1 Global Accelerated Action for the Health

2 of Adolescents (AA-HA!)
3 Guidance to Support Country Implementation
4 Second edition (DRAFT 27 Sep 2022)

5 Table of Contents
6 Section 1: AA-HA! – advancing the case for investment in adolescent health and well-being .............. 8

7 1.1 Understanding adolescent well-being ........................................................................................ 13

8 1.2 Why invest in adolescent health and well-being? ..................................................................... 14

9 1.3 COVID-19, other contemporary threats to adolescent well-being, and opportunities ........... 17

10 1.3.1 The COVID-19 pandemic ........................................................................................................ 17

11 1.3.2 Climate change ....................................................................................................................... 19

12 1.3.3 Armed conflicts and displacements ......................................................................................... 20

13 1.3.4 Opportunities ........................................................................................................................... 20

14 1.4 What is special about adolescence? .......................................................................................... 21

15 1.4.1 Determinants at the individual level ........................................................................................ 22

16 1.4.2 Determinants at interpersonal and community levels ............................................................. 24

17 1.4.3 Determinants at organizational, environmental and structural level ....................................... 25

18 Section 2: The status of health and well-being of the world’s adolescents ........................................... 28

19 2.1 Overview of the adolescent population, mortality and morbidity burdens .................................. 30

20 2.1.1 Mortality burden ............................................................................................................................ 30

21 2.1.2 Morbidity burden ........................................................................................................................... 32

22 2.2 Overview of protective factors for adolescent health and well-being ..................................... 35

23 2.3 Selected outcomes and determinants for adolescent health and well-being ......................... 37

24 2.3.1 Unintentional injury .................................................................................................................. 37

25 2.3.2 Violence ................................................................................................................................... 37

26 2.3.3 Sexual and reproductive health, HIV and other sexually transmitted infections ..................... 39

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27 2.3.4 Communicable diseases ......................................................................................................... 41

28 2.3.5 Non-communicable diseases (NCDs) ..................................................................................... 43

29 2.3.6 Mental health ........................................................................................................................... 45

30 2.3.7 Alcohol and drug use .............................................................................................................. 47

31 2.3.8 Tobacco use ............................................................................................................................ 47

32 2.3.9 Physical activity and sedentary behaviour .............................................................................. 47

33 2.3.10 Nutrition ................................................................................................................................... 48

34 2.3.11 Humanitarian and fragile settings ............................................................................................ 49

35 Section 3: Understanding what works – the AA-HA! package of evidence-based interventions ......... 52

36 3.1 Conceptualizing adolescent health interventions ..................................................................... 53

37 3.2 Positive health and development interventions ........................................................................ 54

38 3.3 Unintentional injury interventions ............................................................................................... 58

39 3.4 Violence interventions ................................................................................................................ 63

40 3.5 Sexual and reproductive health (SRH) interventions, including HIV interventions ......... 71

41 3.6 Communicable disease interventions ........................................................................................ 81

42 3.7 Non-communicable diseases....................................................................................................... 87

43 3.8 Interventions for the prevention and treatment of mental health conditions ......................... 91

44 3.9 Interventions to address alcohol and drug use ......................................................................... 98

45 3.10 Interventions to address Tobacco use ..................................................................................... 103

46 3.11 Physical activity and sedentary behaviour .............................................................................. 105

47 3.12 Adolescent nutrition ................................................................................................................... 107

48 3.13 Interventions in humanitarian and fragile settings.................................................................. 115

49 Section 4: Setting national priorities ........................................................................................................ 118

50 4.1 Needs assessment ...................................................................................................................... 122

51 4.2 Landscape analysis .................................................................................................................... 124

52 4.3 Setting priorities .......................................................................................................................... 129

53 4.4 Additional considerations .......................................................................................................... 131

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54 Section 5: programming: translating priorities into actions and plans ................................................ 134

55 5.1 A logical framework for translating priorities into plans and programmes .......................... 135

56 5.2 Planning multi-sectoral action ................................................................................................... 140

57 5.2.1 Two pathways for programming for adolescent well-being ................................................... 140

58 5.2.2 Approaches to multi-sectoral action ...................................................................................... 141

59 5.2.3 Build leadership within the Ministry of Health and across the government........................... 145

60 5.2.4 Ensure meaningful adolescent and youth engagement ........................................................ 147

61 5.2.5 Secure financing for adolescent well-being programmes ..................................................... 155

62 5.2.6 A renewed attention to school health and mental health programmes ................................. 164

63 5.2.7 Addressing adolescent well-being in humanitarian and fragile settings ............................... 169

64 5.2.8 Gender transformative approaches in programming ............................................................ 174

65 5.3 Implementation areas and strategies in key sectors .............................................................. 178

66 5.3.1 Health .................................................................................................................................... 178

67 5.3.2 Education .............................................................................................................................. 197

68 5.3.3 Social protection .................................................................................................................... 200

69 5.3.4 Criminal justice system ......................................................................................................... 203

70 5.3.5 Labour ................................................................................................................................... 207

71 5.3.6 Telecommunications ............................................................................................................. 209

72 5.3.7 Road and transportation. ....................................................................................................... 214

73 5.3.8 Housing and urban planning. ................................................................................................ 217

74 5.3.9 Energy ................................................................................................................................... 220

75 5.3.10 Environment .......................................................................................................................... 224

76 6.1 Global adolescent health measurement ................................................................................... 228

77 6.1.1 Overview of global frameworks and the Global Action for Measurement of Adolescent health
78 (GAMA) 228

79 6.1.2 Data collection systems for adolescent health indicators ..................................................... 232

80 6.1.3 Global adolescent health databases ..................................................................................... 233

81 6.1.4 Monitoring of inequality and disaggregation of health data .................................................. 234

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82 6.2 Monitoring and evaluation of adolescent health programmes at country level ................... 235

83 6.2.1 Monitoring adolescent health programmes ........................................................................... 235

84 6.2.2 Evaluation of adolescent health programmes ....................................................................... 238

85 6.2.3 Country support for monitoring adolescent health programmes ........................................... 240

86 6.3 Advancing research for adolescent health and wellbeing ..................................................... 240

87 6.4 Involving adolescents in monitoring, evaluation and research ............................................. 241

88 References. .................................................................................................................................................. 244

89
90

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91 Introduction

92

93 Aim of the guidance.

94 The AA-HA! guidance aims to assist governments in identifying national and subnational priorities and
95 implementation strategies as they respond to the health and well-being challenges, opportunities and needs
96 of adolescents in their countries. It is intended as a reference document for national and subnational level
97 policymakers and programme managers to assist them in planning, implementing, monitoring and evaluating
98 adolescent health programmes.

99

100 The first edition.

101 The first edition of the AA-HA! guidance was published in 2017 [1] building on the momentum created by the
102 2030 Agenda for Sustainable Development and the United Nations Secretary-General Global Strategy for
103 Women’s, Children’s and Adolescents’ Health (2016–2030) (the Global Strategy) in support of the 2030 Agenda
104 [2], and in response to the request by the 68th World Health Assembly to develop global guidance on how to
105 take accelerated action for the health of adolescents (AA-HA!).

106

107 The second edition.

108 The second edition uses the same systematic approach to planning and implementing adolescent health and
109 well-being programmes as in the first edition (Figure XYZ). The overall structure of the document also has not
110 changed from the first to the second edition.

111 After a brief introduction which summarizes the main arguments for investing in adolescent health and well-
112 being , as well as opportunities and global threats, the document describes the current status of adolescent
113 health and well-being worldwide, evidence-based interventions to improve it, and then details the key steps
114 in priority setting, planning, implementing, monitoring and evaluating adolescent health programmes. The
115 national level programming process starts with understanding the country’s epidemiological and development
116 profile (needs assessment), analysis of what is already being done and by whom (landscape analysis), and
117 then undertaking a consultative process for setting national priorities for adolescent health and well-being.
118 For the agreed priorities, the guidance describes options for programming, and provides an inventory of key
119 implementation strategies for intersectoral and single-sector actions. Finally, the guidance supports policy
120 makers with tools for designing robust monitoring and evaluation frameworks to enhance accountability and
121 improve programmes. Throughout the document, case studies are provided to demonstrate that what is being
122 recommended can be done, and in some cases has already been implemented.

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123 Figure A. A systematic approach to accelerate action for the health and well-being of adolescents (AA-HA!)

Section 1 Section 2 Section 3 Section 4 Section 5 Section

Building an Understanding Identifying Setting Conceptualizing Strengthening

investment the status of evidence- national and implementing accountability
case. This adolescent based priorities for national for adolescent
section health and interventions adolescent adolescent health health and
provides key well-being for health and and well-being well-being.
arguments worldwide. This adolescent well-being programmes. This This section
about what is section helps to health and programmes. section describes guides policy
special about understand main well-being. This section pathways for makers in
adolescents causes of ill This section guides policy programming for principles of
and why health in provides a makers in the adolescent well- monitoring and
investing in adolescents menu of process of being, approaches to evaluation of
them results globally and evidence-based needs multisectoral action, adolescent
in long-term regionally, and interventions assessment, and key health and well-
societal the determinants across 6 areas landscape implementation being
benefits of health and of adolescent analysis and strategies for programmes,
well-being health priority setting intersectoral and and priorities for
(unintentional to inform the single sector actions research
injury; violence focus of in key sectors
prevention; national (health, education,
SRH and HIV; adolescent social protection,
communicable health and criminal justice,
diseases; non- well-being labour,
communicable programmes. telecommunications,
diseases, road and
nutrition and transportation,
physical housing and urban
activity; mental planning, energy,
health, environment).
substance use
and self-harm;
interventions in
humanitarian
and fragile
settings), and
across well-
being domains

Meaningful youth engagement in programming for adolescent well-being

Addressing adolescent health and well-being in humanitarian and fragile settings

124 What is new in the second edition?

125 Building on the first edition launched in 2017, this publication seeks to strengthen the understanding of the
126 interplay between health and its determinants that contribute to adolescent health and well-being. Whereas
127 the second edition of the AA-HA! guidance features the same systematic approach to programming for
128 adolescents as in the first edition, it provides an improved, evidence-based foundation for programming for
129 adolescent health and well-being by undertaking multisectoral action. The main changes in the second edition
130 are summarized below:

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131 New data

132 The revised edition provides updated data on health, mortality, morbidity, and well-being determinants
133 (section 2), and features the recent consensus of core indicators for adolescent health and well-being (section
134 6) [3].

135 Building on significant political and scientific advances since 2017. In the last 5 years major initiatives
136 were launched [4-6], new insights became available from research [6-9] and guidelines [10-13], and new
137 guidance in support of UHC became available on quality of care [14-16], providers’ competencies , how to
138 advocate for investing in adolescent health within discussions about basic benefit packages [6, 17, 18], and
139 the trade-off between specific programmes and overall system strengthening [19, 20]. (See section XYZ
140 gaining momentum). New evidence synthesis from UN agencies [4, 14, 15, 21-23] has helped to better inform
141 actions by sectors other than health in becoming adolescent-responsive [4, 16, 24-29].

142 All this wealth of up-to-date resources underpin the contents of the second edition, including the menu of
143 evidence-based interventions (section 3), and the approaches to programming (section 5).

144 Integrating learnings from the application of the first edition of the AA-HA! guidance. Since its
145 launch in May 2017, many countries have used the AA-HA! guidance to update and develop comprehensive
146 adolescent health strategies and plans. The learning from these processes is integrated in the second edition
147 including as new case studies, and up to date reference documents.

148 Defining and integrating well-being into programmes. The first edition of the AA-HA! promoted a
149 positive development approach to programming, which integrated the knowledge about the importance of
150 protective factors such as agency and resilience in designing programmes. Since 2017, the thinking has
151 evolved with a consensus about adolescent well-being domains reached by UN H6+ agencies and the
152 Partnership for Maternal, Newborn & Child Health (PMNCH) (see section XYZ) [30]. Therefore, the second
153 edition makes one step further in moving from a largely health-centric perspective to a more holistic
154 understanding of adolescent well-being (see Figure XYZ), and its implication for programming.

155 Integrating learnings from COVID-19. Years, or even decades, of development progress have been
156 halted or reversed, due to the multiple and widespread impacts of COVID-19 [31]. The unprecedented global
157 school closures during the COVID-19 pandemic, and other responses to the pandemic, have affected the
158 learning, development and well-being of adolescents worldwide. These, and other learnings from the
159 pandemic are brought into the second edition of the guidance to inform building resilient education and other
160 systems critical to adolescent health and well-being.

161

162

163 How was the second edition developed?

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164 Regional consultations to clarify the extent of the revision

165 Technical Working Group

166 Peer review

167 Public consultation

168 Youth involvement

169

170

171 Section 1: AA-HA! – advancing the case for

172 investment in adolescent health and well-being
173 What is new in this section?
✓ Summary of lessons learned from the first edition of the
174
AA-HA! guidance included
✓ The key scientific, political developments and
175
programmatic advances since 2017 described
176 ✓ The adolescent well-being framework integrated
✓ The investment case updated
177
✓ COVID-19, other contemporary threats to adolescent

178 well-being, and opportunities described

179

180 Key messages

181 • Adolescence is one of the most rapid and formative phases of human development. The
182 distinctive physical, cognitive, social, emotional and sexual development that takes place during
183 adolescence demands special attention in national development policies, programmes and plans.
184 • The global consensus on adolescent well-being sets the agenda for a new generation of
185 adolescent programmes that consider the interconnectedness of protective and risk factors for
186 adolescent well-being at multiple levels from the macro policies that shape safe and supportive
187 environments, through to good health and optimum nutrition; education, life-skills and
188 employability; connectedness, positive values, and contribution to society; and agency and
189 resilience.

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190 • Investments in adolescent well-being bring a triple dividend of health and economic benefits in
191 the adolescent now, during their future life and into the next generation, and thus enhance
192 human capital. The smartest of all are the coordinated investments in health and education that
193 bring mutually reinforcing benefits.
194 • The 2030 Agenda for Sustainable Development cannot be achieved without investment in
195 adolescent health and well-being, including fulfilment of its goals related to poverty, hunger,
196 education, gender equality, water and sanitation, economic growth, human settlement, climate
197 change and peaceful and inclusive societies.
198 • The COVID-19 pandemic has brought to the spotlight the power of the global community to
199 make investments in health a global priority. It has also brought highlighted the fact that the
200 role of schools goes well beyond education to ensure critical nutrition, social protection, mental
201 health and other services. This offers a unique opportunity to reinvigorate global commitments
202 to adolescent health, well-being, and children's rights, and to increase investments.

203

204 AA-HA! guidance was instrumental to accelerate action in regions and countries . Since its launch
205 in May 2017, the WHO/HQ Interdepartmental Technical Working Group on Adolescent Health and Well-being,
206 and UN agencies from the H6 Partnership have been working closely with countries to support them in
207 updating and developing comprehensive adolescent health strategies and plans. By the end of 2022, most of
208 the countries in the African region (AFR), the South-East Asia region (SEAR), and the region of the Americas
209 (AMR), and selected countries in the Eastern Mediterranean region (EMR) and Western Pacific (WPRO), have
210 used the AA-HA! Guidance to inform their national plans [32, 33]. Moreover, the Guidance was an influential
211 framework to inform regional initiatives and political commitments such as the AFRO Adolescent Health
212 Flagship Programme [33, 34], the PAHO Plan of Action for Women’s, Children’s and Adolescents’ Health 2018-
213 2030 [35], the EMRO Regional Framework of Joint Strategic Actions for Young People and the European
214 adaptation of AA-HA [36, 37].The wide application of the guidance in diverse contexts has demonstrated that:

215 • The AA-HA! systematic approach to plan adolescent health programmes is suitable for countries with
216 different epidemiological profile and diverse socio-political situations and developmental stages
217 • The AA-HA! approach to provide menus of interventions and implementation strategies that countries
218 can chose from rather than a core package of interventions and strategies for all countries, is highly
219 acceptable. The explicit process of national priority setting described in the guidance and the manual
220 for facilitators [38] is conducive for country teams to arrive at national priorities through a transparent
221 process of priority setting, own by all key stakeholders
222 • Although the AA-HA! guidance was aiming to support primarily national programming, its application
223 for district level planning in a number of countries has proven that the approach can be successfully
224 applied for subnational level planning

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225 • The emphasis that AA_HA! has put on involving adolescents in the process of planning adolescent
226 health and well-being programmes has facilitated an increased awareness of policy makers of the
227 importance of doing so, and resulted that in most if not all countries that have used the guidance,
228 adolescents were involved in decisions regarding national and subnational priorities.
229 • The emphasis that AA_HA! has put on inter-sectoral and multisectoral action has resulted that in all
230 or most countries the process of national programming has involved sectors other than health
231 • Although the guidance is dense in content, the level of details is useful for practical application
232 • The accompanying manual [38] is a useful tool to enable country teams to steer the process of
233 national priority setting and programming without or minimal external assistance

234 Advances made in promoting well-being as a positive vision of health. In the last five years major
235 initiatives were launched that advanced the positive vision of health that integrates physical, mental, spiritual
236 and social well-being [31]. The Global Conference on Health Promotion, and its resulting Geneva Charter for
237 Well-being, stressed that well-being societies provide the foundations for all members of current and future
238 generations to thrive on a healthy planet, no matter where they live [31]. The meaning of well-being for
239 adolescents was articulated by the UN H6+ agencies´ Adolescent Well-being Initiative [30] that launched a
240 multi-stakeholder call to action to prioritize adolescent well-being before the Global Forum for Adolescents in
241 2023 that will review progress and aim to increase political and financial investment in this population group.
242 As part of the initiative, a consensus conceptual framework for adolescent well-being was agreed in 2020 by
243 WHO, the Partnership for Maternal, Newborn and Child Health and other global partners [1]. (See Figure
244 XYZ).

245 Progress made in promoting a focus on adolescents in reaching UHC targets . Adolescents were in
246 the spotlight in the lead up to the United Nations High-level Meeting on Universal Health Coverage in 2019
247 that mobilized the highest political support for the entire health agenda under universal health coverage [39].
248 Its resulting political declaration called for increased investment in health promotion and disease prevention,
249 education, health communication and health literacy, as well as safe, healthy and resilient environments
250 enabling adolescents to have increased skills and knowledge to take informed health decisions and improve
251 health-seeking behaviour [40].

252 There is a renewed and unprecedented attention to school health . Today there is an unparalleled
253 attention to school health as exemplified by the Inter-Agency partnership for stepping up school health and
254 nutrition. the well-coordinated joint response to the needs of learners during the COVID-19 pandemic, the
255 uptake of the global initiative to Make Every School a Health Promoting School [6, 18], the recognition by the
256 Transforming Education Summit of learners' health and well-being as key to transforming education , and
257 other global and regional initiatives to strengthen school health [41]. An alliance , between WHO, UNESCO,
258 UNICEF, the Food and Agriculture Organization of the United Nations, the World Food Programme, UNFPA,
259 UNAIDS and the United Nations Environment Programme was built to support school health and health-
260 promoting school programmes and initiatives towards Making Every School a Health Promoting School [42].

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261 Global and regional declarations have since called for more investments in school health [43-45], and a
262 renewed resolve to restore, improve and scale sustainable school meals programmes came through a new
263 Global School Meals Coalition [46].

264 The investment case is stronger. Building the investment case for adolescents has advanced with new
265 insights on the benefits of investing in adolescent health [8], the need to restructure health and social systems
266 to deliver better for adolescent well-being [6-9], and how to better plan and fund intersectoral action [47,
267 48].

268 United Nations’ has strengthened its work for youth. The United Nations has strengthened its
269 engagement with and for young people, and formulated the United Nations Youth Strategy Youth 2030), an
270 ambitious system-wide strategy to guide work with and for young people around the world [49]. The first
271 progress report on the implementation of Youth 2030 was published in 2021 and highlighted the UN system’s
272 response to the needs of youth in COVID-19, and the impact of the ambitious UN reform process on youth
273 programming by UN Country Teams [50]. The second report, published in 2022, highlights progress achieved
274 in 2021 across the UN system, including by UN agencies and UN Country Teams, working for and with youth
275 [51]. The UNFPA new strategy "My Body, My Life, My World!", that encapsulates the latest learning and
276 evidence on adolescent and youth programming, is one example of how UN agencies focus on adolescents
277 and youth, and support the implementation of the UN system-wide agenda Youth2030 [52].

278 Meaningful youth engagement gets global consensus. The movement for meaningful youth
279 engagement has accelerated. The Global Consensus Statement on Meaningful Adolescent and Youth
280 Engagement that has proposed the definition, key principles and recommendations, was co-signed by
281 organizations within and outside the United Nations system [53], and its implementation is being monitored
282 [54]. WHO has established the first WHO Youth Council, which will provide advice on health and development
283 issues that affect young people within a comprehensive, inclusive youth engagement strategy [42]. From
284 youth movements for accelerating action to end TB, to engaging youth against AIDS to disseminate research
285 and consultations on the environment and NCDs, WHO has used appropriate platforms and networks – digital,
286 in-person, audio-visual, media, publications – to reach out to young people, solicit their views and ideas and
287 draw on and learn from their experiences (see for example Box XYZ) [42]

288 Box XYZ

WHO mobilizes youth to end TB

in 2019, WHO launched a special youth initiative titled 1+1- to call for youth mobilization to boost the fight
to end TB. The initiative aims at advancing engagement with young people and amplifying their voices to
end TB. Youth can have a multiplier effect in the fight to end TB, to accelerate progress towards reaching
the ambitious 2022 targets of the UN high-level meeting on ending TB, as well as the larger goal of ending
TB by 2030, as included in the WHO End TB Strategy and the SDGs. This was followed by a Global Youth

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 Townhall to end TB that culminated in a Youth Declaration to End TB. WHO is working with young people
around the world to strengthen their engagement and implement the declaration.

Source: https://www.who.int/activities/mobilizing-youth-to-end-tb.

289

290 Adolescents are visible in many topic-specific agendas’ and progress continues to improve
291 adolescent health and well-being outcomes and their monitoring. Other developments took place to
292 accelerate action related to specific domains of health and well-being:

293 • In 2019, the International Conference on Population and Development +25 celebrated and took
294 stock of progress made in adolescent sexual and reproductive health (SRH) and rights in the 25
295 years since the original Conference in Cairo in 1994. While celebrating achievements, such as
296 substantive reduction in child marriage and HIV infections, it identified the work that remains to
297 be done to meet SRH needs and fulfil the SRH rights of adolescents [55].
298 • A renewed attention to adolescent mental health has resulted in new partnerships, such as the
299 Joint Programme on Mental Health and Psychosocial Well-being and Development of Children
300 and Adolescents, launched by WHO and UNICEF in 2020 [56]. The programme establishes
301 mutual commitments, a shared framework and a coordinated strategy to change laws, policies,
302 services and family and community environments for better mental health and psychosocial well-
303 being for the next generations [42].
304 • Experiences from implementing rights-based and gender transformative approaches in
305 programmes have been documented, and informed new guidance [21][15, 16, 22, 23, 57-60].
306 • For the first time, a comprehensive overview of the scale and consequences of children and
307 adolescents’ exposure to e-waste was documented in a report that summarized the latest
308 scientific knowledge on the links between informal e-waste recycling activities and health
309 outcomes in children, adolescents and pregnant women – the three most at-risk groups for
310 adverse health outcomes, including impaired neurological and behavioural development,
311 negative birth outcomes and immune system impacts.
312 • Political declarations have been made to protect adolescents from the harmful impact of
313 marketing, advertising and promotional activities related to alcoholic beverages [61], and
314 attention to adolescents and young people is given in the substance use prevention,
315 management and treatment guidance [62, 63].
316 • In 2018, WHO announced the WHO Global Initiative for Childhood Cancer that brings together
317 stakeholders from around the world and across sectors with the joint goal of increasing the
318 childhood cancer survival rate by at least 60% by 2030 while reducing suffering and improving
319 quality of life for children and adolescents with cancer globally [64].

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320 • A global consensus was reached about adolescent health measurement globally, facilitated by
321 the Global Action for the Measurement of Adolescent health (GAMA) Advisory Group - a
322 collaborative effort between WHO, UNAIDS, UNESCO, UNFPA, UNICEF, UN Women, the World
323 Bank Group, and the World Food Programme (WFP) (see section 6.X) [3] .

324 1.1 Understanding adolescent well-being

325 The UN H6+ Technical Working Group on Adolescent Health and Well-being stated that adolescent well-being
326 is achieved when “Adolescents have the support, confidence and resources to thrive in contexts of secure and

327 healthy relationships, realising their full potential and rights.” REF #2. It includes five interrelated domains
328 (Figure XYZ).

329 Figure XYZ: The domains of adolescent well-being

330

331

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332 The adolescent well-being framework sets the agenda for what matters for adolescents focusing not only on
333 their survival, but in addition support for them to thrive , and to empower them with the tools to transform
334 themselves and society at large [30]. The framework recognizes that health and nutrition is one of five
335 important domains of adolescent well-being. This definition and conceptual framework of adolescent well-
336 being was developed by the UN H6+ Technical Working Group on Adolescent Health and Well-being and was
337 validated by eight regional-level workshops with adolescents and young people. It has implications for
338 programmes that should aim to increase adolescents’ resilience and protective factors across domains (e.g. a
339 positive school environment and parents who provide structure and boundaries), rather than focusing mostly
340 on reduction of risk factors (e.g. tobacco and alcohol use). A further eight multi-stakeholder consultations
341 were held in 2021 to consider the framework´s implications for programming across the multiple domains of
342 adolescent well-being [5, 65]. As we have shown in the logical framework for programming, the definition of
343 programme’ impacts therefore should be extended to include all the dimensions of well-being (Figure XYZ).

344 1.2 Why invest in adolescent health and well-being?

345 There are at least five arguments why investing in adolescent health and well-being is critical:

346 1. Adolescents have the fundamental right to health yet bear a substantial proportion of the
347 global disease and injury burden

348 Adolescents, like all people, have fundamental rights to life, development, the highest achievable standards
349 of health and access to health services. There rights are enshrined in global human rights instruments, to
350 which almost all countries are signatories [66-68].

351 Yet adolescents suffer a high burden of disease from preventable causes, mainly related to unintentional
352 injuries; violence; sexual and reproductive health, including HIV; communicable diseases such as acute
353 respiratory infections and diarrhoeal diseases; non-communicable diseases, poor nutrition and lack of physical
354 activity; mental health, substance use and self-harm [69-71]. Moreover, inequalities in the abilities of
355 adolescents to achieve their full potential were exacerbated during the COVID-19 pandemic and global,
356 regional and national stakeholders feel that a rights-based approach to programmes should be reinforced to
357 mitigate the impact of the pandemic on the life of adolescents and young people and towards ensuring that
358 the most vulnerable and disadvantaged are not left further behind [5].

359 2. Investments in adolescent health bring a triple dividend of health and well-being benefits
360 [72]:

361 • For adolescents now – adolescent health is immediately benefited by promotion of health literacy [73] and
362 positive behaviours (e.g. good sleep habits and constructive forms of risk-taking, such as sport) and by
363 prevention, early detection, treatment and rehabilitation of problems (e.g. substance use disorders, mental
364 disorders, injuries and sexually transmitted infections) [74]. For example, investing in preventing NCDs among
365 adolescents has been estimated to reduce mortality by almost 10% even within the short-term [74].

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366 • For adolescents’ future lives – to help set a pattern of healthy lifestyles and reduce morbidity and premature
367 mortality later in adulthood, support is needed to establish healthy behaviours in adolescence (e.g. diet,
368 physical activity and, if sexually active, use of condoms and other contraceptives) and reduce harmful
369 exposures, conditions and behaviours (e.g. air pollution, obesity, alcohol, drug and tobacco use). For example,
370 investing in preventing NCDs among adolescents has been estimated to translate into 21 million avoided
371 premature deaths from NCDs over the next 50 years [74].

372 • For the next generation – the health of future offspring can be protected by promoting emotional well-being
373 and healthy practices in adolescence (e.g. managing and resolving conflicts, appropriate vaccinations and
374 good nutrition) and preventing risk factors and burdens (e.g. lead or mercury exposure, interpersonal violence,
375 female genital mutilation, substance use, early pregnancy and pregnancies in close succession).

376 3. Investments in adolescent well-being bring substantial economic benefits and enhance
377 human and social capital [8, 72].

378 Sustaining earlier investments: Human development occurs intensively throughout the first two decades of
379 life, and for a person to achieve his or her full potential, early investments in maternal and child health
380 programmes, including rehabilitation, need to be sustained and amplified through investing in adolescent
381 health and well-being [8, 75]. Investing in adolescent health maintains and reinforces successful health
382 interventions that children benefited from in early childhood, and rectifies earlier health deficits [8, 76].

