info4africa/MRC KZN Community Forum | 15 April 2014 | Adolescent HIV risk and Resilience


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Speaker: Ms Juliet Houghton – Country Director CHIVA South Africa

Risk activities in adolescents are a pervasive and costly problem for all societies, despite many efforts to reduce or prevent these through diverse intervention programmes. This presentation seeks to unpack what the leading adolescent risk behaviours are, why these occur, and what strategies have been successfully tried and tested to mitigate negative behaviours.

Through the examination of strategies to build resilience in young people (historically an educational intervention), Ms Houghton will argue that by shifting our focus from ‘negative’ aspects of risk and focusing on skills development opportunities with young people, young people will be better able to manage their lives, including risk situations.

Examples will be drawn primarily from an HIV/sexual health perspective for the purpose of discussion and debate. Participants will be encouraged to share experiences of successes and challenges.

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  • Jessor, Richard. "Risk behavior in adolescence: a psychosocial framework for understanding and action." Journal of adolescent Health 12.8 (1991): 597-605.
  • James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model beginning in 1977.[11] It is based on analysis and use of different theories of psychotherapy,hence the name "transtheoretical."
    Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books. The model consists of four "core constructs": "stages of change," "processes of change," "decisional balance," and "self-efficacy."[25]
  • Knight JR; Sherritt L; Shrier LA//Harris SK//Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent 156(6) 607-614, 2002.
  • info4africa/MRC KZN Community Forum | 15 April 2014 | Adolescent HIV risk and Resilience

    1. 1. Adherence in Children and Adolescents with HIV InfectionCHIVA SOUTH AFRICA Paediatric & Adolescent Programmes Adolescent HIV Risk and Resilience: What do they do and why do they do it?
    2. 2. Overview  Explore how we make sense of adolescents!  Understand why risks are taken  Resiliency framework  Interventions to mitigate impact of risk  Communicating and consulting  AYFS
    3. 3. Adolescent Risks  Risky activities in adolescence are a pervasive and costly problem for all societies  The scientific explanation is premised on a mental health model that assumes that harsh social environments adversely affect well-being  Focuses on negative outcomes of risks but not potential benefits or opportunities
    4. 4. A Public Health Issue  The greatest threats to adolescent health come from often preventable and self-inflicted causes:-  Violence  Drug and alcohol use  Smoking  Sexual risk-taking  MVAs  Reducing the rate risk-taking would make a substantial improvement of overall population wellbeing
    5. 5. Why do Adolescents Take Risks?  Evolutionary perspective reflects that risky behaviours might reflect adaptations to harsh environments rather than deviations from optimal development  Numerous theories and models  In any approach, it is important to consider why does risk-taking increase between childhood and adolescence, but decline between adolescence and adulthood
    6. 6. Behavioural Model Problem Behavior Theory Look at behaviours as purposeful, meaningful, goal oriented and functional rather than arbitrary or perverse Gaining peer acceptance, establishing autonomy from parents Psychosocial proneness: teens who engage in one type of risk behaviour are also likely to engage in other types
    7. 7. Bio-Psychosocial Model Biological: Pubertal timing, hormonal effects, genetic predisposition Psychological: self-esteem, sensation seeking, cognitive and emotional states Social: how parents, peers and school influence an adolescents life
    8. 8. Trans-theoretical Model  Developed by DiClemente and Prochaska  Integrates current behaviour, intention to change, decisional balance, and strategies  Behaviour is an incremental, continuous, and dynamic process  New behaviour results from decision making processes that occur through series of stages  Each stage of change contains specific tasks
    9. 9. Stages of Change  Precontemplation  Contemplation  Preparation  Action  Maintenance  Termination  Relapse
    10. 10. Pre-Contemplation  Stage in which there is no intention to change in the foreseeable future (approx 6 months)  May be uninformed or under- informed about consequences  May have tried to change and become demoralised
    11. 11. Contemplation  Intend to change in the next 6 months  Are aware of the pros and cons  Profound ambivalence may keep someone stuck here for a long time
    12. 12. Preparation  Self awareness of need to change and intent to do so within a month  May have taken some significant action in past year such as a class or seeing a health or mental health provider  Possible results of change considered  Empowerment, recognising possible substitutes, and how to reward self  “How could we make a plan?”
