Human development occurs in five stages – infancy, childhood, adolescence, adulthood and old age.¹ Of all, the adolescence is the most confusing and most poorly understood. Adolescence which is defined as the transition period from puberty to legal adulthood² appears to be a watershed area in the human development spectrum, with least attention in conventional health care but with huge peculiar public health issues. The adolescent as defined by the World Health Organization is one between the ages of 10 and 19.³ Three distinct periods of adolescence are recognized. They are: early adolescence (Ages 10-13), mid-adolescence (Ages 14-16), and late adolescence (Ages 17-20 and beyond).² From the educational perspective, we have in-school and out-of-school adolescents. These days, young people attain pubertal characteristics younger (albeit, unprepared), leave school earlier, marry later and are often neglected with regards to holistic attention. They can therefore be likened to an ‘endangered group’. In my humble opinion, adolescents are an ‘endangered group’ with several challenges due to some identified factors like: Hormones, Habits, Habitats, Heroes and Hygiene consciousness.

While the hormonal push and pubertal characteristics are normal, their effect, alongside other factors can be modified through a holistic and coordinated approach to health care of the adolescent.⁴ In the context of health as a whole, there is a need to address the various dimensions of young people’s health- physical, social, mental, environmental as well as spiritual.⁴ A deep understanding of the peculiar issues and challenges of an adolescent will be required to address these dimensions and these are the peculiarities this piece sets out to elucidate.⁵

Bayelsa State is one of the six states that make up Nigeria’s South-South geopolitical zone. The 2006 population census put the population of the state at 1,704,515, with an annual growth rate of 2.9% the projected population as at 2018 was 2,332,787. In the year 2006, the population of persons aged 10 – 19 was 403,844.⁶ The family structure in the state varies from place to place, with the polygamous family structure being most common. Such a structure permits neglect of foundational care for adolescents.

The state operates a three-tier health care delivery system and the State Ministry of Health (SMoH) is responsible for public health and health service delivery in the state. There are 274 functional health facilities in the state consisting of public primary, secondary and tertiary health facilities (Federal Medical Centre, Yenagoa and Niger Delta University Teaching Hospital, Okolobiri) and private hospitals complementing the public health facilities. The major health challenges confronting young people in Nigeria and indeed in Bayelsa State vary widely, from sexual and reproductive health and rights, to nutrition, substance abuse, accidents and violence.⁷

Early sexual exposure is an important reproductive risk factor among young people in Nigeria as many of them lack information and life planning. A study carried out among out-of-school female adolescents in a market in Lagos identified 43.7% of the sampled population with mean age of 17 years who have had consensual sexual intercourse and mean age of initiation of sexual activity at 16 years, stating curiosity as the reason.⁸ An unpublished pilot study carried out among senior secondary females in Azikoro (Yenagoa, Bayelsa State) identified about 3.4% of the sampled population of young adolescent females who have already had their sexual debut. The resulting risk of such behaviour is predisposition of these adolescent females to unwanted or unplanned pregnancy, leading to abortion or single parenting, sexually transmitted infections (like hepatitis, HIV, etc) and poor performance in school as a result of the distraction and psychological trauma.⁹

A study carried out among young persons in Bayelsa State observed about 50% of the sampled population, alarmingly unaware of the preventive measures against contracting Hepatitis B infection.¹⁰ Such levels of ignorance coupled with some myths predispose adolescents to risky behaviours. Examples of the myths which lead to early sexual experimentations in adolescence are (1) if a developing boy does not use his penis regularly while developing, it will not develop properly; (2) if one does not engage in sexual intercourse early in life, it would become difficult for one to have children in future; (3) failure to ejaculate often would lead to future prostate challenges; (4) early sexual intercourse is a permanent solution to painful menstruation; (5) sexual intercourse makes one look plump and makes the breasts appear more attractive.^11,12,13 Believing such myths have done damage to the sexuality of adolescents.

A study carried out in South-Eastern Nigeria observed that 6.5% of the sampled populations of young adults attending higher institutions are overweight and even obese as a product of poor diet and lack of recreational activities.¹¹ There are a lot fitness clubs in Yenagoa now, which have not really focused on the adolescent population, as only young adults in their late twenties (most of whom are already obese) are found there. A published study identifying the pattern of substance use among adolescents in Yenagoa revealed that most respondents who took alcohol were 20 years and below, an alarming discovery.⁴ A rise in substance abuse often results in a corresponding rise in cultism and other related militant behaviours.

