PMNCH Knowledge Summary #35 Act Now for Adolescents
Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2016
Language: English only
Adolescence is a critical phase for achieving physical, cognitive, emotional, social and economic capacities that are the foundation of future adult and societal health and well-being.1 Compared with the progress in infant and child health from 2000 to 2012, wherein all causes of childhood mortality declined,2 adolescents (persons 10-19 years are the focus here, but many considerations apply also to young adults 20-24) have benefitted less from the ‘epidemiological transition’. Adolescent mortality declined by only 12% compared with an under-five mortality decline of 52%, partly because of the increase in AIDS-related adolescent deaths.2 Adolescents are often seen as the healthiest cohort and yet, WHO estimates suggest that each year, nearly one million adolescents die from preventable causes, tens of millions suffer injuries, and hundreds of millions develop harmful behaviours with short- and long-term health and non-health impacts.2 Despite these challenges, a recent stronger global response to adolescent health is helping to reverse these trends. This Knowledge Summary briefly highlights achievements and gaps, and future priority actions.
Why We Must Act Now
The Sustainable Development Goals (SDGs) 2016-20303 give more prominence to adolescent health. A clearer understanding of environmental and individual determinants of health in adolescence4 is further advanced by the publication of the Lancet Commission on Adolescent Health and Wellbeing,5 and the updated Global Strategy for Women’s, Children’s and Adolescents’ Health and the Every Woman Every Child (EWEC) movement.1
Adolescents are at a distinct, formative developmental stage, experiencing puberty and neurocognitive maturation and exploring their place in the world.6 Healthy behaviours, selfesteem, skills and competencies established in adolescence benefit both adolescents and their societies.7,8 The current cohort of adolescents is the largest in history because of demographic transition and recent gains in child health.9 There is an ever-greater responsibility to support adolescents, as well as an unprecedented opportunity to benefit from this demographic dividend. The latter refers to the potential for socio-economic development presented by having large numbers of young people relative to the proportion of dependent children and the elderly in the population. The dividend is realised if young people are educated, healthy, confident and safe, they can find employment, control their reproduction, and are therefore able to contribute effectively to their nation’s development. Adolescents are essential human capital and drive current and future economic and social progress. Investments in adolescent health and well-being can thus be viewed as having a triple dividend with health benefits for adolescents today, for the adults they will become, as well as the next generation.5
The three most common causes of preventable deaths in adolescents are road injuries (particularly in males), HIV and self-harm. For girls, complications of pregnancy and childbirth, including unsafe abortion, child marriage and female genital cutting are also major risk factors. Mental health problems, notably unipolar depression, often start in adolescence and can have life-long impacts. Many adolescents, particularly males, initiate harmful behaviours, such as the use of drugs, tobacco and alcohol. Both sexes may engage in sexual and other risk taking behaviour, have a poor diet, and low physical activity. Interpersonal male-on-male violence is a widespread concern, as well as the development of harmful gender biases and sexual and gender-based violence, where women are disproportionately affected.1,2
What We Know
Achievements and Gaps
The 1994 International Conference on Population and Development (ICPD) Programme of Action10 highlighted adolescent sexual and reproductive health, influencing the Millennium Development Goals (MDGs)11 and, more recently, the SDGs.3 The updated Global Strategy1 explicitly includes adolescents and builds on lessons learnt.12 An operational framework, the Global Framework for Accelerated Action for Adolescent Health, has been developed and increased financing pledged.13 Although still insufficient, meaningful youth participation is growing: prominent examples include the Bali Youth Forum’s Declaration14 at the 2012 global ICPD review, African Youth and Adolescents Network (AfriYAN) in 20 African countries, the adolescents technical content work stream for EWEC, and formation of the youth constituency of the Partnership for Maternal, Newborn and Child Health (PMNCH). UNAIDS and the Africa Union emphasise empowering young women and adolescent girls to prevent HIV infection.15
From countries as diverse as Estonia,16,17 Uganda,18,19 and the United Kingdom,20 evidence is mounting of effective programming for different aspects of adolescent sexual and reproductive health (ASRH), primarily for 15-19 year olds.
