P.M.
      • Sabol W.J.
      Prisoners in 2010 (Revised).
      ]. Inmates are also disproportionally people of color [
      • Guerino P.
      • Harrison P.M.
      • Sabol W.J.
      Prisoners in 2010 (Revised).
      ]. In 2016, SAHM published a position statement on youth justice systems, recommending a paradigm shift toward resources that address the antecedents of high-risk criminal behaviors [
      International Youth Justice Systems
      Promoting youth development and alternative approaches: A position paper of the Society for Adolescent Health and Medicine.
      ]. SAHM also recommended that funds be diverted away from the construction of privatized, for-profit prison complexes to address the antecedents of imprisonment. Incarceration and detention have also become prominent features of some immigration policies.
      Threats to connectedness through immigration policies are exemplified in a Photovoice project that was conducted with Latino adolescents [

      Lightfoot AL, Thatcher K, Simán FM, et al. “What I wish my doctor knew about my life”: Using photovoice with immigrant Latino adolescents to explore barrier to healthcare. Qualitative Social Work. doi: 10.1177/1473325017704034.

      ]. We asked them to take photos of “What I wish my doctor knew about my life.” At a community forum, our Latino adolescents asked community participants what feelings were evoked when they saw their photo. When a photo of a police car was shown, some forum participants said it made them feel “safe.” Some African-American participants did not feel safe and actually stated that they feared for their safety. Some Latino adolescents shared that they also did not feel safe, but that they were also fearful that they would come home from school one day and find that their mother or father had been deported. The concerns of safety, fear, justice, and discrimination transcend socioeconomic status and education such that, as an African-American woman and physician, I am also concerned about the safety of my young adult son and adolescent daughter. There are thousands of adolescents and young adults like mine who, despite their talents, strengths, and contributions, are vulnerable every day because they are judged by the color of their skin and not by the content of their character. We should continue to support and cultivate healthy connectedness at all levels of the social ecology and encourage communities and societies to care about and care for all their citizens.
      Connectedness has become a dynamic process, and a new dimension has emerged. Connectedness is now also defined as the degree to which people are connected by technology such as the Internet, email, and social media [
      • von Dijck J.
      The culture of connectivity; a critical history of social media.
      ]. In this sense, our connectedness and communities have become global. As technological advances continue to become an integral aspect of our adolescents' culture, education, and social life, we see an overwhelming amount of new opportunities for teens to connect, communicate, and interact with each other. While we have new opportunities to promote local, national, and global connectedness through social medial and the Internet, it is also necessary to explore the benefits and potential pitfalls of social media in relation to connectedness [
      • Allen K.A.
      • Ryan T.
      • Gray D.L.
      • et al.
      Social media use and social connectedness in adolescents: The positives and the potential pitfalls.
      ]. Through vivid, real-time technology, and digital and social media, our adolescents and young adults are increasingly shaped by our local, national, and global connectedness. Thus, it is important that we are concerned not only about what is happening on our side of the world but also connected to what is happening globally.
      SAHM's greater involvement in global adolescent issues does not mean that we will abandon the unique domestic challenges and opportunities that are within any of our respective countries or local communities. We want to support SAHM members to work locally regardless of the country they are in and to support and strengthen efforts to improve global adolescent health. Our goal is to collaborate and learn ways to improve the health and well-being of all young people.
      There are many similarities among us regardless of our country of origin. No matter where we reside, we are all part of the global society, and global health refers to all of us. Our adolescents and young adults share the same developmental characteristics and similar concerns. Young people, whether they are born and reside in Asia, Africa, North America, South America, Antarctica, Europe, or Australia, all start out as children and must navigate and transition through puberty into adolescence and young adulthood, often encountering challenging conditions. Adolescents and young adults are impacted by their connectedness to others, institutions, and society. All adolescents want to be loved, respected, and cared for and have their basic needs of food, clothing, shelter, and safety met. Adolescents and young adults worldwide have been one of the most neglected generations. However, this is changing across the globe. This has to change! We now have for the first time, the largest generation of adolescents and young adults in human history, and they demand more attention and action. Some of the organizations leading this increased global attention and action are the United Nations (UN), the World Health Organization, and the Lancet Commission. According to the Lancet Commission, we now have 1.8 billion individuals between the ages of 10–24 years, who now represent 25% of the world's population [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ].