 Adolescence can be fitly described as a period of ‘storms and stress’.⁹ No better description can portray the emotional and psychological changes that take place in adolescence and these reflect in their attitude, behaviour and social relationships. In conceptualizing the predisposition to the risks which this ‘endangered group’ face, I have identified and outlined some peculiar attributes and issues such as:

• Identity Crisis: This relates to anxiety about a social role and an uncertainty about identity in life and society. Adolescents often ask themselves questions like, ‘who am I?’
• Independence Craving: A craving or desire for freedom from control by others or freedom from dependence on others especially parents. Some adolescents may go the extent of leaving home or demanding freedom.
• Image Consciousness/concerns: This refers to adolescents having an obsession with how they look before people especially their peers and the opposite gender. Adolescents get worried and worked up meditating on other people’s opinion of them. They worry about their height, colour, weight, body build, size of genitals (especially if they have to bathe in the presence of other adolescents), body odour etc. Images of masculinity portrayed by the media can be confusing, leading to self-doubt, insecurity and misleading concepts about the male gender.
• Idealist Concept: This refers to a belief in and pursuit of certain standards, models and principles which are not realistic. Adolescents tend to live in a world of fantasy. Thanks to the internet, the world truly has become a global village (with Facebook as its capital), and now adolescents have access to endless lists of actors, artistes, football stars and the likes who they idolise and perceive as models of ideal behaviour and comportment, ignoring the flaws and imperfections that exist in their personal lives and off camera. A young boy may hear the voice of a pop music star and think it to be the star’s original voice not realising that the voice has been studio-modified.
• Ideological Conflict: Arising from an idealist concept is an ideological conflict. Adolescents having formed their own set of values and tend to question rules and challenge dogmas that run contrary to theirs. Un-informed, such adolescents carry into adulthood a wrong perception of what is right, wrong, acceptable or unacceptable. Often times, they can be caught yelling saying, “I don’t see anything wrong with it”. They therefore are at risk of being sincerely wrong.
• Intimacy Confusion: Sometimes the adolescent is confronted with the dilemma of how intimate one should be with the opposite gender or how much one should stay away without being regarded as a sociopath (antisocial) and as hormones rage, the confusion heightens.
• Inquisitiveness due to cluelessness: In Adolescence, many unanswered questions come up in the mind from time to time. The ‘whys’ and the ‘why-nots’ must be correctly answered.
• Impulse Control: Adolescents hardly think through before making decisions. Moved by impulse and their feelings, they act before thinking. Obviously, they lack good judgement, the kind that comes with experience. They make unplanned purchases acting on the spur of the moment, they tend to make hasty promises and unplanned trips.
• Instability in choices and moods: this refers to Adolescents being indecisive, or unable to stick to good decisions they have made. There is sometimes the conflict of “to do or not to do” This even progresses to being unsure of what career path they want to pursue, always changing their minds and goals based on their mood.
• Inferiority Complex or else Intimidating confidence: Inferiority complex is an over-developed sense of being inferior to other people especially peers because of a sense of unworthiness or perceived disadvantage. It is a state of being unsure of one’s self because of a seeming lack of acceptance by others. If this is not carefully handled, it could lead to withdrawal, Isolationism or a compensated aggression.
• Increased chances for risk-taking and secrecy: Adolescents being adventurous tend to experiment with drugs, vandalism, substance misuse and cultism. Most times, (doing it to spite over-protective parents), they switch off their handsets and zoom off to questionable places without letting anyone know. They are easily lured to prove a point in risky behaviours especially when dared by their friends to do things they ordinarily would not do. They tend to explore and experiment things they read, watch or are told by their friends. Most times, they do it for self-definition and other times for self-interest. They are almost too sure that they won’t be hurt or caught.
• Insensitive Care-givers: The picture is gloomier when amidst all the above, they have insensitive care givers, parents, teachers or leaders who instead of guiding them or at least sympathizing with them become inconsiderate bullies. Adolescents are forced to help themselves thus exposing themselves to pitfalls.

From the above attributes, it is obvious that a lot of out-of-school adolescents will be left out if the focus on tackling them remains on school adolescent health services. On the other hand, a community-based intervention (which is in most cases a one-off project by philanthropic or training institutions) may not be able to address the deep-seated behavioural issues that the ‘endangered group’ faces. A study carried out evaluating the effect of a community based approach of sexuality education revealed no significant change in sexual practices among sexually active adolescents even after the efforts.⁵ It is therefore pertinent that these identified attitudes and resulting vices, can be successfully tackled by a well-coordinated and Institution-based Behavioural Change Communication within the domains of preventive health at places where adolescents are known to frequently visit. Examples of such places include educational and a few recreational facilities but majorly our health facilities at all levels.

