Are concepts of adolescence from the Global North appropriate for Africa? A debate

Adolescence is a distinct period of physical development

During adolescence, there is an acceleration of physical development at the end of which complete physical maturity is achieved. An example is the achievement of peak bone mass in the skeleton and completion of lung and brain growth. Importantly, it is during this phase of the life course that reproductive potential is achieved, which is critical for the survival of the human race. Development of secondary sexual characteristics occurs during adolescence, with well-defined stages (measured using Tanner Pubertal Staging) including development of breasts and occurrence of menarche in females and penile and testicular growth in males. This is a universal phenomenon with little difference in the timing of puberty between countries, but there is individual-level variability that may be driven by factors such as food insecurity or emotional deprivation.4 5

Neurocognitive development determines behaviour

It is well-recognised that adolescence is a period of substantial brain development. Evidence from cognitive neuroscience demonstrated that the social brain develops significantly during adolescence.6 Importantly, it is the prefrontal cortex which develops most markedly during adolescence. This area of the brain is responsible for judgement, decision-making, organisation, planning and executive functioning.7 8 Emotional development has also been linked to cognitive development.9 In addition, neuroscientists have provided evidence to show that synaptic reorganisation of the prefrontal cortex is associated with many of specific behavioural manifestations during adolescence, for example, risk taking behaviour and experimentation which is particularly marked during adolescence.10 11 Longitudinal studies globally show similar patterns of brain development which are comparable between datasets and cultures.12 The underlying causes and impulses of risk taking, exploration and the pursuit of independence are universal and so are their long-term health implications for adolescents in future.

Experimentation and risk-taking during adolescence are associated with many behaviours such as sexual behaviour, alcohol, smoking and substance use, which in turn are risk factors for some of the leading causes of morbidity and mortality later in the life-course worldwide, for example, HIV and cardiovascular disease. Therefore, a specific focus on addressing these behaviours during adolescence is key to improving health both immediately and later in life.

The universal legal structuring of adolescence

It is during adolescence that autonomy to make decisions and social responsibility is obtained. This is enshrined in legal frameworks across the globe, examples including

• The right to vote.

• The right to drink alcohol.

• The right to marry.

Using five countries as examples, table 1 shows the age when it becomes permissible by law to vote, drink alcohol and marry, regardless of underlying social constructs. Adolescents in all these regions experience similar emancipation during adolescence.

While it may be argued that the legal frameworks may have origins in and been adopted from those in the Global North, in many instances it is short sighted to completely discredit a system based on its origins. More broadly this approach would discount the importance of global exchange of different types of knowledge, which has occurred for generations. In terms of legislature, there are many components of African traditional justice systems such as the need to resolve disputes, consensus-based decision-making and cooperation that are identical to the underpinnings of formal or Western justice systems.13 These systems universally recognise the growing responsibilities and decision-making abilities that come with age.

Rites of passage and coming of age celebrations

The autonomy and change in social status discussed above that is achieved during adolescence is marked by celebrations which are practiced globally. Although the specific practices vary across cultures, religions and geographies, rites of passage and coming of age ceremonies are not unique to the Global North or South. Examples include the first holy communion in the Roman Catholic faith, the Bar and Bat Mitzvah ceremonies in the Jewish faith, the Misaq in the Islamic faith—all of which place responsibility of upholding religious responsibilities on to an individual. Other cultural rites of passage include the sweet 16 celebrations in north America, Russ celebrations in Norway, Okuyi celebrations in several West African nations and Ulwaluko (male circumcision) in South Africa which is also practiced by Indigenous Australians and the Maasai in Kenya to mention a few.14 These events and celebrations landmark changes from childhood to adulthood and the recognition of the increased sense of responsibility accompanying this change. This demonstrates global recognition of a distinct life stage, supporting the case for the universality of the concept of adolescence.