Two important approaches are the provision of comprehensive sexuality education (CSE) and youth-friendly sexual and reproductive health (SRH) services. These programmes adhere to specific criteria, including community embeddedness, and implementing a core package of inter-related actions in the context of a safe and supportive environment.1,2,21
Nonetheless, most countries lack comprehensive national policies for adolescents, and programmes are often patchy and based on insufficiently disaggregated data.1,2,20 Primary reasons for weak policy frameworks and inadequate implementation include: competing priorities and limited commitment to adolescents as a special group; insufficient funds; discomfort regarding key adolescent health issues among policy makers, service providers and parents; lack of technical capacity in adolescent health programming; and poor accountability. There may be low awareness of environmental and individual determinants of adolescent health and the challenges they face. Lessons learnt are not shared widely, rigorously applied and/or brought to scale. Adolescents are usually subsumed in health systems within programmes for children or adults, without attention to specific age-related needs, marital status, or gender. Critical gaps remain in disaggregated demographic and health data, as well as knowledge around scaling up and sustaining effective projects or programmes while retaining quality and intensity.1,2 Detailed operations research in different contexts is also lacking.22 Data are particularly poor for younger adolescents (10-14) and for adolescents in key populations affected by HIV, substance abuse, humanitarian settings and physical, mental or social abuse.
Furthermore, potential multi-sectoral partners may not always collaborate due to a lack of awareness of the benefits of interlinked approaches or different priorities and mandates that are not easily integrated. Finally, youth-led networks are insufficiently supported and empowered; strengthening them would help ensure that adolescents’ voices are heard and valued.
Priority Future Actions
Adolescents’ basic needs and rights need to be met within enabling environments for them to survive, thrive and develop their full transformative potential. The definition of health and well-being needs to be universal and holistic, and the response should be multi-dimensional. Meeting the basic needs and rights of adolescents requires multiple constituencies to collaborate effectively through functional structures at all levels.
Policy and programming for adolescents should combine public health priorities with a strong human rights1,2,5,23 and gender transformative approach, raising accountability and transforming a client-service frame into one of obligation between duty bearers and rights holders. Despite their commonalities, the needs of adolescents 10-19 vary widely, and responses must be tailored based on local circumstances, age, sex, gender, educational and marital status, and other factors.
Figure 1 provides a model of the interlinked determinants of adolescent health and well-being that underlie multiple risk behaviours, health literacy and the adoption of care-seeking behaviours. Long-term, structural factors, such as national wealth and income inequality, play a key role.4 Using prevention science approaches to address simultaneously different levels of risk, and to promote protective factors, shows potential to contribute to better programming in countries.24
Different means are required to communicate programme and research results effectively to diverse audiences.21,22 Appropriate messaging is thus key to translating both what worked and what did not, and to enable learning.
It is important to identify, prioritise and implement to scale a small number of interlinked, evidence-based approaches specific to local contexts, needs and gaps. Ensuring robust assessment of feasibility and sustainability over time without losing sufficient intensity, quality or coverage can yield lasting results. Key measures include:
- Identifying critical unmet needs and strategic opportunities for bold, innovative actions;
- Undertaking simple actions at scale to address unmet needs (such as for iron-folate, deworming, Human Papillomavirus and other vaccines, and basic commodities including contraceptives, condoms and sanitary products), including of marginalised and vulnerable groups. Where feasible, use these actions as entry points and incorporate strategies to achieve wider outcomes and reach meaningful targets;
- With rigorous process monitoring and evaluation of results,22 developing a package of complementary interventions, each of which is delivered based on known criteria for success;
- Closely documenting new approaches relevant to adolescents in different contexts, and sharing lessons learnt.
Governments, with multi-sectoral partners, need to set nationally realistic, yet sufficiently ambitious outcome and impact targets against known baselines in order to assess trends over time. Monitoring frameworks need to use SMART (specific, measurable, achievable, relevant, time-bound) and internationally agreed indicators,25 and to reflect a gender-transformative approach. Key measures include:
- Collecting, analysing and disseminating trend data, disaggregated by sex and age (at a minimum, age groups 10-14, 15-19, 20-24) and by other demographic and criteria such as educational, socio-economic and marital status;26
- Undertaking gender audits of policies, strategies and programmes and ensuring that they espouse gender transformation to benefit both females and males;
- Developing capacity to utilise available trend data to inform adolescent health policies and programmes, and ensuring commensurate funding needed to deliver results.
