Week 3 Assignment 1

Journal of Adolescent Health 56 (2015) 3e6

www.jahonline.org

Review article

Health for the World’s Adolescents: A Second Chance in the Second Decade

Bruce Dick, M.B. a,*, and B. Jane Ferguson, M.Sc. b a Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland b World Health Organization, Geneva, Switzerland

Keywords: Adolescent health; Mortality; Disability-adjusted life years; Health-related behaviors; Determinants; Policies; Universal health coverage; Indicators; Intersectoral collaboration; Program guidance

A B S T R A C T

TheWorldHealthOrganizationhasproducedamultimedia,interactiveonlinereportentitledHealthfortheWorld’s Adolescents: A Second Chance in the Second Decade. The report provides an overview of global and regional esti- mates of adolescent mortalityand disability-adjusted lifeyears,disaggregated byage, sex, and cause, and country- level dataon health-related behaviors and conditions among adolescents. Itoutlines the reasons whyadolescence is a unique period in the life course requiring special attention and synthesizes current thinking about the determinants that underlie the differences inhealth statusbetween adolescents. Forthe firsttime, thisnew report pulls together recommendations and guidance from across the World Health Organization relating to interventions directed to a range of priority health problems, including use of alcohol and other psychoactive substances, AIDS, injuries, mental health, nutrition, sexual and reproductive health, tobacco use, and violence, focusing on four core functions of the health sector: supportive policies, service provision, strategic information, and working with other sectors. The report concludes with 10 key actions that would strengthen national responses to adolescent health, and outlines the approaches that are needed to overcome the obstacles to accelerating evidence-informed actions to improve the health of adolescents worldwidedwith all the benefits that this will have for public health in the present and across the life course, for this generation and the next.

� 2015 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

* Address correspondence to: Bruce Dick, M.B., Chemin des Noyers 5bis, 1295 Tannay, Switzerland.

E-mail address: [email protected] (B. Dick).

1054-139X/� 2015 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. http://dx.doi.org/10.1016/j.jadohealth.2014.10.260

Much has been written over the past 25 years about the need to direct more attention and resources tothehealthand development of adolescents. During this time, we have seen progress on many fronts: a better understanding of the health status of adolescents; growing clarity about the determinants underlying death, disease, and health-related behaviors during adolescence; a stronger evidence base for interventions; and increased commitment and action from national governments and nongovernmental organi- zations. This journal exemplifies the growing body of research focusing on adolescent health, although evidence from the low- and middle-income countries where the vast most of the world’s adolescents live is still relatively limited.

A number of recent publications have advocated on behalf of adolescents from a range of perspectives, including public health, human rights, and socioeconomic development [1e10]. However, although highlighting the progress that has been made, these re- ports also stress that much more needs to be done if we are to take advantage of this period of the life course to improve the present and the future for individuals, families,communities, and countries.

The World Health Organization’s Health for the World’s Adolescents:a second chance in the seconddecade (H4WA) willboth contribute to the groundswell of attention being directed toward adolescents and support accelerated action, including follow-up to the 2011 World Health Assembly Resolution on Youth and Health Risks.

H4WA is a multimedia, interactive online, fully referenced report that can be found at http://www.who.int/adolescent/ second-decade. Readers can download and print a summary

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that is available in all official UN languages, but the report itself is only Web based, which allows the inclusion of videos, interactive graphics, and direct links to documents that are mentioned in the report.

H4WA focuses primarily on the health of adolescents (10e19 years) and the role of the health sector in improving and maintaining adolescent health. It is directed at senior-level and mid-level staff in ministries of health, and partners in the health sector who are providing technical, financial, and implementa- tion support for interventions that contribute to adolescent health and development. However, it should also appeal to many other audiences: advocates, service providers, educators, and even young people themselves.

H4WA has received input from across the World Health Organization (WHO) and from experts in the field of adolescent health. In addition, WHO organized two online consultations, one with primary care providers and the other with adolescents.

The consultation with primary care providers covered a range of issues relating to the provision of health services to adoles- cents. It was conducted via an open-access online survey in English, and 735 primary care providers from 81 countries participated, most from high- and middle-income countries.

The adolescent consultation was open to all adolescents aged between 12 and 19 years and was conducted via an open-access online survey that was available in Arabic, Chinese, English, French, Russian, and Spanish. A total of 1,143 adolescents from 104 countries participated in the consultation, most from low- and middle-income countries.

WHO additionally organized a global photo competition for adolescents aged 14e19 years. All the photos included in H4WA were taken by the 10 winners of the competition.

A Picture of Adolescent Health

H4WA provides new estimates of mortality and disability- adjusted life years (DALYs) lost during adolescence, based on the 2012 WHO global health estimates. Data from the 2000 es- timates are provided for comparison. The estimates are available by cause, sex, age (10e14, 15e19, and 10e19 years), and WHO regions. There are also country-level data on health-related behaviorsdincluding trendsdfrom the health behavior in school-age children surveys and the global school-based student health surveys.