    13. 13. Action  Has made overt changes in lifestyle in the last 6 months  For this stage must attain the criteria that professionals agree reduces risk i.e. with smoking total abstinence is required
    14. 14. Maintenance  Estimate that this stage lasts from 6 months to 5 years  Are not working as hard to prevent relapse as in action stage  Less temptation and more confidence
    15. 15. Relapse  Treat as re-entry into another cycle  Recognise that stages from pre-contemplation or contemplation need to be relived
    16. 16. Termination  Applies to some behaviours  No temptation and 100% self –efficacy  It is as if one never acquired the habit/risk in the first place
    17. 17. Neurophysiology  Risk-taking increases due to changes at puberty in the brain’s socio-emotional system  This leads to increased reward-seeking; especially with peers  Fueled mainly by a dramatic remodeling of the brain’s dopaminergic system  Risk-taking declines between adolescence and adulthood due to changes in the brain’s cognitive control system – improved capacity for self-regulation  Structural and functional changes within the pre- frontal cortex and other brain regions
    18. 18. Why do Adolescents Take Risks? It is a unique developmental stage:- Distinct from both childhood and adulthood A time of physical and emotional changes A time to test independence from the family A time for new relationships - peers, partners, parents
    19. 19. Why do Adolescents Take Risks?  Developing one’s own moral code and establishing an identity, separate from parents/caregivers is a major task of adolescence  Early adolescence (ages 11-14) – first stages of separation from parents, desire to look and act like peers, difficulty with impulse control  Middle adolescence (ages 15-17) – further distancing from parents and allying with peers, feelings of omnipotence and immortality can lead to dangerous behaviors  Late adolescence (ages 18-21) - fully identify one’s own moral code, more confident and better able to delay gratification, can be protective factors
    20. 20. What This Means  Acceptance that testing limits is part of normal adolescent emotional and psychological development  Adolescent risk behaviours can lead to significant morbidity and mortality  Risk behaviors are often interrelated  Adolescents who participate in multiple risky behaviors may also experience mental health challenges
    21. 21. Risk and Resilience  Risk factors identified that can make children, families and whole communities vulnerable to poor mental health and development  Resilience is defined as ‘normal development under difficult circumstances’ or ‘the human capacity to face, overcome and ultimately be strengthened by life’s adversities and challenges’  Resilience can be taught and learned – as we learn we increase the range of strategies available to us when the going gets tough
    22. 22. Youth and Resilience  At some time most individuals experience considerable stress, hardship and misfortune as a result of various personal and/or situational experiences  Common resiliency factors that operate on two broad sets of developmental strengths (internal and external) will encourage and support the coping skills of adolescents  Adolescents are going through many changes; building their resilience is crucial to mitigating the impact of negative events
    23. 23. Resiliency Framework  Viable model of understanding the major components that contribute to the development of resiliency and well-being  Strength-based approach to build capability to cope successfully in the face of stress-related, at-risk or adversarial conditions  Developmental framework identifies protective factors that encourage and enhance the well-being and development of all individuals in our communities
    24. 24. Resiliency Framework Cont …  External factors (family, peers, community)  Internal factors (empowerment, self-control, cultural sensitivity, self-concept and social sensitivity)  Developmental strengths that contribute to resiliency exist within the individual and through the situational and relational experiences related to family, peers, school and community  Additive effects of both internal and external strengths enable greater resiliency
    25. 25. Resiliency Actions  Challenging negative self-talk and helping to develop positive but realistic explanations of what happens can transform engagement and future outcomes  Consistently model reflective capacity for young people, rather than simply reacting to behaviours and perceived attitudes  Adherence counselling is a huge opportunity for initiating and continuing positive, reflective engagement