      The Lancet Commission states that we must transform our views of adolescents and young adults to a resiliency and positive youth development framework and think of them not as a big problem, but a huge opportunity. This generation of adolescents and young adults can transform all our futures; there is no more pressing task in global health than ensuring they have the resources to do so [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ].
      Major challenges for adolescents and young adults worldwide within their own contexts include youth unemployment, armed conflict, promotion of unhealthy life styles and obesity, less stable families, environmental degradation, and mass migration [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Armed conflict can lead to mass migration and refugee crises. Refugees are defined by the UN as persons who have been forced to flee their country because of persecution, war, or violence. They have a well-founded fear of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group [
      USA for UNHCR
      The UN Refugee Agency.
      ]. They are recognized under the UN statutes as deserving of protection. We are all vulnerable to needing aid from one of our neighbors or allies in the world. Adolescent and young adult refugees are particularly vulnerable to lost connections and abuse such as human trafficking. To assist, we must cultivate connections and build bridges with our neighbors, not walls. We must tear down the walls that separate us. Who are our neighbors? Our neighbors are the people placed in our path who we have the opportunity to touch and help.
      An opportunity lies in addressing the different health challenges faced by adolescents across the world. The Lancet Commission classifies three main burdens for adolescents clustered by regions [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Most of the global adolescent population (51%) comes from multiburden countries, such as India and countries in Africa, that are fraught with infectious and vaccine preventable diseases, undernutrition, and sexual and reproductive health needs. The Lancet Commission refers to these conditions as diseases of poverty [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Thirty-seven percent of the global adolescent population comes from countries such as Australia and those in North America that are burdened with noncommunicable diseases categorized as physical disorders, mental health disorders, and substance use disorders. Twelve percent of the global adolescent population comes from the injury-excess countries within Central and South America and parts of Europe, where violence, including armed conflict, self-harm and suicide, and unintentional injury including traffic accidents predominate as the leading causes of morbidity and mortality [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ].
      The leading causes of mortality worldwide for adolescents and young adults aged 10–24 years are also described in the Global Burden of Disease Study [
      • Kassebaum N.J.
      • Bertozzi-Villa A.
      • Coggeshall M.S.
      • et al.
      Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis of the global burden of disease study 2013.
      ]. Overall, among males and females aged 15–24 years, the top two leading causes of death globally are road injuries and self-harm/suicide, respectively; among 10- to 14-year-olds, they are HIV/AIDS and road injuries [
      • Kassebaum N.J.
      • Bertozzi-Villa A.
      • Coggeshall M.S.
      • et al.
      Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis of the global burden of disease study 2013.
      ]. Other leading causes of death include interpersonal violence, drowning, intestinal infectious diseases, tuberculosis, and lower respiratory infections. There are some differences by gender. Among females aged 15–24 years worldwide, the leading cause of death is self-harm or suicide; for 10- to 14-year-old females, the leading cause of death is HIV/AIDS. Globally, among males aged 10–24 years, the leading cause of death is road injuries [
      • Kassebaum N.J.
      • Bertozzi-Villa A.
      • Coggeshall M.S.
      • et al.
      Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis of the global burden of disease study 2013.
      ]. U.S. data depict a similar epidemiology for U.S. mortality among 10- to 24-year-olds as the Global Burden Disease Study; motor vehicle crashes and suicides are the leading causes of death [
      CDC's Web-based Injury Statistics Query and Reporting System (WISQARS™).
      ]. The similarities in morbidity and mortality worldwide can lead to the development of common strategies.