The leading causes of death among adolescents globally in 2012 were road injury, AIDS, suicide, lower respiratory infections, and interpersonal violence. The most important dif- ference from the 2000 mortality data is that human immuno- deficiency virus (HIV) is now estimated to be the number 2 cause of mortality among adolescents; in 2000, HIV was not among the top 10 causes of death.

The increase in adolescent HIV mortality is likely the result of more children living to adolescence through improved pediatric HIV treatment and care. It may also reflect the limitations in our current knowledge and estimation of survival times for HIV-positive children. At the same time, there is good evidence on the poor quality of, and retention in, services for adolescents living with HIV, indicating the need for improved service de- livery for this group.

Between 2000 and 2012, there were significant declines in mortality among adolescents because of maternal causes and measles, which demonstrates what is possible with concerted efforts.

Regional mortality highlights include

(1) One of every three deaths among adolescent males in the low- and middle-income countries in the Americas Region is due to interpersonal violence.

(2) One of every five deaths among adolescents in high-income countries is due to road traffic injuries.

(3) One of every five deaths among adolescent males in the low- and middle-income countries of the Eastern Mediterranean region is due to war and conflict.

(4) One of every six deaths among adolescent females in the south-east Asia region is due to suicide.

(5) One of every six deaths among adolescents in the African region is due to HIV.

DALYs declined between 2000 and 2012 for all adolescents except 15- to 19-year-old males in the Eastern Mediterranean region and the Americas Region. DALYs for all adolescents declined most in the south-east Asia region (21%) and the Western Pacific and European regions (16% and 17%, respectively). The smallest declines took place in the Eastern Mediterranean region (4%).

The major causes of DALYs changed little between 2000 and 2012. In 2012, depression, road injuries, iron-deficiency anemia, HIV, and intentional self-harm were the top five global causes of DALYs for adolescents. The one notable change from 2000 was the high ranking of HIV.

The DALYs highlight not only the epidemiologic transition that takes place during adolescence but also a number of gender differences (e.g., more interpersonal violence and war-related deaths among male adolescents and maternal problems affecting females).

In terms of health-related behaviors, the report shows that fewer than one in four adolescents meets recommended guide- lines for physical activity; in some countries, as many as one in every three is obese. And in most countries in every region, at least half of younger adolescent boys report serious injuries in the preceding year.

Fortunately, there is also some positive news concerning adolescent behavior. In most countries, half or more of 15-year- olds who are sexually active report using condoms the last time that they had sex, and cigarette smoking is decreasing among younger adolescents in many high-income countries.

In addition to these data, the report has a section outlining the availability and important gaps in strategic information, particu- larly program input and output data A clear message from the report is that the data available to inform policy-making and pro- gramdesignandmonitoringare farlessadequatethanthedatathat are available for other age groups. This requires urgent attention.

Support for Action in Countries

For the first time, H4WA collates all WHO recommendations and guidance from across the organization relating to adolescent health, including use of alcohol and other psychoactive sub- stances, HIV, injuries, mental health, nutrition, sexual and reproductive health, tobacco use, and violence.

Health services

A number of specific analyses were carried out for H4WA to place the provision of health services for adolescents within the context of universal health coverage. In terms of needed health

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services, the report compiles all the health services and interventions addressed in WHO Guidelines, including HIV, immunization, the integrated management of common condi- tions, mental health, nutrition, physical activity, sexual and reproductive health and maternal health, substance use, tobacco control, violence, and injuries. Concerning sufficient quality, a new synthesis of standards for the provision of health services to adolescents has identified eight standards on the basis of the national standards from 25 countries, existing WHO guidance, and a literature review. Finally, in response to the need to ensure that services do not expose the user to financial hardship, obstacles and solutions of particular importance to adolescents were identified to maximize the range of services and the number of adolescents covered by effective prepaid pooling arrangements, and to reduce out-of-pocket payments at the point of use.

Strategic information

H4WA includes 32 proposed core adolescent health indicators, on the basis of the WHO/International Health Partnership measurement framework, for use in countries. Thirteen of the indicators measure impact, eleven measure outcome/coverage, five measure inputs/outputs, and three measure determinants. Seventeen of the 32 indicators have already been reviewed in terms of their quality and availability, an additional eight are included in existing nationally representative multicountry surveys, and five others are collected in WHO-supported surveys.

Supportive policies

H4WA includes a new analysis of 109 national health policy documents. Eighty-four percent of the policies included some attention to adolescents, with three-quarters of them focusing on sexual and reproductive health, including HIV/AIDS; approxi- mately one-third address tobacco and alcohol use among adolescents and one-quarter address mental health. Specific consideration of other important issues, such as injuries, nutrition or physical activity among adolescents, is infrequent in national policies. Fifty-two of the countries specify goals related to adoles- cents, but only 32 of the countries spell out measureable targets in their policy documents, and these mostly address changing the prevalence of a specific health condition or increasing coverage or access to health services for adolescents. H4WA also includes a specific review of mental health policies from 30 countries.