383 High cost-effectiveness and benefit-cost ratios from investing in adolescent health and well-being: Many
384 programmes to improve adolescent well-being have a cost–benefit ratio of 5–10 (i.e. an investment of US$ 1
385 yields a return of US$ 5–10), with some having a cost–benefit ratio of well over 10 [77]. Addressing the needs
386 in early adolescence through a school-based approach, and addressing the needs of older adolescents through
387 a mixed community and media and health systems approach offer high cost-effectiveness and benefit-cost
388 ratios [8, 78].

389 The smartest of all are the coordinated investments in health and education that bring mutually reinforcing
390 benefits [8].

391 Additional benefits from greater productivity and enhanced human and social capital. The returns on
392 investments in nutrition, health care, quality education, and skills are enhanced through greater productivity
393 and enhanced human capital [79, 80], not least because adolescents comprise a substantial proportion of a
394 country’s population (16% of the world´s population and 23% of the population of low income countries)
395 and, if empowered, offer opportunities for economic growth and social development [5]. For example,
396 investing in a comprehensive package of interventions to prevent NCDs during adolescents will translate into
397 about US$400 billion in cumulative economic benefits [74]. (REF) Investing in adolescents’ connectedness
398 and agency further potentiate the effects and increase social capital.

399 In low- and middle-income countries (LMICs), investment in adolescent health and well-being is likely to result
400 in declines in fertility rates, which can contribute to accelerated economic growth. With fewer births each
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401 year, a country’s young dependent population grows smaller in relation to the working-age population (aged
402 15–64 years), creating a window of opportunity for rapid economic growth [81, 82]. In high-income countries
403 (HICs) as well, investment in the health and well-being of low-income adolescents, including those who have
404 high birth rates and are more exposed to risk factors for ill-health, can help to break the transmission of
405 poverty and disadvantage across generations [83, 84].

406 4. Adolescents are not simply old children or young adults; they have particular needs

407 Simply investing in population health without accounting for adolescents’ special needs is not sufficient.
408 Adolescence is one of the most rapidly changing, formative phases of human development [85]. Health and
409 well-being determinants take particular forms and have unique impacts in adolescence (Figure 2), therefore
410 the solutions need to be adolescent sensitive.

411 5. The 2030 Agenda for Sustainable Development cannot be achieved without investment in
412 adolescent health and well-being.

413 Investment in adolescent health and well-being is essential to achieve the 17 SDGs and their 169 targets.
414 Some SDGs, such as those addressing health and food security, broadly encompass the health and well-being
415 of adolescents within their targets for broader populations. Others specifically address adolescents, as
416 summarized in Box 1.1.

417
Box 1.1. Sustainable Development Goal targets that specifically
address adolescents
Sustainable Development Goal targets that specifically address adolescents
• Reduce by at least half the proportion of children living in poverty in all its dimensions according
to national definitions (Target 1.2).
• Address the nutritional needs of adolescent girls (Target 2.2).
• Ensure that all girls and boys complete free, equitable and quality primary and secondary
education leading to relevant and effective learning outcomes (Target 4.1).
• Substantially increase the number of youths who have relevant skills, including technical and
vocational skills, for employment, decent jobs and entrepreneurship (Target 4.4).
• Eliminate gender disparities in education and ensure equal access to all levels of education and
vocational training for children in vulnerable situations (Target 4.5).
• Ensure that all youth achieve literacy and numeracy (Target 4.6).
• Build and upgrade education facilities that are child sensitive and provide safe, non-violent,
inclusive and effective learning environments for all (Target 4.a).
• End all forms of discrimination against all girls everywhere (Target 5.1).
• Eliminate all forms of violence against all girls in the public and private spheres, including
trafficking and sexual and other types of exploitation (Target 5.2).

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 • Eliminate all harmful practices, such as child, early and forced marriage and female genital
mutilation (Target 5.3).
• Adopt and strengthen sound policies and enforceable legislation for the promotion of gender
equality and the empowerment of girls at all levels (Target 5.c).
• Achieve access to adequate and equitable sanitation and hygiene for all and end open
defecation, paying special attention to the needs of girls (Target 6.2).
• Achieve full and productive employment and decent work for all young people, and equal pay
for work of equal value (Target 8.5).
• By 2020, substantially reduce the proportion of youth not in employment, education or training
(Target 8.6).
• Take immediate and effective measures to eradicate forced labour, end modern slavery and
human trafficking and secure the prohibition and elimination of the worst forms of child labour,
including recruitment and use of child soldiers, and by 2025 end child labour in all its forms
(Target 8.7).
• By 2020, develop and operationalize a global strategy for youth employment and implement
the Global Jobs Pact of the International Labour Organization (Target 8.b)
• Provide access to safe, affordable, accessible and sustainable transport systems for all,
improving road safety, notably by expanding public transport, with special attention to the
needs of children (Target 11.2).
• Provide universal access to safe, inclusive and accessible green and public spaces, in particular
for children (Target 11.7).
• Promote mechanisms for raising capacity for effective climate change-related planning and
management in least-developed countries and small island developing states, including
focusing on youth (Target 13.b).
• End abuse, exploitation, trafficking and all forms of violence against and torture of children
(Target 16.2).
418

419 1.3 COVID-19, other contemporary threats to adolescent well-being, and

420 opportunities

421 Adolescents today are healthier than decades ago and have more opportunities to develop their full potential.
422 However, the scale and scope of the global threats to their well-being, including conflicts, climate crises, and
423 other humanitarian emergencies, all compounded by COVID-19, now put decades of progress at grave risk
424 [86].

425 1.3.1 The COVID-19 pandemic

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426 The COVID-19 pandemic has exposed social inequalities and highlighted the ecological, political, commercial,
427 digital and social determinants of health and health inequities, within and between social groups and nations.
428 Adolescents have experienced lower COVID-19 morbidity and mortality than adults [87], but have been
429 disproportionately affected by public health and social measures as described below [88].

430 • School closures have severly dispupted education and the digital divide put at further
431 disadvantage millions of adolescents with limited access to remote learning opportunities such
432 as those living in rural areas, those with disabilities, those in conflict and post-conflict settings,
433 refugees, the displaced, those from minority communities, and from poor families. Millions of learners
434 are at risk of not ever catching up on months of education disrupted or even of not returning to
435 school, and those affected have been estimated to incur a US$10 trillion loss in lifetime earnings
436 [89]. See case study XYZ from Colombia on the disruption of education for most vulnerable during
437 the lock-down.
438
439 • Loss of school related safety nets, benefits and services. Adolescents have been missing
440 health and well-being activities offered as part of routine education programs such as physical activity,
441 school meals, school-based or school-linked health services, deworming, water, sanitation and
442 hygiene (WASH) and other services targeted to children with disabilities or those with specific needs
443 such as learning support, speech therapy, counselling, behavioral support and social skills training
444 [90, 91]. See case study XYZ from South Africa on efforts to restore school meals and nutrition
445 services during the pandemic.
446 • The risk of violence against children in their homes, communities and online has
447 increased, exacerbated by the compromised ability of child protection systems to promptly detect
448 and respond to cases of violence during lockdowns [92].
449 • An increase in mental health problems and addictive behaviours (gaming) was also reported
450 during COVID-19 [93]. Estimates have shown that in the first year of the COVID-19 pandemic the
451 proportion of youth experiencing clinically elevated depression and anxiety symptoms have doubled
452 comparing to prepandemic levels [94].
453 • The risk of poor sexual and reproductive health increased. Mediated by an increased risk of
454 sexual violence during social isolation, and lost of livelihoods, adolescent pregnancy and child marriage
455 increased during the pandemic [92, 95], all of which increase the probability of missing further
456 education and of poor pregnancy outcomes. The domestic abuse and poor sexual and reproductive
457 health outcomes disproportionately affected females than males exacerbating the gender divide [96].
458 • Declining immunization coverage and TB testing. Routine immunization services have also
459 been negatively affected as a result of the pandemic response, thereby exacerbating the potential
460 resurgence of vaccine-preventable diseases such as measles, tetanus, yellow fever, HPV, and others
461 [97] . Add related to TB

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462 • Decline in physical exercise, food security and nutrition. Implementation of lockdowns and
463 other public health and social measures led to decreases in physical activity and increases in sedentary
464 behaviours due to changes in work patterns and reduced opportunities for general mobility, and
465 access to fitness facilities. The measures affected food security and nutrition by decreasing
466 affordability of quality food, limiting supply of quality food, and increasing consumption of processed
467 food.
468 •

Case study 1
COVID-19 and the right to education in Colombia
On March 16, 2020, the Colombian government suspended in-person classes due to the national emergency
of the COVID-19 pandemic. Later in June, the government provided guidelines for remote classes and
sanitary measures within the classrooms.
Public authorities had provided the necessary means for remote classes. However, many parents felt that
the public authorities did not uphold their duty to guarantee the access to education of their children during
the COVID-19 pandemic, and failed to take adequate measures, such as providing access to internet and
computers. They argued that they did not have the financial resources to buy the necessary means for
remote classes and that their children were discriminated.
The case against public authorities was brought by parents to Court, on behalf of their children, alleging a
violation to their right to education. The Court found that the COVID-19 pandemic had created a serious
disruption for the education of children regarding teaching techniques and access, especially in
impoverished communities. Likewise, it found that, due to the emergency, authorities had a special duty
to reinforce the protection of the right to education in regards to its economic burdens. Since there was no
internet connection in many towns and no cellphones nor computers, among other things, authorities had
to adapt to the emergency and ensure the right to remote education for children, always considering the
best interests of the children.
The Court ordered authorities to devise a plan to correct the shortcomings the pandemic had created in
terms of education.

Source: COVID-19 litigation, Open access case law database. https://www.covid19litigation.org/case-

index/colombia-constitutional-court-su-0322022-2022-02-03. Accessed December 1st, 2022

469 1.3.2 Climate change

470 Effects of climate change such as rising temperatures, severe storms, floods, and droughts are becoming
471 more frequent, posing a serious barrier to the realization of adolescent health, well-being, and human rights
472 [98-100]. Evidence is emerging that climate change is associated in multiple ways with adverse health and
473 well-being outcomes in adolescence [99]:

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474 • Rising temperatures increase the risk of heat-related mortality, adverse birth outcomes, infectious
475 diseases, and respiratory disorders.
476 • Excessive rainfall, extreme temperatures, and drought are associated with under-nutrition,
477 particularly among young children.
478 • Higher temperatures, rainfall variability, and air pollution are associated with poorer cognitive ability,
479 lower school enrollment, and reduced grade completion.
480 • Family functioning worsens (i.e., hostile and anxious parenting, child neglect and violence, low
481 connectedness, parent-child or family conflict) in disaster-affected families.
482 • Gender-based violence increases during or after extreme climate events.

483 1.3.3 Armed conflicts and displacements

484 At least 415 million children under the age of 18 years worldwide were living in conflict-affected areas in 2018
485 [101], with the number expected to have increased further following recent escalation of conflicts in
486 Afghanistan, Ethiopia, and Ukraine, all exposing millions more families and children to enormous additional
487 physical and mental health risks [102]. By May 2022, more than 100 million people were forcibly displaced
488 worldwide by persecution, conflict, violence, human rights violations or events seriously disturbing public order
489 [103]. This represents a more than 100% increase compared to 2012 when there were 42.7 million forcibly
490 displaced people. At least 40% of the displaced people are children (<18 years) [103]. Children and
491 adolescents are exposed to family separation, physical violence and other violations of their human rights,
492 including sexual abuse and exploitation, military or armed attacks, trafficking, limited access to education,
493 health services, and food [104, 105]. Many suffer from neglect and violence due to parental substance use in
494 humanitarian settings [106]. Section 2 provides more details on the state of health and well-being in
495 humanitarian and fragile settings and section 5 describes corresponding effective national programming
496 options.

497 1.3.4 Opportunities

498 The Covid-19 pandemic has increased awareness of adolescent mental health and the importance of school-
499 linked safety nets. It also offered a glimpse of what is possible when the global community comes together in
500 solidarity and makes investments in health a global political priority [86]. This offers an opportunity to invest
501 long-term in strengthening the resilience to shocks of systems upon which adolescents´ health and well-being
502 depend:

503 • reinvigorate global commitments to adolescent health, wellbeing, and children's rights,
504 • equitably scale up evidence-based interventions delivered through resilient primary health care to
505 achieve universal health coverage [86].
506 • establish resilient, flexible, and easily adaptable systems for delivering adequate nutrition, social
507 protection, and education [75, 102].

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508 • ensure equitable distribution of the systems and interventions supporting learning, development,
509 health and well-being targeting the digital divide, the gender divide, disability, marginalized and hard-
510 to-reach adolescents in diverse settings [75, 102].

511 Broad multisectoral anti-poverty policies and programmes should be the foundation of strengthening such
512 resilience, and need to be urgently strengthened to offset the impact of COVID-19 on poverty and to promote
513 the health and development of adolescents, both in the short-and long-term [107].

514 1.4 What is special about adolescence?

515 The 1.3 billion adolescents in the world today represent more than one sixth (16%) of the global population
516 [108]. They are extremely diverse, differing age and developmental stage, in culture, nationality, wealth,
517 education, family, geography and many other ways, which can have a great impact on their health and well-
518 being. Nonetheless, across all societies and settings, adolescents share key developmental experiences as
519 they transition from childhood to adulthood which makes adolescence a unique, formative stage of human
520 development. This stage is characterized by rapid physical growth, hormonal changes, sexual development,
521 new and complex emotions, an increase in cognitive and intellectual capacities, moral development and
522 evolving relationships with peers and families [85, 109].

523 Critically, adolescents are not simply old children or young adults. The range of determinants that influence
524 human health take particular forms and have unique impacts in adolescence [110]. Figure XYZ illustrates how
525 such determinants can influence adolescent health at the individual, interpersonal, community, organizational,
526 environmental, structural and macro levels of an ecological model. Determinants at different levels may come
527 together to cause intersectional discrimination. For example, children with disabilities (individual level
528 determinant) are 27-33% more likely to not attend secondary school (organizational level determinant when
529 schools are not inclusive) [111].

530 Figure XYZ. Examples of factors at different ecological levels that have unique impacts in adolescence

Individual Rapid, physical, neurocognitive and psychosocial changes, e.g., hormonal

changes and puberty; new and complex sensations and emotions; sexual
awareness and gender identity; burst of electrical and physiological brain
development; enhanced and
evolving cognitive ability; context influenced emotional and impulse control
Interpersonal Evolving social competence; increased engagement beyond the family;
questioning of authority; increasingly autonomous decision-making; heightened
significance of peer relationships; formation of romantic relationships
Community Increasing interest in fairness and justice; influence of community values and
norms, e.g., related to gender and age

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 Organizational More years in education and training due to the expansion of primary and
secondary education; later onset of employment and family formation; more
independent involvement in health services while still having limited confidence
in navigating health systems which may be ill prepared to serve adolescents’
special needs
Environmental Water and sanitation facilities (e.g., menstruating girls); road infrastructure
(e.g., as pedestrians without adult accompaniment); air quality and fire safety
(e.g., girls cooking using unsafe stoves); increased vulnerability to lead
exposure and e-waste; inadequate legal and policy environment (e.g. in the
context of increasingly sophisticated advertising and promotion techniques of
unhealthy products)
Macroeconomic and Limited access to practical resources (e.g., finances, transportation); limited
other structural representation in decision-making bodies and few opportunities for lobbying;
factors [112, 113] laws and policies to protect health and rights, e.g., sexual and reproductive
health
Increased vulnerability in humanitarian and fragile settings;
Increased vulnerability to some aspects of globalization
(e.g., gaming addiction and online bullying due to internet and social media
exposure; the transmission of alcohol marketing messages across national
borders and jurisdictions, exacerbated by the difficulty to target young adult
consumers without exposing cohorts of adolescents under the legal age to the
same marketing);
Increased vulnerability to the consequences of poverty and food insecurity,
climate change, unemployment or precarious employment conditions
531

532

533 1.4.1 Determinants at the individual level

534 Puberty is one of the most powerful biological determinants of physical, neurological, sexual and emotional
535 well-being during adolescence. It also sets the trajectories for mental health, some forms of cancers, and
536 cardiovascular and metabolic risks over the life course [85]. Therefore, its importance as a window of
537 opportunity for interventions that may affect health throughout life cannot be overestimated [85].

538 Starting earlier than most recognize, between the ages of six and eight years, it begins with activating the
539 adrenal glands that contribute to the structural and functional development of the brain and associated
540 behaviors in adolescence, and affects the risks for mental health problems and a range of cardio metabolic
541 issues [85]. Followed by the growth spurt, the process of sexual maturation and achievement of reproductive

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542 capacity marks a major change for both boys and girls. However, there is a marked gender dimension to how
543 boys and girls experience puberty. For boys, the shift of puberty is much more explicitly linked to sexual
544 feelings in a positive way, whereas for girls this moment often marks the beginning of conflicting messages
545 about sexuality, virginity, fertility and womanhood [114]. Other differences, such as an increased girls’ risk of
546 anxiety and depression, especially in relation to menstrual problems, and increased social aggression and risk-
547 taking in boys, are common [59]. Socially constructed gender differences in how boys and girls experience
548 puberty are also related to cultural taboos and stigma that force girls to sleep or eat away from their families
549 or to miss school while they are menstruating. In many countries, schools do not have toilets that facilitate
550 privacy, cleanliness or proper disposal of menstruation-related products [114].

551 Early adolescence is also a period when the brain undergoes a tremendous burst of neuro-physiological
552 development [109, 115], with two key processes: significant growth and change in regions of the prefrontal
553 cortex, and improved connectivity between regions of the prefrontal cortex and regions of the limbic system
554 [85, 109]. Changes occur more rapidly in the limbic system (responsible for pleasure seeking, reward
555 processing, emotional response and sleep regulation), with somewhat slower rate in the pre-frontal cortex
556 (responsible for decision-making, organization, impulse control and planning for the future) [109, 115]. This
557 developmentally normal mismatch between intense affective and behavioral reactions and less automatic
558 cognitive ability to integrate executive control, may explain some of the adolescent propensity for exploration,
559 experimentation and risk-taking, resulting in greater vulnerability especially when performing tasks under high
560 demands [85, 116]. However, this also enables adolescents to respond in novel and adaptive ways [85] and
561 increase adolescents’ ability to adjust to changing social contexts [115]. It is important to recognize
562 adolescence as a window of opportunity for programmes and policies to design strategies for constructive and
563 positive risk taking, such as engagement in extreme sports, art and other activities that answer adolescents’
564 desire for sensations seeking. Specific learning or training experiences during adolescence (e.g., mindfulness,
565 see BOX XYZ) may support building self-control and other cognitive, affective and social capacities [117, 118].

566 As adolescents develop, cognitive domains, including learning, reasoning, information processing, and
567 memory, improve [85, 109, 115]. Executive functioning capabilities, which facilitate self-regulation of
568 thoughts, actions, and emotions, continue to develop in parallel with changes in the prefrontal cortex [85].
569 The evolving nature of the emotional, social and cognitive capacity during adolescence has profound
570 implications for how the policy goals of protection and autonomy are balanced (see section XYZ, Box XYZ on
571 adolescent capacity for autonomous decision making) [119, 120].

572 "I think getting older is kind of fun, because you get to do new things, and you get to learn new things."
573 Young adolescent boy in the USA

574

575 Box XYZ Mindfulness meditation impacts on the adolescent brain

Mindfulness meditation impacts on the adolescent brain

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 Mindfulness meditation often refers to non-judgmental attention to experiences in the present moment
such as thoughts, emotions and sensations. Mindfulness involves training attention and self-control,
capacities that are crucial for adolescents in school, in future work and in relationships. It has been
suggested that mindfulness meditation includes at least three components that interact closely to constitute
a process of enhanced self-regulation:
• enhanced attention control,
• improved emotion regulation and
• altered self-awareness.
The latest neuroscientific findings on mindfulness meditation suggest that mindfulness meditation is a low-
cost and effective intervention which could induce neuroplasticity that supports building self-control and
other cognitive, affective and social capacities in adolescents. These skills can support positive changes in
school, work and relationships over the lifespan. One form of mindfulness training called integrative body–
mind training (IBMT) has shown positive effects in attention, learning performance, emotion and behaviour.
Since IBMT only needs a few hours of practice to benefit students, including adolescents, it is relatively
easy to implement within a school system and to fit into a daily curriculum.

While Mindfulness-Based Programmes (MBPs) in children and adolescents show promising results for some
outcomes, to realise the potential of MBPs in supporting adolescent mental health a new generation of
research is necessary that is designed and adequately powered to answer questions of
what works, for whom and how, as well as considering key contextual and implementation factors for
sustained benefits.

Sources: adapted from [121-123]

576

577

578 All of these changes mean that young adolescent girls and boys should have timely access to information,
579 advice, support and protection, and be enabled to make safe, healthy and informed choices as they transition
580 through puberty. Healthy and positive choices should be made available and easy, and health-compromising
581 choices difficult or inaccessible.

582 1.4.2 Determinants at interpersonal and community levels

583 At interpersonal and community levels, new social skills and competencies develop during adolescence and
584 family and peer relationships are transformed. Adolescents assign greater weight than adults to social
585 outcomes such as peer acceptance, are less resistant to peer pressure, and peer and family values increasingly
586 diverge [85]. They seek greater independence and responsibility and wish to disengage from parental control
587 while asserting more autonomy over their decisions, emotions and actions. At the same time family remains

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588 an important determinant for a number of outcomes in adolescents including obesity [124], mental health
589 [125], school engagement [126], problematic internet use [127] and other outcomes [128]. As adolescents
590 increasingly move outside of the confines of their families and start taking independent decisions – ranging
591 from whom they spend time with to what food they eat – it is important to build around them safe and
592 supportive environments, so they can explore their creativity and individuality without harms, and by taking
593 constructive forms of risks [115]. Therefore, the immediate environments of families, schools and communities
594 become a powerful determinant of adolescent health and well-being.

595 In older adolescence, the importance of peer group influence starts to diminish, and more complex and
596 philosophical understandings of ethics, social issues and human rights are developed. Consistent with a
597 growing development of values and concern for their communities, youth are often involved in social and
598 political movements [23, 26, 129-131]. However, opportunities for youth to engage in governance and
599 participate in local and national decision-making processes depend largely on the political, socioeconomic, and
600 cultural contexts where social norms in many parts of the world result in multiple forms of discrimination
601 against youth in general and young women in particular [131].

602 With the rapid expansion of digital media, interpersonal and social interactions, and the ability of adolescents
603 and youth to unite around a common cause have undergone and continue to undergo profound changes.
604 This has raised questions about the safe and health-promoting way of using internet, social media, mobile
605 phones and other new communication technologies, and how to ensure a safe, inclusive, and empowering
606 digital environment [132].

607 1.4.3 Determinants at organizational, environmental and structural level

608 At the organizational level, schools – including primary, secondary, tertiary and vocational institutions – play
609 a vitally important role in promoting and protecting adolescent health. Schools are essential for adolescents
610 to acquire knowledge, socioemotional skills including self-regulation and resilience, and critical thinking skills
611 that provide the foundation for a healthy future. Access to education and safe and supportive school
612 environments have been linked to better health outcomes [6]. School social–emotional environment which
613 fosters equity, including gender equity, by promoting inclusiveness and welcoming diversity, no tolerance of
614 discrimination, bullying, corporal punishment or harassment, is linked to better health and well-being
615 outcomes [133]. Conversely, education systems that do not address discrimination, leave behind vulnerable
616 learners such as those with disabilities who are more likely to have never attended school, or be out of primary
617 or upper-secondary school [111].

618 The education system is particularly well situated to promoting health and well-being among children and
619 adolescents in poor communities without effective health systems who otherwise might not receive health
620 interventions. There are typically more schools than health facilities in all income settings, and rural and poor
621 areas are significantly more likely to have schools than health centers [134]. In turn, good health is linked to

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622 reduced drop-out rates and greater educational attainment, educational performance, employment and
623 productivity [41].

624 Health systems also have a crucial influence on adolescent well-being. Adolescents have different healthcare
625 needs than younger children and adults, due to their unique and rapidly evolving physical, sexual, cognitive
626 and emotional development, and these needs should be addressed in a developmentally sensitive manner
627 [135]. Nonetheless, historically most health systems have been focused on services for mothers, younger
628 children and the elderly, and in many countries health systems performance for adolescents is poorer than
629 for other population groups [7].

630 Determinants functioning at the environmental level can also profoundly affect adolescent health and
631 development [136]. For example, during adolescence, nutrition has a formative role in the timing and pattern
632 of puberty, with consequences for cardiorespiratory fitness, neurodevelopment, immunity, adult height,
633 muscle, and fat mass accrual, as well as risk of non-communicable diseases in later life [137-139]. Much of
634 the environmental burden of disease on adolescents is completely preventable, for example, by improving
635 water and sanitation, limiting pollution and safely disposing of chemical waste [137-139]. The biological
636 environment (e.g., prevalence of malaria or HIV), the food environment, chemical environment (e.g. pollutants
637 such as lead, mercury or other endocrine disruptors) and the physical environment (e.g., roads or water and
638 sanitation infrastructure) can have profound effects on adolescent girls and boys [76, 136, 140]. For instance,
639 the most sensitive window of exposure to endocrine disruptors is during critical periods of human
640 development, such as puberty [136, 140, 141].

641 The legal and policy environment affects adolescent well-being in many ways, e.g., through taxation, health
642 warnings and restrictions to limit or prohibit harmful exposure to marketing by the tobacco, alcohol, food and
643 beverage and fashion industries [61, 62, 75, 133, 142-144]. Even though adolescents are intensively
644 consuming media, it is not the same as participating in the digital economy, and adolescents and youth
645 growing up in poverty are the least likely of all cohorts to use technology or develop digital skills. The odds
646 worsen for girls or people with a disability [52], and for forcibly displaced [145].

647 At the macroeconomic level, global economic policies and trade agreements can have impacts on adolescent
648 health [107, 144]. For example, in places with limited availability of low-cost nutrient-dense foods, the diets
649 of adolescent girls are more expensive when compared to boys of the same age, demonstrating their
650 vulnerability [146]. Macroeconomic policies can incentivize adolescents to stay in school, and influence
651 whether there are fulfilling jobs for them to strive for after they leave school. Early-life poverty can have a
652 lasting effect on health and development of adolescents and human capital [61, 107, 142], therefore, anti-
653 poverty policies and programmes should complement specific health and nutrition interventions delivered at
654 an individual level, particularly at a time when COVID-19 continues to disrupt economic, health, and
655 educational gains achieved in the recent past [107].

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656 Youth participation in political processes can be constrained by structural barriers. People under the age of 35
657 are rarely found in formal political leadership positions. In a third of countries, eligibility for the national
658 parliament starts at 25 years or higher and it is common practice to refer to politicians as ‘young’ if they are
659 below 35-40 years of age. Youth is not represented adequately in formal political institutions and processes
660 such as parliaments, political parties, elections, and public administrations. The situation is even more difficult
661 for both young women as well as women at mid-level and decision-making/leadership positions [131].

662 Notably, some determinants affect adolescent health and well-being across multiple ecological levels [11]. For
663 example, gender norms affect adolescents’ expectations and their sense of what is acceptable and appropriate
664 at the individual level. At the interpersonal level, they may also influence family decisions about allocation of
665 resources and the relative importance of education for boys and girls. At organizational and structural levels,
666 these norms are reflected in inequalities and restrictions in jobs and education [16, 21, 23, 147]. Health
667 literacy is another example. Although representing the personal knowledge and competencies thus operating
668 at the individual level, health literacy is accumulated through daily activities, social interactions and across
669 generations (thus influenced by interpersonal level factors), and is mediated by the organizational structures
670 and availability of resources that enable adolescents to access, understand, appraise and use information and
671 services in ways that promote and maintain good health and well-being for themselves and those around
672 them [148].

673

674

675

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676 Section 2: The status of health and well-being of the
677 world’s adolescents
678

679 Key messages

680 • At least 1.2 billion (over 15%) of the global population are adolescents between the ages of 10 and
681 19 years.
682 • Over the last 20 years, mortality rates from all causes have declined among adolescents globally in
683 all regions, with the largest decline in older (15-19 years) adolescent girls. However, progress has
684 been uneven across different regions and adolescent population groups.
685 • Globally, road injury was the most important cause of death for both younger (10–14-year-olds) and
686 older (15–19-year-olds) adolescent males in 2019. Among younger and older adolescent females this
687 was diarrheal diseases and tuberculosis, respectively. While some of the main causes of death (e.g.
688 maternal conditions) vary by region, other causes including road traffic injury, self-harm and drowning
689 are consistently high across regions.
690 • Reductions in the non-fatal disease burden among adolescents have been limited over the past 20
691 years, with some increases in some regions and age groups. The main conditions causing this burden
692 include mental health conditions (depressive and anxiety disorders, childhood behavioral disorders),
693 iron-deficiency anemia, skin diseases and migraine across regions. Conditions such as malaria or drug
694 use disorders are more specific to some regions.
695 • Globally in 2019, across adolescent sex and age groups, the most important risk factors for mortality
696 and morbidity included iron deficiency, unsafe water source, low birth weight and short gestation,
697 and unsafe sanitation.
698 • Evidence of the role of protective factors at individual, family and societal levels on adolescents’ health
699 and well-being is growing.