To deliver key services, support and information that adolescents need, develop effective and sustainable partnerships and mechanisms. Strategic collaboration is required between diverse sectors including governments, civil society, international development agencies, communities, adolescents and other stakeholders. Other effective approaches could include the increased use of interactive media and affordable new technologies to promote linkages, particularly those favoured by young people. Increasingly, private-public partnerships provide considerable support but require strong accountability frameworks to safeguard against profit-making, without commensurate health and social gains. Additional actions include:
- Building the capacity of, and creating opportunities for, networks of adolescents and young adults to participate effectively in relevant policy-making, programme design and implementation and assessment, and documenting the outcomes of their active involvement;
- Ensuring that health, welfare, education, law enforcement, humanitarian responses and other systems integrate adolescents’ needs in staff training, financing, monitoring, and in special service provisions (e.g. for adolescents with disabilities, gender and interpersonal violence, girls at risk of child marriage, and youth involved in gangs or substance abuse, and young people in humanitarian settings).
Advocate for countries to develop and enforce supportive legislation and policy frameworks. Supportive legislative, policy and regulatory frameworks, while insufficient on their own,27,28 create the enabling environment29,30 needed to safeguard adolescents, particularly regarding sexual orientation, informed consent for HIV testing,31 and accessing harm reduction measures.32 Additional steps include:
- Promoting accountability through effective oversight to ensure that legislation and policies are consistently adhered to, duty bearers are adequately trained, and individuals know their rights;
- Utilising proven community development strategies and ensuring that positive legislation is backed by strong community programmes to change harmful traditions and practices (e.g. child marriage);
- Actively involving gatekeepers, service providers and opinion-leaders, as well as adolescents themselves.
Strengthen implementation research to understand why different approaches do or do not work in different settings and for different adolescents. Efforts may be short-term with insufficient intensity, or applied piecemeal without the complementary elements that build success;21 they may miss the most marginalised or vulnerable, or only measure short term results. Likewise, some programmes fail to engage the community and address structural impediments to adolescent health, or to provide interlinked services.
Collaboration between, and actions by multiple sectors (for instance health, education, social protection, employment and justice), can contribute significantly to adolescent health and well-being. For instance, schools can provide a supportive environment for physical and mental health as well as health and sexuality education; adolescent safety can be enhanced by preventing violence and improving road safety; mass media can encourage healthier social norms; safe, non-exploitative work opportunities can assist adolescent development.2
In a regional report on school-based CSE commissioned jointly by UNESCO, UNFPA and UNICEF, only a few out of the 10 countries assessed in East and Southern Africa33 met international standards. Furthermore, little attention was paid to empowering adolescents with agency and advocacy skills, despite evidence that these are essential for success,34 as are factors such as community engagement and complementary actions.
With global and national commitment, we must ensure that adolescents survive, thrive and contribute to transforming their future. The timing is strategic to build on the health gains in the first decade, and to utilise evidence-informed frameworks and guidelines. We can and must all rise to the challenge to address the most pressing needs and rights of all adolescents, everywhere.