Strengthening other sectors

Responding to the major causes of mortality and lost DALYs during the adolescent years will require engaging a range of sectors beyond just the health sector. Section 9 of the report focuses on interventions with parents, the creation of safe and supportive communities, education and the school environment, social protection, and preparing for and obtaining decent work. It highlights success stories and lessons learned about overcoming the challenges to convergence between sectors.

Ten Key Actions to Strengthen National Responses

H4WA proposes the following:

(1) Understand that adolescent health is essential for public health.

(2) Strengthen advocacy for adolescent health. (3) Incorporate a focus on adolescents into all health policies,

strategies, and programs. (4) Use the response to adolescent health as an indicator of

equity. (5) Involve adolescents and maintain a positive perspective

toward them. (6) Support interventions that go beyond the individual

adolescent. (7) Improve the collection, analysis, and use of data. (8) Focus on universal health coverage for the second decade. (9) Work with other sectors to improve the health of

adolescents. (10) Define and fund research priorities.

Although many of these recommendations would be appli- cable to all population groups, they are of particular importance to the second decade because this period of the life course has been so neglected.

There are many reasons why adolescent health has been neglected in comparison with other age groups:

(1) Data are not disaggregated by age; what we fail to measure we fail to act on.

(2) Consensus around global indicators to monitor adolescent health is lacking.

(3) Interventions are often more complex than those for child health.

(4) Action is required from a range of sectors. (5) Many of the issues are culturally and politically sensitive. (6) Research is limited, particularly in low- and middle-income

countries.

H4WA highlights a number of ways in which these obstacles can be overcome.

(1) Move beyond the myths. There are still many myths about adolescents that obstruct accelerated action: that they are healthy and therefore do not need much attention; that the only real problems that they face are related to sexual and reproductive health; and that the evidence base is weak and we do not really know what to do. None of these are true.

(2) Define priorities beyond mortality. Deaths in adolescence are important, and no adolescent should die from a cause that is preventable or treatable. But for public health more gener- ally, more attention needs to go toward preventing the health-compromising behaviors and conditions that arise during adolescence and have a long-term impact on health across the life course.

(3) Focusbeyondtheindividual.Althoughprovidinghealthservices and improving adolescents’ own knowledge and skills are important, these alone will not be enough to improve adoles- cent health. Structural, environmental, and social changes will also be essential, including more support for parents and schools, and policies that protect and promote adolescents’ health.

(4) Act beyond single-problem thinking. Many of the behaviors and conditions that undermine the health of adolescents have common determinants and are linked. We must focus on interventions that more effectively address the common determinants of multiple risk behaviors.

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(5) Develop programs that are beyond “business as usual.” As countries move toward universal health coverage, ensuring that adolescents receive adequate consideration is essential. There are many untapped resources to improve and maintain the health of adolescents, including adoles- cents themselves and interactive media and technologies.

(6) Be challenged beyond aspirations. A human rightsebased approach stresses the obligations of governments. Setting clear goals and targets and monitoring progress give focus to these obligations. Consensus is needed on a set of measur- able and achievable goals and targets, which countries can select and adapt as necessary.

In the second decade of the millennium, we have many op- portunities to improve health in the second decade of life. H4WA aims to support countries, and partners accelerate action and increase accountability for adolescent health. It was launched at the 2014 World Health Assembly, and there have been proposals for adolescent health to be taken up in subsequent sessions of WHO’s Governing Bodies.

References

[1] Lloyd CB. Growing up global: The changing transitions to adulthood in developing countries. Washington, D.C: The National Academies Press; 2005.

[2] Jimenez EY, Fares J, Gauri V, et al. World development report 2007: Development and the next generation. Washington, D.C: The World Bank; 2006.

[3] The state of the world’s children 2011. Adolescence: An age of opportunity. New York: United Nations Children’s Fund; 2011.

[4] Progress for children: A report card on adolescents, number 10. New York: United Nations Children’s Fund; 2012.

[5] Moving young. New York: United Nations Population Fund; 2006. [6] Generation of change: Young people and culture. New York: United

Nations Population Fund; 2008. [7] The Lancet series on adolescent health, 2012. London: The Lancet, 2012.

Available at: http://www.thelancet.com/series/adolescent-health-2012. Accessed February 13, 2014.

[8] The Lancet series on adolescent health, 2007. London: The Lancet, 2007. Available at: http://www.thelancet.com/series/adolescent-health. Accessed February 13, 2014.

[9] Emerging issues in adolescent health. J Adolesc Health 2013;52- (Supplement 2):S1e45. Available at: http://www.jahonline.org/issues? issue_key¼S1054-139X%2812%29X0007-7. Accessed February 6, 2014.

[10] Supplement on multiple risk behaviour in adolescence. J Public Health 2012;34:i1e56.