Frankly speaking, adolescent issues should not be abandoned in the domains of families to tackle as is the case with geriatric issues, because the ripple effect of neglect will in one way or the other impact on the health of the public. There exists a National policy guide for health and development of Adolescents and young people in Nigeria published in 2007.⁷ Part of the objectives of the policy is the establishment of youth friendly and gender sensitive services in youth centres, private and public health institutions including tertiary hospitals.⁷ The problem however seems to be the seeming hesitation in implementation and domestication of the policy by various states of the federation as observed in a subsequent report 2 years after the policy guide was released.¹² These findings seem more obvious in states where the activities of the Federal Ministry of health are minimal even in recent times. In Bayelsa State, there exist no formal Adolescent health services either as a stand-alone or as a unit in our health facilities even in tertiary health centres. The health centres in our University communities have sadly been reduced to treatment centres. At the level of the relevant agencies, it is still not obvious if there is any domestication of the various national policies on holistic adolescent health by relevant agencies in the state even as the focus on anything related to adolescents seems to have shifted to only sports development. The consequence of this neglect is the reason why our correctional facilities are filled with young adults either awaiting trials or serving varying durations of jail terms. Little wonder the mental health clinics in the state seem to have a huge chunk of adolescent patients managed for varying substance use disorders. Bearing in mind the stigma associated with the typical psychiatric clinic, (which is usually more rehabilitative than preventive), it is my opinion that a holistic Adolescent focused preventive health service cannot be left to that domain nor to occasional outreach programs embarked on by philanthropic associations like the Medical Women Association, FIDA or even the Association of Resident Doctors, but will be better situated and coordinated in a public health facility.

With the foregoing, it is pertinent to have a paradigm shift in handling adolescent related issues by service providers in educational and health facilities. I therefore propose a robust adolescent friendly clinic domiciled in major health facilities and a revamping of adolescent health focused school health services. These interventions in my opinion could fast track the attainment and implementation of the noble policies for Adolescent health in Nigeria and could ultimately address the peculiar adolescent issues.

Portrait of the adolescent friendly unit/clinic

• As a Referral Centre: University Health Centres and Sick Bays of Boarding Schools can refer Adolescents to Adolescent clinics in tertiary health facilities on identified health issues. Activities of school health services by relevant residency training departments can trigger such collaborations.
• As A Research Centre: In partnership with noble Non-Governmental Organizations (NGOs) and Youth- Focused foundations, sponsored researches on adolescent issues can be carried out. Training of Doctors in Adolescent Health at Senior Residency or sub-specialty levels and nurses can be achieved. Development of Behavioural Change Communications programmes and materials can be achieved also.

1. As a Rehabilitative clinic: in deep collaboration with mental health units and social welfare unit of tertiary health facilities.

Proposed Components of an Adolescent Health Clinic

• Siting: As a unit under the Department of Community Medicine and Public Health in the Tertiary Health Centres of the State.
• Personnel
  • A Consultant Public Health Physician with interest in Adolescent Medicine/ Reproductive and Family Health
  • Senior Registrars and Residents with interest in Adolescent Medicine
  • Public health nurses with training in adolescent health
  • A Psychologist
  • Other support staff
• Services:
  • Adolescent Counselling Services
  • Adolescent Screening Services
  • Treatment
  • Health education
  • Referrals/linkages for social welfare and specialist care (Psychiatry, Paediatrics, Obstetrics)

CONCLUSION

An urgent consideration of the domestication of policy guidelines on holistic Adolescent health steered by leading health facilities in Bayelsa State will go a long way to address the deep-seated afore mentioned psycho-socio-medical issues which our adolescents grapple with for a positive impact on the health of the public

RECOMMENDATIONS

• To the health facilities: University health centres should endeavour to collaborate with teaching hospitals in their catchment areas for easy referrals. Tertiary Health facilities should make efforts to begin youth friendly clinics and provide leadership for more research into Adolescent health issues
• To the State Ministry of Health: The State Ministry of Health should set up model centres which are youth friendly in health facilities of each Senatorial district for a start and also provide Leadership for the implementation and integration of the policy guidelines
• To the Federal Ministry of Health: The Federal Ministry of Health should conduct a National survey to ascertain if federal tertiary hospitals across the country are providing adolescent friendly services as enunciated in the policy guidelines.

ACKNOWLEDGMENT

The author wishes to acknowledge Prof. K. Odeyemi of the Department of Community Health and Primary Care, Lagos University Teaching Hospital for the very helpful inputs and review done before this final manuscript. All editors and reviewers are also acknowledged. Dr Abisoye Oyeyemi is also acknowledged for the useful review of the manuscript and Dr Abanda Sotonye is acknowledged for assistance in the initial proof reading.