700

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701 Section overview

702 This section describes the situation of adolescent health and well-being. Sections 2.1, 2.2 and 2.3 begin with
703 an overview of the adolescent mortality and morbidity burden. Sections 2.4 and 2.5 present an overview of
704 risk and protective factors for adolescent health and well-being. Section 2.6 then gives more details about
705 selected outcomes and determinants for adolescent health and well-being. Finally, Section 2.7 details the
706 particular nature of adolescent burdens in humanitarian and fragile settings.

707 The mortality and morbidity data displayed here are from the WHO Global Health Estimates (GHE) 2019 [149].
708 Similar to previous reports, mortality and morbidity estimates were generated globally and by WHO regions
709 that were modified to only include low and middle-income countries (LMICs) [150, 151]. A separate group
710 was created for all high-income WHO member states (HICs) globally. The income classifications were based
711 on a country’s gross national income per capita in the year 2019 [152]. The relative rankings of cause of death
712 and burden of disease reflect the best of our knowledge at this time given the availability and quality of data
713 on cause of death, and the prevalence and incidence of diseases worldwide. As data quality improves, the
714 estimates will become more robust, and the picture may change for certain regions. In addition to the GHE,
715 other data sources have been used in this section for selected outcomes and determinants for adolescent
716 health and well-being.

WHO African Region, LMICs: Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cabo Verde, Cameroon, Central African Republic, Chad, Comoros, Congo. Côte d’Ivoire,
Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania,
Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, South Africa, South Sudan, Swaziland, Togo, Uganda, United Republic of
Tanzania, Zambia, Zimbabwe.

WHO Region of the Americas, LMICs: Argentina, Belize, Bolivia (Plurinational State of), Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Grenada,
Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Venezuela (Bolivarian Republic
of).

WHO Eastern Mediterranean Region, LMICS: Afghanistan, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Lebanon, Libya, Morocco, Pakistan, Somalia, Sudan, Syrian
Arabi Republic, Tunisia, Yemen.

WHO European Region, LMICs: Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kyrgyzstan, Montenegro, Republic of
Moldova, Romania, Russian Federation, Serbia, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, Uzbekistan.

WHO South-East Asia Region, LMICs: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste.

WHO Western Pacific Region, LMICs: Cambodia, China, Fiji, Kiribati, Lao People’s Democratic Republic, Malaysia, Micronesia (Federated States of), Mongolia, Papua New Guinea,
Philippines, Samoa, Solomon Islands, Tonga, Vanuatu, Viet Nam.

High-income countries: Antigua and Barbuda, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Brunei Darussalam, Canada, Chile, Cyprus, Czechia, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Oman, Poland,
Portugal, Qatar, Republic of Korea, Saudi Arabia, Seychelles, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, Trinidad and Tobago, United Arabi Emirates, United Kingdom,
Unites States of America, Uruguay.

717

Page 29 of 259
718 2.1 Overview of the adolescent population, mortality and morbidity burdens

719 Over 1.2 billion of the global population are adolescents aged 10-19 years. Only about 11% of the world’s
720 adolescents live in HICs (Table 1), while about two thirds live in LMICs of the WHO African, South-East Asian
721 and Western Pacific regions.

722 In 2019, an estimated 0.9 million adolescents died. Approximately two thirds of these deaths happened in
723 LMICs of the WHO African and South-East Asian region. This is reflected in the highest mortality rates (deaths
724 per 100,000 adolescent population) in these regions.

725 The global non-fatal disease burden among adolescents was 69 million years of healthy life lost due to
726 disability (YLDs) in 2019. YLDs capture morbidity as the amount of time lived in states of less than good
727 health. For example, a YLD rate of 544 per 100,000 adolescent population for a specific condition means that
728 among 100,000 adolescents in a given year, 544 years of healthy life have been lost due to poor health related
729 to this condition. YLD rates from all causes were highest in African LMICs (6,120) and lowest in Western
730 Pacific LMICs (4,211) in 2019 (Table 1).

731 Table 1. Overview of the adolescent population, mortality and morbidity globally and by modified WHO
732 region, United Nations Population Division 2019 and WHO Global Health Estimates 2019.

Global African American Eastern European South-East Western High-

LMICs LMICs Mediterranean LMICs Asian LMICs Pacific income
LMICs LMICs countries
Adolescent 1,240 249 (20) 103 (8) 129 (10) 53 (4) 362 (29) 214 (17) 131 (11)
population in millions (100)
% of global total)
Number of 857 321 (38) 67 (8) 104 (12) 19 (2) 244 (28) 73 (8) 29 (3)
adolescent deaths in (100)
thousands (% of
global total)
Mortality rate 69 129 65 81 36 67 34 22
(deaths per 100,000
adolescents)
Number of 69 15 (22) 6 (8) 8 (11) 3 (4) 21 (30) 9 (13) 8 (11)
adolescent YLDs in (100)
millions (% of global
total)
YLD rate (YLDs per 5,538 6,120 5,637 5,919 4,871 5,776 4,211 5,762
100,000
adolescents)

733 2.1.1 Mortality burden

734 An estimated 0.9 million adolescents aged 10 to 19 years died in 2019. Figure 1 shows estimates of global
735 and regional trends of adolescent all-cause mortality by sex and age from 2000 to 2019. Global adolescent

Page 30 of 259
736 death rates are estimated to have fallen by approximately 34% since 2000. Older adolescents registered an
737 approximately 10% greater decline than younger adolescents. The largest decline was among the female 15-
738 to 19-year-old age group (38%). The decline in death rates has been mirrored in most of the modified WHO
739 regions with the highest being 51% in European LMICs, and lowest decline being 11% for American LMICs.

740

741 Table 2 lists the five leading causes of adolescent death in 2019, at global and regional levels, and by sex and
742 age group. Road injury is the leading cause of death in males of both age groups (9/100 000 population
743 among 10-14-year-old males and 18/100 000 population among 15–19-year-old males), but for females the
744 leading cause of death changes from diarrheal diseases in younger adolescents to tuberculosis for older
745 adolescents. Some causes have a particularly high ranking only among males (e.g., drowning) or females
746 (e.g., maternal conditions), or among younger (e.g., lower respiratory infections) or older adolescents (e.g.,
747 interpersonal violence and self-harm).

748

749 Some conditions are major causes of death in most regions, e.g., road injury, self-harm and drowning. Some
750 conditions are high-ranking causes of death only in specific modified WHO regions, i.e., meningitis and AIDS
751 in African LMICs; diarrheal diseases and tuberculosis in South-East Asian LMICs; interpersonal violence in
752 HICs and Americas LMICs; diarrheal diseases in Eastern Mediterranean LMICs; congenital anomalies in
753 European LMICs, HICs and Western Pacific LMICs; and leukemia in Western Pacific LMICs.

754

755 Figure 1. Adolescent all-cause mortality by sex and age, global and by modified WHO region, 2000-2019.
756 WHO Global Health Estimates 2019.

Page 31 of 259
757 Table 2. Main causes of adolescent mortality by sex, age, and modified WHO region, 2019. WHO Global
758 Health Estimates 2019.

Males Females Males Females

Age Cause Mortality rate (per 100,000) Cause Mortality rate (per 100,000) Age Cause Mortality rate (per 100,000) Cause Mortality rate (per 100,000)

Global European low- and middle-income countries

Road injury 9 Diarrhoeal diseases 8 Road injury 4 Road injury 2
10-14 years

10-14 years
Diarrhoeal diseases 9 Road injury 5 Drowning 3 Lower respiratory infections 2
Drowning 4 Lower respiratory infections 3 Self-harm 2 Congenital anomalies 1
Lower respiratory infections 3 HIV/AIDS 3 Lower respiratory infections 2 Drowning 1
HIV/AIDS 3 Meningitis 2 Congenital anomalies 2 Self-harm 1
Road injury 18 Tuberculosis 9 Road injury 12 Self-harm 6
15-19 years

15-19 years
Interpersonal violence 12 Maternal conditions 7 Self-harm 11 Road injury 5
Tuberculosis 10 Self-harm 5 Interpersonal violence 4 Lower respiratory infections 2
Self-harm 6 Road injury 5 Drowning 4 Interpersonal violence 1
Diarrhoeal diseases 5 Diarrhoeal diseases 4 Lower respiratory infections 2 Leukaemia 1

African low- and middle-income countries South-East Asian low- and middle-income countries
Road injury 22 Diarrhoeal diseases 15 Diarrhoeal diseases 13 Diarrhoeal diseases 13
10-14 years

10-14 years
Diarrhoeal diseases 18 Road injury 12 Road injury 7 Tuberculosis 3
HIV/AIDS 12 HIV/AIDS 11 Drowning 4 Lower respiratory infections 3
Lower respiratory infections 9 Meningitis 8 Tuberculosis 3 Road injury 2
Malaria 9 Lower respiratory infections 8 Lower respiratory infections 2 Drowning 2
Road injury 27 Maternal conditions 20 Tuberculosis 19 Tuberculosis 21
15-19 years

15-19 years
Tuberculosis 18 HIV/AIDS 13 Road injury 16 Self-harm 11
Interpersonal violence 17 Tuberculosis 12 Diarrhoeal diseases 7 Diarrhoeal diseases 8
HIV/AIDS 13 Road injury 8 Self-harm 6 Maternal conditions 4
Diarrhoeal diseases 8 Diarrhoeal diseases 6 Interpersonal violence 4 Road injury 4

American low- and middle-income countries Western Pacific low- and middle-income countries
Interpersonal violence 6 Road injury 3 Drowning 6 Road injury 2
10-14 years

10-14 years
Road injury 5 Interpersonal violence 2 Road injury 4 Drowning 2
Leukaemia 3 Leukaemia 2 Leukaemia 2 Leukaemia 1
Drowning 2 Congenital anomalies 2 Congenital anomalies 2 Congenital anomalies 1
Congenital anomalies 1 Self-harm 1 Falls 1 Rabies 1
Interpersonal violence 66 Interpersonal violence 7 Road injury 16 Road injury 5
15-19 years

15-19 years
Road injury 24 Road injury 6 Drowning 6 Self-harm 2
Self-harm 9 Self-harm 4 Self-harm 4 Leukaemia 2
Drowning 5 Maternal conditions 3 Leukaemia 2 Tuberculosis 1
Leukaemia 3 Leukaemia 2 Tuberculosis 2 Drowning 1

Eastern Mediterranean low- and middle-income countries High-income countries

Diarrhoeal diseases 11 Diarrhoeal diseases 9 Road injury 2 Road injury 1
10-14 years

10-14 years

Road injury 8 Road injury 5 Self-harm 2 Self-harm 1

Lower respiratory infections 4 Congenital anomalies 4 Congenital anomalies 1 Congenital anomalies 1
Congenital anomalies 3 Lower respiratory infections 3 Brain & nervous system cancers 1 Brain & nervous system cancers 1
Drowning 3 Violence and legal intervention 2 Leukaemia 1 Leukaemia 1
Road injury 20 Maternal conditions 9 Road injury 10 Road injury 4
15-19 years

15-19 years

Interpersonal violence 10 Tuberculosis 6 Self-harm 9 Self-harm 4

Self-harm 8 Diarrhoeal diseases 6 Interpersonal violence 6 Drug use disorders 2
Diarrhoeal diseases 8 Road injury 6 Drug use disorders 4 Interpersonal violence 1
Tuberculosis 7 Self-harm 4 Drowning 1 Congenital anomalies 1

759 Communicable, maternal, perinatal, and nutritional conditions Injuries

760 2.1.2 Morbidity burden

761

762 The morbidity burden here is expressed in years of healthy life lost due to disability (YLDs), a measure
763 capturing the non-fatal disease burden as the amount of time lived in states of less than good health. For
764 example, a YLD rate of 544 per 100,000 adolescent population for a specific condition means that among
765 100,000 adolescents in a given year, 544 years of healthy life have been lost due to poor health related to
766 this condition.

767 Figure 2 shows estimates of global and regional trends of adolescent morbidity presented as YLDs, by sex and
768 age, from 2000 to 2019. Since 2000, global adolescent morbidity rates showed minimal changes across age
769 groups, gender and regions. Morbidity decline was highest in African LMICs and lowest in HICs, where an
770 upward trend was registered. Morbidity is consistently higher in older female adolescents (6,902 per 100,000
771 in 2019) than all other categories (5,405 per 100,000 for older adolescent males), both at global and regional
772 levels. In 2000, the YLD rate for older female adolescents was 7,078 per 100,000 while that of older male
773 adolescents was 5634 per 100,000. Adolescent morbidity is consistently lowest among the 10 -14-year-old
774 males (4,818 per 100,000 in 2000, and 4,730 per 100000 in 2019).

775 Table 3 lists the five leading causes of adolescent morbidity at global and regional levels, and by sex and age
776 group. Apart from iron-deficiency anemia, non-communicable diseases account for all YLDs in both age groups

Page 32 of 259
777 at the global level. The regional picture is similar with HICs, Western pacific LMICs, and American LMICs
778 having only non-communicable diseases as the top 5 causes of morbidity. The only communicable, maternal,
779 perinatal and nutritional conditions -appearing in the top 5 causes of morbidity are iron-deficiency anemia in
780 Africa LMICs, South East Asia LMICs, Eastern Mediterranean LMICs; malaria in Africa LMICs; and diarrheal
781 diseases in European LMICs.

782 Among the non-communicable diseases, mental and substance use disorders are the most common across all
783 regions, in both age groups and regardless of sex. The most common mental and substance use disorders
784 are depressive disorders, anxiety disorders, childhood behavioural disorders, and idiopathic intellectual
785 disability.

786

787

788

789 Figure 2. Adolescent morbidity from all causes (expressed as YLDs), by sex and age, global and by modified
790 WHO region, 2000-2019. WHO Global Health Estimates 2019.

791 Table 3. Main causes of adolescent morbidity (expressed as YLDs), by sex, age, and modified WHO region,
792 2019. WHO Global Health Estimates 2019.

Page 33 of 259
 Males Females Males Females
Age Cause YLD rate (per 100,000) Cause YLD rate (per 100,000 Age Cause YLD rate (per 100,000) Cause YLD rate (per 100,000

Global European low- and middle-income countries

Childhood behavioural disorders 544 Iron-deficiency anaemia 525 Childhood behavioural disorders 576 Anxiety disorders 385
10-14 years

10-14 years
Iron-deficiency anaemia 378 Anxiety disorders 416 Anxiety disorders 267 Childhood behavioural disorders 350
Anxiety disorders 265 Migraine 339 Migraine 194 Migraine 332
Skin diseases 259 Childhood behavioural disorders 314 Skin diseases 179 Back and neck pain 233
Migraine 204 Skin diseases 292 Diarrhoeal diseases 175 Skin diseases 232
Depressive disorders 371 Depressive disorders 631 Childhood behavioural disorders 387 Depressive disorders 608
15-19 years

15-19 years
Childhood behavioural disorders 358 Anxiety disorders 535 Depressive disorders 384 Anxiety disorders 511
Anxiety disorders 334 Migraine 505 Anxiety disorders 331 Migraine 509
Migraine 305 Iron-deficiency anaemia 436 Migraine 289 Back and neck pain 380
Skin diseases 279 Gynecological diseases 403 Back and neck pain 286 Gynecological diseases 356

African low- and middle-income countries South-East Asian low- and middle-income countries
Iron-deficiency anaemia 668 Iron-deficiency anaemia 709 Iron-deficiency anaemia 588 Iron-deficiency anaemia 939
10-14 years

10-14 years
Childhood behavioural disorders 539 Anxiety disorders 381 Childhood behavioural disorders 521 Migraine 359
Anxiety disorders 255 Childhood behavioural disorders 345 Idiopathic intellectual disability 340 Idiopathic intellectual disability 356
Skin diseases 248 Migraine 272 Skin diseases 283 Skin diseases 314
Malaria 223 Skin diseases 267 Preterm birth complications 255 Childhood behavioural disorders 305
Depressive disorders 459 Depressive disorders 689 Childhood behavioural disorders 335 Iron-deficiency anaemia 934
15-19 years

15-19 years
Childhood behavioural disorders 356 Anxiety disorders 498 Migraine 326 Migraine 525
Anxiety disorders 345 Migraine 416 Idiopathic intellectual disability 317 Depressive disorders 455
Iron-deficiency anaemia 296 Gynecological diseases 371 Depressive disorders 298 Gynecological diseases 416
Migraine 277 Malaria 368 Skin diseases 292 Anxiety disorders 357

American low- and middle-income countries Western Pacific low- and middle-income countries
Childhood behavioural disorders 580 Migraine 511 Childhood behavioural disorders 532 Anxiety disorders 526
10-14 years

10-14 years
Anxiety disorders 328 Anxiety disorders 508 Anxiety disorders 316 Skin diseases 356
Asthma 296 Depressive disorders 369 Skin diseases 311 Migraine 267
Migraine 283 Childhood behavioural disorders 346 Hearing loss 175 Childhood behavioural disorders 259
Skin diseases 269 Skin diseases 301 Uncorrected refractive errors 165 Back and neck pain 203
Anxiety disorders 424 Depressive disorders 782 Skin diseases 355 Anxiety disorders 563
15-19 years

15-19 years
Childhood behavioural disorders 390 Anxiety disorders 717 Anxiety disorders 341 Migraine 413
Depressive disorders 370 Migraine 636 Childhood behavioural disorders 341 Skin diseases 409
Migraine 355 Gynecological diseases 433 Back and neck pain 268 Depressive disorders 391
Skin diseases 280 Back and neck pain 366 Migraine 243 Gynecological diseases 370

Eastern Mediterranean low- and middle-income countries High-income countries

Childhood behavioural disorders 556 Iron-deficiency anaemia 592 Childhood behavioural disorders 590 Anxiety disorders 575
10-14 years

Anxiety disorders 382 Anxiety disorders 533 10-14 years Asthma 359 Depressive disorders 467
Iron-deficiency anaemia 355 Migraine 388 Anxiety disorders 351 Migraine 360
Migraine 278 Depressive disorders 311 Back and neck pain 228 Childhood behavioural disorders 330
Idiopathic intellectual disability 274 Childhood behavioural disorders 301 Depressive disorders 217 Back and neck pain 312
Depressive disorders 481 Depressive disorders 797 Depressive disorders 561 Depressive disorders 1118
15-19 years

15-19 years

Anxiety disorders 452 Anxiety disorders 701 Drug use disorders 491 Anxiety disorders 752
Migraine 375 Migraine 551 Anxiety disorders 444 Migraine 605
Childhood behavioural disorders 372 Gynecological diseases 454 Childhood behavioural disorders 405 Back and neck pain 559
Idiopathic intellectual disability 259 Iron-deficiency anaemia 431 Back and neck pain 382 Gynecological diseases 426

793 Communicable, Maternal, Perinatal and Nutritional conditions Non-Communicable diseases

794 Overview of risk factors for adolescent health and well-being

795 Most of the published literature on the global adolescent health burden focuses on mortality and morbidity
796 [149, 153-156]. Systematic global assessments of risk factors – such as those done for adults – are lacking
797 for adolescents [157].

798 The Global Burden of Disease (GBD), an effort to measure epidemiological levels and trends worldwide,
799 provides an opportunity to extract global risk factors for different population groups [158]. Table 4 presents
800 results of the 2019 GBD study showing the top ten risk factors associated with adolescent Disability Adjusted
801 Live Years (DALYs). DALYs are a measure of the overall health burden combining mortality and morbidity.

802

803 Table 4: Top 10 Global risk factors associated with adolescent DALYs, by sex and age, 2019.

Page 34 of 259
804

805 The GBD results show that in 2019, the global leading risk factors for adolescent morbidity and mortality
806 showed little variation by age group or by sex. Iron deficiency, unsafe water source, unsafe sanitation, no
807 access to hand washing facility, low birth weight and short gestation (less than 38 weeks), bullying
808 victimization, and particulate matter pollution were among the top 10 in both age groups and sexes. Some
809 risk factors were in the top 10 list only among younger adolescents such as child growth failure and lead
810 exposure, while others were key among the older age group such as occupational ergonomic factors.

811

812 2.2 Overview of protective factors for adolescent health and well-being

813 Protective factors are conditions, characteristics or behaviors that increase the probability of good health and
814 well-being, minimize effects of stressful life events, increase an individual’s ability to avoid hazards, and
815 promote social and emotional competence. Adolescent health and well-being can be improved by enhancing
816 protective factors that build agency and resilience, and that promote other dimensions of positive health and
817 well-being.

Page 35 of 259
818 Evidence of the role of protective factors at individual, family and societal levels on adolescents’ health and
819 well-being is growing. For example, a survey administered to young people from nine Caribbean countries
820 found that connectedness with parents and school and attendance at religious services were associated with
821 fewer health risk behaviors [159]. A review of South African literature identified factors associated with
822 adolescent well-being in relation to family relationships, social resources, religiosity and conservatism, and
823 socio-economic conditions [160]. An analysis of indicators of youth–adult connectedness in two groups of
824 adolescents at high risk for poor health outcomes found that strong, positive relationships with parents and
825 other caring adults protected adolescents from a range of poor health-related outcomes and promoted positive
826 development [161, 162]. Results from the Global Early Adolescent Study showed that school safety was
827 associated with emotional and behavioural outcomes across countries [161].

828 There is also growing evidence around health literacy being considered an asset for health and well-being
829 with which adolescents can pursue their full health potential and act as informed participants in decision-
830 making about health and development. According to WHO, health literacy represents the personal knowledge
831 and competencies that accumulate through daily activities, social interactions and across generations. Personal
832 knowledge and competencies are mediated by the organizational structures and availability of resources that
833 enable people to access, understand, appraise and use information and services in ways that promote and
834 maintain good health and well-being for themselves and those around them.

835 In spite of the importance of health literacy, its level among adolescents is considerably low. For example, as
836 a part of the WHO collaborative Health Behaviour in School aged Children (HBSC) survey of 2017/2018, a
837 study on adolescent health literacy levels provided findings from 10 countries in Europe. Data revealed a
838 wide range of variation between countries and within the same country. On the average, low health literacy
839 has been found in about 13.3 % of adolescents (aged 13 and 15 years), while high health literacy was found
840 in about 19.5 % of the same age group. [163] [73].

841 Finally, there is increasing recognition that sleep has an important role in maintaining health and well-being
842 of adolescents. This includes, for example, the positive impact of good sleep on weight control, mental health,
843 pain, and illness [164, 165]. Although the association between sleep and good health has been well
844 demonstrated [164, 166], and effective treatment is possible [167], epidemiological data on nationally or
845 regional disease burden, risk factors and distribution is limited.

846 There has been recent progress in defining and measuring positive and protective factors in adolescent
847 development. A new definition and conceptual framework on adolescent well-being has been proposed by the
848 United Nations H6+ Technical Working Group on Adolescent Health and Well-being and partners [30] (Figure
849 XYZ). The conceptual framework consists of five domains: 1. Good health and optimal nutrition; 2.
850 Connectedness, positive values and contribution to society; 3. Safety and a support environment; 4. Learning,
851 competence, education, skills and employability; and 5. Agency and resilience. However, current measurement
852 to track progress in adolescent well-being at national and global levels is inconsistent, and global data,
853 particularly on protective factors for adolescent health and well-being, are lacking [168]. Where data exist,
Page 36 of 259
854 they often only cover a few countries or are not consistently tracked over time, or only cover limited, specific
855 aspects of adolescent well-being [169]. Work is currently underway to propose a set of priority indicators for
856 adolescent well-being and to develop guidance on how they should be measured and monitored [170].

857

858 2.3 Selected outcomes and determinants for adolescent health and well-
859 being

860 2.3.1 Unintentional injury

861 Unintentional injuries are injuries that occur without purposeful intent, and the main categories include road
862 injuries, poisonings, falls, drowning, exposure to mechanical forces, natural disasters, and fire, heat and hot
863 substances [149]. Unintentional injuries are the leading cause of death among adolescents.

864 Road injuries. In 2019, over 100,000 adolescents (10–19 years) died as a result of road injuries [149]. All
865 sex, age and regional adolescent subgroups were affected, but older adolescent boys and young men
866 experienced the greatest burden. Road injury was the leading or second leading cause of adolescent death in
867 all the seven modified WHO regions. Many of those who died were vulnerable road users, namely pedestrians,
868 cyclists or users of motorized two-wheelers.

869

870 Drowning is also among the top causes of death among adolescents, in particular younger adolescent boys.
871 More than 30,000 adolescents, over three quarters of them boys, are estimated to have drowned in 2019.
872 South East Asia and Western Pacific LMICs contributed 60% of the global number of adolescent deaths due
873 to drowning. Drowning was among the top five causes of death in all regions except in African LMICs. Of note
874 however is that African LMICs ranked third after South East Asia and Western Pacific LMICs in absolute
875 numbers of adolescent deaths due to drowning, but this was outranked by other disease burdens within the
876 region [171].

877

878 Fire, heat and hot substances also make a substantial contribution to the global adolescent disease burden
879 with approximately 6000 deaths reported in 2019. Approximately 50% of the global total number of deaths
880 from fire, heat and hot substances were from African and South-East Asian LMICs [172], often due to open
881 fire cooking or inherently unsafe cookstoves.

882

883 2.3.2 Violence

Page 37 of 259
884 Interpersonal violence is the intentional use of physical force or power against another person with a high
885 likelihood of its resulting in injury, death, psychological harm, mal-development or deprivation [173]. Violence
886 during adolescence can have severe short- and long-term physical, sexual and mental health consequences.
887 It increases the risks of injury, disabilities and gastro-intestinal disorders, HIV and other sexually transmitted
888 infections, post-traumatic stress, anxiety, depression, externalizing symptoms, eating disorders, problems with
889 relationships, sleep disorders, self-harm, and suicidal thoughts, poor school performance and dropout, early
890 pregnancy, reproductive health problems, and communicable and non-communicable diseases.

891 Interpersonal violence is among the leading causes of death in adolescents and young people globally. Its
892 prominence varies substantially by world region with 40% of reported deaths in American LMICs and 30% in
893 African LMICs. It causes nearly a third of all adolescent male deaths in LMICs in the WHO Region of the
894 Americas.

895 Child and adolescent maltreatment as one form of violence is widespread but often hidden. Nearly a quarter
896 of adults suffered physical abuse as a child or adolescent, 36% experienced emotional abuse and 16%
897 experienced neglect. Overall, 18% of girls and 8% of boys have experienced some form of sexual abuse [174-
898 177]. Child and adolescent maltreatment can also overlap with other forms of violence against children and
899 intimate partner violence, for example in the context of child marriage.

900 A 2019 UNESCO report found that 32% of students reported having been bullied by their peers at school at
901 least once in the last month. The proportion of bullying varies by region ranging from 22.8% of children being
902 victimised in Central America, through 25.0% and 31.7% in Europe and North America, respectively, to 48.2%
903 in sub-Saharan Africa [178].

904 Young persons with disabilities under the age of 18 are almost four times more likely than are their peers
905 without disabilities to be victims of abuse, with young persons with intellectual disabilities, especially girls, at
906 greatest risk [179]. Children and adolescents with disabilities are 32% more likely to experience severe
907 physical punishment at home, compared to those without disabilities [111].Children and adolescents with
908 disabilities also experience significantly higher rates of bullying than children without disabilities, with evidence
909 that 37% of poorer mental health among adolescents with disabilities is explained by exposure to peer-bullying
910 [111, 180].

911 Collective violence refers to the instrumental use of violence by members of a group against another group,
912 to achieve political, economic or social objectives [173]. It includes coups, rebellions, revolutions, terrorism,
913 and war. Legal intervention refers to injuries inflicted by law-enforcing agents while arresting lawbreakers,
914 suppressing disturbances, maintaining order, and taking other legal action. Collective violence and legal
915 intervention are major concerns in specific regions and in localized humanitarian and fragile settings. In 2019,
916 collective violence and legal intervention combined were among the top 5 causes of adolescent death in
917 Eastern Mediterranean LMICs which recorded 4,600 deaths accounting for 62% of the global cause specific

Page 38 of 259
918 mortality (Table 2). The overall global burden has declined compared to 2015 when the Eastern Mediterranean
919 LMICs recorded 27,000 adolescent deaths due to collective violence and legal intervention.