Cross-cutting health needs across adolescence

The challenge that faces the global health community today is to improve health worldwide and achieve Universal Health Coverage. As such it is imperative to focus on and deal with cross-cutting health inequities. Adolescents constitute a sixth of the world’s population (the largest cohort ever in history). Unlike maternal and child health, a focus on adolescents has been lacking until recently, due to poor visibility and lack of political commitment and funding. Strikingly, adolescent mortality has declined less than that of all other age groups. Adolescents worldwide confront grave inequalities in accessing health essential services, with healthcare delivery barriers to access being similar across many settings. In both the USA and Ghana for example, challenges included long waiting times and insufficient privacy and confidentiality.15 16 Health outcomes among adolescents living with HIV are worse compared with those in adults, across different settings.17 This highlights the need to listen to the voices and needs of adolescents wherever they may be and for the need for age-appropriate services.

We now live in a global community with increasing calls for the decolonisation of global health and the imperative to redress the dominance and power of the Global North. However, as noted above, public health challenges are cross-cutting and a more interlinked and open world has the potential to transcend and overcome cultural and national bottlenecks, to facilitate the provision and uptake of effective health interventions. Beaglehole and Bonita in their 2010 paper describing the meaning and scope of Global Health note that health is determined by problems, issues and concerns that transcend national boundaries.18

It is also important to acknowledge that the lived experience of adolescence is going to differ between individuals, including between adolescents within the same households and indeed within the same communities and geographical regions.19 20 However, what is consistent across all settings are the developmental, emotional, social and legal changes that characterise this life phase which are associated with specific health needs, and the critical imperative to help adolescents achieve their potential. Improving adolescent health will bring a triple dividend: healthy adolescents now, healthy and productive adults in the future, and healthy children in the next generation.

Adolescents need unhindered access to youth friendly health promotion, prevention and care services regardless of context. What adolescents view as responsible youth friendly healthcare is similar across countries of all income levels and it is regressive to make inferences about differences or similarities simply based on geography. Instead, given that adolescence is a period of substantial development and social transition health professionals, policy-makers and advocates need to focus on the heterogeneity in needs across the adolescent period, for example, the differing needs of younger versus older adolescents. Divisions will not solve the global health challenges of today but may only exacerbate them and we argue for cross-learning across geographies to develop a concerted approach to improve health service delivery for adolescents.

Cultural structuring of adolescence and social adolescence

The interaction between culture and context is important in framing human development and understanding adolescence.26 27 It is widely accepted that adolescence is a transitional phase which involves multidimensional biological, neuropsychological, cognitive changes. However, adolescence is more than a universal biological stage—as with other life stages, it is underpinned by beliefs, values and expectations.28 However, as important as these are, it is often less recognised and considered in the development and implementation of health interventions. Through the sociocultural lens, we get a better understanding of values, interdependence, how one perceives themselves and others and cultural normativeness, which influences behaviours and uptake of health interventions and programmes. For example, cultural norms shape agency and behavioural constructs, which are critical to the effectiveness of interventions for adolescents, as they heavily rely on these constructs.29 30 Saraswathi highlighted the need to consider indigenous understandings of cultures including the importance of social class and gender in understanding adolescence, especially in cultures where these factors play an important role in how communities live and how decisions are made (eg, education, and marriage).31 Gender socialisation in adolescence is inherently linked to culture. Gender socialisation is the process involved in the development of behaviour through internalising gender norms and roles.32 Culture determines the socially constructed gender roles and the degree of autonomy and power attributed to particular genders.33 For example, a patriarchal structure in some African cultures plays a significant role in how adolescents conceptualise and experience sexuality and relationships. In such a setting, it would therefore not be effective to develop an HIV prevention intervention that targets only adolescent girls and young women as they are not empowered to change behaviours and practice by themselves. It would also not be effective to target adolescent girls for gender-based violence programmes and not include men, and sometimes parents due to issues of structuring.

Similarly, understanding cultural norms may have to identify and address factors that inadvertently prevent certain groups from accessing interventions, for example, young women, and similarly to facilitate uptake of interventions, for example, uptake of voluntary medical male circumcision.