    26. 26. Making Sense of Experience  Well-being shaped not only circumstances but the meaning we make out of what happens  Two people may experience the same event but interpret causes and outcomes very differently  The capacity to integrate experience into belief system and value base - and to process events in a meaningful and positive way (reflect) – powerfully influences a sense of well-being
    27. 27. Resilience Cont …. Mastery over stressful events While self-esteem is important, self-efficacy is equally important to building resilience Defined as the measure of belief in one’s own ability to complete tasks and reach goals Most importantly, the capacity to be pro-active in the face of stressful, difficult events and to gain mastery over such events
    28. 28. Self-Efficacy Actions …. Mastery over stressful events Assist young people to develop reflective skills such as:- - what happened - why it happened - what strategies could help overcome/prevent this - who can help and support you This enables young people to understand that they have options and choices when things get difficult
    29. 29. Resilience Cont… Creating a benign cycle Just as risk is cumulative, so resilience is developmental Requires practice and accepts developmental abilities of young person As the number of resilient individuals increases, the strength of a whole community is enhanced – increasing the ability to better understand and support each other
    30. 30. Resiliency and At-Risk Behaviours  Youth with higher resiliency factors and developmental strengths are less likely to be involved with a number of risk-taking activities  Those with higher resiliency also more likely to be involved with a number of positive and constructive activities  Based on studies that looked at common risk- taking behaviours such as substance abuse, alcohol abuse, violence, smoking and high-risk sexual behaviour
    31. 31. Constructive Behaviours Actions  Promoting constructive behaviours improves youth resiliency and achievement and builds positive relationships with healthcare staff  Consider areas such as:- - success in school - values diversity - helping others - maintains good health - volunteerism - exhibiting leadership - resisting danger - delaying gratification - overcomes adversity  Above = ideal peer educator!
    32. 32. External Factors
    33. 33. Strengths Family strengths: caring, communication, role models, support, involvement in school, and high expectations Peer strengths: positive peer relationships and positive peer influence School strengths: boundaries, caring, high expectations, youth engagement, attachment to school and high achievement Community strengths: caring neighbourhood, adult relationships, values youth, and boundaries Internal strengths: empowerment, self control, self-concept, cultural sensitivity, and social sensitivity Resilience Cont …
    34. 34. Risks and Protective Factors Domain Risk Factors Protective Factors Biological • HIV infection • Congenital malformations • Genetic tendency to psychiatric disorder • Malnutrition • Other illness • Age appropriate physical development • Good physical health Psychological • Psychiatric disorder • Maladaptive personality traits • Effects of emotional, sexual abuse and neglect • Self-stigma • Orphanhood • Ability to learn from experiences • Good self-esteem • High level of problem- solving ability • Supportive peer group • Effective social skills • Supportive parent/caregiver Blum, RW, Mmari. KN (2005). Risk and protective factors affecting adolescent reproductive health in developing countries. WHO
    35. 35. Risks and Protective Factors Domain Risk Factors Protective Factors Family • No family • Deceased parents • Divorce • Family conflict and domestic abuse • Poor family discipline • Poor family management • Secure family attachment • Opportunity for positive involvement in family • Safe family relationships • Fair discipline practices School • Academic failure • Learning disability • Poor commitment to schooling • Inadequate/inappropriate educational provision • Opportunities for involvement in school activities • Supportive and safe school environment Community • Community disorganisation • Effects of discrimination • Exposure to violence • Mobility • Poverty • Transitions (i.e. urbanisation) • Transactional or intergenerational sex • Connectedness to community • Opportunities for constructive use of leisure • Safe environment • Positive role models • Supportive legislation • Appropriate gender equity norms
    36. 36.  Recognise that not all teens are behaving badly  Programmes to address single risk behaviour not successful  Helping teens attain a sense of competency, usefulness, empowerment, and resilience  Protective factors: family connectedness, spirituality, school connectedness, positive self-identity, self- efficacy What Can We Do?