      The Lancet Commission recommends five strategies that can be implemented to create opportunity and improve the health and well-being of adolescents and young adults globally. These strategies include (1) providing universal comprehensive health care that includes mental health; (2) providing access to free, quality secondary education for males and females; (3) protecting the rights of adolescents; (4) promoting healthy environments, including clean water; and (5) establishing national youth commissions so that adolescents and young adults can be empowered to meaningfully engage in the development of programs for their benefit and the benefit of their communities [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ].
      We must create opportunities for all youth to be engaged not just the routinely recognized leaders, those with advantage or privilege, but also those who may not be traditionally involved in these efforts. Youth of color, indigenous youth, LGBTQ youth, youth with disabilities, poor and homeless youth, and youth in juvenile detention or refugee camps often have the greatest health needs and must be engaged. Reflective of society, within any country, there are marked differences in health and inclusion between different regions and within different adolescent groups with poverty, gender, and social marginalization being important determinants. The need to create equity and eliminate macroaggression and microaggression for adolescents and their providers is the subject of an upcoming SAHM position paper led by the Diversity Committee. To create equity in health and well-being is not just about doing the same thing for every adolescent but giving everyone what they need to have access to the same opportunity. Equity is about fairness. Sometimes our differences and our history can create barriers to participation, so we must first ensure equity before we can enjoy equality [
      • Levitan J.
      The difference between educational equality, equity and justice and why it matters.
      ].
      Improving equity and the health and well-being of adolescents and young adults is crucial because of the triple dividends it provides. First, it helps adolescents directly, and second, it allows them to develop the positive skills and health habits they need to transition into and through healthy adulthood. Third, since the health, well-being, and social environment of adolescents and young adults also affect the children they will produce, investment in them augments the health of their children and future generations [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ].
      Increased investment and attention in adolescents and young adults is also demonstrated in the Global Strategy for Women's, Children's and Adolescents' Health developed by the UN [
      United Nations Secretary-General
      The global strategy for women's, children’s and adolescents' health (2016–2030): Survive thrive transform.
      ]. The three overarching themes of this strategy are survive, thrive, and transform. SAHM has an important role to play in the UN Global Strategy to ensure that our adolescents and young adults around the world not only survive by ending preventable deaths but also thrive by ensuring optimal health and well-being. We can partner to transform the world by expanding enabling environments, so that by 2030, we may live in a world where every adolescent in every setting realizes their rights to physical and mental health and well-being and has equitable social and economic opportunities [
      United Nations Secretary-General
      The global strategy for women's, children’s and adolescents' health (2016–2030): Survive thrive transform.
      ].
      Our investment in adolescents and young adults is critical because our adolescents and young adults are potentially the most powerful change agents for improving their own health, improving equity and social justice, and achieving prosperous and sustainable societies [
      United Nations Secretary-General
      The global strategy for women's, children’s and adolescents' health (2016–2030): Survive thrive transform.
      ]. Our adolescents and young adults have grown up with more diversity and cross-cultural global connections than prior generations and they will be more diverse than ever by 2030 [
      • Peterson S.J.
      American demography 2030: Bursting with diversity, yet a baby bust.
      ]. Many adolescents and young adults have cultivated global connections and communities through social media. Adolescents and young adults are curious, engaged, and innovative. They challenge the status quo, accelerate progress, and advance human potential. We have a unique opportunity to focus on this previously neglected age group in a way that is beneficial for adolescents, for society, and perhaps even for the health of our planet [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Our adolescents and young adults give us great reasons to be optimistic, to have audacious hope, and to have bold faith!
      So you may be asking yourself, what are some of the things that SAHM can do, and what are some of the things that I intend to do during my presidency to provide adolescents and young adults with the opportunities they need and improve their health and well-being? We can cultivate, advocate, and strategize.

