For some years now I have become increasingly convinced of the need to reassess the basis of adolescent health promotion particularly as it emanates from international agencies and organizations. In this document I have reviewed what I believe to be prevailing implicit assumptions, the harmful consequences of those assumptions for both ‘developing’ and ‘developed’ countries, why this is happening, and what we might do to improve the situation.
I believe we are right to recognize that adolescent health is heavily dependent on behavior and that behavior is heavily dependent on the stage of human development which the young person has reached. But we are wrong to base health promotion in all societies on a Western framework for human development which implicitly values intellectual and economic achievement at the expense of other human qualities. As a result of this we also err in implicitly assuming that societies which are economically successful and which emphasize the value of academic and scientific achievement, are necessarily culturally superior and therefore better able to promote both adolescent health and adolescent development.
The effect of these assumptions leads to two distinct negative consequences. First, by placing emphasis on certain kinds of achievements we unconsciously denigrate the cultures in societies that place emphasis on others. This risks diminishing the respect young people have for the primary source of their cultural heritage—their families. This, in turn, can drive a wedge between younger and older people and result in a loss of self-esteem in both groups—the older because they are made to feel inadequate, and the younger because they feel they are inherently disadvantaged.
Next, by ignoring or implicitly devaluing other aspects of human development that are inherently valuable to the individual and society, we diminish their chances of flourishing. This can be damaging not only to the cultures that traditionally value them, but to those societies, particularly in the West, which are badly in need of them.
What constitutes human development?
Each human being has enormous potential, most of which is probably only ever partially realized. The capacity to use all one’s faculties depends on many things including having one’s basic physical needs met, but also feeling loved and valued, and having the opportunity to express oneself in many different ways.
Human development has many facets including physical, intellectual, economic, artistic, spiritual, emotional, social, moral dimensions as well as the development of humor.
The rapid, if uneven, changes that take place in adolescence provide windows of opportunity for the expression and development of different individual attributes. But cultures differ with respect to what they may value most, and what they expect from their adolescent children of each sex. The degree of support and opportunity available to each culture within a society will also make a difference, and it is here, particularly that minority cultures often try to make the most of the opportunities most accessible to them. The same will be true of the majority of people living in each society in that opportunities differ from country to country and that will affect the flowering of human potential.
When emphasis is placed on family relations and older traditions, emotional, social, and spiritual development may take precedence over physical and intellectual development with less emphasis on educational and economic expectations. The converse will also be true (see Table 1
Table 1Common Cultural Conflicts
How can promoting adolescent health and development cause cultural conflict?
Adolescence differs from infancy and early childhood in that health problems are determined more by voluntary actions and less by passively acquired infection. Adolescents have greater autonomy to make decisions and act in ways that profoundly affect their health. Eating, exercise, rest, learning, recreational activities, smoking, drinking, the use of other drugs, and sexual relations are just some of the areas in which young people make choices. But as adolescent health is heavily dependent on behavior, conflict can be generated by programmed intervention for health. This can happen, for example, when cultural values are seen to be threatened by encouraging independent decision making and behavioral choices in the young. Below are some examples of how adolescent health promotion may conflict with indigenous values in some societies, especially when they are inadequately justified (see Table 2
Table 2Conflicts Between Health Promotion and Cultural Values
‘Sex education’ is often assumed by the public to be primarily about teaching young people how to have sexual relations, and perhaps how to avoid pregnancy when they do. It is commonly believed that sex education encourages young people to have sex before marriage. On these grounds alone it is often seen as immoral and dangerous. There is, of course, evidence, to show that sexual education especially combined with counseling, is not harmful, but will prevent unwanted pregnancy and sexually transmitted diseases (STD), will not result in earlier sexual relations, and may even delay their onset. However, these arguments are usually countered by the fact that such research has been done in other cultures, usually meaning Western societies, which is largely true; and the image of Western societies in developing countries is one of sexual license and promiscuity. But there is also underlying resistance to the manner in which sexual education is offered, especially the emphasis placed on individual decision-making by strengthening the knowledge and skills of adolescents to make sound decisions by themselves about whether or when to have sexual relations.