    37. 37. Risk: Smoking  Smoking among adolescents is on the rise in SA  Ages 11-15 commonly start of smoking behavior  Girls:  Smoke to look cool  To keep from gaining weight  Boys :  Also smoke to look cool  Also use smokeless tobacco: chew and snuff
    38. 38. Risk: Alcohol  Experimentation is common  First use of alcohol often before 13 years old  Regular use of alcohol is prevalent in ages 15-18  Daily use and heavy drinking more common in males  Reduces self-control and increases risky behaviour  Primary cause of injuries (including MVAs, violence and premature deaths)  Adolescents who abuse alcohol are more likely to have suicidal thoughts and attempt suicide  Binge drinking is most common amongst 15-24 year olds
    39. 39. Risk: Substance Use Drugs commonly used in South Africa include:- Marijuana (dagga) use is most common (after alcohol and tobacco) Mandrax (white pipe) Cocaine and crack cocaine (rocks, street base) Crystal methamphetamine (rock, ice) Methamphetamine (tic) Heroin Ecstasy (MDMA) ‘Drug of choice’ varies around the country due to availability, status and social norms Increases risk of mental health problems Can have negative effect on health outcomes for all, but especially those living with HIV (lower CD4, higher OI incidence, lower adherence, increased disease progression)
    40. 40. Signs: Alcohol and Drugs Experimentation and occasional use is different to addiction or a disorder when one or more of the following occur within a 12 month period:- As a result of substance use – poor performance at school or work; failure to fulfil obligations at home; absenteeism; expulsion; neglect in personal appearance Recurrent substance abuse use in situations that are potentially hazardous (i.e. driving or use of heavy machinery) Trouble with the law as a result of substances – shoplifting, disorderly conduct, violence, DUI Continued substance use in spite of the problems it causes and in spite of negative consequences including punishment
    41. 41. Interventions CRAFFT screening tool Have you ever travelled in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? Do you ever use alcohol or drugs Alone? Do you ever Forget things you did while using alcohol or drugs? Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? Have you ever got into Trouble while you were using alcohol or drugs? Scoring: 2 or more positive items indicate the need for further assessment Adapted from Knight JR; Sherritt L; Shrier LA//Harris SK//Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent 156(6) 607-614, 2002.
    42. 42. Risk: Sex Ability to negotiate sex influenced by many factors including:- Age and developmental stage Alcohol and substance use Influence of peers, family and community Environmental risks (home, school and community) Cultural norms and beliefs Beliefs concerning intergenerational, transactional sexual relationships and multiple concurrent partners Ability to consent Inability to do so may lead to an increased risk of:- Unintended pregnancy STI acquisition HIV acquisition
    43. 43. Sex: Actions As healthcare workers, we can:- Work with young people to address their sexual health needs Work with colleagues to understand our own values and beliefs and how these impact on access to services Ensure that services meet the needs of young people in our communities Work to challenge negative behaviours in our communities (gender-based violence; intergenerational and transactional sex; school attrition; forced marriage) Work in partnership with other key stakeholders:- Education Social welfare SAPS/NPA Community/Faith leaders NGOs/CBOs
    44. 44. Risk: Depression & Suicidality  Depression is one of the most common mental illnesses found in adolescents living with HIV  Depression is a continuum, ranging from sadness to an extreme inability to function  Clinical depression is a mood disorder in which feelings of sadness, loss, anger, lack of motivation, and impaired functioning last for six weeks or longer  Also a common problem for general adolescent population
    45. 45. Depression: Features Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (i) depressed mood or (ii) loss of interest or pleasure i) Depressed mood most of the day ii)Loss of interest or pleasure in all or most activities iii)Significant unintentional weight loss or gain iv)Insomnia or sleeping too much v)Agitation or psychomotor retardation noticed by others (irritability) vi)Fatigue or loss of energy vii)Feelings of worthlessness or excessive guilt viii)Diminished ability to think or concentrate, or indecisiveness ix)Recurrent suicidal thoughts (often seen in adolescents) Working with adolescents living with HIV: management of mental health and psycho-social wellbeing of adolescents living with HIV (2014) – awaiting publication