920

921 2.3.3 Sexual and reproductive health, HIV and other sexually transmitted infections

922 HIV

923 In 2021, at least 1.7 million adolescents aged 10-19 years were living with HIV, with adolescent girls
924 constituting 57% of the total estimate. Further a total of 160,000 of adolescents were newly infected with
925 HIV, with girls constituting approximately 75% of the total newly infected cases. Multiple factors, including
926 age-disparate sex, low condom use, sexual violence and coercion, gender norms and early sexual debut,
927 contribute to the disproportionate risk of females acquiring HIV. In the same year, the estimated number of
928 aids-related deaths was 29,000. East and Southern Africa recorded the highest number of aids-related deaths
929 among adolescents aged 10-19 years in 2021 (17,000 cases) [181]. Stigma, discrimination, punitive laws and
930 policies, violence and entrenched societal and gender inequalities continue to hinder access to care for
931 adolescents living with and at risk of HIV.

932 Other sexually transmitted infections

933 The incidence of other sexually transmitted infections (STIs) among adolescents was 7,089 per 100,000
934 population in 2019, with the largest age group-specific incidence being among young adolescents aged 10-14
935 years [182]. For multiple reasons, sexually active adolescents have a particularly high risk of acquiring an STI
936 compared to other age groups. These include increased exposure, biological susceptibility to infection and
937 relatively poor access to and/or use of health services [183]. For example, the peak time for acquiring infection
938 with either human papillomavirus (HPV) or herpes simplex virus-2 (HSV-2) for both males and females is
939 shortly after a person first becomes sexually active, which generally happens in adolescence [184-186]. Based

940 on a 2010 meta-analysis, the global HPV prevalence (all types) among adult women with normal cytological
941 findings was estimated to be 12% detected in cervical specimens. The highest prevalence was in sub-Saharan
942 Africa (24%); Latin America and the Caribbean (16%), Eastern Europe (14%), and South-Eastern Asia (14%)
943 [187].

944 Adolescent birth rate

945 Globally, adolescent birth rates (ABR) have decreased from 65 births per 1,000 women in 2000 to 43 births
946 per 1,000 women in 2021. However, rates of change have been uneven in different regions of the world with
947 the sharpest decline in Southern Asia, and slower declines in Latin America and the Caribbean, and sub-
948 Saharan Africa. This decrease is reflected in a similar decline in maternal mortality rates among girls aged 15–
949 19 years [185].

Page 39 of 259
950 While the estimated global ABR has declined, the actual number of childbirths to adolescents continues to be
951 high. Approximately 12 million girls aged 15–19 years and at least 777 000 girls under 15 years give birth
952 each year in LMICs. The largest numbers of estimated births in 2021 occurred in sub-Saharan Africa, with
953 6,114,000 births among 15-19 year olds, and 332,000 births among adolescents aged 10-14 years [185].

954 Child marriage

955 Child marriage places girls at increased risk of pregnancy because girls who are married very early typically
956 have limited autonomy to influence decision-making about delaying child-bearing and contraceptive use [188].
957 In 2021, the estimated global number of child brides was 650 million [189]. In many places girls choose to
958 become pregnant because they have limited educational and employment prospects. Often in such societies,
959 motherhood – within or outside marriage/union - is valued, and marriage or union and childbearing may be
960 the best of the limited options available to adolescent girls [189].

961 Contraception, unintended pregnancies and abortion

962 Contraceptives are not easily accessible to adolescents in many places. Even when adolescents can obtain
963 contraceptives, they may lack the agency or the resources to pay for them, knowledge on where to obtain
964 them and how to correctly use them. They may face stigma when trying to obtain contraceptives. Further,
965 they are often at higher risk of discontinuing use due to side effects, and due to changing life circumstances
966 and reproductive intentions [190]. Restrictive laws and policies regarding the provision of contraceptives based
967 on age or marital status pose an important barrier to the provision and uptake of contraceptives among
968 adolescents. This is often combined with health worker bias and/or lack of willingness to acknowledge
969 adolescents’ sexual health needs.

970 In 2019, an estimated 21 million adolescents aged 15-19 years in LMICs had pregnancies, of which
971 approximately 50% were unintended. Between 2.2 – 4 million (at least 55%) of these unintended pregnancies
972 ended in abortions, which are often unsafe in LMICs [191]. This results in adolescent girls from LMICs suffering
973 from a significant and disproportionate share of deaths and morbidity from unsafe abortion practices, when
974 compared to adult women. Estimates suggest that 14% of all unsafe abortions in developing countries involve
975 adolescent girls aged 15–19 years [192], while globally 11% of all births take place in this age group [193].
976 Of these unsafe adolescent abortions in developing countries, Africa accounts for 26%, while Latin America
977 and the Caribbean combined account for a further 15% [192].

978 Complications from pregnancy and childbirth

979 Complications from pregnancy and childbirth are among the leading causes of death for girls aged 15–19 years
980 globally. Maternal conditions include haemorrhage, sepsis, hypertensive disorders, obstructed labour,
981 complications of abortion, indirect maternal deaths, late maternal deaths, and maternal deaths aggravated by
982 AIDS, tuberculosis and other infections or non-communicable diseases. Maternal conditions were the second
983 leading cause of death in this group in 2019, causing 7 deaths per 100,000 (Table 1). The rate of maternal
984 mortality among 15- to 19-year-old girls was very high among African LMICs (20 per 100,000), followed by
Page 40 of 259
985 the Eastern Mediterranean, South-East Asian and Americas LMICs (9, 4, and 3 deaths per 100,000 population
986 respectively). [192] [193-195]

987 Gender-based violence

988 Many adolescent girls experience gender-based violence, i.e., violence by an intimate partner or family
989 member; sexual violence; trafficking; acid throwing; female genital mutilation; child, early and forced
990 marriage; and sexual harassment in schools, workplaces, public places and, increasingly, online through the
991 internet or social media [196]. Child sexual abuse increases the risk of unintended pregnancies and the
992 consequences of gender-based violence can last a lifetime. Sexual violence can occur at any age, but is
993 believed to have highest prevalence soon after the onset of puberty [197]. One in 10 girls (120 million) under
994 age 20 has been a victim of sexual violence [2]. Estimates suggest that in 2020, at least 1 in 8 of the world’s
995 children had been sexually abused before reaching the age of 18, and 1 in 20 girls aged 15-19 years had
996 experienced forced sex during their lifetime. Both sexual violence and intimate partner violence are mainly
997 perpetrated by men and boys against girls and women, but boys and men may, though less commonly, also
998 be victims [198]. Globally, the lifetime prevalence of sexual abuse of girls in childhood is estimated to be 18%,
999 while for boys it is estimated to be 8% [199]. Evidence also indicates that children with disabilities have a
1000 nearly three-fold increased risk of sexual violence compared to non-disabled peers [200], with heightened
1001 risk among girls with disabilities during adolescence [201]. Adolescent girls with disabilities may also be
1002 subjected to forced sterilization, contraception and abortion at the request of family members and health
1003 professionals. These procedures are often legitimized through claims of “medical necessity” or “best interests”,
1004 but are considered acts of violence in human rights frameworks. Girls with intellectual disabilities, psychosocial
1005 disabilities and / or living in residential institutions are most risk of this form of violence [201-206].

1006 Female genital mutilation

1007 Female genital mutilation (FGM) comprises procedures to remove external genitalia partially or totally, or
1008 otherwise to injure the female genital organs for nonmedical reasons [207]. No form of FGM has health
1009 benefits. On the contrary, the removal of or damage to healthy genital tissue interferes with the natural
1010 functioning of the body and may cause several immediate and long-term health consequences [208]. FGM is
1011 mostly carried out on girls between the ages of 0 and 15 years. The practice is prevalent in 30 countries in
1012 Africa and in several countries in Asia and the Middle East, but now is also present across the globe due to
1013 international migration. In Africa, it is estimated that 12 million girls between the ages of 10 and 14 years
1014 have experienced health complications related to FGM, most notably in Ethiopia, Kenya, Nigeria and Uganda
1015 [208, 209].

1016

1017 2.3.4 Communicable diseases

1018

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1019 Five of the top 10 leading causes of death among adolescents are communicable diseases (Figure 3). Apart
1020 from HIV, the other five are diarrheal diseases, tuberculosis, lower respiratory infections, and meningitis.
1021 These four diseases accounted for 200,000 deaths among adolescents in 2019 with individual disease death
1022 rate ranging from 2 per 100,000 for meningitis, to 6 per 100,000 for diarrheal diseases.

1023

1024 Figure 3: Communicable diseases among the top 10 causes of adolescent deaths in 2019

1025

1026 Diarrheal diseases

1027 Diarrheal diseases are mainly caused by infections which have a fecal-oral transmission route – the disease
1028 organisms are commonly ingested through contaminated food or water. They are a particularly important
1029 cause of death in young adolescents. Globally, diarrheal diseases ranked first and second in 2019 as a cause
1030 of death among young adolescent girls and boys respectively, and ranked fifth among both sexes for the 15-
1031 to 19-year-old group. In 2019, diarrheal diseases had the greatest impact on adolescent health in African,
1032 South-East Asian, and Western Pacific LMICs than all other regions.

1033 Lower respiratory infections

1034 Lower respiratory infections, such as influenza, pneumococcal pneumonia and Haemophilus influenza type B,
1035 were a major cause of adolescent death both globally and in most of the modified WHO regions in 2019.
1036 Lower respiratory infections were estimated to be a particularly high cause of death in young adolescents who
1037 accounted for two thirds of the approximately 32,000 associated deaths recorded globally in 2019.

1038 Tuberculosis
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1039 Each year, approximately 1.8 million adolescents and young adults (10-24 years) develop TB. An estimated
1040 71,000 adolescents (aged 10-19) without HIV infection died of TB in 2019 [210]. TB was the third leading
1041 cause of death in adolescents with overall rate of 6 per 100,000 population. The death rate was higher among
1042 older adolescents than younger adolescents. It was the top cause of deaths among adolescent girls aged 15
1043 to 19 and the third leading cause among boys of the same age group. At regional level, TB was in the top five
1044 cause of death for at least one age group in African, South-East Asian, Western Pacific, and Eastern
1045 Mediterranean LMICs corresponding to the high incidence and prevalence in these areas.

1046 Risk factors to develop TB include undernutrition, HIV infection, alcohol use, smoking and diabetes. However,
1047 there is considerable variation among countries in the relative contribution of the five factors, and thus also
1048 variation in which of these factors need to be prioritized as part of national efforts to reduce the burden of
1049 TB. Addressing broader determinants of the TB epidemic requires multisectoral action and accountability
1050 [211].

1051 Meningitis

1052 Meningitis was the eighth leading cause of global adolescent death among adolescents in 2019, with an overall
1053 burden of 22,000 deaths. Younger adolescents accounted for approximately 70% of all the deaths due to
1054 meningitis but there was no difference by sex. Approximately 70% of all meningitis deaths among adolescents
1055 in 2019 occurred in African LMICs, the remaining 30% was mainly from South East Asian, Western Pacific and
1056 East Mediterranean LMICs. Meningococcal meningitis cases occur throughout the world. However, large
1057 recurring epidemics constitute an enormous public health burden in the 26 African countries within the so-
1058 called Meningitis Belt that spans Africa from Mauritania, Senegal, Gambia and Guinea-Bissau in the west to
1059 Sudan, Eritrea, Ethiopia, Kenya and the United Republic of Tanzania in the east.

1060 COVID-19

1061 Although experiencing much lower direct morbidity or mortality from COVID-19 [212], adolescents have been
1062 severely affected by the pandemic response measures including school closures, lockdowns, mobility
1063 limitations and widespread service disruptions [213]. As described in section 1, the pandemic has widened
1064 existing gender and age inequalities among adolescents, and has led to increases in age- and gender-based
1065 violence . The inequalities, the violence, and economic challenges faced by adolescents due to COVID-19 and
1066 associated pandemic management measures have affected their physical and mental wellbeing [88, 214].

1067

1068 2.3.5 Non-communicable diseases (NCDs)

1069 Non-communicable diseases (NCDs) are non-transmissible diseases of often long duration, such as mental
1070 health conditions (described separately below), cancers, skin disease, migraine, asthma, stroke, heart disease,
1071 diabetes, uncorrected refractive error, hearing loss and oral diseases. Many of the top 10 causes of YLDs
1072 among the adolescent sex- and age groups are NCDs, namely: anxiety disorders, childhood behavioral
Page 43 of 259
1073 disorders, depressive disorders, migraine, back and neck pain, uncorrected refractive errors, hearing loss, and
1074 idiopathic intellectual impairments. Most of these NCDs are related to mental health, which is discussed in the
1075 next subsection.

1076 Cancers

1077 Leukemia caused 15,000 adolescents' deaths globally in 2019 and was the 13th leading cause of death among
1078 adolescents. Leukemia was among the top five causes of death in sex and age disaggregated data presented
1079 in Table 1 for High Income countries and in the LMICs of the Western Pacific, American, and European regions.

1080 Skin diseases

1081 Skin diseases, including dermatitis, psoriasis, scabies, fungal and viral skin diseases and acne vulgaris, were
1082 estimated to be the sixth leading cause of YLD among adolescents globally. Skin diseases were the top five
1083 causes of YLD for both younger and older adolescents, of both sexes in almost all LMIC modified WHO regions.
1084 Acne is the most prevalent skin disease in adolescent populations and is nearly universal; it can range from
1085 mild to severe forms and can result in emotional distress and physical scarring [215, 216].

1086 Migraine

1087 Migraine is a neurological disorder characterized by recurrent headaches caused by the activation of a
1088 mechanism deep in the brain that leads to release of pain-producing inflammatory substances around the
1089 nerves and blood vessels of the head [217]. In 2019, migraine was the fifth leading cause of morbidity among
1090 adolescents (338 YLD rate per 100,000 population). At regional level, migraine was consistently within the
1091 top five causes of YLDs among the age and sex disaggregated data in Table 2. Females had a YLD rate twice
1092 that of males.

1093 Asthma

1094 Asthma is a chronic respiratory disease, commonly affecting children and adolescents. Asthma ranked 12th for
1095 YLDs among adolescents globally in 2019. Among young adolescent boys, asthma was the second leading
1096 cause of YLDs in high-income countries and the third in American LMICs. The Global Asthma Network recently
1097 reported that worldwide, one in twenty school-aged children have severe asthma symptoms. Asthma diagnosis
1098 and treatment can be challenging, in countries of all income classes. In LMICs, under diagnosis and
1099 inappropriate treatment frequently lead to uncontrolled asthma symptoms [218]. Access to diagnostic tools
1100 and inhaled medicines, particularly inhaled corticosteroids, remains a challenge in many countries [218-220]
1101 In the years to come, the global climate crisis will likely contribute to asthma among adolescents becoming
1102 an even greater problem, including through higher pollen levels, longer pollen seasons, worsening air quality
1103 and increasing thunderstorms all increasing the risk of actue asthma attacks [99].

1104 Congenital anomalies

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1105 Congenital anomalies such as neural tube defects (e.g., spina bifida, orofacial clefts), heart anomalies, and
1106 Down’s syndrome generally have their largest effects in infants and younger children, but they also have a
1107 major impact on adolescent health [221]. In 2019, congenital anomalies caused 20,000 deaths among
1108 adolescents and were the tenth leading cause of death, with an average rate of 2 deaths per 100,000
1109 adolescents. Congenital anomalies are also associated with significant morbidity among adolescents. In 2019,
1110 congenital anomalies ranked 16th on the list of top causes of morbidity accounting for 1.1 million YLDs. The
1111 morbidity and mortality were distributed across all regions but the highest burden was in African and South
1112 East Asian LMICs.

1113 Sensory impairments

1114 Sensory impairments, especially impairments in vision or hearing [222-225], if unaddressed, have a significant
1115 impact on children and adolescents, including difficulties in communication, classroom learning, social
1116 functioning, cognitive abilities, and quality of life [226-228]. Myopia affects an estimated 312 million children
1117 and adolescents under 19 years globally [229], making uncorrected myopia the leading cause of vision
1118 impairment and blindness among child populations. The prevalence of hearing loss in school-age children and
1119 adolescents ranges from 0.88%-46.7% [230]. Exposure to loud sounds and noises, especially in recreational
1120 settings, is a common cause for hearing loss in this age group. In the United States, for example, an estimated
1121 12.5% population between 6-19 years old have permanent hearing damage due to noise exposure [231].
1122 WHO estimates that globally, over one billion young people are at risk of avoidable hearing loss due to unsafe
1123 listening through headphones/earphones and in entertainment venues such as discos and clubs [232].

1124 Oral health

1125 It is also important to note that many risk factors common to NCDs are experienced by adolescents and may
1126 not translate into high morbidity until later in life [233, 234]. In the context of oral diseases high sugar intake,
1127 insufficient oral hygiene and the high likelihood of oral injuries and trauma through contact sports or risk-
1128 taking behaviours are leading risk factors in adolescence that can set individuals on a course for poor oral
1129 health throughout their lifetime. For example, untreated dental caries has many negative impacts in different
1130 phases of life. Repeated episodes of pain as well as chewing and sleeping difficulties reduce quality of life and
1131 productivity. Other common NCD risk factors include unhealthy diet and the consumption of tobacco and
1132 alcohol which increases an individual’s lifetime risk of cancer, cardiovascular disease and type 2 diabetes [233,
1133 234].

1134

1135 2.3.6 Mental health

1136 Mental health disorders among adolescents cause both a large fatal as well as non-fatal disease burden.
1137 Approximately 14% of adolescents globally experience a mental health condition [125]. Many factors have an
1138 impact on the mental health of adolescents. Violence, poverty, stigma, exclusion, and living in humanitarian
1139 and fragile settings can increase the risk of developing mental health problems. The consequences of not
Page 45 of 259
1140 addressing adolescent mental health conditions extend to adulthood, impairing both physical and mental
1141 health and limiting opportunities to lead fulfilling lives as adults [235].

1142

1143 Self-harm was the fifth-ranked cause of adolescent death in 2019, resulting in an estimated 46,000
1144 adolescent deaths. This figure encompasses both suicide and accidental death resulting from self-harm
1145 without suicidal intent. The South-East Asian LMICs accounted for at least 40% of all adolescent deaths due
1146 to self-harm. Self-harm was within the top five causes of death among adolescents in at least one age and
1147 sex category for each region except African LMICs where it led to in similarly high death rates but was
1148 outranked by other disease burdens. Self-harm largely occurred among older adolescents.

1149

1150 The overall leading cause of morbidity among adolescents in 2019 was anxiety disorders with 4.7 million
1151 YLDs. The third and fourth leading causes of morbidity were childhood behavioural disorders and depressive
1152 disorders. These three mental health disorders dominated the global, regional, age and sex specific morbidity
1153 burden.

1154

1155 Anxiety disorders may involve panic or excessive worry and are slightly more common among older than
1156 among younger adolescents. An estimated 3.6% of 10–14-year-olds and 4.6% of 15–19-year-olds experience
1157 an anxiety disorder [125]. In 2019, anxiety disorders were a key cause of YLDs in all WHO regions with YLD
1158 rates per 100,000 population ranging from 246 in South East Asian LMICs to 517 in East Mediterranean LMICs.

1159

1160 Childhood behavioural disorders is an umbrella term that includes conduct disorders, which are
1161 characterized by repeated aggressive, disobedient or defiant behaviour that is persistent, severe and
1162 inappropriate for the adolescent’s developmental level [236]. Childhood behavioural disorders were in the top
1163 five causes of adolescent morbidity in all modified WHO regions in 2019, regardless of sex or age group. The
1164 burden of childhood behavioural disorders is particularly high amongst 10–14-year-old males where in 2019
1165 they ranked as the leading cause of YLDs.

1166

1167 The classification of depressive disorders includes major depressive disorder and dysthymia, which are
1168 characterized by pervasive sadness, irritability, or anhedonia [237]. Depressive disorders accounted for 4.1
1169 million YLDs among adolescents in 2019, and a global average of 376 per 100,000 population. The regional
1170 morbidity rates ranged from 211 per 100,000 population in Western Pacific LMIC to 590 in HICs. Among older
1171 adolescents, depressive disorders were the global leading cause of morbidity, and were in the top five in most
1172 modified WHO regions.

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1173

1174 2.3.7 Alcohol and drug use

1175 Alcohol and drug use among adolescents is a major concern in countries of all income groups [238-240]. In
1176 high income countries, drug use disorders were among the top five ranked causes of adolescent morbidity
1177 and mortality in 2019. Alcohol and drug use contribute to about 3.5 million deaths each year as well as to
1178 disabilities and poor health of millions of people. Substance use most commonly begins in adolescence, with
1179 about 37.5% of adolescents (15-19 years) consuming alcohol globally (current of former drinkers).

1180 Alcohol and drug use among adolescents is associated with a wide range of negative health and social
1181 consequences. This ranges from injuries, accidents, violence and risky behaviours (such as unsafe sex or
1182 dangerous driving) [241], and are an underlying cause of injuries (including those due to road traffic
1183 accidents), violence and premature deaths.

1184 Worldwide, more than a quarter of all people aged 15–19 years are current drinkers, amounting to 155 million
1185 adolescents. Prevalence of heavy episodic drinking among adolescents aged 15–19 years was 13.6% and
1186 45.7% among drinking adolescents in 2016, with males most at risk [242].

1187 Cannabis is the most widely used psychoactive drug among young people with about 4.7% of people aged
1188 15–16 years using it at least once in 2018 [243, 244]. Alcohol and drug use in children and adolescents is
1189 associated with neurocognitive alterations which can lead to behavioural, emotional, social and academic
1190 problems in later life [241, 245, 246].

1191

1192 2.3.8 Tobacco use

1193 The vast majority of people using tobacco today began doing so when they were adolescents. Prohibiting the
1194 sale of tobacco products to minors (under 18 years) and increasing the price of tobacco products through
1195 higher taxes, banning tobacco advertising and ensuring smoke-free environments are crucial. A global survey
1196 including adolescents aged 13 to 15 from 143 countries found that 11·3% (95% CI 10·3–12·3) of boys and
1197 6·1% (5·6–6·6) of girls reported cigarette smoking on at least 1 day during the past 30 days [247]. The survey
1198 also found that 11·2% (9·9–12·6) of boys and 7·0% (6·4–7·7) of girls reported use of tobacco products other
1199 than cigarettes (eg, chewing tobacco, snuff, dip, cigars, cigarillos, pipe, electronic cigarettes) on at least 1
1200 day during the past 30 days [247].

1201 2.3.9 Physical activity and sedentary behaviour

1202 Physical activity provides fundamental health benefits for adolescents, including improved cardiorespiratory
1203 and muscular fitness, bone health, maintenance of a healthy body weight, and psychosocial benefits [248].
1204 WHO recommends for adolescents to accumulate at least 60 minutes of moderate to vigorous intensity
Page 47 of 259
1205 physical activity on average per day across the week, which may include play, games, sports, but also activity
1206 for transportation (such as cycling and walking), or physical education [248]. Globally, in 2016, only 1 in 5
1207 adolescents were estimated to meet these guidelines [249].

1208

1209 Prevalence of physical inactivity is high across all WHO regions, and higher in female adolescents as compared
1210 to male adolescents [249, 250]. An analysis of data from 298 school-based surveys including 1·6 million
1211 students aged 11-17 years from 146 countries and territories showed that in 2016, 81% were insufficiently
1212 physically active (78% boys and 85% girls) [249]. This pattern was similar in 2001, demonstrating the
1213 longstanding nature of the problem. The high prevalence of insufficient physical activity was widespread with
1214 no significant differences identified by region or country income group [249].

1215

1216 WHO guidelines for physical activity and sedentary behaviour recommend that school-age children and
1217 adolescents limit their sedentary time, particularly their recreational screen time [248]. Recreational screen
1218 time is one of the contributing factors to the high prevalence of both physical inactivity and disturbed sleep
1219 [251, 252]. Recreational screen time is defined as time spent watching screens (television (TV), computer,
1220 mobile devices) for purposes other than those related to education/study or work [248]. Recreational screen
1221 time is very common among adolescents, most of whom use smartphones, tablets, games consoles,
1222 computers and televisions [251]. Growing evidence amongst child populations strongly implicates lifestyle risk
1223 factors, including intensive near vision activity (as a risk factor) and longer time spent outdoors (as a protective
1224 factor), in the onset and progression of myopia.

1225

1226 2.3.10 Nutrition

1227 Some of the key nutrition challenges during adolescence are malnutrition by deficit or excess (undernutrition
1228 and obesity), and micronutrient deficiencies, all which may relate to socio-economic circumstances, lifestyle,
1229 eating behaviours, underlying psychosocial factors, and constitute important threats to adequate nutrition
1230 [164]. Many boys and girls in lower income countries enter adolescence undernourished, making them more
1231 vulnerable to disease and early death. Most habits detrimental to health are acquired during adolescence and
1232 youth and manifest themselves as health problems in adulthood [253].

1233

1234 Iron deficiency anemia is the leading nutritional deficiency associated with adolescent morbidity. Iron-
1235 deficiency anaemia was ranked as one of the leading causes of adolescent YLDs in 2019. Except in older male
1236 adolescents, it was the leading cause of morbidity in both sexes and age groups. South East Asian and African

Page 48 of 259
1237 LMICs showed the highest and second highest morbidity rates secondary to iron deficiency anaemia in 2019
1238 and contributed 50% and 30% of all associated YLDs.

1239

1240 Overweight and obesity are defined as ''abnormal or excessive fat accumulation that presents a risk to health''
1241 and pose what the WHO describes as one of the most serious public health challenges of the 21st century
1242 [254]. Globally, in 2016, over 1 in 6 adolescents were overweight. Prevalence varied across WHO regions,
1243 from lower than 10% in the WHO South-East Asia Region to over 30% in the WHO Region of the Americas
1244 [255]. The wide variation of overweight and obesity among adolescents across countries may be due to
1245 differences in food quality and other health risk factors [256]. Adolescents with intellectual disabilities are 1.5
1246 and 1.8 times more at risk of overweight-obesity and obesity than adolescents without intellectual disabilities
1247 [257].

1248

1249 Nutrition has a profound impact on the current and future health of adolescents (ages 10–19 years). A
1250 sustainable healthy diet and healthy eating practices during adolescence have the potential to limit any
1251 nutritional deficits and linear-growth faltering generated during the first decade of life and may limit harmful
1252 behaviours contributing to the epidemic of noncommunicable diseases in adulthood. Investing in adolescent
1253 health brings triple dividends: better health for adolescents now, improved well-being and productivity in their
1254 future adult life and reduced health risks for their children. Assuring optimal nutrition among adolescents
1255 requires coordinated actions across multiple sectors.

1256

1257 2.3.11 Humanitarian and fragile settings

1258 Humanitarian and fragile settings include areas affected by armed conflicts, natural disasters, and other
1259 emergencies. In 2018, at least 415 million children and adolescents under the age of 18 years worldwide were
1260 living in conflict-affected areas [101]. The number of displaced adolescents increased from 13 million in 2009
1261 to 19 million in 2017 [258]. Globally, the worst rates of preventable mortality and morbidity among adolescents
1262 occur in humanitarian and fragile settings [259]. Many health burdens increase in such contexts because
1263 governance and health infrastructures break down, and protective social and health services become much
1264 less accessible [259].

1265

1266 While often still children themselves, adolescents take on adult responsibilities in emergencies, including caring
1267 for siblings or generating revenue to support their families [258, 260]. Those who are separated from their
1268 families during an emergency lack the livelihood, security and protection afforded by family structures. They
1269 may be compelled to drop out of school, marry early or engage in transactional sex in order to meet their

Page 49 of 259
1270 basic survival needs. Adolescents who are especially vulnerable in humanitarian and fragile settings include
1271 those who are: young (10–14 years); have a disability; members of ethnic or religious minorities; child
1272 soldiers; other children associated with fighting forces; girl mothers; orphans; heads of households; survivors
1273 of sexual violence, trafficking and other forms of gender-based violence; engaged in transactional sex; in
1274 same-sex sexual relationships; or HIV-positive [261].

1275

1276 In such crises, key concerns for adolescent health and well-being include the following [260]:

1277 • malnutrition, e.g. wasting, underweight or micronutrient deficiencies;

1278 • inadequate assistance, treatment and care of adolescents with disability or injury;
1279 • violence, e.g. as experienced by child soldiers who are primarily boys, and survivors of sexual
1280 exploitation and abuse (including early or forced marriage, and FGM), who are primarily girls and
1281 women;
1282 • HIV and other STIs, early pregnancy, maternal conditions, unsafe abortion and general SRH
1283 needs, e.g. access to condoms and other forms of contraception;
1284 • water, sanitation and hygiene (WASH) needs, e.g. materials and facilities for menstrual hygiene
1285 management;
1286 • mental health problems, e.g. anxiety or trauma;
1287 • interrupted supply of medicines for chronic conditions (such as asthma and type 1 diabetes);
1288 • interrupted education;
1289 • Separation from protective familial or peer networks, which adds to risk of violence, abuse and
1290 exploitation.