The family is excluded. Such education does not typically deal with how to discuss such matters within the family or how to get advice from adults. On the contrary the emphasis on skills is on autonomous decision making and on the right of young people to decide for themselves.
When youth-friendly health services are promoted, perhaps the single most important characteristics identified is confidentiality, especially withholding information from the adolescent’s family. There is no question that young people who are frightened of the reaction of their families are more likely to use a service which has a reputation for confidentiality, but this is a notion that runs against the grain of adults (and some young people) who believe that it is the family that should influence the decisions made by its younger members in such an important matter.
A parallel source of concern and resistance arises from the concept that health workers and counselors should be non-judgmental in helping young people with difficulties. This is understood to mean that adults in professional roles should not advise young people on what is right and wrong, and from that the assumption is made that moral issues are considered irrelevant to the choices that adolescents must make. There are a number of reasons why a non-judgmental approach to the individual makes counseling more effective – the young person is much more likely to reveal his or her worries if they are not afraid of immediate censure, and without such revelations they cannot be effectively helped. The moral issues will almost certainly be raised by the young person in effective counseling anyway as this is often the major source of conflict, and it is also very likely that the values of the young person will be the same as both the family and the counselor. However, all of these matters needs to be explained and understood before a non-judgmental approach is promoted.
Although a powerful case can be made for both a non-judgmental approach and confidentiality in adolescent health services, as well as for strengthening the knowledge and skills of young people, unless attention is given to the legitimate concerns they raise, they will be seen by many people as promoting the exclusion of the family and will be resisted on moral and cultural grounds for driving a wedge between young people and their families.
Another key area of concern and resistance is the issue of education for girls and decisions about when and whom they should marry. The promotion of equal education for girls and boys by international agencies is based, among other things, on the Convention on the Rights of the Child and the Convention for the Elimination of all Forms of Discrimination Against Women which are legally binding in virtually all countries of the world. Despite such law there is considerable anxiety and resistance to education of girls in schools, as well as delaying marriage, on several grounds which should not be ignored. The fear is that girls who delay marriage will be more exposed to premarital sexual relations and thus more vulnerable to unwanted pregnancies, hazardous abortions, STD, HIV and AIDS and the physical, psychological, social and spiritual consequences of all these conditions. There is certainly evidence to support the fact that these problems have risen among young people in most societies in which the average age of marriage has increased.
It is also assumed, in many cultures of the world, that parents and other elders in the family are in a better position to choose potential brides and grooms for their children, than are their children acting on their own. In contemporary times this usually means offering choices to the young people and not forcing them to marry wholly against their wishes. Many young people accept the value of their family’s help in such matters. The belief runs that if left to themselves young people’s choices are more likely to lead to unhappy marriages, divorce, and children who suffer as a result. Again, there is certainly evidence to indicate that divorce and broken families are more common in societies where parents or other family elders play little or no role in choosing mates for their children.
This is not to say that adolescent girls should not be fully educated, not to argue that they (or adolescent boys) should have no say in choosing their marital partners, but it certainly obliges those who promote these objectives first to understand the reasons for resistance and to find solutions that are satisfactory to the majority of people who are affected by them.
What is being lost?
The apparent objectives of individual autonomy rather than inter-generational interdependence, individualism rather than a social approach to decision-making, and competition rather than cooperation, seem to predominate in Western society and it is not surprising that such values underlie the contemporary promotion of adolescent health globally. This lends itself to the reinforcement of a youth culture independent of the social contexts in which young people live. This has been hugely boosted by the spread of mass media across cultures as well as rapid and mass travel and mobility. Without arguing for or against the value of this, or even whether the tide of change can be slowed, it should be recognized that it has created great concern and distress in many societies which feel that social structures based upon respect for authority and which include highly differentiated roles for young and old, and men and women, are being seriously threatened. If this is true, and it seems very much to be the case, it is vital to recognize what is being lost, and act to preserve what is best, or minimally, recognize its value. Without such efforts whole cultures will continue to be denigrated.