    46. 46. Links Between Risks  Behaviours do not occur in isolation  Substance use and sexual behaviour  High risk of unintended pregnancy  Increases in sexually transmitted diseases including HIV  Multiple sex partners = increased risk  Sexually active more likely to ride in a car under the influence of alcohol/drugs  High correlation between alcohol intoxication and fatal accidents, homicides, street and domestic violence and suicide
    47. 47. Tips for Health Workers  Ask about current and past alcohol and substance use  Ask about sexual partners (sexual history taking)  Observe for:- - appearance and presentation - attitude and behaviour - mood and emotions - speech, thinking and perception - level of alertness and orientation - social and intellectual skills  Liaise with others (school, community etc) as everybody’s challenge and responsibility!
    48. 48. Consulting with Adolescents 8 Step approach to psychosocial assessment:- 1.Ensure privacy & give assurance about confidentiality 2.Establish trusting, caring relationship & two-way communication 3.Take a history to get information from the adolescent about the nature of their visit 4.Perform a physical examination (If indicated) 5.Make a diagnosis, and discuss the diagnosis/ treatment options with the adolescent (If indicated) 6.Provide treatment and/or counselling (as appropriate) for their physical, psychological & social needs 7.Use the opportunity to provide essential counselling of SRH & self-protection behaviour 8.Ensure continuity of care and/or referral to other appropriate services so as to assist the adolescent’s needs fully
    49. 49. Communicating with Adolescents 5 As approach from WHO:- A-SSESS • Adolescent goals for this consultation - they may be different from yours • Assure of confidentiality (within legal bounds) • Physical and mental status, understanding that HIV may progress differently in adolescents than in children or adults • Review current treatment and assess adherence • If sexually active or not (or planning to become sexually active), whether using condoms and/ or other contraception • Young women for pregnancy • Other risky behaviours/ factors for HIV transmission • Knowledge, beliefs, concerns and daily behaviours related to HIV • Assess support structure and who knows about their HIV status
    50. 50. Communicating with Adolescents A-DVISE •Using plain, neutral and non-judgmental attitude and language Include parents or guardians in discussions if adolescent is agreeable •Correct any inaccurate knowledge and fill gaps in the adolescent’s understanding of his/her condition •Sexual activity, condom use, contraception and other aspects of positive prevention •Being young and living with HIV (relationships, sex, alcohol/ drug use) •Discuss couples counselling and the benefit of disclosure to chosen people, in order to develop support structures •Peer support from other adolescents living with HIV •Adherence
    51. 51. Communicating with Adolescents A-GREE •Where the adolescent should choose to receive treatment and support •To whom they choose to disclose their HIV Status •How and when they wish to disclose their status, and the support they may need •Treatment plan that has been developed •Goals that reflect the adolescent’s priorities and are:- Negotiated Clear Measurable Realistic Under the adolescent’s direct control Limited in number
    52. 52. Communicating with Adolescents A-SSIST •Written or pictorial summary of the plan •Referrals to adolescent-friendly health workers and services in the community, as required •Links to support services for young people living with HIV •Treatments and other medications (prescribe or dispense) •Condoms and contraception, as required •Skills and tools to assist with self-management and adherence •Address obstacles to adherence •Strengthen the links with available support: Family, friends Peer support groups Community Services Treatment supporter/ Buddy or Guardian
    53. 53. Communicating with Adolescents A-RRANGE •Arrange what the adolescent will do in the time between visits to you •Arrange for referral for group counselling or relevant support group (if available/desirable) •Record what happened during the visit •Arrange for the next appointment date: reinforce the importance of attending even if they feel well and have no problems