1291 Some of these conditions are closely interrelated. For example, sexual violence may result in multiple burdens,
1292 including physical injury, STIs, unintended pregnancy, non-pathological distress (e.g. fear, anger, self-blame,
1293 shame, sadness or guilt), anxiety disorders (e.g. posttraumatic stress disorder), depression, medically
1294 unexplained somatic complaints, alcohol and other substance-use disorders, and suicidal ideation and self-
1295 harm. Social trauma can include stigma, which can lead to social exclusion, discrimination and rejection by
1296 family and community [262].

1297

1298 Adolescent girls have a particularly heightened risk of abuse and exploitation during humanitarian crises,
1299 increasing their vulnerability to early sexual initiation, unwanted pregnancy and STIs, including HIV. They are
1300 readily targeted for abuse because they have limited life experience, options and skills to negotiate their
1301 rights. In many conflict-affected contexts, sexual and gen- der-based violence, including forced marriage, is
1302 a weapon of war used against girls [263].

1303

Page 50 of 259
1304 Even within a relatively protected family setting, resource scarcity, limited employment opportunities for
1305 caregivers and a lack of protection mechanisms during humanitarian crises may contribute to families
1306 arranging marriages for their daughters, in order to ease the household burden and secure dowry payments.
1307 Families may perceive having their daughters marry as a way to protect the girls and to preserve their honour
1308 in the face of external violations and vulnerabilities, such as sexual violence and harassment. In Jordan, for
1309 example, the proportion of registered marriages among the Syrian refugee community where the bride was
1310 under 18 rose from 12% in 2011 (roughly the same as the figure in pre-war Syria) to 18% in 2012, and as
1311 high as 25% by 2013 [207, 264]. The number of Syrian boys registered as married in 2011 and 2012 in Jordan
1312 was 1%, suggesting that girls are being married to older males [207]. Child marriage among Syrian refugees
1313 has also reportedly increased in Iraq and Lebanon [265].

1314

1315 An important way that adolescent boys may be affected by violence in conflict settings is as child soldiers who
1316 may experience combat-related injuries, such as the loss of hearing, sight or limbs [197]. These injuries partly
1317 reflect the greater sensitivity of children’s bodies and partly the ways in which they may be involved in conflicts
1318 – such as being forced to undertake particularly dangerous tasks (e.g. laying and detecting landmines). Child
1319 recruits are also prone to health hazards not directly related to combat, including injuries caused by carrying
1320 weapons and other heavy loads, malnutrition, skin and respiratory infections and infectious diseases, such as
1321 malaria. Girl recruits and, less commonly, young boys are often forced to have sex as well as to fight. In
1322 addition, child recruits are sometimes given drugs or alcohol to encourage them to fight, creating problems
1323 of substance dependency. Adolescents recruited into regular government armies are usually subjected to the
1324 same military discipline as adult soldiers, including initiation rites, harsh exercises, punishments and
1325 denigration designed to break their will. The impact of such discipline on adolescents can be highly damaging
1326 mentally, emotionally and physically.

1327 Finally, children and adolescents in emergency settings have oftentimes no access to education, and thereby
1328 risk losing their futures. In addition, these young people do not have the protection from physical dangers
1329 around them that schools usually offer – including protection from abuse, exploitation and recruitment into
1330 armed groups. They also don’t have access through schools to food, water, and health care, nor the
1331 psychosocial support that schools may offer [266].

1332

1333

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1334 Section 3: Understanding what works – the AA-HA!
1335 package of evidence-based interventions
1336

What’s new in section 3?

✓ Updated with the most recent evidence on proven adolescent health and wellbeing
interventions.
✓ Guidelines published since the last version of the AA-HA are now incorporated.
✓ A more substantial treatment of positive development interventions is included

1337

1338 Key messages

1339

1340 Today we know more about how to support adolescent health and wellbeing than ever before. Many
1341 interventions have a substantial evidence base, and when implemented with fidelity can have significant
1342 positive impacts on the wellbeing of adolescents. Countries can take effective action now to promote and
1343 protect adolescent health.

1344 Interventions for adolescents should operate at all levels of the ecological framework, from the individual level
1345 to the structural level. To reduce major burdens and risk factors, it is important to ensure that interventions
1346 – even those aimed ad wider population groups - are tailored to adolescents’ specific needs and circumstances,
1347 such as the provision of adolescent-responsive health services. Interventions should be delivered with quality
1348 and universal coverage, such as the enforcement of road traffic laws and policies or the implementation of
1349 policies and legislation that reduce the affordability of tobacco, alcohol, and unhealthy foods and beverages.

1350 Given the multi-dimensionality of adolescent wellbeing, collaboration across sectors through multisectoral or
1351 integrated programming is crucial. The education sector can be particularly important for influencing
1352 adolescent behaviour, health and well-being through intensive, long-term, large-scale initiatives implemented
1353 by professionals.

1354 There are important gaps in the evidence base of interventions to promote and protect adolescent
1355 development, health and well-being, including limited knowledge of what works in humanitarian crises, gender
1356 transformative programs and digital interventions.

1357 Section overview

1358
Page 52 of 259
1359 This section describes evidence-based adolescent health interventions. Interventions are presented by areas
1360 of adolescent health and development with greatest disease burdens and risk factors, as described in Section
1361 2. The interventions are primarily selected from most recent relevant guidelines from all WHO departments.
1362 Interventions were also drawn from recommendations of other UN agencies with the relevant mandate (e.g.
1363 from UNAIDS on HIV prevention interventions) , and if needed from other major international agency
1364 publications and/or review articles in established academic journals. Importantly, the intervention examples
1365 provided here are not exhaustive.

1366 The COVID-19 pandemic shed a light on several important domains of adolescent wellbeing including the
1367 importance of adolescent mental health, connections and supportive family and peer environments as well as
1368 the need for access to reproductive health and other services. Section 3.7 discusses responses to COVID-19
1369 in adolescents.

1370

1371 3.1 Conceptualizing adolescent health interventions

1372 Evidence-based interventions for adolescent well-being take many forms, depending on the determinants or
1373 conditions of interest (e.g., interventions to promote mental health or better hygiene practices), the target
1374 population (e.g., general population or adolescents only), the context in which they are implemented (e.g.
1375 humanitarian or high income contexts), the ecological level it addresses (e.g., interventions that target
1376 individuals or interventions designed for implementation at the institutional level), and lead sector (e.g., health
1377 sector or education sector).

1378 In this section we describe interventions that fall into several categories.

1379 Adolescent-specific interventions. Many effective interventions to address major adolescent conditions are
1380 adolescent-specific, i.e., they are directed exclusively, or mostly, to adolescents. Examples include human
1381 papillomavirus (HPV) immunization, provision of school health services and comprehensive sexuality
1382 education [114].

1383 Interventions with wider impacts but particular benefits for adolescents. It is important to recognize that
1384 adolescents will benefit substantially from many interventions that are targeted to wider age groups or the
1385 population as a whole. For example, reducing urban air pollution contributes significantly to healthier urban
1386 environments from which all will benefit. However, because of children and adolescents’ greater vulnerability
1387 to air pollution, the impacts in them will be particularly powerful.

1388 Interventions with wider impacts in need for age-appropriate design to be effective in adolescents. Many
1389 organizational (e.g., improving the quality of care in primary care facilities) and structural interventions (e.g.,
1390 limiting the promotion and availability of alcohol) need to be designed with adolescent needs in mind,
1391 otherwise, while being effective for adults or other population groups, they will be less effective for
1392 adolescents. For example, limiting access to alcohol and protecting against its marketing is an intervention
Page 53 of 259
1393 that should take into account the locations where adolescents convene and their susceptibility to online
1394 marketing relative to older members of society. Similarly, if efforts to improve the quality of care in facilities
1395 are to benefit adolescents, they should include investing in providers’ education and training in adolescent-
1396 responsive care [269, 270]. Many individual-level interventions also need age-appropriate adaptation (e.g.,
1397 providing additional, adolescent-friendly adherence and disclosure support to adolescents living with HIV).

1398 This section summarizes all three types of interventions. It aims to make the adolescent-specific aspects of
1399 the interventions clear and highlights the importance of addressing the special needs of adolescents in the
1400 design and implementation of interventions at any level of the ecological framework – from structural or
1401 environmental to individual. At the structural and environmental levels, we describe interventions that operate
1402 in the macro- environment, and largely include policies or legislation. At the organizational level, we share
1403 interventions that describe systems level responses, in health, but also other sectors. At the community or
1404 interpersonal environment, we describe interventions that operate in communities, families, peers or with
1405 partners. At the individual level we share interventions directed at the adolescent themselves, recognizing
1406 that they may require support to access and benefit from that intervention. Some interventions operate across
1407 multiple ecological levels (e.g., adolescent participation). In each intervention area, example interventions are
1408 provided..

1409 3.2 Positive health and development interventions

1410 Positive development approaches are based on the fact that young people possess resources that can be
1411 developed, nurtured and cultivated. Positive health and development interventions aredeveloped to enable
1412 young people to develop these positive assets to deliver broad behavioural, developmental and wellbeing
1413 benefits. Interventions to promote and ensure positive adolescent development span many sectors and target
1414 different physical and psychosocial aspects of adolescent development. The main determinants of adolescent
1415 health are largely outside of the health system, for example family and community norms, education, labour
1416 markets, economic policies, legislative and political systems, food systems and the built environment [194].

1417 Working with parents, families and communities is especially important because of their great potential to
1418 positively influence adolescent behaviour and health. The education sector also provides a critically important
1419 opportunity for intensive, long-term and large-scale initiatives implemented by professionals.

1420

1421 Table 1 provides examples of key positive development interventions within health sector, the education sector
1422 and the broader community.

1423

1424 Table 1: Interventions to promote positive development [271-273]

1425

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Ecological Level Intervention Further Comment

Structural Gender responsive policies and To achieve the goal of gender equality, policies
and environmental programs should respond to structural factors that
perpetuate gender inequalities, and programmes
need to apply the process and strategy of gender
mainstreaming. Gender responsive programs
encompass both gender specific (which
intentionally targets a specific group of girls or
boys for a specific purpose; doesn’t challenge
gender roles and norms) _ and gender
transformative (which address the causes of
gender inequality; transforms harmful gender
roles, norms and relations; promotes gender
equality.)

More information and good practice examples are

provided in Section 5.

Online protection for Develop and implement a national strategy for

adolescents child online protection, including a legal
framework, law enforcement resources and
reporting mechanisms, and education and
awareness resources.

Organizational Adolescent-responsive services Healthcare should be accessible and acceptable,

and systems promote health literacy and provide an
appropriate package of services, including
routine, age-appropriate appointments (e.g.,
vaccinations). Adolescent-friendly sexual and
reproductive health (SRH) services are especially
important, as stigma and discrimination prohibit

Page 55 of 259
 adolescents from accessing them in many
settings. Eight standards for quality-of-care
services for adolescents have been developed and
are described in Section 5 [274].

Positive Youth Development Interventions to promote the 5Cs including

Interventions [275] adolescent competence, confidence, connection,
character and caring include resilience building
programs, as well as character development
programs.

Making every school a health A health-promoting school is “a school that is

promoting school [18] constantly strengthening its capacity as a healthy
setting for living, learning and working”. The
concept of health-promoting schools embodies a
whole-school approach to promoting health and
educational attainment in school communities by
using the organizational potential of schools to
foster the physical, social–emotional, and
psychological conditions for health as well as for
positive education outcomes. Examples of
interventions include school feeding programs,
hygiene and sanitation programs in schools. WHO
and UNESCO have established 8 standards for
health promoting schools: (1) Government
policies and resources, (2) School policies and
resources, (3) School governance and leadership,
(4) school and community partnerships, (5) school
curriculum, (6) school social -emotional
environment, (7) school physical environment and
(8) school health services. Embedding in policy
and institutions and a strong, interconnected
system of governance by the education and health
sectors are key elements for the successful
implementation of sustainable HPS initiatives.

Digital health interventions for Explore the potential of effective adolescent

health education and digital health interventions focused on improving
quality and access to health interventions (e.g.,

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 adolescent involvement in their chronic illness management; SRH education, such
own care as STI prevention), and employing a variety of
digital approaches (e.g., web-based on-demand
information services , active video games,
targeted-client communication via text
messaging, and mobile phone or tablet software
applications), consistent with WHO guidelines
recommendations on digital health interventions.

Community and Civic engagement programs Meaningfully engaging and supporting youth in
interpersonal their communities can promote their sense of
empowerment and promote self-efficacy, thereby
leading to improved health and wellbeing. This
may involve creating demand for youth
participation, including among the most
vulnerable adolescents. Interventions include
strengthening platforms for adolescent civic
engagement, community support to create
solutions and lead change, develop skills and
voice their opinions. UNICEF’s guidelines Engaged
and Heard! Support the design of meaningful and
equitable Adolescent participation and civic
engagement.

Page 57 of 259
 Parenting or caregiver Work with parents to promote positive, stable
interventions emotional connections with their adolescent
children, promoting connection, regulation,
psychological autonomy, modelling and
provision/protection. Parenting programs can
have multiple benefits for adolescents including
their mental health, communication skills,
cyberbullying risk and onset of eating disorders
among others. Parents can also be supported to
communicate with their children about SRH, as a
complement to school based CSE. UNICEF
program guidance presents core content topics as
well as key delivery strategies including how to
improve parent-adolescent communications,
managing behavioral difficulties, positive
discipline techniques and creating a safe
environment [276].

Individual Adolescent participation Facilitation of adolescent participation includes

initiatives involving them in programme design,
implementation, governance and monitoring and
evaluation.

1426

1427

1428 3.3 Unintentional injury interventions

1429 Even though road traffic injury is a leading cause of adolescent death across the globe, the interventions most
1430 likely to reduce it effectively may differ greatly depending on the setting. For example, in countries where the
1431 main adolescent victims of road traffic accidents are adolescent drivers and their passengers, adolescent-
1432 specific interventions e.g. low blood alcohol limits, limiting the availability of alcohol, and other restrictions on

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1433 young drivers, see case study 2- Success in Zero Tolerance Approach for Alcohol Consumption among Young
1434 Drivers in Germany) may be the most effective interventions to reduce the adolescent burden. However, in
1435 countries where few adolescents are drivers – but the rates of road traffic injury among adolescent
1436 pedestrians, cyclists and public transport passengers are very high – better implementation of population-
1437 level interventions e.g. legal disincentives to drive unsafely and speed limits to reduce road traffic injuries
1438 among adolescents. Such conditions are most likely to occur in middle-income countries (MICs) and especially
1439 low-income countries (LICs), where road traffic injury deaths largely involve vulnerable road users, i.e.
1440 motorcyclists, pedestrians and cyclists. In practice, a mix of multiple interventions of both types, tailored to
1441 the specific setting, is likely to maximize positive impact.

Case Study 2
Success in Zero Tolerance Approach for Alcohol Consumption among Young Drivers in
Germany

In 2007, Germany implemented a law targeting young/novice drivers and their drinking behaviors with the
aim of reducing alcohol-related driving incidents. Existing evidence has linked high risk behaviors such as
alcohol consumption with increased collisions. The new law implemented zero tolerance for alcohol
consumption among new drivers, those within their first 2 years and drivers under the age of 21.
Young/novice drivers who are caught drinking and driving could have their license suspended or, depending
on the circumstances, could be fined between 125-1000 euros. Assessments conducted after the
implementation of the law reported reduced traffic related incidents among the first cohort of young/novice
drivers when compared to a reference group or young/novice drivers before the implementation of the law.
This was confirmed in a follow-up evaluation.

Source: https://etsc.eu/wp-content/uploads/PIN-Flash-41_web_FINAL.pdf
1442

1443 Table 2: Interventions to prevent and mitigate road traffic injuries among adolescents [277-279][280]

1444

Ecological Level Intervention Further Comment

Drinking age laws Raising the legal drinking age to 21 years reduces drinking,
driving after drinking and alcohol-related accidents and

Structural and injuries among youth.

environmental Blood alcohol Set a lower permitted blood alcohol concentration limit (0.02
concentration laws g/dl) for young drivers than recommended for older drivers
(0.05 g/dl). Enforce blood alcohol concentration limits, e.g.

Page 59 of 259
 random breath testing of all drivers at a certain point, or
only those who appear to be alcohol-impaired.

Protection against Limits on easy access to alcohol and its marketing, including
alcohol marketing school policies on zero tolerance

Seat-belt laws When laws requiring seat-belt use are enforced, rates of use
increase, and fatality rates decrease. Although most
countries now have such laws, half or more of all vehicles in
LICs lack properly functioning seat-belts.

Helmet laws Create mandatory helmet laws for two-wheeled vehicles and
enforce them. Establish a required safety standard for
helmets that are effective in reducing head injuries.

Mobile phone laws While the evidence on the effects of penalising mobile phone
use on road traffic fatalities is still developing, emerging
evidence suggests a potential decrease in the prevalence of
mobile phone use and fatalities for all-driver primary
enforcement hand-held bans and texting bans.

Speed limits Roads with high pedestrian, child or cyclist activity should
allow speeds no higher than 30 km/h. Limits should be
enforced in such a way that drivers believe there is a high
chance of being caught if they speed.

Restriction of young A graduated licensing system phases in young driver

or inexperienced privileges over time, such as first an extended learner period
drivers involving training and low-risk, supervised driving; then a
licence with temporary restrictions; and ultimately a full
licence.

Restriction of Reducing hours, days or locations where alcohol can be sold,

availability of alcohol and reducing demand through appropriate taxation and
to young drivers pricing mechanisms, are a cost-effective way to reduce drink
driving among young people.

Legal disincentives to Make unsafe behaviour less attractive, e.g. give penalty
drive unsafely points or take away licences if people drive while impaired.

Traffic calming and Examples include infrastructural engineering measures (e.g.

safety measures speed humps, mini-roundabouts or designated pedestrian
crossings); visual changes (e.g. road lighting or surface

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 treatment); redistribution of traffic (e.g. one-way streets);
and promotion of safe public transport.

Pre-hospital care Standardize formal emergency medical services, including

equipping vehicles with supplies and devices for children as
well as adults. Where no pre-hospital trauma care system
exists: teach interested community members basic first aid
techniques; build on existing, informal systems of pre-
hospital care and transport; and initiate emergency services
on busy roads with high-frequency crash sites.
Organizational
Hospital care Improve the organization and planning of trauma care
services in an affordable and sustainable way to raise the
quality and outcome of care

Rehabilitation Improve services in health-care facilities and community-

based rehabilitation to minimize the extent of disability after
injury and help adolescents with disability to achieve their
highest potential.

Alcohol campaigns Make drinking and driving less publicly acceptable; alert
people to risk of detection, arrest and its consequences; and
raise public support for enforcement.

Designated driver Designated drivers choose not to drink alcohol so they may
campaigns safely drive others who have drunk alcohol. Such initiatives
should only be targeted at young people over the minimum
drinking age, so as not to promote underage drinking.

Seat-belt campaigns Public campaigns about seat-belt laws can target

Community
adolescents to increase awareness and change risk-taking
social norms.

Helmet campaigns Educate adolescents about the benefits of wearing helmets

on two-wheeled vehicles, using peer pressure to change
youth norms regarding helmet acceptability and to reinforce
helmet-wearing laws.

Community-based Community projects can employ parents and peers to

projects encourage adolescents to wear seat-belts.

Helmet distribution Programmes that provide helmets at reduced or no cost

Individual
enable adolescents with little disposable income to use

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 them. Distribution can be taken to scale through the school
system.

Motorized two- Promote use of daytime running lights; reflective or

wheeler interventions fluorescent clothing; light-coloured clothing and helmets;
and reflectors on the back of vehicles to reduce injury.

Cyclist interventions Promote front, rear and wheel reflectors; bicycle lamps;
reflective jackets or vests; and helmets to reduce injury.

Pedestrian Promote white or light-coloured clothing for visibility;

interventions reflective strips on clothing or articles like backpacks;
walking in good lighting; and walking facing oncoming traffic
to reduce injury.
1445

1446 Drowning: Adolescent drowning can be prevented through strategies targeting the general population, as
1447 well as communities at risk. Many of these have been successfully implemented in low income settings, and
1448 settings that are prone to flood risks [281] [282] (See Table 3).

1449 Table 3: Interventions to prevent drowning

Ecological Level Intervention Further comment

Structural and Appropriate policies Setting and enforcing safe boating, shipping and ferry
environmental and legislation regulations; Building resilience and managing flood risks
locally and nationally; Coordinating drowning-prevention
efforts with those of other sectors and agendas; Developing
a national water safety plan.

Community and Infrastructure Improved community infrastructure (e.g. Barriers to water

interpersonal improvements supply, bridges and levees)
Installing barriers controlling access to water

Training Training community members in safe rescue and

resuscitation

Public awareness Strengthening public awareness of adolescent vulnerability to

drowning (because they tend to be less supervised than small
children and are more likely to consume alcohol and engage
in other risky behaviour around water).

Individual Public swimming Make teaching school-aged children basic swimming, water
programs safety and safe rescue skills free of charge
1450
Page 62 of 259
1451 Burns [172]: Burns are one the few forms of injury that have a higher burden in adolescent females
1452 than males, because worldwide approximately 2 billion people in LMICs – the vast majority female –
1453 cook on unsafe, fires or very basic traditional stoves in their own homes or as domestic workers [283,
1454 284]. Due to their youth, they are on average less skillful and more prone to burns than adult women
1455 [285].

1456 Burns are preventable. High-income countries have made considerable progress in lowering rates of burn
1457 deaths, using a combination of prevention strategies and improvements in the care of people affected by
1458 burns. Most of these advances in prevention and care have been incompletely applied in low- and middle-
1459 income countries. Increased efforts to do so would likely lead to significant reductions in rates of burn-
1460 related death and disability [172].

1461 Prevention strategies should address the hazards for specific burn injuries, education for vulnerable
1462 populations and training of communities in first aid. An effective burn prevention plan should be
1463 multisectoral and include broad efforts to:

1464 • improve awareness

1465 • develop and enforce effective policy
1466 • describe burden and identify risk factors
1467 • set research priorities with promotion of promising interventions
1468 • provide burn prevention programmes
1469 • strengthen burn care
1470 • strengthen capacities to carry out all of the above.

1471 Careful assessment of the cause of adolescent injury is also important because some adolescents or
1472 their guardians may falsely state that an injury was due to an accident when in fact it was due to self-
1473 harm or interpersonal violence. In some countries, for example, so-called honour killings and death by
1474 fire account for a significant number of reported cases of familial or intimate partner violence against
1475 adolescent girls, and survivors of such assaults may be compelled by the perpetrators to claim the injuries
1476 were accidental [197, 283]. Similarly, alcohol/drug use is a major risk factor for many forms of injury,
1477 both when an adolescent is the drinker and when the drinker (e.g. a parent or an intimate partner) causes
1478 harm to an adolescent [112, 286]. In these instances, additional interventions related to mental health
1479 and substance use disorder, and/or legal interventions may be warranted. Some examples are discussed
1480 later in this section.

1481

1482 3.4 Violence interventions

1483 Violence against adolescents can have strong, long-lasting effects on brain function, mental health,
1484 health risk behaviours, noncommunicable diseases, infectious diseases such as HIV and sexually
1485 transmitted diseases, and social functioning.

Page 63 of 259
1486 Table 4. Interventions to address youth violence [287-294][287]

Ecological Level Intervention Further Comment

Laws banning violent Institute laws banning violent punishment of children by

punishment and parents, teachers or other caregivers
criminalizing sexual Legislation that criminalizes sexual abuse and exploitation
abuse and exploitation of children and adolescents, including laws criminalizing
child marriage, forced labour, trafficking, child
pornography, harmful practices and online harms.

Reduce access to and Programmes may require new legislation, additional police
misuse of firearms to supervise implementation, public awareness campaigns
and more elaborate monitoring systems.

Reduce access to and Regulate the marketing of alcohol to adolescents; institute

the harmful use of laws that prevent alcohol misuse; restrict alcohol
alcohol availability; reduce demand through taxation and pricing;
raise awareness and support for policies; and implement
interventions for the harmful use of alcohol.

Income and economic Cash transfers, group saving and loans and/or
strengthening, microfinance programs combined with gender equity
Structural and
including to attend training can reduce violence through a number of
environmental
school pathways, including lowering household stress, improved
parental monitoring, or delaying sexual debut. Grants to
cover school costs (e.g. school fees and supplies) as well
as opportunity costs (e.g. when families lose income from
child labour), have been successful at keeping adolescents
in school.

Spatial modifications For areas with high levels of violence, situational crime
and urban upgrading prevention includes a security assessment, a stakeholder
analysis, and a planning process involving communities,
local government, and housing, transport and other
sectors.

Poverty de- These strategies offer vouchers or other incentives for

concentration residents of economically impoverished public housing
complexes to move to less impoverished neighbourhoods.

Hotspot policing Police resources are deployed in areas where crime is

prevalent. Mapping technology and geographic analysis

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 help identify hotspots based on combined crime statistics,
hospital emergency records, vandalism and shoplifting
data and other sources.

Addressing restrictive Community mobilization programmes and programmes

and harmful gender and that increase bystander intention to intervene can prevent
social norms violence particularly against dating partners and
acquaintances

Demand- and Drug control may focus on reducing drug demand, drug
supply-side supply or both. Most interventions require substantial
interventions for drug technical capacity within health services and the police
control force.

School-based violence Work with teachers on values and beliefs, and train them
prevention in positive discipline and classroom management,
including in pre-service training.
Prevent violence through curriculum-based activities.
Train teachers to recognize and explain bullying to
students, what to do when it occurs, effective relationship
Organizational skills and skills for bystanders.
Establish school policies and coordination procedures to
support a whole school approach.
Review and adapt school buildings and grounds, including
ensuring the annual budget includes funding for improving
school infrastructure to student child safety.
Address online abuse in school safety programs (bullying
prevention, dating abuse prevention, sexual education)
[290]
Please see case study 3, which illustrates a Peer Violence
Program to reduce bullying and victimization in schools

Health facility Health-care providers should seek explanations for injuries

responses to child or symptoms that may be caused by physical, sexual,
maltreatment emotional abuse or neglect from parents and carers, and
the adolescent in an open and non-judgmental manner,
seeking their informed consent for all decisions and
actions taken and appropriate with their age, evolving
capacity and the legal age of consent for obtaining clinical
care. To do so, health facilities may require additional

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 training and on-going support enabling staff to adequately
care maltreated adolescents, have access to safe, private,
and properly resourced locations for exams, and
document and report crimes as needed [295].

Gang and street This may focus on reducing gang enrolment, helping
violence prevention members leave gangs and/or suppressing gang activities.
interventions Community leaders are engaged to convey a strong
message that gang violence is unacceptable. Police
involvement, vocational training, and personal
development activities may also be included.

Community Community- and The systematic use of police-community partnerships and

problem-orientated problem-solving techniques identifies and targets
policing underlying problems to alleviate violence. Necessary
preconditions are a legitimate, accountable, non-
repressive, non-corrupt and professional policing system,
and good relations between police, local government and
the public.

Parenting programmes Goals are to promote parental understanding of

and home visiting adolescent development and to strengthen parents’ ability
to assist their adolescents in regulating their behaviour.
These can be delivered through home visits or in
community settings. Home visiting programmes can
monitor and support families where there is a high risk of
maltreatment.

Peer mediation Peer mediators may be nominated by a class and receive

Interpersonal
20–25 hours of training on how to mitigate peer conflicts
and seek help if needed. Other students may also be
trained in conflict resolution skills.

Dating violence School-based or after-school participatory activities

prevention address the characteristics of caring and abusive
relationships; how to develop a support structure of
friends; communication skills; and where and how to seek
help in case of sexual assault.

Life-skills development These age-specific programmes help adolescents to

Individual and social and understand and manage anger and other emotions, show
emotional learning empathy for others and establish relationships. They
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 involve 20–150 classroom sessions over several years
[296].

After-school and other Structured leisure time activities can include cognitive and
structured leisure time academic skills development; arts, crafts, cooking, sport,
activities music, dance and theatre; activities related to health and
nutrition; and community and parental engagement.

Academic enrichment Adolescents are targeted through mass media, after-

school lessons or private tutoring to help them keep up
with school requirements and prevent them from dropping
out of school.