Children and adolescents flourish in a society which provides a mixture of structure, where the rules are clear and become internalized, and where they are given opportunity to stretch their potential under the guidance of the older and more experience members of society. Giving young people the chance to grow is of paramount importance to the future of all societies. But both parts of the equation are essential: human development in the young can’t flourish without structure. Where multiple generations live closely together, the role of grandparents is of great importance to children. They are able to deal differently with the natural conflicts which arise between adolescent and parent, provide a cultural stability and wisdom, and gain from the pleasure and creativity of interacting with young people. In some of the more traditional societies of the world, such as the aboriginal community in north Queensland, Australia and in other indigenous societies the mutual love and respect between old and young, despite all that has happened to destroy their cultures, is a wonder to behold and a stunning reminder of how much has already been lost in more ‘modern’ societies. In some of the most economically developed countries of the world there seems to be a very real crisis of free floating anxiety and rootlessness which, I believe, is very closely related to the absence of strong inter-generational bonds. In the younger cultures of ‘developed’ countries this quality needs to regenerated, and in the older cultures of ‘developing’ countries it needs to be sustained to the fullest extent possible, before it is lost.
What can we do to preserve what is best while benefitting from change?
Programming for adolescent health
Make values explicit
Perhaps the first step in minimizing conflict when programming for adolescent health and development is to recognize the implicit values underlying the changes being promoted, especially as they affect adolescent development and family and other personal relationships. The second step is to compare these values with the prevailing cultural norms of the community(ies) in which the adolescent lives. If they appear to be in conflict, some reassessment may be needed to see if: (a) there is genuine need to foster such change, or whether some other means might achieve the same end; and (b) if it is necessary, to learn more about the nature of the conflict likely to arise, and prevent it to the extent possible through advance consultation and explanation.
Build consensus around goals
The vast majority of people, regardless of their religious or political beliefs, want their children to be healthy and to develop their natural potential. These goals will be shared by those promoting adolescent health and is the best starting point for building consensus. Educators, social workers, health professionals, religious leaders, youth workers and even the police can be united around these common goals. Each has something to contribute to it as well.
Help adolescents clarify their values
Research has shown that most young people share the deeper values of their parents. The differences typically arise over more superficial practices of dress, music and leisure activities which are natural ways for young people to be creative and stretch their wings, rather than profound beliefs of right and wrong. But this distinction is often lost and the ‘generation gap’ that exists is taken to mean that young people disagree with the basic ethical systems that their parents subscribe to. Young people may need some help in clarifying and making explicit their values but this can serve the dual purpose of helping them make choices consonant with those values, and helping reduce adult fears.
Help adults understand adolescents
Adults change very slowly in comparison to their adolescent children. This inevitably produces something of a time lag which requires the young person to demonstrate increased maturity. However, the adolescent doesn’t feel the need to justify the fact that since they are older they must also be more mature. This results in their demand of rights that go with greater maturity while their parents refuse them. Helping adults see that the underlying values of their children are their own, reduces some of the potential conflict and builds confidence. This becomes particularly important when parents feel their authority as well as their value systems threatened by what is being promoted as appropriate behavior for adolescents regardless of its source. Thus, for example, when health professionals encourage the provision of sex education in the school system, unless the parents have confidence in the values of their adolescents, as well as confidence in the appropriateness of what is being promulgated, resistance will be strong.
Attend to adolescents caught between two cultures
Many young people who live in ethnic minorities in their societies are caught between two cultures. The values of their families may be somewhat different from that of the mainstream society in which they live or work. This may be of special relevance if the adolescent comes from a culture which is more traditional and places value on respect for elders and differentiation of gender roles.
Monitor both development and health
In order to remain sensitive to cultural values and what is being promoted for young people it is essential to monitor the development of adolescents of both sexes, as well as their health. This means using, or developing, indicators of physical, psychological, social, spiritual, artistic and economic maturation and monitoring the ways in which health promotion affects each or any of these areas.
Share results across all cultures
Calling attention to the role of cultural values in the promotion of adolescent health and development, can be invaluable in making people more aware of these linkages, and the potential conflicts which may arise from them. Learning more about what different cultures value in the development of young people helps people appreciate aspects of human development which may otherwise be ignored and devalued. Successful mechanisms for reducing conflict and promoting health and development within cultural contexts can be shared and utilised across countries.