    54. 54. Communicating with Adolescents DO AVOID • Be truthfultruthful about what you know and what you don’t know • Giving inaccurate information (to scare them or to make them behave) • Be professionalprofessional and technically competent • Threatening to break confidentiality “for their own good” • Use words and concepts which they can understand and relate to. Assess if they understandunderstand • Use pictures and flipcharts to explain • Giving them information that you think they will understand • Using medical terms they will not understand • Treat them with respectrespect in terms of how you speak and how you act • Talking down to them, shouting, getting angry or blaming them • Give all the information/choices and then help them decidethem decide what to do • Telling them what to do because you know best and they “are young” • Accept that they may choose to show their individuality in dress or language • Being critical of their appearance or behaviour, unless it relates to their health of well-being
    55. 55. HIV Prevention: AYFS “We need accessible clinics with non-judgmental, friendly staff and reduced waiting times” “They usually judge why adolescents seek treatment or contraceptives and this affects how they help young people even if he or she is at risk.” “Society expects responsible behaviour from us [adolescents], but the same society doesn’t even begin to teach us about responsible sexuality” “Our peers should be trained to support more of our friends because entering the clinic the first time I really suffered”
    56. 56. Essential Services Package for AYFS 1. Information education and counselling on sexual and reproductive health 2. Information, counselling and appropriate referral for violence/ abuse and mental health problems 3. Contraceptive information and counselling, provision of methods including: Oral contraceptive pills, emergency contraception, injectable and condoms 4. Pregnancy testing and counselling, antenatal and postnatal care 5. Pre and Post TOP counselling 6. STI information, including effective prevention of STI and HIV, diagnosis and syndromic management of STI’s including partner notification 7. HIV information, pre and post test counselling, and appropriate referral for voluntary testing if services not available
    57. 57. AYFS 10 Standards 1. Management systems are in place to support effective provision of adolescent-friendly health services 2. The Clinic has policies and process that support the rights of adolescents 3. Appropriate adolescent Health services are available and accessible 4. The clinic has a physical environment conducive to the provision of adolescent-friendly health services 5. The Clinic has the drugs, supplies and equipment necessary to provide the essential service package for adolescent friendly health care
    58. 58. AYFS 10 Standards Cont … 6. Information, education, and communication consistent with the essential service package is provided 7. Systems are in place to train staff to provide effective adolescent friendly health services 8. Adolescents receive an adequate psychosocial and physical assessment 9. Adolescents receive individualised care based on standards case management guidelines/protocols 10. The clinic provides continuity of care for adolescents
    59. 59. The Way Forward  Work in partnership with children, adolescents and their families  Understand adolescent development  Understand the risks and opportunities that are present during adolescence  Work to ensure services are accessible and welcoming to adolescents  Work with key stakeholders to share responsibilities and improve outcomes for all
    60. 60. The Way Forward  Standard behavioural change interventions have limited effect on youth risk  Suggest that focus should shift from risk to resilience based focus  By building resiliency in young people, we equip them with the life skills to make better decisions  With these skills, young people placed in a position where they can positively reduce their risks; have increased autonomy; and a greater positive impact on families and communities
    61. 61. References Jessor, Richard. "Risk behavior in adolescence: a psychosocial framework for understanding and action." Journal of adolescent Health 12.8 (1991): 597-605 Prochaska, JO; Norcross, JC; DiClemente, CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994. WHO – IMAI – Orientation on Adolescents Living with HIV WHO – Guidelines on HIV testing and counselling for adolescents and care for adolescents living with HIV LoveLife – Values clarification workshop for Master Trainers
    62. 62. Thank You Any Questions? CHIVA South Africa Cell: 084 964 0362 Cell: 083 500 7222