1.Every Woman Every Child 2015. The Global Strategy for Women’s and Children’s and Adolescents’ Health (2016-2030): Survive, Thrive, Transform; 2015. http://globalstrategy.everywomaneverychild.org/ (accessed April 2016). 2.Health for the World’s Adolescents: A second chance in the second decade. Geneva: World Health Organization; 2014. http://www.who.int/maternal_child_adolescent/second-decade/ (accessed April 2016). 3.Sustainable Development Goals 2016-2030. New York: United Nations Development Program; 2016. http://www.undp.org/content/undp/en/home/sdgoverview.html (accessed April 2016). 4.Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. The Lancet. 2012; 379:1641-1652. 5.Patton GC, Sawyer SM, Santelli J, et al. Our future: a Lancet Commission on Adolescent Health and Wellbeing. The Lancet. 2016; doi.org/10.1016/ S0140-6736(16)00579-1. 6.Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, Ezeh AC, et al. Adolescence: a foundation for future health. The Lancet. 2012; 379:1630-1640. 7.Blum RW, Bastos FI, Kabiru CW, Le LC. Adolescent health in the 21st century. The Lancet. 2012; 379:1567-8. 8.Resnick MD, Catalano RF, Sawyer SM, Viner R, Patton GC. Seizing the opportunities of adolescent health. The Lancet. 2012; 379:1564-7. 9.The Power of 1.8 Billion: Adolescents, Youth and the Transformation of the Future. State of the World Population. New York: UNFPA; 2014. http://www.unfpa.org/swop (accessed April 2016). 10.International Conference on Population and Development. Cairo 5-13 Sept, 1994. http://www.un.org/popin/icpd/coference/offeng/poa.html (accessed April 2016). 11.United Nations Millennium Development Goals Report 2015. United Nations: New York; 2015. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf (accessed April 2016). 12.The Global Strategy on Women’s and Children’s Health, 2010 – 2015. New York: UNSG; 2010. http://www.everywomaneverychild.org/global-strategy-2 (accessed April 2016). 13.Global Financing Facility in support of Every Woman, Every Child. Washington DC: World Bank; 2015 http://www.worldbank.org/content/dam/Worldbank/document/HDN/Health/GFFExecutiveSummaryFINAL.pdf (accessed April 2016). 14.ICPD Beyond 2014. Bali Global Youth Forum Declaration; 2012. 15.Empower Young Women and Adolescent Girls: Fast-Tracking the end of the AIDS epidemic in Africa. New York: UNAIDS; 2015. http://www.unaids.org/en/resources/documents/2015/JC2746 (accessed April 2016). 16.Kempers J, Ketting E, Chandra-Mouli V, Raudsepp T. The success factors of scaling-up Estonian sexual and reproductive health youth clinic network - from a grassroots initiative to a national programme 1991–2013. Reproductive Health. 2015; 12:2. 17.Haldre J, Part K, Ketting E. Youth and sexual health improvement in Estonia 1990-2009: The role of sexuality education and youth-friendly services. The European Journal of Contraception and Reproductive Health Care. 2012; 17: 351–362. 18.Santelli J, Edelstein Zr, Wei Y, Mathur S, Song X, Schuyler A, et al. Trends in HIV acquisition, risk factors and prevention policies among youth in Uganda, 1999-2011. AIDS. 2015 ; 29(2) : 211-9. 19.Crossland N, Hadden WC, Vargas WE, Valadez JJ, Jeffery C, et al. Sexual and Reproductive Health among Ugandan youth: 2003-04 to 2012. Journal of Adolescent Health. 2015; 57(4): 393-8. 20.Hadley A. The teenage pregnancy strategy for England: concerted effort can make a difference. Entre Nous. 2014;80:28-29. 21.Chandra-Mouli V, Lane C, Wong S. What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices. Global Health: Science and Practice. 2015;3:3. 22.Oakley A, Strange V, Bonell C, Allen E, Stephenson J, RIPPLE Study Team. Process evaluation in randomised controlled trials of complex interventions. BMJ. 2006;332;413-416. 23.Knowledge Summary #34. Operationalising human rights in efforts to improve health. Geneva: Partnership for Maternal, Newborn and Child Health. http://www.who.int/pmnch/knowledge/publications/summaries/ks34/en/ (accessed April 2016). 