There is a growing body of evidence exploring the links between mental health, gender and adolescence. However, these issues have been neglected in health systems debates in many developing countries, especially with regard to the mental health and psychosocial needs of adolescent girls in fragile and postconflict settings. This article draws on qualitative+Qualitative tools included in-depth interviews, key informant interviews, focus group discussions and intergenerational trios (see http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9826.pdf). Visual techniques were used and participatory photography was conducted in Sri Lanka. In all countries, a mapping of mental health and psychosocial services was also carried out alongside Health Facility Assessments. fieldwork conducted in 2014–15 in three conflict-affected contexts – Gaza, Liberia and Sri Lanka – to explore adolescent girls’ (10–19 years+UNICEF, The State of the World’s Children (New York: United Nations Children’s Fund, 2011) psychosocial vulnerabilities and the psychosocial service environment. The study concludes that, unless gender, age and related gendered social norms are taken into account in psychosocial service provision, responses are likely to be inadequate and may even perpetuate discriminatory norms.
Why adolescents – an in particular adolescent girls?
Adolescence is a critical stage in life, when girls and boys start experiencing a range of changes, including physical and emotional. It is also the stage when they start to feel the influence of gendered social norms on many areas of their lives (e.g. education, marriage, mobility). For many girls and young women, this period is one of deprivation, danger and vulnerability, including an increased risk of sexual and domestic violence.
Adolescence and pathways beyond are also influenced by contextual and societal factors, including customs, policies and the external environment. In this study, the external environment is one of post-conflict fragility, where countries, households and individuals are recovering or continuing to deal with violence, disruption, displacement and loss of livelihoods. These experiences are often gendered, as social norms shape how families react to and cope with external shocks and stresses, often with negative outcomes for girls. Evidence tells us that the majority of mental health and psychosocial problems begin during adolescence and continue into adulthood if not appropriately treated.+See for example C. Kieling et al., ‘Child and Adolescent Mental Health Worldwide: Evidence for Action’, The Lancet 378 (9801), 2011; WHO, Helping Youth Overcome Mental Health Problems (Geneva: World Health Organization, 2007). While adolescence is an already stressful phase, it becomes even more difficult in conflict/post-conflict situations: children and adolescents miss out on education, economic and social opportunities, and many are exposed to violence, lose their parents, or are abused, abducted or forced to fight. All of these factors can lead to serious mental health and emotional consequences, changing the way adolescents see themselves, relate to each other and think about their future.
Understanding adolescent psychosocial vulnerabilities in fragile contexts
Figure 1 maps the key wellbeing domains surrounding adolescent girls. The girls themselves are then situated within their households or families, their communities and the state. These are in turn influenced by a changing global context, including global trends and learning with regard to adolescent and MHPSS programming. The service environment also plays a key role in girls’ ability to achieve psychosocial wellbeing.
Access to education was seen by adolescent girls and their parents as critical to shaping their psychosocial wellbeing. Access to household-level economic opportunities and assets also played a vital role in girls’ psychosocial wellbeing in all countries. In Liberia, lack of access to economic opportunities and assets not only causes distress and psychosocial suffering, but it also leads to adolescents engaging in risky behaviour, including transactional sex:
We engage in sexual activities because at times, the things we wish to have our parents are not able to afford them … At times our parents coerce us to get involved in early sex … don’t you see your friends going out there – (Adolescent girl in FGD, New Kru Town).
Sustaining and building social connections and relationships was another vital ingredient in psychosocial wellbeing. Most adolescents in Sri Lanka said one or both parents were the closest person to them and provided the most support. However, many also felt a sense of frustration or disappointment with their parents due, for instance, to a father’s drunken behaviour or being punished by a parent. In Liberia, even if not living with their biological families, both boys and girls indicated that having relationships with close kin and extended family members, peers and neighbours played a vital role in their psychosocial wellbeing. In Gaza, the role of family support was also mixed. While a number of adolescents highlighted that they turned to family members for advice and solace, others expressed concern that parents did not listen to them or pay attention to their needs.
Adolescents feel that they are not adequately valued by the family and the community. Families don’t understand the needs of adolescents. There are many communication gaps between adolescents and their families: adolescents don’t understand parents’ concerns and worries about them and also parents don’t understand needs, aspirations and desires that adolescents have. It’s a mutual misunderstanding – (Social protection specialist, Gaza City).
An inability to participate in family and community decision making and to exercise agency about important life decisions was a key psychosocial risk experienced by adolescent girls.In Sri Lanka and Liberia, despite more responsibilities being assigned to both girls and boys as they reach adolescence, they are still considered children in public life and are not given the space to participate and be heard in household or community decision-making processes. Similarly in Gaza, adolescent girls’ ability to participate is constrained by social norms which place strong restrictions on their mobility and social activities outside the home.
An inadequate sense of self-worth is another risk to psychosocial wellbeing repeatedly raised by adolescent girls. Enablers and indicators of self-worth in Sri Lanka included: having the affection and support of parents and extended family members; participating in school or community events; and having aspirations for the future. Barriers to self-worth included: living in remote locations and a lack of opportunities for young people to use their skills; the absence of an encouraging environment or socially accepted spaces where girls can congregate; and negative labeling of adolescents. In Gaza, adolescent girls interviewed repeatedly complained that they were not accorded the same value as their male counterparts by family and community members.