Vocational training Vocational training for at-risk youth can have a meaningful
impact on violence prevention if integrated with economic
development and job creation. Ensure the capacity of
training institutions, available technical equipment,
existing cooperation with businesses and sustainable
financing models.

Mentoring Volunteer mentors receive training in adolescent

development, relationship-building, problem-solving,
communicating and specific concerns (e.g., alcohol and
drug use). A mentor shares knowledge, skills and
perspective to promote an at-risk adolescent’s positive
development.

Therapeutic Qualified mental health specialists or social workers work

approaches with individual adolescents on social skills and behavioural
training, anger- and self-control techniques and cognitive
elements (e.g. moral reasoning and perspective-taking to
appreciate the negative impacts of violence on victims).
Families and social networks of at-risk adolescents may
also be targeted.
1487

Case Study 3
Roots Indonesia Peer Violence Program reduces bullying and victimization in schools

In line with Indonesian Ministry of Women Empowerment and Child Protection’s goal of preventing and
reducing violence and bullying among youth, UNICEF and partners implemented an adapted version of the

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 anti-bullying intervention program Roots. The Roots program is geared towards improving anti-bullying
efforts through student led activities. In Indonesia, the Root intervention included a teacher training
program meant to increase teachers’ knowledge of positive discipline practices. The program draws from
evidence based effective anti-violence and anti-bullying intervention tools that have been used successfully
in other parts of the world. The intervention recruited students who served as Change Agents after being
voted by their peers to serve in that role. The Change Agents hold regular sessions to identify violence and
bullying related problems in their schools and went on to work on solutions with young facilitators. Schools
that took part in the program successfully developed anti-bullying agreements and observed a reduction in
bullying and victimization related incidents. However, in certain areas where the program was implemented,
the number of anti-bullying related incidents also increased due to improved mechanisms for reporting
bullying. Overall, in all regions of Indonesia, notable improvements were observed in students, Change
Agents and teachers on their responses towards bullying.

Source:
https://www.unicef.org/indonesia/media/7021/file/Roots%20Indonesia%20Programme%20Evaluation.pd
f
1488

1489 Table 5: Prevention and response to sexual and other forms of gender-based violence
Ecological Intervention Further Comment [297-300]
Level
Structural and Systems Strengthen the system response by integrating services for GBV
environmental strengthening into existing primary health care programmes including
and integration dedicated adolescent services, and SRH and HIV services
reaching adolescents.

Organizational Health services Health care providers should consider exposure to child
for adolescent maltreatment when assessing adolescents with conditions that
survivors of may be caused or complicated by maltreatment, in order to
sexual and/or improve diagnosis/identification and subsequent care, without
intimate partner putting the child at increased risk [295].
violence
Based on signs and symptoms, train and support health workers
to empathically provide first-line support that is survivor-
centered and uses the LIVES-CC approach which involves
Listening, Inquiring about their needs, Validating, Enhancing
their safety and facilitating social Support; creating a Child and
adolescent friendly environment including training providers and

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 providing support to non-offending Caregivers to support the
adolescent [293].

Mental health care in accordance with WHO guidelines; and

referral for other legal, psychosocial and shelter needs
Interventions to School-based programmes to prevent dating violence;
reduce and Multicomponent violence-prevention programmes; School-
respond to based training to help children recognize and potentially avoid
interpersonal sexually abusive situations; School-based social and emotional
violence skills development initiatives; counselling services

Community Interventions to Interventions based on social norms theory and focused on

and reduce and changing social and cultural gender norms; Media-awareness
interpersonal respond to campaigns; Targeted work with men and boys [293, 295]
interpersonal
violence

Support for Involve parents or caregivers only where the adolescent

survivors specifically wants or agrees to it, or their safety or life is at risk

Individual Support to Interventions specifically for children exposed to such violence,

survivors such as psychological treatment to improve cognitive,
emotional, and behavioural outcomes

Identify and treat conduct and emotional disorders

1490
1491 WHO recommends that child abuse interventions should be multifaceted to address the specific needs of
1492 adolescents more effectively, including enhancement of professional training and education about the
1493 nature and impact of adolescent maltreatment; development and extension of prevention and treatment
1494 services for adolescent victims and their families; and systems that better assess and intervene with
1495 maltreated adolescents [301]. Furthermore, these interventions should consider intersectional factors
1496 which add to the risk of violence and abuse among specific groups of adolescents, such as those with
1497 disabilities, and affects their access to appropriate services and support. Comprehensive activities that
1498 help to prevent violence and which involve all stakeholders who are important in a young person’s life
1499 have been proven to be more effective in preventing violence than activities that just focus on one
1500 particular target group. This approach works towards making sure that whole schools and communities
1501 shares the same vision towards reducing violence, and that teachers, healthcare workers, parents and
1502 the community work together with adolescents towards this common goal.

1503

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1504 Box 1: Strategies to reduce online violence against children and adolescents [302]

1505 Technology is now a regular part of growing up in adolescence. Access to digital technologies provide
1506 many benefits, but such platforms can also manifest harm. Violence against children online, also called
1507 technology-facilitated violence, is the use of computers, mobile phones or other forms of digital
1508 communication to access, threaten and/or harm children or adolescents. It can result in short and long
1509 term physical, sexual or emotional suffering and takes many forms. Sometimes adolescents meet future
1510 perpetrators for the first time online. Sexual abuse is happening in the physical world can be filmed and
1511 shared online. Unsolicited sexting and sexual extortion can include sending unwanted sexual messages
1512 or images to children or pressuring children to send explicit messages or images, or using these without
1513 consent. Solicitation and grooming can occur by asking a child to provide sexual images or luring a child
1514 into meeting for sexual contact. In other instances, bullying in school can continue through social media
1515 at home, exposing young people to online threats or hate speech (including racist, homophobic and sexist
1516 messages.)

1517

1518 WHO suggests the following strategies to counteract online violence against adolescents:

1519

1520 • Strengthen laws and improve enforcement. This can be achieved by enacting comprehensive
1521 national legislation to protect young people from violence online and offline. Training law
1522 enforcement to recognize and respond to online abuse, and creating safe and accessible reporting
1523 mechanisms are important parts of the structural response.
1524 • Address risk factors that make children vulnerable to recruitment by sex offenders. Poverty, drug
1525 use and neglect are known determinants of children recruitment. Address these risks by improving
1526 economic opportunities, preventing drug use and stabilizing families.
1527 • Provide technological oversight. Working with digital providers, embed safety features in the
1528 design of online services, reduce production and dissemination of child sexual abuse imagery, and
1529 prevent abusers from using digital platform to access young people.
1530 • Engage parents, caregivers and teachers. Providing parents with the skills to talk to their children
1531 can be achieved by building online safety into parenting programs. Digital safety should be
1532 integrated into school curricula, and teachers trained to respond to threats of online abuse.

1533 END BOX

1534

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1535 3.5 Sexual and reproductive health (SRH) interventions, including HIV
1536 interventions

1537 Adolescent SRH knowledge and access to SRH services are limited in many low- to middle-income
1538 countries. Despite efforts to improve uptake, unmet needs remain high and many adolescents suffer from
1539 undesirable outcome such as unintended pregnancy, unsafe abortions, sexual violence, STI and HIV. Girls
1540 remain particularly vulnerable, and disproportionately affected by poor SRH services and inadequate SRH
1541 education.

1542

1543 Table 6: Sexual and reproductive health interventions, including HIV [114, 303-311]

1544

Ecological Intervention Further Comment

Level

Structural Policies and funded Develop and implement laws and policies, that clearly
and environmental implementation plans state that all adolescents can obtain accurate,
comprehensive sexual and reproductive health
information, support in decision-making from a qualified
health professional, respectful treatment, and voluntary
choice of a full range of contraceptive methods
regardless of age, marital status or parity.

Include adolescent contraception in universal health

coverage (UHC) and national insurance schemes and/or
use other approaches such as offering vouchers or
offering subsidized services through social marketing,
social franchising, and cost-recovery schemes;
Implement interventions to reduce the financial cost of
contraceptives or make them free for adolescents.

Organizational Peer education programs Peer education should not be used in isolation, but rather
in combination with other effective approaches as part
of a package of actions to provide information, build
positive attitudes and promote behaviour change and
increased service use. Peer education programmes must
also be accessible to and inclusive of marginalized
groups of adolescents, such as those with disabilities,

Page 71 of 259
 not only increasing their access to health information,
but also to strengthen their protective peer networks.

Providing Comprehensive In all countries CSE should be integrated into school

Sexuality Education (CSE) curricula and should include the promotion of gender
equality and respect for human rights. Training and
information should be provided to relevant health sector
workers, including at the policy level. To reach
adolescents who are out of school, include focus on both
school-based and out-of-school CSE, and build synergies
between the two. Identify and address barriers to
accessing CSE programmes faced by some groups of
adolescents, such as those with disabilities [312]. Begin
CSE programmes begin in childhood and continue
through adolescence, taking care to follow the
International Technical Guidance on and age- and
developmentally-appropriate SE (ITGSE). Attitude and
norm formation is incremental and important to begin
early. A good example of this is gender attitudes and
norms which form early in life.

Provide contraceptive Contraceptive care should be accessible and acceptable,

counselling and services age-appropriate, not stigmatize, discriminate or prohibit
adolescents from accessing them. Adolescent friendly
health services that take a client centered approach can
help health care workers to understand and respond to
the differing and changing needs of different groups of
adolescents.

Implement interventions at scale that provide accurate

information and education about contraceptives, in
particular curriculum-based sexuality education, to
increase contraceptive use among adolescents. The full
range of methods, including emergency contraception
should be provided where legally available. Health
workers should be trained and informed about what
circumstances they are permitted to provide safe

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 abortion care, within the context of their country’s laws
and policies.

Provide STI and HIV STI and HIV testing and care services should be provided
prevention and care services in a way that protects privacy and confidentiality;
Monitor adolescents receiving anti-retroviral medication
carefully and provide them with support to help them
stay on their medication, even if they face challenges
e.g. side effects.

Leverage digital decision- Software systems that reinforce WHO recommended

support and patient clinical care guidelines with decision-support and patient
management systems to management, strengthen health providers capacity to
strengthen care support, screen, refer, and manage adolescents in
coordination and quality of relation to their sexual and reproductive health needs.
service delivery [313-315]

Community and Offer a range of channels for Expand community-based distribution and supply,
interpersonal young people to access including mobile outreach services, pharmacies and drug
contraception and reach shops, and school- or workplace-based services
them where they are

Care of adolescents living Comprehensive care of children (including adolescents)

with HIV living with, or exposed to, HIV

Individual Adolescent participation Engage a diversity of young people as dedicated

advocates to create momentum for scale up. Invest in
youth leadership who reflect different groups including
indigenous and gender minorities, or persons with
disabilities.

Adolescent HIV prevention Voluntary medical male circumcision (VMMC) in

countries with generalized HIV epidemics; Access to
condoms and other contraceptive methods;

Behavioural interventions which commonly address

knowledge, attitudes, risk perception, norms, HIV
service demand and skills. These include interpersonal

Page 73 of 259
 and media communication, financial and other
incentives, as part of a comprehensive package

Adolescent HIV treatment ART should be initiated in all adolescents with severe or
advanced HIV clinical disease (WHO clinical stage 3 or
4) and adolescents with CD4 count ≤350 cells/ mm3.
Also, all pregnant and breastfeeding adolescents living
with HIV should initiate ART, and this should be
maintained at least for the duration of mother-to-child
transmission risk.

1545

1546

1547 Box 2: Integration of HIV and STIs in contraceptive services [316]

Integration of HIV and STIs in contraceptive services

Integrated services can expand the reach, quality and care to better serve adolescent girls and women at
high risk of acquiring HIV or STIs and who are accessing contraception.
• Adolescent girls and young women should have more contraceptive choices available in all types
of service delivery settings, including family planning clinics and primary healthcare clinics. This
should include free male and female condoms, which are the only available multipurpose tools for
preventing HIV, STIs and unintended pregnancy.
• Adolescent girls and young women accessing contraceptive services — especially in high HIV
burden countries — should have easy and affordable access to quality integrated HIV and STI
testing, prevention and treatment services that are responsive to the rights and preferences of
adolescent girls and women.
• The rights of adolescent girls and women to full and unbiased information should be guaranteed
in all healthcare settings and in the community. This includes basic information on STI and HIV
risk factors, advantages, disadvantages and risks of different contraceptive methods, including the
message that methods other than condoms do not prevent STIs or HIV and all relevant regulatory
changes and requirements.
• Contraceptive, HIV and STI services need to be part of a broader health response that includes
both SRH and primary healthcare services in the context of universal health coverage.
1548

1549 Table 7: Interventions to prevent Female Genital Mutilation

Ecological Level Intervention Further Comment

Page 74 of 259
 Structural Introduction and For more information see [317, 318]
and environmental enforcement of anti-
FGM laws and
enforcement
Mass media initiatives This can take the form of radio, music, storytelling
and poems [319]
Organizational Health sector support to Recommendations include deinfibulation, mental
victims health and female sexual health. For girls and
women living with any form of FGM, cognitive
behavioural therapy should be considered if they
are experiencing symptoms consistent with anxiety
disorders, depression or post-traumatic stress
disorder, and sexual counselling is recommended
for preventing or treating female sexual dysfunction
[320]
Health workers can act Person- centered communication for FGM
as opinion leaders prevention using the ‘ABCD approach’ has been
shown to be effective in changing knowledge and
attitudes of women attending antenatal care in FGM
prevalent settings [321]
Community and Communication for For more information see [317]
Interpersonal change
Alternative right of For more information see [317]
passage rituals
1550

1551 Table 8: Interventions to prevent early child marriage [322] [263]

Ecological Level Intervention Further Comment

Structural Political leadership, planners and A multisectoral, multipronged
and environmental community leaders to formulate and approach is likely to be more effective
enforce laws and policies to prohibit it in ending child marriage than
changing laws and policies alone
Social protection This can include transfers, insurance
and services to improve resilience
and prevent negative household
coping strategies

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 Organizational Increasing educational opportunities
for girls through formal and non-formal
channels
Investing in girls’ education and
vocational skills
Invest time in identifying the key Although gender-discrimination is a
drivers of child marriage in local central determinant of child marriage,
settings the precipitating factors vary from
place to place. They include poverty,
lack of opportunities to study and
work, restrictive social and cultural
norms, and insecurity resulting from
war or civil strife. The mix of these
and other factors will need to
determine the package of actions
used in each setting [323].
Improve access to services for married This could take the form of
adolescents psychological support or reproductive
health services. With limited agency
and power in marital relationships
and, in some cases, little mobility,
adolescent girls may require special
outreach of youth-friendly services
where appropriate.
Community and Implementing interventions to inform
Interpersonal and empower girls
1552

1553 Table 9: Promotion of preconception, antenatal and pregnancy care in adolescents [324, 325]

Page 76 of 259
Ecological level Intervention Further comments

Organizational Leverage digital Software systems that reinforce WHO

decision-support and recommended clinical care guidelines with decision-
patient management support and patient management, strengthen
systems to strengthen health providers capacity to support, screen, refer,
care coordination and and manage adolescents in relation to their
quality of service antenatal health needs, in an adolescent-friendly
delivery manner [313]

Community and Ensure access to Antenatal care including birth preparedness and
interpersonal adolescent-friendly complication readiness. Interventions are
antenatal, childbirth recommended to increase the use of skilled care at
and postnatal services birth and to increase the timely use postnatal y care
for both the adolescent girl, newborn and the
family.

Interventions to promote the involvement of men

during pregnancy, childbirth and after birth are
recommended to facilitate and support improved
Address delays in
self-care of women, improved home care practices
seeking and receiving
for women and newborns, improved use of skilled
appropriate maternal
care during pregnancy, childbirth and the postnatal
health care
period for women and newborns, and increase the
timely use of facility care for obstetric and newborn
complications.

These interventions are recommended provided

that they are implemented in a way that respects,
promotes and facilitates women’s choices and their
autonomy in decision-making and supports women
in taking care of themselves and their newborns. In
order to ensure this, rigorous monitoring and
evaluation of implementation is recommended.

Ensure the availability Where traditional birth attendants remain the main
of adolescent-friendly providers of care at birth, dialogue with traditional
antenatal health birth attendants, women, families, communities and

Page 77 of 259
services that are service providers is recommended in order to define
accessible, acceptable and agree on alternative roles for traditional birth
and appropriate for attendants, recognizing the important role they can
adolescents play in supporting the health of women and
newborns.

Use of lay health workers, including trained

Expand availability of
traditional birth attendants, is recommended for
antenatal, childbirth
promoting the uptake of a number of maternal- and
and postnatal care to
newborn-related health-care behaviours and
adolescents
services, providing continuous social support during
labour in the presence of a skilled birth attendant,
and administering misoprostol to prevent
postpartum haemorrhage.

Use of lay health workers, including trained

traditional birth attendants, to deliver the following
interventions is recommended, with targeted
monitoring and evaluation: distribution of certain
oral supplement-type interventions to pregnant
women (calcium supplementation in women living
in areas with known low levels of calcium intake;
routine iron and folate supplementation in pregnant
women; intermittent presumptive therapy in malaria
in pregnant women living in endemic areas; vitamin
A supplementation in pregnant women living in
areas where severe vitamin A deficiency is a serious
public health problem); and the initiation and
maintenance of injectable contraceptives using a
standard syringe.

Ongoing dialogue with communities is

recommended as an essential component in
defining the characteristics of culturally appropriate,
quality maternity care services that address the
needs of women and newborns and incorporate
their cultural preferences. Mechanisms that ensure
women’s voices are meaningfully included in these
dialogues are also recommended.

Page 78 of 259
Continuous companionship during labour and birth
is recommended for improving women’s satisfaction
with services.

Continuous companionship during labour and birth

is recommended for improving labour outcomes.

Implementation of community mobilization through

facilitated participatory learning and action cycles
with women’s groups is recommended to improve
maternal and newborn health, particularly in rural
settings with low access to health services.

Implementation of facilitated participatory learning

and action cycles with women’s groups should focus
on creating a space for discussion where women are
able to identify priority problems and advocate for
local solutions for maternal and newborn health.

Community participation in quality-improvement

processes for maternity care services is
recommended to improve quality of care from the
perspectives of women, communities and health-
care providers.

Communities should be involved in jointly defining

and assessing quality. Mechanisms that ensure
women’s voices are meaningfully included are also
recommended.

Community participation in programme planning,

implementation and monitoring is recommended to
improve use of skilled care during pregnancy,
childbirth and the postnatal period for women and
newborns, increase the timely use of facility care for
obstetric and newborn complications and improve
maternal and newborn health. Mechanisms that
ensure women’s voices are meaningfully included
are also recommended.

Page 79 of 259
 Maternity waiting homes are recommended to be
established close to a health facility where essential
childbirth care and/or care for obstetric and
newborn complications is provided to increase
access to skilled care for populations living in
remote areas or with limited access to services.

Community-organized transport schemes are

recommended in settings where other sources of
transport are less sustainable and not reliable.
However, measures should be taken to ensure the
sustainability, efficacy and reliability of these
schemes while seeking long-term solutions to
transport.

Community-organized transport schemes are

recommended in settings where other sources of
transport are less sustainable and not reliable.
However, measures should be taken to ensure the
sustainability, efficacy and reliability of these
schemes while seeking long-term solutions to
transport.

Individual Improve the use of Maternity waiting homes are recommended to be

antenatal, childbirth established close to a health facility where essential
and postnatal care of childbirth care and/or care for obstetric and
pregnant adolescents newborn complications is provided to increase
access to skilled care for populations living in
Provide nutritional
remote areas or with limited access to services.
support during
pregnancy

1554

1555

1556

1557 Broad maternal health interventions that reduce delays in seeking and receiving appropriate health-care
1558 can reduce adolescent maternal disorders, including those detailed in the 2015 WHO Recommendations on
1559 Health Promotion Interventions for Maternal and Newborn Health and the 2013 Guidelines on Maternal,
1560 Newborn, Child and Adolescent Health: Recommendations on Maternal and Perinatal Health [324].

Page 80 of 259
1561

1562 Actions can be taken to improve the use of antenatal, childbirth and postnatal care by adolescents through:
1563 expanding availability of such services and emergency obstetric care; reinforcing recommended care practices
1564 for adolescent friendly services through the use of health provider-facing digital decision-support and client
1565 management software systems [313]; informing adolescents and community members about their
1566 importance; and following up to ensure that adolescents, their families and communities are well prepared
1567 for birth and related emergencies [322]. Care for a pregnant adolescent should include: counselling about the
1568 option to abort during the first visit (where this is legal); social support (including home visits); nutritional
1569 support (including counselling and supplementation); advice to avoid household air pollution; systematic
1570 assessment of violence; screening and brief intervention on alcohol and drug use among pregnant women; a
1571 plan for birth; management of anaemia and malaria where it is endemic; and counselling for breastfeeding
1572 and postpartum contraception [192][325]. Postpartum contraceptive services are especially important to
1573 support healthy child spacing and to prevent rapid, repeat pregnancies [326, 327].

1574 3.6 Communicable disease interventions

1575 As described in Section 2, infectious diseases (such as tuberculosis and respiratory infections) remain the
1576 leading cause of mortality and morbidity in low- and middle-income countries. Interventions for improved case
1577 detection and management of high burden diseases in this age group are crucially needed to reduce morbidity
1578 and mortality. In some cases, for example WASH interventions to prevent diarrheal disease, these can be
1579 easily expanded along the lines of those being implemented for younger children. In other cases, such as for
1580 vaccinations, further attention may be needed during implementation to ensure the unique needs and
1581 vulnerabilities of adolescents are being addressed.

1582 Box 3: Recommended responses for COVID-19 in adolescents [87, 97].

Recommended responses for COVID-19 in adolescents

The SARS-CoV-2 typically causes less severe illness and fewer deaths in children and adolescents compared
to adults. Milder symptoms and asymptomatic presentations may mean less frequent care seeking in these
groups, thus adolescents may tend to be tested less and cases may go unreported. Children and
adolescents can experience prolonged clinical symptoms (known as “long COVID-19”, post COVID-19
condition, or post-acute sequelae of SARS-CoV-2 infection), however the frequency and characteristics of
these conditions are still under investigation, and to date they appear to be less frequent compared to
adults.
Several risk factors for severe COVID-19 in children and adolescents have been reported, including older
age, obesity, and preexisting conditions. The preexisting conditions associated with higher risk of severe
COVID-19 include type 2 diabetes, severe asthma, heart and pulmonary diseases, seizure disorders and

Page 81 of 259
other neurologic disorders, neurodevelopmental (e.g. Down Syndrome) and neuromuscular conditions, and
moderate to severe immunocompromising conditions.
Despite their lower risk of severe COVID-19 disease, children and adolescents have been disproportionately
affected by COVID-19 control measures. The most important indirect effects are related to school closures
which have disrupted the provision of educational services and increased emotional distress and mental
health problems. When unable to attend school and socially isolated, children are more prone to
maltreatment, sexual violence, adolescent pregnancy, and child marriage, all of which increase the
probability of missing further education and of poor pregnancy outcomes.
Currently, WHO considers vaccination to be a viable prevention strategy for COVID-19 disease in children
and adolescents. In phase 2/3 trials for both mRNA vaccines, safety profiles in adolescents were similar to
young adults. There are risks of rare, though serious, side effects of mycocarditis/pericarditis occurring in
younger men (16-24 years old), and after a second dose of vaccine, which are higher than risks seen in
children and older adults. After weighing risks and benefits, the Global Advisory Committee on Vaccine
Safety (GACVS) concluded that in all age groups the benefits of mRNA COVID-19 vaccines in reducing
hospitalizations and deaths due to COVID-19 outweigh the risks.

• COVID-19 vaccines with WHO Emergency Use Listing that have undergone clinical trials in children
and adolescent are safe and effective in preventing disease in children and adolescents.
• Children with comorbidities and severe immunocompromising conditions should be offered
vaccination.
• As children and adolescents tend to have milder disease compared to adults, unless they are in a
group at higher risk of severe COVID-19, it is less urgent to vaccinate them than older people, and
those with chronic health conditions and health workers.
• UNICEF and WHO have developed guidance on how to minimize transmission in schools and keep
schools open, regardless of vaccination of school-aged children. Teachers, family members, and
other adult contacts of children and adolescents should ideally all be vaccinated for direct
protection.
• Countries should consider the individual and population benefits of immunizing children and
adolescents in their specific epidemiological and social context when developing their COVID-19
immunization policies and programs.
• Countries’ strategies related to COVID-19 control should facilitate children’s participation in
education and other aspects of social life, and minimize school closures, even without vaccinating
children and adolescents
• Throughout the roll out of COVID-19 vaccinations, it is of utmost importance for children to
continue to receive the recommended childhood vaccines for other infectious diseases.
• Country response plans should ensure adequate responses to the socio-economic impacts of
COVID-19. In addition to ensuring uninterrupted access to health services and support, response

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 measures can focus on school reintegration, prioritizing mental health and food security, online,
physical and emotional safety, reducing child marriage, and ensuring productive livelihoods.
1583

1584 Table 10: Prevention, detection and treatment of communicable diseases [328, 329]

Disease Ecological Level Intervention Further Comment

Tuberculosis Structural and Develop clear national child WHO TB estimates provide a good starting
environmental and adolescent TB targets. point in the development of national targets.
The global targets include the SDG target on
ending TB by 2030
Implement policies for the
Services need to be made adolescent-friendly.
transition of adolescents
They need to respect privacy and
from paediatric to adult TB
confidentiality to avoid stigma. They need to
services.
have flexible opening hours so that
adolescents can stay as much as possible in
education. Adolescents should have access to
shorter treatment options (for treatment of TB
infection and treatment of TB disease) which
are known to increase adherence and
treatment completion. As much as possible
services need to be offered for TB and co-
morbidities at the same time and place [330].

Organizational Expand the provision of The full cascade of care includes TB

services to cover the full prevention, screening, diagnosis, treatment of
cascade of care. drug-susceptible TB, treatment of TB
meningitis, treatment of multidrug resistant
and rifampicin resistant TB, treatment of
extrapulmonary TB, post TB, and
rehabilitation of TB related functional
Systematically implement
impairments.
TB screening for children
and adolescents at public This should occur in facilities focusing on adult
and private in- and and paediatric chest and TB; nutrition; HIV;
outpatient settings adolescent health; ANC; immunization clinics;
and dedicated screening events, followed by
appropriate management or referral to TB

Page 83 of 259
 preventive, treatment and rehabilitative care
services. Symptom screening, chest X-ray or
molecular WHO-recommended rapid
diagnostic tests should be used alone or in
combination

Consider bi-directional screening for COVID-

19 and TB in settings with a high burden of
TB.

Community and If adolescents younger than Symptom screening includes any one of
interpersonal 15 years are in close cough, fever or poor weight gain; or chest
contacts of someone with radiography; or both.
TB, systematic screening
for TB disease should be
conducted.

Empower communities and This can include working with community

implement peer programs health and outreach workers and primary care
to strengthen the TB providers to scale up active contact tracing,
response and social provide family-integrated TB treatment and
accountability mechanisms preventive therapy, and engaging adolescents
in their care. Peer counselling has shown a
significantly higher treatment completion rate
when compared with usual care [331][330].

Individual Limiting exposure to This can include reducing exposure to alcohol,

household environmental tobacco smoke, or indoor air pollution
risks

Respiratory tract Structural and Improve standards and Ambient air pollution has been shown to have
infections environmental introduce public policies to an impact on mortality from respiratory
reduce adolescent harmful infections, and is especially exacerbated in
exposure to air pollution contexts of undernutrition and poor health
[332] care [333].

Organizational Integrate environmental All health professionals should consider air

health to health pollution a major risk factor for their patients

Page 84 of 259
 professional training and understand the sources of environmental
programs exposure in the communities they serve

Community and Educate families and This can include information regarding the
interpersonal communities causes and consequences of exposure to
indoor air pollution, and household mitigation
measures

Individual Reduce adolescent and Measures include:

general population exposure
switching from wood, dung or charcoal to more
to indoor air pollution while
efficient, modern and less polluting fuels;
meeting household energy
needs and decreasing the locating a stove outside of a home or in a well-
amount of fuel needed. ventilated area;

ventilating cooking areas using eaves and smoke

hoods; and changing behaviours, such as keeping
children away from the smoking hearths, drying
fuel wood before use, using lids on pots to shorten
cooking time and improving ventilation by
opening windows and doors.

Diarrheal Structural and Policies and programs to This can include:

diseases environmental promote safe water,
Implement water safety plans and guidelines for
sanitation and
drinking-water quality at a national level;
handwashing
implementation of sanitation safety plans and
guidelines for safe use and disposal of
wastewater, greywater and excreta;

policies and programmes to promote the

widespread adoption of appropriate hand
washing practices.