24.Catalano RF, Fagan AA, Gavin LE, Greenberg MT et al. Worldwide application of prevention science in adolescent health. Adolescent Health 3. Lancet. 2012;379:1653-1664. 25.Hindin MJ, Tuncalp O, Gerdts C, Gipson JD, Say L. Monitoring adolescent sexual and reproductive health. Bulletin of the World Health Organization. 2016; 94:159. 26.Neal SE, Chandra-Mouli V, Chou D. Adolescent first births in East Africa: disaggregating characteristics, trends and determinants. Reproductive Health. 2015;12:13. 27.Svanemyr J, Scolaro E, Blondeel K, Chandra-Mouli V, Temmerman M. The contribution of laws to change the practice of early marriage in Africa. Paper prepared by WHO for the Inter-Parliamentary Union. Geneva: World Health Organization; 2013. 28.Johansen REB, Diop NJ, LaverackG, Leye E. What works and what does not: a discussion of popular approaches for the abandonment of female genital mutilation. Obstet Gynaecol Int. 2013;348248. 29.HIV and Human Rights in Southern and East Africa. Namibia: Arasa; 2014. http://www.arasa.info/files/6714/0498/7909/ARASA_report2014_web_full.pdf (accessed April 2016). 30.Pankhurst A. Child Marriage and FGM: evidence from Ethiopia; 2014. http://www.younglives.org.uk/content/child-marriage-and-fgm-evidence-ethiopia (accessed April 2016). 31.HIV and Adolescents: Guidance for HIV Testing and Counselling and Care for Adolescents Living with HIV. Geneva: World Health Organization; 2013. http://www.youngpeopleandhiv.org/files/HIV_Testing_guideline.pdf (accessed April 2016). 32.Rapid Assessment of Adolescent and HIV Programme Context in Five Countries: Botswana, Cameroon, Jamaica, Swaziland and Zimbabwe. New York: UNICEF; 2015. http://www.childrenandaids.org/publication/synthesis-report-rapid-assessment-adolescent-and-hiv-programme-context-five-countries (accessed in April 2016). 33.Sexuality education: a ten-country review of school curricula in East and Southern Africa. Paris: UNESCO; 2012. http://unesdoc.unesco.org/images/0022/002211/221121e.pdf. 34.Haberland N, Rogow D. Sexuality education: emerging trends in evidence and practice. J Adolescent Health. 2015;56(1).
Scientific writer: Helen Jackson. Technical Contributors (alphabetical order): AfriYAN (Patrick Sewa Mwesigye, Yemurai Nyoni), Espolea (Cecilia Garcia), Every Woman Every Child, Girls Not Brides (Heather Hamilton, Kate Whittington, Lakshmi Sundaram), Government of India (Anshu Mohan), IFMSA (Kelly Thompson, Michalina A. Drejza), Independent Consultants (Bewa Joannie, Bruce Dick, Jennifer Franz-Vasdeki, Meheret Ogbazghi Melles), J&J ( Joy Marini), Merck Sharp & Dohme (MSD ) (Farouk Shamas Jiwa), Pfizer (Charles A Thompson), PMN CH (Robin Gorna), UNF (Daniela Ligiero, Hannah Smalley), UNFPA (Danielle Engel, Laura Laski), The University of Melbourne and Murdoch Childrens Research Institute (George Patton, Susan Sawyer), Wellbeing Foundation Africa (Luther-King Fasehun), WHO (David Ross, Valentina Baltag, Venkatraman Chandra-Mouli), World YW CA (Hendrica Okondo). Coordinator: Vaibhav Gupta. Design: Roberta Annovi. Photo: Flickr Creative Commons License/UNAMID/UNMEER/Martine Perret.
- The Lancet Commission on Adolescent Health and Wellbeing
- Every Woman Every Child 2015. The Global Strategy for Women’s and Children’s and Adolescents’ Health (2016-2030): Survive, Thrive, Transform. 2015
- UNFPA Strategy on Adolescents and Youth. 2013
- UNFPA. ICPD Review Bali Youth Forum Declaration: Beyond 2014. 2013
- WHO. 2014. Health for the World’s Adolescents. A second chance in the second decade
- Women Deliver is a leading global advocate for the health and well-being of girls and women regarding maternal, sexual and reproductive health and rights. Access www.womendeliver.org. Their toolkit, Respecting, protecting and fulfilling our sexual and reproductive health and rights: A Toolkit for Young Leaders, March 2015, is also relevant to much wider youth advocacy efforts. Access the toolkit
For extensive links for research