Dissonance of concepts from the Global North applied to Africa

Euro-American societies operate on the premise that development during adolescence is characterised by personal choice and autonomy.34 These are values that are explicitly different from an interdependent pathway that places more emphasis on social obligations and relatedness.35 36 Although this portrayal of adolescence as an independent phase is universally accepted, this concept is a nineteenth century cultural–historical construction developed during the industrial revolution when mandatory formal schooling was introduced and enforced, the completion of schooling providing a ‘qualification’ towards adulthood.37 Hall acknowledged the influence of culture in his study of adolescence and stated that this was reflective of American society. While globalisation and social media expose adolescents globally to other perspectives and fosters new social worlds and channels of interaction, many health programmes and policies are developed based on the socioculture belief systems which most African communities have been forced to subscribe to. Euro-American systems are explicitly considered the universal norm and enforce adoption of policies that do not encompass the sociocultural norms of people in Africa, an inherently problematic symptom and consequence of colonialism. An example is family planning programmes that promote the delivery of contraception and family planning, but do not acknowledge that having a child is important to a young women to reinforce her role and her position within her society.38 Importantly, we acknowledge that this should not condone harmful cultural practices.

Individualism versus communalism

Many African cultural concepts view the person within communal values and practices, promoting a relational-oriented personhood. An example is the Ubuntu philosophy—while different definitions exist, ubuntu is defined as ‘A collection of values and practices that people of Africa or of African origin view as making people authentic human beings. While the nuances of these values and practices vary across different ethnic groups, they all point to one thing—an authentic individual human being is part of a larger and more significant relational, communal, societal, environmental and spiritual world’.39 We in no way imply or make the assumption that all African cultures are the same, and knowledge about one culture is generalisable to other cultures. We suggest that the concept of Ubuntu, which in various forms exists in different African settings, is an approach that could be used to shape health interventions for adolescents in Africa. Such an approach would prioritise the group or collective above the individual and focus on relatedness and connectedness and promote acceptability by aligning with local values, and potentially overcoming many barriers to uptake. In addition, development of interventions that promote collective responsibility dissipate stigma and reduce risk of failure. It would also redress the legacies of colonialism that enforced concepts that originated in the Global North as a universal paradigm, even if they did not account for the lived realities of the people from and living in Africa. An example of this approach which is often not sufficiently acknowledged is how the vast numbers of AIDS orphans in southern and eastern Africa have been collectively cared for in communities rather than being institutionalised.40–42

Examples of the use of African concepts in intervention development

The argument put forward by this motion is for an increased focus on local and cultural specificity in developing and implementing interventions rather than pushing for universality. Local conceptualisation is particularly pertinent for adolescents who are in a transition stage of articulating, reflecting on experience and communicating complex feelings in a language construct of their understanding.43

Interventions that use contextual sensitivity are more likely to be accepted within local populations. A successful example is the ‘Friendship bench’, a brief psychological intervention that is built around the local concept of ‘kufungisa’ or thinking too much, instead of the Euro-American concept and definition of depression.44 Encapsulating this local concept has made the intervention understandable and acceptable to those that need it. Another example is the update in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition which has incorporated a cultural formulation in diagnosis and providing patients with an interpretive framework that considers the experience and expressions of ill health.1 Cultural idioms of phenomena help in developing interventions that make sense to communities as they underlie a person’s self-understanding and self-representation.45 46 An example used with youth in Nigeria is the PEN three cultural model which examines beliefs, values, resources to promote uptake of HIV self-testing in Nigeria. The relevance of this model within African contexts is that it is centred in cultural identity, relationships and expectations (in communities) and cultural empowerment.47 It is underpinned and informed by a collectivist approach which speaks to a majority of African cultures.

The exclusionary colonialist process of only regarding adolescence within the knowledge systems and definitions that have originated in the Global North and are regarded as universal can be limiting and result in potential adverse health outcomes as observed in the COVID-19 pandemic when lockdowns were mandated in many African countries imposing substantial stress on households that relied on daily wage-earning.48 Instead, local sociocultural constructs should be integral to the design and delivery of health interventions not only for adolescents but more broadly across global health.