Organizational Ensure schools and health Building such infrastructure in schools led to a
facilities are equipped with significant reduction in odds of school absence
proper water and sanitation due to diarrhea
infrastructure

Expanded handwashing programs in schools

(including soap for school sinks, peer hygiene
Page 85 of 259
 Promote handwashing monitors) can lead to reduced absenteeism
programs in schools [334].

Community and Scale up water treatment Evidence suggests that water treatment
interpersonal programs probably reduces diarrhea by almost 40%.
This can include: lifestraw filter treated water,
ceramic water purifier, iron-rich ceramic
purifier, and water treatment with concrete
BioSand filter.
Educate communities about
water safety and improved
sanitation measures they
This can include safe storage of household
can take
water; increased access to basic sanitation at
the household level; improved sanitation in
households (e.g. flushing to a pit or septic
tank; dry pit latrine with slab; or composting
toilet.

Individual Maintain good hand Hand-washing with soap is an effective

washing practices, washing preventive intervention against infectious
hands before eating, after diseases, including reducing diarrheal disease
using the toilet and with by 23-48% [335].
soap.

Meningitis [336] Structural and Strengthen primary health This includes introducing and expanding
environmental care and health systems licensed/WHO prequalified vaccines in
and increase immunization countries in line with WHO recommendations,
coverage and implementing locally appropriate tailored
immunization strategies to achieve and
maintain high vaccination coverage

Organizational Develop, update and This should pay attention to spatial units,
implement strategies on including consideration of mass gathering
surveillance, preparedness issues, and enhancement of infection
and response to meningitis prevention and control programmes
epidemics.

Antibiotics for close contacts of those with

Fight antimicrobial meningococcal disease, when given promptly,
resistance by expanding decreases the risk of transmission. However
Page 86 of 259
 vaccination. Use schools as high usage of antibiotics in the treatment of
platform to share suspected meningitis can lead to the
information on detection, development of antimicrobial resistance.
monitoring and
management of meningitis
sequelae

Community and Create community This can involve integrated communication

interpersonal awareness of meningitis, programmes and activities that increase
including dispelling myths population awareness of the risk, symptoms,
and addressing vaccine signs and consequences of meningitis and
hesitancy sepsis and of the recommended health-
seeking response.

Individual Increase the availability of Meningitis can cause severe long term
appropriate rehabilitative complications including neurological
care for adolescents with problems, such as hearing loss, visual
functioning difficulties impairment, seizures, and learning
resulting from meningitis impairments. Adolescents can also suffer from
depressive symptoms and fatigue that can
contribute to lower educational attainment
and greater reduction in quality of life [337].

1585

1586 3.7 Non-communicable diseases

1587 As shown in Section 2, some of the major causes of adolescent death and disease are NCDs such as cancer,
1588 migraines, skin diseases and asthma. Congenital anomalies and iron-deficiency anaemia also contribute to
1589 adolescent disease burden. NCDs can manifest during adolescence, or later in life as a result of risk factors
1590 experienced during adolescence (such as tobacco use which may be a strong contributing factor to developing
1591 chronic obstructive pulmonary disease (COPD) or cancer during adulthood). Indeed, many of the NCD risk
1592 factors and burdens seen in adults first begin as risk behaviours in adolescence, underscoring the importance
1593 of intervening with adolescents to protect their health in both the short-term and the long-term. This section
1594 will focus on experiences of NCDs during adolescence, while subsequent sections will focus on adolescent risk
1595 factors for NCDs later in life.

1596

1597 Box 4: Leukemia and other cancers during adolescence [338-345]

Page 87 of 259
 Leukemia and other cancers during adolescence

WHO provides detailed guidance on leukaemia and other cancers in the Cancer Control series, which
consists of six publications on planning, prevention, early detection, diagnosis and treatment, palliative
care and policy and advocacy. Each of these documents provides examples of priority interventions, and
categorizes them according to the available level of resources, i.e. core (with existing resources),
expanded (with a projected increase in, or reallocation of, resources) and desirable (when more
resources become available). Taking the example of a low-resource country in which less than 20% of
children with acute lymphocytic leukaemia have access to full treatment and over 80% die within five
years, these guides recommend to:
• Include palliative care medication, chemotherapy drugs and antibiotics used for treating
paediatric acute lymphatic leukaemia in the national essential medicines list (core)
• Improve quality and coverage of diagnostic, treatment and palliative care services for acute
lymphatic leukaemia in children, and mobilize further social support for patients and their
families (expanded)
• Develop special strategies for increasing the adherence of children to treatment for acute
lymphatic leukaemia (desirable)
Recent evidence supports the efficacy of motor and exercise intervention for adolescents with acute
lymphoblastic leukemia. While evidence is still growing, there is also support for interventions using
various digital modalities to improve health behaviours and reduce cancer-related symptoms among
adolescent survivors.
1598

1599 Box 5: Management of Asthma

Management of Asthma

Asthma symptoms include cough, wheeze and difficulty in breathing. These symptoms typically vary
from day to day and can be made worse by exposure to triggers including dust, fumes, smoke and viral
infections. Effective long-term management with inhaled medicines, including an inhaled corticosteroid,
can improve daily symptoms and reduce asthma attacks. This is important to avoid school absence and
emergency health care use, and the associated costs for the family and health system. For resource-
limited settings, the WHO package of essential noncommunicable (PEN) disease interventions for
primary health care includes guidance for the acute and long-term management of asthma, using core
medicines included in the WHO Essential Medicines List [346, 347]. Effective long-term management
with inhaled medications can control the disease and enable people with asthma to enjoy a normal,
active life.
1600

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1601 Box 6: Skin diseases [348-350]

Skin diseases

Several skin diseases are associated with long-term disfigurement, disability and stigma. Among
adolescents, they are known to contribute to psychological burden, anxiety and depression [351]. In
2018, WHO developed a pictorial training guide to combine control, treatment and care activities for
skin-related diseases to maximize the use of limited resources and expand treatment coverage. The
training guide is designed for front-line health workers who do not have thorough knowledge of common
skin disease, particularly those manifesting as a result of neglected tropical diseases.

In general populations, patient education has been found to be effective in improving quality of life and
decreasing the severity of skin diseases, even in the long-term management of chronic skin diseases.
Detailed guidance to clinicians on how to diagnose, treat and manage acne, different kinds of eczema
and other skin conditions – including key clinical features and treatment for severe, moderate and mild
forms of these conditions – can be found in the WHO 2011 IMAI District Clinician Manual.

1602

1603 Box 7: HPV vaccination to reduce cervical cancer risk [352]

HPV vaccination to reduce cervical cancer risk

Worldwide, cervical cancer is the fourth most frequent cancer in women with an estimated 604 000 new
cases in 2020. In high-income countries, programmes are in place which enable girls to be vaccinated
against HPV and women to get screened regularly and treated adequately. Screening allows pre-
cancerous lesions to be identified at stages when they can easily be treated. In low-and middle-income
countries, there is limited access to these preventative measures and cervical cancer is often not
identified until it has further advanced and symptoms develop. In addition, access to treatment of
cancerous lesions (for example, cancer surgery, radiotherapy and chemotherapy) may be limited,
resulting in a higher rate of death from cervical cancer in these countries. A large majority of cervical
cancer (more than 95%) is due to the human papillomavirus (HPV). HPV is the most common viral
infection of the reproductive tract. Most sexually active women and men will be infected at some point
in their lives, and some may be repeatedly infected. More than 90% of the infected populations
eventually clear the infection, but when infection becomes chronic it can lead to precancerous lesions
and invasive cancer.

WHO recommends:

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 • HPV vaccination in girls 9-14 years old. HPV vaccine can be an important pillar of
adolescent health programmes
• Girls and boys should be offered health information regarding sex education, tailored
to age
• Condom promotion and provision for those engaged in sexual activity
• Male circumcision
There are currently 6 vaccines licensed, and 4 that have been prequalified by WHO, all protecting against
HPV types 16 and 18, which are known to cause at least 70% of cervical cancers. The 9-valent vaccine
protects against 5 additional oncogenic HPV types, which cause a further 20% of cervical cancers. Two
of the vaccines also protect against HPV types 6 and 11, which cause anogenital warts.
HPV vaccines have been shown to be safe and effective in preventing infections with HPV infections,
high grade precancerous lesions and invasive cancer. The vaccines work best if administered prior to
exposure to HPV. Therefore, to prevent cervical cancer WHO recommends vaccinating girls aged 9 to
14 years, when most have not started sexual activity. Some countries have started to vaccinate boys as
the vaccination prevents HPV related diseases and cancers in males as well as.
1604

1605 Box 8: Prevention and management of unaddressed sensory (vision or hearing) impairments in adolescents

Most common causes of vision loss and many common causes of hearing loss in adolescents can be
prevented or treated.

To prevent and address vision loss in adolescents, WHO recommends [353]:

• Increasing the accessibility and availability of spectacles or contact lenses, both of which can
fully correct reduced vision from myopia and other refractive errors. Spectacles are among the
most practical and cost–effective of all health-care interventions to implement.
• Regular screening for refractive errors for preschool- and school-aged children in order to avoid
the negative impact of uncorrected refractive errors on academic performance.
• Implementation of public health campaigns to modify population behavior toward limited near
vision activities and longer time spent outdoors to reduce onset and progression of myopia.

To prevent and address hearing loss in adolescents, WHO recommends [232, 354-356]:
• Raising awareness among the adolescents, parents and teachers about healthy ear care
practices and safe listening (for prevention of noise-induced hearing loss).
• Adoption of the WHO-ITU global standard for safe listening for safe listening devices by private
sector entities. When implemented in devices such as smartphones and headphones, this can
help adolescents to moderate their sound exposure and protect hearing.

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 • Implementation by governments of the WHO global standard for safe listening entertainment
venues, which intends to protect the hearing of young people frequenting concerts and clubs.
• Regular school-based screening for ear and hearing problems, that can facilitate their early
identification and timely management.

1606

1607 3.8 Interventions for the prevention and treatment of mental health
1608 conditions

1609 As section 2 describes the prevalence of mental health conditions among adolescents is unacceptably high.
1610 Up to 50% of all mental health conditions start before the age of 14 years and up to one in five adolescents
1611 experience a mental disorder each year. Suicide is one of the leading causes of death among older adolescents.
1612 Poor adolescent mental health is associated with a range of high-risk behaviours, including selfharm, tobacco,
1613 alcohol and substance use, risky sexual behaviours and exposure to violence, the effects of which persist
1614 throughout the life-course and have serious implications. The COVID-19 pandemic has severely impacted the
1615 well-being of young people and has put them at an increased risk of suicide, substance use and other mental
1616 health problems [357]. Additionally, adolescents living in challenging contexts such as protracted conflicts
1617 may need more attention. Box 4 provides as case study of youth mentoring and counselling during the
1618 protracted crisis in West Bank and Gaza Strip.

1619

1620 Table 11: Common mental health conditions in adolescence, including anxiety, depression, post-
1621 traumatic stress disorder and developmental delays [357, 358]

Ecological level Further comment

Structural and Expand capacity of The number and diversity of mental health
environmental mental health and practitioners varies across context. Bolstering
psychosocial support this capacity is an important national strategy to
frontline workers, increase coverage of services, in addition to
including those with exploring telehealth and peer-based strategies.
advanced degrees
through appropriate
education, recruitment
and retention programs
to develop a diverse
pipeline of mental health
practitioners.

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Organizational Universal interventions to Universal interventions should include the
promote positive mental prevention and reduction of suicidal behaviour,
health and reduce mental mental disorders such as depression and anxiety,
health conditions aggressive, disruptive and oppositional
behaviours and substance use. These can
include:

Supporting training and professional

development in whole-school approaches to
mental health for pre-service and in-service
school staff including the mental health and
Strengthening mental leadership team (e.g., online bullying, identifying
health using a HPS and signs of distress and need for health services,
systems approach crisis management, suicide prevention, protocol
for referring learners/families to mental health
services where relevant).

Establishing a HPS committee to plan, implement

and evaluate mental health initiatives made up
of education sector staff, learners, parents and
carers, community and religious leaders, health
staff, civil society organisations.

Involving all teachers, school health staff,

student representatives, and parents and carers
in decision-making to promote HPS and mental
health.

Developing and communicating relevant school

policies and standards in all local languages
(e.g., anti-bullying, respectful relationships, child
protection policies).

School-based programmes focused on cognitive,

problem-solving and social skills

Community-based interventions to reduce child

abuse, neglect and bullying

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 Selective interventions Interventions to help coping with major life
with adolescents who are events (e.g. parental death or divorce), or those
at relatively high risk of seeking to block the transgenerational transfer of
depression depression and related problems (e.g.
adolescents with depressed parents)

Indicated interventions This can include:

for adolescents with
Group work with at-risk adolescents to promote
elevated levels of
positive thinking, challenge negative thinking
depressive symptoms,
styles and improve problem-solving skills
and adolescents with
emotional symptoms Anxiety prevention programmes

Group-based CBT may be considered for

adolescents with emotional symptoms

Provide psychosocial These interventions are particularly beneficial for

interventions to preventing mental disorders (depression, anxiety
adolescents affected by and disorders related specifically to stress) and
humanitarian crises. may be considered for reducing substance use in
these populations.

Consider psychosocial Cognitive behavioural skills-building programs

interventions for are an example that could be considered for this
pregnant adolescents group.
and adolescent parents.

Community and Parenting skills Supporting parents and families. This can include
interpersonal
promoting positive, stable emotional connections
between parents and adolescents (e.g. to
enhance adolescent self-esteem and social
competence);

assisting parents to establish rules, communicate

expectations and learn to exercise consistent and
effective monitoring of adolescent behaviours
(e.g. to reduce adolescent risk-related sexual
behaviour, substance use and delinquency);

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 assisting parents to respect the individuality of
adolescents and to avoid intrusive, manipulative
and unduly controlling behaviours (e.g. to reduce
adolescent antisocial behaviours);

encouraging parents to adopt attitudes and

behaviours that are supportive of health (e.g. not
smoking) while also reflecting supportive
prevailing social norms (e.g. positively to
influence adolescent behaviour).

Parental psychoeducation for an adolescent with

developmental delay or disorder

Care for children with developmental delays

Individual Treatment options and Psychosocial support and rehabilitation services

services for adolescents for adolescent mental health and well-being

Treatment of emotional disorders such as

depression and anxiety through:

Psychological interventions such as cognitive

behavioural therapy,

Interpersonal psychotherapy

Strengthening adolescents’ emotional resilience

and cognitive skills to avoid or to manage anxiety
disorders

Cognitive-behavioural therapy as an early

intervention method to prevent post-traumatic
stress disorder, short-term cognitive workshops
for those who have experienced a first panic
attack

1622 Table 12: Preventing adolescent suicide [112, 358-360]

Ecological Level Intervention Further Comment

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Structural and Adoption of Related to suicide, these should focus on: strengthening
environmental national mental effective leadership and governance; providing
health policies comprehensive, integrated and responsive services in
community-based settings; implementing strategies for
prevention; and strengthening information systems,
evidence and research.

Policies to reduce Policy options include policies related to drink-driving and

harmful use of the marketing and availability of alcohol
alcohol

Restriction of Restriction includes legislation to limit access to pesticides,

access to means firearms and medications commonly used in suicide and
safer storage and disposal of each, as well as
environmental interventions to prevent suicide by
jumping.

Responsible Media guidelines should stress avoidance of detailed

media reporting descriptions of suicidal acts; sensationalism; glamorization
and oversimplification; use of responsible language;
minimizing the prominence of suicide reports; and
educating the public about suicide and available
treatments.

Organizational Improved access Adequate, prompt and accessible treatment for mental
to health-care and substance use disorders can reduce the risk of suicidal
behaviour. Implementing health-literacy policies and
practices throughout health systems and institutions is
also key.

Surveillance of Sustainable and long-term surveillance of suicide cases,

suicide and and hospital presentations due to suicide attempts and
suicide attempts self-harm, provide critical information for prevention,
intervention and treatment.

Electronic media Online suicide prevention strategies include self-help

strategies for programmes and professionals engaging in chats or
service delivery therapy with suicidal individuals. Text messaging is an
alternative, particularly when the internet is not accessible.

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 Raising Awareness-raising campaigns aim to reduce stigma and
awareness about promote help-seeking and access to care. Different types
mental health, of exposure (e.g. television, print media, the internet,
substance use social media and posters) can reinforce key messages. At
disorders and the local level, awareness raising can target specific
suicide vulnerable populations.

Community and Interventions for These interventions should be tailored and targeted
interpersonal vulnerable toward groups that are most at risk of suicide in particular
groups with a settings. For example, interventions targeting lesbian, gay,
higher risk of bisexual, transgender and intersex (LGBTI) adolescents
suicide should focus on addressing risk factors such as mental
disorders, substance abuse, stigma, prejudice and
individual and institutional discrimination.

Gatekeeper For people in a position to identify whether someone may

training be contemplating suicide (e.g. clinicians or teachers),
gatekeeper training develops knowledge, attitudes and
skills for identifying adolescents at risk, determining the
level of risk and referring at-risk adolescents for treatment.

Crisis helplines Crisis helplines are public call centres that people can turn
to when other social support or professional care is
unavailable or not preferred. Helplines can be in place for
the wider population or may target certain vulnerable
groups, e.g. with peer assistance.

Individual Assessment and The WHO mhGAP intervention guide recommends

management of assessing comprehensively everyone presenting with
suicidal thoughts, plans or acts of self-harm. The guide
behaviours recommends asking any person over 10 years of age who
is experiencing a priority mental, neurological or
substance-use disorder – or chronic pain or acute
emotional distress – about his or her thoughts, plans or
acts related to self-harm and suicide.

Assessment and This involves training primary health-care workers to

management of recognize depression and other mental and substance use
mental & disorders, and to perform detailed evaluations of suicide

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 substance use risk. Training should take place repeatedly over years and
disorders should involve the majority of health workers in a country.

Follow-up and Repeated follow-up by health workers for patients

community discharged after suicide attempts, and community
support support, are low-cost, effective interventions that are easy
to implement. Follow-up can include postcards, telephone
calls or brief in-person visits.

1623

1624 Case Study 4

1625 West Bank' and Gaza Strip' youth mentoring and counselling during a protracted crisis

1626 The West Bank and Gaza Strip area has experienced a pro-tracted crisis for decades, which contributed to 1.9
1627 million of its 4.5 million population being in need of humanitarian assistance in 2015 (269). Violence, closures,
1628 restrictions and economic hardship are part of Palestinian adolescents’ daily lives (270). For some adolescents
1629 this has resulted in acute psychological problems, such as apathy, self-doubt, withdrawal and a sense of
1630 hopelessness. Palestinian youth have very few opportunities for recreation or constructive participation in
1631 community development, which might help improve their mental health.

1632 In response to this situation, the United Nations Children’s Fund (UNICEF) and the Palestinian Youth
1633 Association for Leadership and Rights Activation developed a youth mentoring and counselling programme.
1634 University student volunteers were trained to provide psychosocial support, mentoring and recreational
1635 activities for adolescents in schools and community centres. Following the eight-day training course, the
1636 volunteers conducted a series of school-based psychosocial support sessions, working most closely with
1637 adolescents in violence-affected areas. The school-based sessions provided a peaceful and reassuring outlet
1638 for participants to express their views, opinions, hopes and fears, and to find ways to deal with their stress.

1639 After the sessions were concluded, adolescents were given the opportunity to express themselves in
1640 constructive and creative ways. For example, adolescents planned their own small-scale projects to improve
1641 their schools and neighborhoods with the support of the volunteers. A telephone hotline operated by university
1642 students was also established to provide one-on-one psychosocial support to adolescents, especially during
1643 times of restricted mobility and curfews. The adolescents and university students also produced a Youth Times
1644 newspaper with a circulation of 100 000 and a weekly youth TV programme. Qualitative evaluation of the first
1645 years of the programme suggested it had a positive impact on both the volunteers and the participants.

1646 Source: UNICEF. Adolescent programming experiences during conflict and post-conflict: case studies; 2004.
1647 (https://www.unicef. org/adolescent_conflict.pdf)

1648 END OF BOX

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1649 3.9 Interventions to address alcohol and drug use

1650 Use of psychoactive substances usually starts in adolescence (10–19 years old) and even childhood. The
1651 earlier substance use starts, the greater the risks for more rapid progression to heavy use and substance use
1652 disorders. It is important to remember though that the highest proportion of adolescents typically fall into a
1653 low use group, which at times includes experimental or low levels of alcohol or drug use. However, alcohol
1654 and drug use can affect normal development and result in a range of negative health and social outcomes
1655 and lead towards the development of substance use disorders [359]. Special difficulty might be associated
1656 with multiple substance use with those in lower socioeconomic status and older age being at higher risk [360].
1657 Appropriate attention should be given to the prevention of the initiation of alcohol and drug use among
1658 children and adolescents and providing support with quitting substance use and reducing its negative
1659 consequences, while addressing special needs of this group.

1660
1661 Table 13: Interventions to prevent alcohol and drug use and address substance use disorders
1662 among adolescents [361, 362]

Ecological level Intervention Further comments

Structural and Strengthen restrictions on Enacting and enforcing restrictions on

environmental alcohol and drug availability commercial or public availability of
alcohol through laws, policies, and
programmes are important ways to
reduce harmful use of alcohol. Such
strategies provide essential measures
to prevent easy access to alcohol by
young people and other vulnerable
and high-risk groups. This includes
reduction of density of alcohol outlets
and hours or days when alcohol
beverages can be sold and
establishing an appropriate minimum
age for purchase or consumption of
alcoholic beverages and other policies
to prevent sales to, and consumption
of, alcoholic beverages by those below
the legal age and introduce
mechanisms for placing liability on
sellers and servers.

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Advance and enforce drink Road users who are impaired by
driving counter measures alcohol have a significantly higher risk
of being involved in a crash. Enacting
and enforcing strong drink-driving
laws and low blood alcohol
concentration limits via sobriety
checkpoints and random breath
testing will help to turn the tide.

Enforce bans or Bans and comprehensive restrictions

comprehensive restrictions on on alcohol advertising, sponsorship
alcohol advertising, and promotion are impactful and cost-
sponsorship, and promotion effective measures. Enacting and
enforcing bans or comprehensive
restrictions on exposure to them in the
digital world will bring public health
benefits and help protect children,
adolescents and abstainers from the
pressure to start consuming alcohol.

Raise prices on alcohol Alcohol taxation and pricing policies

through excise taxes and are among the most effective and
pricing policies cost-effective alcohol control
measures. An increase in excise taxes
on alcoholic beverages is a proven
measure to reduce harmful use of
alcohol and it provides governments
revenue to offset the economic costs
of harmful use of alcohol.

Facilitate access to screening, Health professionals have an

brief interventions and important role in helping people to
treatment for drug and alcohol reduce or stop their drinking to reduce
abuse health risks, and health services have
to provide effective interventions for
those in need of help and their
families.

Page 99 of 259
 Population-based Documents include range of actions
interventions in accordance including restriction of availability,
with drug conventions (1961, distribution, production, export and
1971 and 1988), as well as import of psychoactive drugs and
implementation of other actions on preventing the
recommendations of the initiation and continuation of drug use
UNGASS on World Drug by children, adolescents and young
Problem (2016) people as well as on increasing access
on need to address specific needs of
adolescents in treatment of drug use
disorders.

Organization Retaining children in schools, School policies on substance use

school policies on substance mandate that substances should not
use and other interventions in be used on school premises and during
educational settings school functions and activities by both
students and staff. Policies also create
transparent and non-punitive
mechanisms to address incidents of
use transforming it into an educational
and health promoting opportunity.

Other interventions may include

prevention based on individual
psychological vulnerabilities, wider
programmes to increase access to
education and enhance school
attachment

Addressing special needs of To treat children with substance use

children and adolescents in disorders, it is necessary to design
treatment programmes for psychosocial treatments to fit their
substance use disorders needs, level of cognitive development,
life experiences, legal status. This
includes psychosocial and
pharmacological interventions, e.g. for
management of withdrawal, continued
treatment and relapse prevention

Page 100 of 259

Community and Community-based multi- At the community level, mobilization
Interpersonal component initiatives efforts to create partnerships, task
forces, coalitions, action groups, etc.
bring together different actors in a
community to address substance use.
Some community partnerships are
spontaneous. However, the existence
of community partnerships on a large
scale is normally the product of a
special programme providing financial
and technical support to communities
to deliver and sustain evidence based
prevention interventions and policies
over time. Community-based
initiatives are normally
multicomponent, taking action in
different settings (e.g. schools,
families, media, enforcement etc.).
This also includes mobilization of
communities to prevent the selling of
alcohol to, and consumption of alcohol
by, underage drinkers.

Develop and support alcohol- Communities can be supported and

free environments, especially empowered by governments and
for youth and other at-risk other stakeholders to use their local
groups. knowledge and expertise in adopting
effective approaches to prevent and
reduce the harmful use of alcohol by
changing collective rather than
individual behaviour while being
sensitive to cultural norms, beliefs and
value systems.

Family-based and parenting Parenting skills programmes support

skills programmes parents in being better parents, in very
simple ways. A warm child-rearing
style, where parents set rules for

Page 101 of 259

 acceptable behaviours, closely monitor
free time and friendship patterns, help
to acquire personal and social skills,
and are role models is one of the most
powerful protective factors against
substance use and other risky
behaviours.

Individual Addressing individual Some personality traits such as

psychological vulnerabilities, sensation-seeking, impulsivity, anxiety
personal and social skills sensitivity or hopelessness, are
education associated with increased risk of
substance use. These indicated
prevention programmes help these
adolescents that are particularly at-
risk deal constructively with emotions
arising from their personalities,
instead of using negative coping
strategies including alcohol use. The
programmes provide opportunities to
learn skills to be able to cope with
difficult situations in the daily life in a
safe and healthy way.

Addressing mental health Mental disorders (e.g. anxiety,

disorders depression) and behavioural disorders
(e.g. ADHD, conduct disorder) are
associated with higher risk of
substance use later in adolescence
and in life. In both childhood and
adolescence, supporting children,
adolescents and parents to address
emotional and behavioural disorders
as early as possible is an important
prevention strategy.

Page 102 of 259

 Prevention education based During skills based prevention
on social competence and programs, trained teachers engage
influence students in interactive activities to give
them the opportunity to learn and
practice a range of personal and social
skills (social competence). These
programs focus on fostering substance
and peer refusal abilities that allow
young people to counter social
pressures to use substances and in
general cope with challenging life
situations in a healthy way

Mentoring “Natural” mentoring refers to the

relationships and interactions between
children/adolescents and non-related
adults such as teachers, coaches and
community leaders and it has been
found to be linked to reduced rates of
substance use and violence. These
programmes match youth, especially
from marginalised circumstances
(selective prevention), with adults who
commit to arrange for activities and
spend some of their free time with the
youth on a regular basis.

1663
1664

1665 3.10 Interventions to address Tobacco use

1666 Tobacco kills up to half its users and is considered one of the biggest public health threats killing smokers
1667 directly, and many others through exposure to second-hand smoke [363]. When tobacco users become aware
1668 of the dangers of tobacco, most want to quit. However, nicotine contained on tobacco products is highly
1669 addictive and without cessation support only 4% of users who attempt to quit tobacco use will succeed.
1670 Professional support and proven cessation medications can more than double a tobacco user's chance of
1671 successful quitting.

Page 103 of 259

1672 Increasingly, young people are being exposed to Electronic Nicotine Delivery Systems (ENDS) also knowns as
1673 vaping or electronic cigarettes (e-cigarette). E-cigarettes are particularly risky when used by adolescents.
1674 Nicotine is highly addictive and young people’s brains develop up to their mid-twenties. ENDS use increases
1675 the risk of heart disease and lung disorders.

1676 ENDS use increases the risk of heart disease and lung disorders. There is some evidence between adolescent
1677 vaping and smoking initiation [364, 365]. However, it is too early to provide a clear answer on the long-term
1678 impacts of using them or being exposed to them.

1679 Advertising, marketing and promotion of ENDS has grown rapidly, through internet and social media channels
1680 in particular. In many cases, this marketing gives rise to concern about deceptive health claims, deceptive
1681 claims on cessation efficacy, and targeting towards youth (especially with the use of flavours).

1682 Table 14: Interventions to reduce tobacco use and exposure

Ecological level Intervention Further explanation

Structural and Reduce the affordability of Reduce affordability of tobacco products by

environmental tobacco increasing tobacco excise taxes.

Ban tobacco advertising Enforce comprehensive bans on tobacco

advertising, promotion and sponsorship, including
cross-border advertising, internet and social media.
Also actively promote the entertainment media,
cinema and drama as smoke-free.