Research to reduce conflict arising from programming
Identify goals for adolescent development
Each culture may place emphasis on different aspects of adolescent development. If these are made explicit there is a greater chance of preserving what is currently valued, and perhaps adding other developmental potential to the existing ones.
Identify conflict between health promotion and cultural values
Are there conflicts between the ways in which adolescent health is being promoted and the deeper values of the society? Is emphasis being placed on adolescent decision-making and behaviors, which may unwittingly run counter to the prevailing norms by which adolescents and their families are meant to interact? Are their aspects of adolescent education that worry adults? The answers to such questions may identify conflict but will also contain the seeds of reducing it.
Compare adolescent with adult values
What are the contemporary values of young people and do they differ from adults is an important question. If the differences are relatively superficial adult fears will be reduced and confidence in young people may be increased. This is important both for their self-esteem and the increase in opportunity for development which is likely to ensue. If adults in society do not feel that their value systems are threatened by the young, they may be more willing to enable them to have the education and skills they need for exploring new behaviors in a changing world.
Identify appropriate indicators
The monitoring of adolescent development requires the use of indicators of a diversity of aspects of development including physical, psychological (emotional and cognitive), social, spiritual, economic, and artistic expression, among others. Some areas, notably physical development relatively universally, and cognitive development in the Western world, are reasonably well charted, but the others do not form a part of the usual battery of indicators when we think of adolescent development.
Develop appropriate measures of indicators
The identification of an indicator must be accompanied by the development or adaptation of measures which are sensitive enough to evaluate them in each culture. How can emotional maturity, spiritual development, or the maturation of artistic expression in an individual best be measured? How can it be done in the context of a particular culture? These are questions which need to be answered along with the choice of indicator
The values of people living in different cultures can be markedly different. This is often reflected in what is valued most among the richly diverse aspects of human potential including the physical, psychological, social, sexual, spiritual, artistic, and economic development of the individual along with the flowering of a sense of humor. Many of these qualities are given a window of opportunity during the highly dynamic period of adolescence. Providing the necessary support and chances for development to young people to fulfill their potential is the surest way to enrich society, but this is sometimes stifled by cross cultural attempts in the promotion of adolescent health that emphasize some values which may not be indigenous to a culture, at the expense of those which are.
Because of the predominance of ‘Western’ influence in international health promotion, there is a frequent tendency for the behaviors encouraged by exported programs to run counter to the grain of more traditional societies. Adolescent independence, competitiveness, non-differentiation between the sexes, and professional intervention are sometimes promoted at the expense of familial decision-making, cooperativeness, respect for elders, social cohesion and differentiated roles for each gender. Economic and academic achievement are sometimes promoted at the expense of emotional and spiritual expression and social relationships, especially within the family. This is heavily supported by the explosion of mass media and mass travel, which has given rise to a global ‘youth culture’ that emanates from more to less economically developed societies. Promoting aspects of adolescent development that are not germane to the culture runs the risk of denigrating that culture, along with the self-esteem of both young and old, and of losing qualities that are of great importance to those cultures, and, indeed, need restoration in the newer societies.
While change is inevitable, and brings a tremendous richness of opportunity especially to the young, how societies adapt to it is of paramount importance to their well being. A first crucial step is in recognizing the values that are implicit in the way adolescent health is promoted and noting whether it conflicts with cultural norms. Bringing people together within those cultures to recognize such conflict and unite them around the common goal of their children’s well being, will help them find ways to adapt to change that enable them to sustain what is best. Recognizing that young people tend to share the deeper values of their parents will also help to reduce the fear of change. At the same time people in the younger cultures of the ‘developed’ countries need to re-assess what the older cultures in the ‘developing’ countries have to offer to them, and consider ways of restoring some of what has been lost—much as mutual love and respect between old and young has sustained the cultures of the older societies over many generations.
The rapid upsurge of priority being given to the health and well-being of young people holds much promise for the whole world because of the energy, creativity, idealism, and unrestrained excitement the young can bring to it. This needs to be supported, without being stifled, by the wisdom of older generations, and perhaps especially from the older cultures in order to balance the predominance of the newer cultures in communication and economic power. Re-learning from such cultures, while challenging, holds immense promise.