      Cultivate

      Consistent with our conference theme, we will continue to cultivate our connections and partnerships with local, national, and international organizations and individuals dedicated to adolescent health. Internationally, we are particularly interested in strengthening our connections with the International Association of Adolescent Health, the UN, the Lancet Commission, and the World Health Organization. With leadership from the SAHM Executive Board and the International Chapter, SAHM reviewed and provided comments and content for the World Health Organization's, Global Accelerated Action for the Health of Adolescents Implementation Guidance document also known as the AA-HA! framework. We will also strengthen our connections and cultivate new connections with collaborators concerned with global adolescent health. The SAHM international travel award is another important initiative to cultivate our connections and relationships with scholars and practitioners from middle- and low-income countries. I would also like to cultivate connections with the Confederación de Adolescencia y Juventud de Iberoamérica, Italia y el Caribe.
      We will also expand our cultivation of connections through the use of social media including rapid responses to appropriate issues of concern for our membership. For example, SAHM is using social media, especially Twitter, and the Internet at this meeting to enhance and cultivate our connections and inform our membership. We will also disseminate educational resources such as an outstanding adolescent curriculum developed by the education committee and the Board of Directors and expand online training and discussion groups to adolescent health providers in high-, middle- and low-income countries. We will also work to promote the use of language and terms that are affirming to populations and inclusive and sensitive to other countries.

      Advocate

      As SAHM leaders, we have appreciated and responded to members' requests to advocate and respond to acts of discrimination, injustice, and violence. We will continue to do this through our journal under the exceptional leadership of Dr. Charles Irwin, rapid responses, press releases, position statements, and sign-ons with other organizations. Our organizational capacity and the daily or weekly emergence of alarming tweets or issues will not allow us to be able to respond to everything, but we will respond strategically and in partnership with others. We will even ask you to engage with and educate your local and national legislators.
      Our advocacy press release before this meeting to legislators was about protecting transgender youth. We do not care what bathrooms young people chose to use based on their gender identity, but we do care that schools create a safe school environment that is conducive to learning. We do care that students may be discriminated against in a way that can lead to stigmatization or physical and mental harm. We will continue to advocate against discrimination of any kind against anyone because it is unfair, unjust, and unkind. We do not have to be Muslim, Jewish, black, a woman, or a member of any group that is experiencing discrimination to advocate for them.
      In the spirit of digital media and taking lessons from this year's Oscar nominated films, in our advocacy, we want to be as tenacious as “lions” to ensure our young people can overcome the challenges and “fences” that are placed around them. We need to ensure that their worth, dignity, diversity, talents, and intelligence are illuminated such that they will no longer be “hidden figures” or revealed only in the “moonlight”.

      Strategize

      We are undergoing a formal strategic process this year to assess and prioritize the needs of our members and our organizational goals. We will also strengthen our organization to fulfill our mission and vision. The board hired an outside facilitator through a request for proposal process. The facilitator will interview diverse, key stakeholders of SAHM in person during this meeting and by phone. He will also review SAHM materials and conduct a membership survey. All data generated will be synthesized and analyzed at face-to-face and phone meetings of the Strategic Planning Task Force and the Board of Directors. Our members are the heart of our organization, and I desire everyone to be engaged in the process.
      There is one more thing we can do and that is to inspire.

      Inspire

      We should inspire our adolescents and young adults to reach further and fly higher than they ever thought possible.Full of faith,fearlessand free.Because we will support them,and advocate for them,and care for them.They have been created with all the toolsand talents they need to changeand sustain the world.We just need youand them, toNever,Never,Never,Never give up,despite the obstacles that confront them.
      I need you to utilize your connections, your clinical care, your research, and your advocacy and work harder than you ever have before. This is not a time for complacency. We need you, and we need our adolescents and young people to improve our world. Our young people are one of our greatest resources.
      The theme of our 2018 conference will be global adolescent health equity. At this conference, we will also be celebrating the 50th anniversary of SAHM. It will be an exciting opportunity to reflect on our history and create a strong future. Let us continue to cultivate connections to grow our organization and its influence for the health and well-being of adolescents and strategize to make our organization's next 50 years even greater! I value what each professional contributes to our overall mission, and celebrate all the activities of our members—clinical practice, teaching, research, and advocacy—because collectively this enables SAHM to have the best chance of truly transforming the lives of adolescents and young adults.

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        SAHM Issues Statement on Orlando Tragedy.
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