Inadequate protection and security – in terms of physical and psychological harm – was another key theme in all the study sites, but especially in Liberia, where unhappy family relationships and physical and sexual abuse of girls were major risks. Nearly all adolescent girls in the study reported being subjected to physical beatings as part of how their parents or guardians disciplined them. A significant proportion of sexual violence was perpetrated by relatives or teachers. As this 14-year-old girl noted: ‘in school if a girl fails a particular subject and asks the teachers to help her, the teacher will want to sleep with her; she may accept to sleep with the teacher; then the teacher exploits the girl’.
Other risks to physical and mental wellbeing found in all countries include aggression or violence at home, separation of parents and families, the migration of one or both parents and parents’ remarriage. All can result in adolescents having to live with their extended families, where they often have to take on heavy workloads, lack support to continue their education and are frequently subjected to scolding and insults. In Gaza, there was the added vulnerability of displacement, and distress at living in mixed sex shelters in the immediate aftermath of the 2014 Gaza–Israel conflict.
Informal support and coping
In all the countries in our study, adolescent girls had developed strategies to cope with psychosocial vulnerability. Girls spoke about drawing on ‘inner strength’, reading, painting, writing stories, using social media and day-dreaming. Religion, spirituality or traditional healing were another important means of coping. Family support, both nuclear and extended, was an important coping strategy in all countries; aunts in particular were frequently mentioned since they were often closer in age to adolescent girls and were better able to understand the issues and challenges facing girls than their mothers. In the wider community, friends, teachers and formal service providers were mentioned by respondents as being important elements in a girl’s coping repertoire.
Formal service provision
Despite different levels of MHPSS service provision in these three countries, generally speaking tailored age- and gender-sensitive services and programmes for adolescent girls are extremely limited. In Gaza and Sri Lanka, programmes often focus on younger children, overlooking adolescents. In Liberia, while some health and social service programmes target adolescents, they vary in quality. In terms of gender sensitivity, in Gaza some (male) health providers were reluctant to treat adolescent girls unless they were accompanied by a family member. According to one caregiver in Gaza:
The general physician stopped following up my daughters, especially the older one, and he asked me to stop treating her because she is now a young lady, and continuing receiving mental health services will affect her reputation and she will be stigmatised forever … he said ‘It is enough. Don’t take her to any doctor. This will affect her if people know about her case.
In Sri Lanka, service providers’ attitudes were similarly influenced by gendered social norms and notions of what constituted appropriate moral conduct for adolescent girls.
A consistent theme in our research was the negative role of stigmatising and discriminatory community attitudes towards mental health service uptake generally, and by adolescent girls in particular. In Gaza, although multiple strategies have been developed to reduce stigma, they have proved largely ineffective, and often result in delayed access to services as traditional healers are consulted first. In Sri Lanka, social norms also played an important role in hindering effective uptake of MHPSS services, with social and religious priorities often overshadowing a girl’s right to access appropriate services. In Liberia, despite training in child and adolescent services, of mental health clinicians have largely focused on adults and those with serious mental illness.
Several gaps in MHPSS provision were identified. First, there are few preventive activities targeting adolescents or activities to identify groups at greater risk of mental health problems. Second, there is significant service fragmentation and MHPSS services in all three contexts are poor-quality. Third, there is limited overarching strategic direction for MHPSS, including a short-term perspective and lack of systematic follow-up mechanisms. Fourth, there is a lack of evidence-based practice. Fifth, although adolescent girls’ psychosocial wellbeing is a complex multi-dimensional phenomenon, service provision remains siloed both within and across sectors, and is poorly coordinated. And sixth, in all three contexts there is a significant problem with under-resourcing in terms of budgets and competent human resources.
Conclusions and recommendations
Reflecting on the implications for future policy and practice, we highlight three broad areas.
First, measures for addressing the risk of psychosocial ill-health among adolescent girls in fragile contexts include: providing adolescent- and gender-friendly safe spaces and training adolescents and their caregivers on basic coping strategies. Working with supportive teachers and the education sector more broadly to help develop adolescents’ self-esteem and self-confidence is critical. The persistent stigma that hinders access to psychosocial services needs to be addressed through the integration of services, media and education and community mobilisation.
Second, building capacities of service providers is critical. Areas for capacity-building include the early detection of psychosocial and mental health disorders, provision of GBVrelated services and treating substance abuse. The service environment should also include space for productive activities, creative expression and recreational activities.
Third, enhancing policies to regulate and coordinate actors providing MHPSS services at different levels (community, sub-national and national) is also critical. There is also a need to strengthen national institutions and ministries so they become recognised as legitimate regulators of psychosocial services, and can provide improved licensing and accreditation processes. Finally, greater evidence informed programming, including more robust data collection focused on adolescents, is needed.
Fiona Samuels is a Senior Research Fellow in the Gender Equality and Social Inclusion programme at the Overseas Development Institute, where Nicola Jones is a Principal Research Fellow. Bassam Abu Hamad is Professor in the Pharmacy Department at Al-Quds University, Gaza.
This article is based on one submitted elsewhere. This version is substantially rewritten for publication here. See: https://academic.oup.com/heapol/article/32/suppl_5/v40/4718142.