Smoke-free environments Create bylaws ensuring completely smoke-free

environments in all schools, recreational areas,
indoor workplaces, public places and public
transport.

Organizational and Campaigns to raise Conduct regular and effective mass-media

community awareness of the dangers campaigns to raise awareness of the dangers of
of tobacco tobacco. Include pictorial health warnings on
packaging and in mass media campaigns

Tobacco prevention within Integrate tobacco prevention within school policies,

school programmes skills-based health education and health services.
See Tobacco Use: An Important Entry Point for the
Development of Health-Promoting Schools for age-
appropriate knowledge, attitude and skills-building
targets. In no circumstances should these

Page 104 of 259

 programmes be implemented in collaboration with
or funded by the tobacco industry.

Interpersonal and Guidance on stopping Clinicians should encourage all non-smokers not to
individual tobacco use start smoking; strongly advise all smokers to stop
smoking, and support them in their efforts; and
advise individuals who use other forms of tobacco
to quit. See Toolkit for Delivering the 5A’s and 5R’s
Brief Tobacco Interventions in Primary Care for
more specific guidance.

1683

1684 3.11 Physical activity and sedentary behaviour

1685 Regular physical activity is proven to help prevent and manage noncommunicable diseases such as heart
1686 disease, stroke, diabetes and several cancers. It also helps prevent hypertension, maintain healthy body
1687 weight and can improve mental health, quality of life and well-being. Despite these benefits, more than 80%
1688 of the world's adolescent population is insufficiently physically active.

1689 WHO guidelines recommend adolescents should:

1690 • do at least an average of 60 minutes per day of moderate-to-vigorous intensity, mostly aerobic,
1691 physical activity, across the week.
1692 • incorporate vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, at
1693 least 3 days a week.
1694 • limit the amount of time spent being sedentary, particularly the amount of recreational screen time.

1695 Table 15: Interventions to promote adolescent physical activity [366, 367][368]

Ecological level Intervention Further comment

Structural and Urban planning policies Governments should partner with communities, the
environmental private sector and NGOs to develop inclusive safe
spaces for physical activity and accessible facilities for
sports, recreation and leisure. Active transport policies
should ensure that walking, cycling and other non-
motorized transport are accessible and safe for all.
Provide free or subsidized transportation to accessible
fitness and sports centers (e.g.; for adolescents with
disabilities).

Page 105 of 259

 School and public facilities Adequate facilities should be available on school
premises, youth workplaces and in public spaces for
physical activity during recreational time for all
adolescents (including those with disabilities), with the
provision of gender-friendly spaces where appropriate.

Organizational Public awareness Provide guidance to children and adolescents, their

and community programmes on physical parents, caregivers, teachers and health professionals
activity on healthy body size, physical activity, sleep behaviours
and appropriate use of screen-based entertainment.

Physical education A good physical education curriculum develops abilities

curricula in schools and conditioning; provides activity for specific needs
and to all children; encourages continued sports and
physical activity into later life; and provides recreation
and relaxation.

Implement best practice communication campaigns,

linked with community-based programmes, to heighten
awareness, knowledge and understanding of, and
appreciation for, the multiple health benefits of regular
physical activity and less sedentary behaviour,
according to ability, for individual, family and
community well-being

Regular, structured sports Regular, structured sports activities among adolescents

activities strengthens the link between physical activity, sports
and health, and reduces sedentary behaviours.

Interpersonal and Guidance on physical Physical activity for health for adolescents is at least 60
individual activity for adolescents minutes of moderate to vigorous-intensity activity per
day on average.

• incorporate vigorous-intensity aerobic

activities, as well as those that strengthen
muscle and bone, at least 3 days a week.
• limit the amount of time spent being sedentary,
particularly the amount of recreational screen
time.

Page 106 of 259

 Implement regular mass participation initiatives in
public spaces, engaging entire communities, to provide
free access to enjoyable and affordable, socially- and
culturally-appropriate experiences of physical activity.

1696

1697 3.12 Adolescent nutrition

1698 Optimal nutrition practices can have a profound impact on the current and future health of adolescents [369].
1699 During this second intense growth window, nutritional deficiencies that persisted from childhood can be
1700 addressed and catch-up growth may be possible. Additionally, adolescence provides an opportunity to adopt
1701 changes in diet that can have life-long impacts. The nutritional challenges experienced by adolescents include
1702 micronutrient deficiencies, food insecurity, sub-optimal diet quality and rising obesity.

1703 Achieving optimal nutrition among adolescents requires coordinated actions that ideally include health,
1704 education, social protection, media and other systems. Schools provide an important platform for delivery of
1705 interventions targeted to high-risk groups, for example iron and folic acid supplementation for adolescent
1706 girls. At the same time, health professionals are a trusted source of information and implementation of
1707 screening and treatment programs.

1708 Table 16: Interventions to promote adolescents having healthy diets [144, 370][371]

Ecological level Intervention Further comment

Structural and Nutrient profiles Develop and use nutrient profiles to identify unhealthy
environmental foods and beverages.

Nutrient labelling Implement a standardized global nutrient labelling system;

system control the use of misleading health and nutrition claims;
and implement mandatory front-of-pack labelling.

Reduce access and Tax and increase the pricing of energy-dense, nutrient-
affordability of poor foods and sugar-sweetened beverages.
unhealthy foods and
Government policy action is required to restrict the
beverages
availability of highly processed foods.

Reduce the impact of Reduce the impact of marketing of foods and beverages
marketing of high in sugar, salt and fat. Establish cooperation between

Page 107 of 259

 unhealthy foods and Member States related to cross-border marketing.
beverages Implement the Set of Recommendations on the Marketing
of Foods and Non-alcoholic Beverages to Children.

Food policies and These should have clear definitions for the key components
standards of food policies, thereby allowing for a standard
implementation process

Social protection Cash transfers to increase uptake of healthy meals and

micronutrient supplementation. See Case study 5 on
Preventing teen pregnancies and supporting pregnant
teenagers in Ecuador

Organizational Healthy food Require settings frequented by adolescents (e.g. schools,

environments in childcare settings, children’s sports facilities and events
schools and other and youth workplaces) to create healthy food
public institutions environments

Improved access to Improve the availability and affordability of healthy foods

healthy food in public institutions and settings, particularly in
disadvantaged communities.

Nutrition education Nutrition education such as growing school gardens,

knowledge of dietary diversity, food environment, and
practical skills; use opportunity of school curricula to
support nutrition and food preparation

Community and Nutrition literacy Ensure that appropriate and context-specific nutrition
interpersonal campaigns information and guidelines are developed and
disseminated in a simple, understandable and accessible
manner to all.

Use social media to promote healthy behaviour or influence

social norms and provide overweight and obesity control
interventions

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 Campaigns to raise Campaigns should target policymakers, medical staff and
awareness of adults, adolescents and children in general, promoting
adolescent obesity capacity building related to adolescent obesity and its risk
factors.

Community Increasing community ownership of interventions,

ownership of inclusive of culturally relevant information; include
interventions mentoring from community members to increase impact of
interventions

Individual Guidance on a healthy For example, clinical dietary guidance for adolescents
diet includes:

Restrict sodium intake to less than 2 g per day, reduce it

when cooking, and limit processed and fast foods.

Restrict free sugars to less than 10% of total energy intake.

A further reduction to below 5% or roughly 25 g (six
teaspoons) per day would provide additional health
benefits.

Have five servings (400–500 g) of fruit and vegetables per

day. One serving is equivalent to one orange, apple,
mango or banana or three tablespoons of cooked
vegetables.

Limit fatty meat, dairy fat and cooking oil (less than two
tablespoons per day); replace palm and coconut oil with
olive, soya, corn, rapeseed or safflower oil; replace other
meat with chicken (without skin).

All food-grade salt, used in household and food processing,

should be fortified with iodine as a safe and effective
strategy for the prevention and control of iodine deficiency
disorders.

Daily iron supplementation is recommended as a public

health intervention in menstruating adult women and
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 adolescent girls living in settings where anaemia is highly
prevalent (40% or higher prevalence of anaemia), for the
prevention of anaemia and iron deficiency.

Intermittent iron and folic acid supplementation is

recommended as a public health intervention in
menstruating women living in settings where anaemia is
highly prevalent, to improve haemoglobin concentration
and iron status and reduce the risk of anaemia in
populations where the prevalence of anaemia among non-
pregnant women of reproductive age is 20% or higher.

Weight management Develop and support family-based, multicomponent,

interventions for lifestyle weight management services for adolescents who
obese adolescents are overweight (including nutrition, physical activity and
psychosocial support). These should be delivered by multi-
professional teams as part of universal health coverage.

1709

Case Study 5
Cash Transfers improves outcomes for Pregnant Teenage Girls in Ecuador

A pilot cash transfer program jointly implemented by three Government ministries, WFP and Plan
International was launched on the northern Ecuadorian border between July and December 2019. The
goal of the program was to prevent early pregnancies and improve the diet of pregnant adolescent girls.
Areas targeted by the pilot included communities at high risk of gender-based violence and teenage
pregnancy. Girls residing in mostly rural and peri-urban settings who were considered poor or extremely
poor were included in the intervention. The project provided cash transfers of USD 50 to cover costs of
recommended diets that they could otherwise not afford. Recipients used funds to purchase food,
sanitation products and costs to access health services. In addition to the cash transfer, they also
received site visits from implementers to encourage compliance, and sessions on food security and
healthy sexual behaviours. Despite the short program implementation duration, recipients of the cash
transfers increased their food consumption and mean daily diets by over 20%. In addition to direct
benefits, girls reported increased annual visits as well as knowledge of sexual behaviours.

Source: https://www.ennonline.net/fex/66/preventingteenpregnancies

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1710

1711

1712 Box 8: WHO recommendations for healthy diets in adolescence [372-374]

Sugars intake for adults and children (2015)

WHO recommends a reduced intake of free sugars throughout the life course.
In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of
total energy intake.
WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake.

Potassium intake for adults and children (2012)

WHO suggests an increase in potassium intake from food to control blood pressure in children aged 2–15
years. The recommended potassium intake of at least 90 mmol/day in adults should be adjusted downward
for children, based on the energy requirements of children relative to those of adults.

Sodium intake for adults and children (2012)

WHO recommends a reduction in sodium intake to control blood pressure in children aged 2–15 years.
The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted downward
based on the energy requirements of children relative to those of adults.

1713

1714 Table 17: Management of acute malnutrition among TB infected adolescents [375]

Ecological level Intervention Further comment

Individual level Adolescents presenting Management of severe acute malnutrition

with weight loss assessed
School-age children and adolescents (5–19 years), and
for underlying causes and
adults, including pregnant and lactating women, with
managed accordingly
active tuberculosis and severe acute malnutrition should
be treated in accordance with the WHO
recommendations for management of severe acute
Offer nutritional
malnutrition.
counselling and
information on optimal,
healthy weight
Management of moderate undernutrition

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 School-age children and adolescents (5–19 years), and
adults, including lactating women, with active
If available, enrol
tuberculosis and moderate undernutrition, who fail to
adolescents at risk of
regain normal body mass index after 2 months’
malnutrition in
tuberculosis treatment, as well as those who are losing
programmes where
weight during tuberculosis treatment, should be
nutritional assessment,
evaluated for adherence and comorbid conditions. They
counselling and support
should also receive nutrition assessment and counselling
are available
and, if indicated, be provided with locally available
nutrient-rich or fortified supplementary foods, as
necessary to restore normal nutritional status.
All people with active
tuberculosis should receive Pregnant women with active tuberculosis and moderate
tuberculosis diagnosis, undernutrition or with inadequate weight gain should be
treatment and care provided with locally available nutrient-rich or fortified
according to WHO supplementary foods, as necessary to achieve an average
guidelines and weekly minimum weight gain of approximately 300 g in
international standards of the second and third trimesters.
care
Patients with active multidrug-resistant tuberculosis and
moderate undernutrition should be provided with locally
available nutrient-rich or fortified supplementary foods,
as necessary to restore normal nutritional status.

An adequate diet, containing all essential macro- and

micronutrients, is necessary for the well-being and health
of all people, including those with tuberculosis or other
infections.

1715

1716 Table 18: Micronutrients including fortification and supplementation in adolescents [376-380]

Ecological level Intervention Further comment

Structural and Prevent and control iron Fortification of maize flour and corn meal with iron is
environmental deficiency and iron deficiency recommended to prevent iron deficiency in
level anaemia populations, particularly vulnerable groups such as
children and women.
Prevent and control iodine
deficiency disorders

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Reduce the risk of folic acid Fortification of maize flour and corn meal with folic
deficiencies and occurrence of acid is recommended to reduce the risk of occurrence
births with neural tube defects of births with neural tube defects.

Fortify staple foods such as

flour with micronutrients
All food-grade salt, used in household and food
Fortify condiments such as salt processing, should be fortified with iodine as a safe
with appropriate fortificants and effective strategy for the prevention and control
of iodine deficiency disorders in populations living in
stable and emergency settings.

At the population level, red blood cell folate

concentrations should be above 400 ng/ mL (906
nmol/L) in women of reproductive age, to achieve the
greatest reduction of NTDs.

The above red blood cell folate threshold can be used

as an indicator of folate insufficiency in women of
reproductive age. Because low folate concentrations
cannot explain all cases of NTDs, this threshold
cannot predict the individual risk of having a NTD-
affected pregnancy, and thus it is only useful at the
population level.

No serum folate threshold is recommended for

prevention of NTDs in women of reproductive age at
the population level. Countries interested in using
this indicator may consider first establishing the
relationship between both serum and red blood cell
folate and use the threshold value for red blood cell
folate to establish the corresponding threshold in
serum.

Microbiological assay is recommended as the most

reliable choice to obtain comparable results for red
blood cell folate across countries.

Daily iron supplementation is recommended as a

public health intervention in menstruating adult
women and adolescent girls, living in settings where

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Community Prevent and control anaemia is highly prevalent (40% or higher
and micronutrient deficiency prevalence of anaemia), for the prevention of
interpersonal among vulnerable groups anaemia and iron deficiency.

Intermittent iron and folic acid supplementation is

recommended as a public health intervention in
Set distribution mechanisms to
menstruating women living in settings where
reach menstruating adolescent
anaemia is highly prevalent, to improve haemoglobin
girls in areas where anaemia is
concentration and iron status and reduce the risk of
a significant public health
anaemia in populations where the prevalence of
problem
anaemia among non-pregnant women of
reproductive age is 20% or higher

Daily iron supplementation is recommended as a

public health intervention in school-age children aged
60 months and older living in settings where anaemia
is highly prevalent, for preventing iron deficiency and
anaemia.

In malaria-endemic areas, the provision of iron

supplementation in infants and children should be
done in conjunction with public health measures to
prevent, diagnose and treat malaria.

Intermittent iron supplementation is recommended

as a public health intervention in preschool and
school-age children to improve iron status and
reduce the risk of anaemia in settings where the
prevalence of anaemia in preschool or school-age
children is 20% or higher.

Oral iron supplementation, either alone or in

combination with folic acid supplementation, may be
provided to postpartum women for 6–12 weeks
following delivery for reducing the risk of anaemia in
settings where gestational anaemia is of public health
concern.

Routine use of multiple micronutrient powders during

pregnancy is not recommended as an alternative to

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 standard iron and folic supplementation during
pregnancy for improving maternal and infant health
outcomes.

Vitamin A supplementation in postpartum women is

not recommended for the prevention of maternal and
infant morbidity and mortality.

Individual Treat anaemia among those Follow national guidelines for the treatment of
diagnosed anaemia

1717

1718 3.13 Interventions in humanitarian and fragile settings

1719 Humanitarian emergencies increase risks to and exacerbate the vulnerabilities of young people. Protective
1720 familty and social ties can be disrupted, and risks to abuse and exploitation increase as security systems are
1721 rendered unfunctional. Increasingly, forced displacements and humanitarian crises unfold over longer periods
1722 of time, such as months or years, sometimes affecting young people for large portions of their adolescence.

1723 Launched at the World Humanitarian Summit (2016), the Compact for Young People in Humanitarian Action
1724 is a collective commitment of 60+ humanitarian actors working to ensure that the priorities of young people
1725 are addressed and informed, consulted, and meaningfully engaged throughout all stages of humanitarian
1726 action. Five key actions were identified [381]:

1727 • Action 1: Promote and increase age- and gender responsive and inclusive programmes that contribute
1728 to the protection, health and development of young women, young men, girls and boys within
1729 humanitarian settings;
1730 • Action 2: Support systematic inclusion of engagement and partnership with youth, in all phases of
1731 humanitarian action through sharing of information and involvement in decision-making processes at
1732 all levels, including budget allocations
1733 • Action 3: Recognize and strengthen young people’s capacities and capabilities to be effective
1734 humanitarian actors in prevention, preparedness, response and recovery, and empower and support
1735 local youth-led initiatives and organizations in humanitarian response, such as those targeting
1736 affected youth, including young refugees and internally displaced persons living in informal urban
1737 settlements and slums;
1738 • Action 4: Increase resources intended to address the needs and priorities of adolescents and youth
1739 affected by humanitarian crises, including disasters, conflict and displacement, and identify ways to
1740 more accurately track and report on the resources allocated to young people in humanitarian contexts;
1741 and

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1742 • Action 5: Ensure the generation and use of age and sex- disaggregated data pertaining to adolescents
1743 and youth in humanitarian settings

1744 Table 19: Adolescent interventions in humanitarian and fragile settings [12, 261, 273, 288, 382-
1745 395][396]

Intervention Further comment

Nutrition Assess conditions and ensure adequate rations for adolescent population
groups according to age, gender, weight, physical activity levels and other
key factors, considering both energy and micronutrient requirements

Disability and injury Ensure core health services are accessible to adolescents with disabilities and
adolescents with functioning difficulties resulting from injury in an
emergency, including rehabilitation services and essential medicines in the
appropriate dosages and formulations

Violence Provide medical screening of former child soldiers, clinical management and
community-based psychosocial support for survivors of sexual and/or gender-
based violence and support their reintegration into families and communities.
Implement virtual and safe spaces including in schools,

Sexual and Several evidence-based SRH interventions may be effective for young people
reproductive health in humanitarian and LMIC settings, in particular contraceptive and condom
use skills and STI and HIV prevention. Consider implementing a minimal initial
SRH service package and build a more comprehensive response, including
psychosocial support, a protection system that addresses sexual violence and
child marriage, and family planning and STI programmes for adolescents

Water, sanitation and Ensure safe access to and use and maintenance of toilets; materials and
hygiene facilities for menstrual hygiene management; water and soap or ash for hand
-washing; the hygienic collection and storage of water for consumption and
use; hygienic food storage and preparation; and efficient waste management.

Peacebuilding Promote peacebuilding by creating safe spaces, enhancing knowledge and

skills through education, building trust between youth and governments,
promoting intergenerational exchange, and supporting youth to contribute to
their communities. The Youth for Peace Portal (Homepage | Youth4Peace
Portal) provides a knowledge hub to share the positive contributions of youth
to peace processes and conflict resolution.

Mental health Promote inclusive recreational activities for adolescents, re-start of formal or
informal education, and involvement in concrete, purposeful common interest

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 activities. Employ Psychological First Aid techniques to provide general
support for adolescents and their parents. For first-line management of
adolescent mental, neurological and substance-use conditions by non-
specialist health-care providers, follow the mhGAP Humanitarian Intervention
Guide.
Play-based programming, using sport and play, is showing increasing
promise. Consider these in refugee centers and adolescent-friendly spaces
1746

1747

Page 117 of 259

1748 Section 4: Setting national priorities
1749
1750
1751 Key messages:

1752 • National and sub-national governments need to identify and address adolescent health and well-being
1753 programming priorities, because:
1754 - the scope for adolescent health and well-being programmes is very broad
1755 - the nature, scale and impact of adolescent health and well-being needs are unique in each
1756 country;
1757 - all governments face resource constraints, so they must make difficult choices to ensure their
1758 adolescent health resources are used most effectively;
1759 • The process of national prioritization should be explicit, transparent, and involve all relevant
1760 stakeholders, across key sectors. This process should include:
1761 - a needs assessment to identify which conditions have the greatest impact on adolescent
1762 health and development, both among adolescents, by age, sex and part of the country, and
1763 among those most vulnerable;
1764 - a landscape analysis of existing adolescent health programmes, policies, legislation, capacity
1765 and resources within the country, as well as a review of current global and local guidance on
1766 evidence-based interventions; and
1767 - priority setting by applying explicit criteria such as the magnitude and public health
1768 importance of the issue; the potential to address the needs of vulnerable
1769 populations/underserved groups; the existence of effective, appropriate and acceptable
1770 interventions to reduce priority burdens; and the feasibility of delivering the intervention(s)
1771 and potential to go to scale.
1772 • Over time, countries should reassess their adolescent health priorities and programming to ensure
1773 that they still meet changing adolescent needs. New trends in health and health services, economic
1774 development, education, employment, migration, urbanization, conflict, environmental degradation
1775 and technological innovation should all be considered.
1776 • While national and sub-national priorities will guide local action, local level data should help adjust
1777 national and sub-national recommendations to local contexts, by identifying priority groups of
1778 adolescents and best ways of reaching them with interventions and services, and by making the best
1779 use of local resources.

1780 Section’s overview

1781 Adolescent health programming starts with identifying priorities for adolescent health programmes. This
1782 section explains why prioritization is necessary, and describes the process of national prioritization and its 3

Page 118 of 259

1783 steps: needs assessment, landscape analysis, setting priorities. It provides example how is this process
1784 conducted to integrate considerations across all domains of well-being.

What is new in Section 4?

✓ The process of national prioritization is explained through the
lenses of all domains of well-being
✓ A deeper focus on gender analysis during needs assessment and
landscape analysis is presented.
✓ The need for priority setting at sub-national and local level is
recognized
✓ New case studies are featured
1785

1786 Governments have increasingly recognized that diverse and complex adolescent health needs, as shown in
1787 sections 1 and 2, require prioritization so that effective use of national resources is amplified. The process of
1788 national prioritization includes three steps for strategic decision-making on national adolescent health
1789 programming:

Step 1 – A needs assessment Step 2 – A landscape analysis is Steps 3 – A priority-setting

takes stock of the adolescent
based on a review of existing exercise considers the high-
health and well-being situation
adolescent health and well- priority adolescent conditions
in the country, considering the
being programmes and policies and populations identified in
current status as well as trends
as well as related legislation, Step 1, and the most
and inequities in exposure to risk
capacity and resources within evidence-based and feasible
factors, burdens and health-
the country. It should also interventions and delivery
service access. It identifies
examine the barriers to mechanisms to address them,
which conditions have the
services that all adolescents and as identified in Step 2. This
greatest impact on adolescent
vulnerable sub populations face. process should take into
health and development both
In addition, the landscape consideration the most
among adolescents in general
analysis should be based on vulnerable adolescents; the
and among those most at risk.
a review of current global and urgency, frequency, scale and
It should also account for
local guidance to determine consequences of burdens; the
differences between girls and
which interventions are the existence of effective,
boys and between younger
most evidence-based and appropriate and acceptable
and older adolescents, as well as
effective to address the interventions to reduce them;
other factors such as disability
conditions identified in the and the availability of
and socioeconomic status
needs assessment. resources and capacity to
(among others) which affects
implement or expand priority
health equity.
interventions equitably.
Page 119 of 259
1790

1791 Mechanisms should be put in place to ensure that adolescents participate and are able to contribute
1792 meaningfully to each step outlined above. Time, human resource capacity and funding will often dictate the
1793 level and depth that these steps encompass.

1794 Guided by the first edition of the AA-HA! guidance, many countries have applied these steps to get national
1795 consensus of adolescent health priorities. As countries will be developing a new generation of programmes
1796 that will integrate better well-being considerations, it is important that the needs are assessed, and the
1797 landscape analysis is done, across all domains of well-being. See Box XYZ how the needs of adolescents with
1798 TB span across well-being domains, and what are the implications for needs assessment and landscape
1799 analysis.

Box XYZ
Needs assessment and landscape analysis across well-being domains in the context of
Adolescents with TB
Physical and mental health
Assessing needs of adolescents with TB:
✓ What is known how adherence, stigma, mental health and quality of life impacts are impacted
by the adverse effects of TB treatment, especially second-line treatment?
✓ What is the prevalence of substance or alcohol use among adolescents with TB?
✓ What is known about the impacts of substance or alcohol use on adverse events and TB care
outcomes?
✓ Is there any data on TB risk and outcomes for pregnant adolescents?
✓ What is the effect of family challenges, poverty, stigma, attending work or school, and
migration, on adolescent engagement with TB treatment?
✓ What is the role of anticipated stigma, concerns about confidentiality, travel costs, and need to
attend school or work in ensuring equal access to for all adolescents to the facility-based directly
observed therapy?
Landscape analysis:
✓ What are the current strategies for recognizing and managing substance or alcohol use in
adolescents with TB?
✓ Are adolescents an explicit target group for TPT, and are they prioritized for TPT provision?
✓ Is data on TPT uptake and completion for adolescents regularly reported?
✓ How stigma, costs or challenges associated with clinic visits, affects coverage with TPT?
✓ Is facility-based directly observed therapy equally accessible and acceptable for all adolescents?
Connectedness and positive contribution to society
Assessing the needs:

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 ✓ What is the psychosocial and emotional impacts on adolescents of prolonged isolation and
hospitalization?
Landscape analysis:
✓ Are inpatient facilities adolescent-responsive and conducive to maintain family and peer
relationships during prolonged period of hospitalization?
Safety and a supportive environment
Assessing the needs:
✓ What is known about how well the rights of adolescents with TB are protected, including rights
to safety, basic needs, access to health care without discrimination, protection against
unnecessary hospitalization, and benefit from scientific progress?
✓ What is known about the impact on adolescents and their families of catastrophic expenditures,
loss of income and food insecurity from TB and its treatment?
✓ Are gender differences observed for certain outcomes, such as adolescent females’ increased
risk of HIV infection and, subsequently, TB disease?
Landscape analysis:
✓ Are there mechanisms to monitor that the rights of adolescents with TB are protected, including
rights to safety, basic needs, access to health care without discrimination, protection against
unnecessary hospitalization, and benefit from scientific progress? Are there mechanisms for
complain and redress?

Learning, competence, education, skills and employability

Assessing the needs:
✓ What is known about the impact on education of TB and its treatment, including of prolonged
isolation or hospitalization?
Landscape analysis:
✓ What are the mechanisms to prevent and mitigate the disruption in education resulting from TB
and its treatment, and to ensure that adolescents’ future livelihoods are not affected?

Agency and resilience

Assessing the needs:
✓ What is known about how stigma and hierarchical models of care such as facility-based
treatment undermine adolescent agency?
✓ What are the threats to social networks related to TB and its treatment?
✓ What is the impact of increased in mental health challenges on adolescent resilience?
Landscape analysis:
✓ Are there peer support groups and other mechanisms to support adolescents with TB in finding
a sense of purpose or meaning from their illness experience?

Page 121 of 259

 Source:[330]
1800

1801 4.1 Needs assessment

1802 What is a needs assessment?

1803 A needs assessment involves a systematic review of the health and well-being status of adolescents in that
1804 country [116]. It should include a review of available data disaggregated by sex; age subgroups; disability;
1805 education level; school status; literacy level; marital status; location (e.g. urban versus rural); living
1806 arrangements; socioeconomic status; access to and use of digital applications and services that impact on
1807 adolescent health; and other variables that may be important within the local context, such as ethnicity. As
1808 part of needs assessment, it is critical to conduct a gender analysis (see the check list for gender analysis of
1809 adolescent health programming in Box XYZ).

1810 What type of data should be analyzed during needs assessment?

1811 Based on the most recent, accurate and representative research, the needs assessment should identify the
1812 main causes of adolescent mortality, morbidity and disease prevalence, and contributing risk and protective
1813 factors across all domains of well-being. Section 2 of this document provides an example of a needs
1814 assessment at a global level. Ideally, something similar would be done at country level, and at subnational
1815 level.

1816 It is critical that the reviewers consider data across all key areas of adolescent health and well-being, and not
1817 limiting analysis for certain health areas only (e.g. SRH or nutrition) where there might be more data. If there
1818 is no or limited data on certain conditions (e.g. adolescent mental health, FGM or STIs other than HIV) this
1819 should be acknowledged as a finding of needs assessment. Later at the stage of setting priorities this finding
1820 will inform a decision to establish mechanisms to gather missing data.

1821 Specifically, the needs assessment should examine the:

1822 • main health and well-being issues and challenges affecting adolescents;
1823 • adolescent behaviours most proximately linked to these health and well-being challenges;
1824 • adolescent behaviours that could lead to health and well-being problems in the future (e.g. risk factors
1825 including tobacco consumption, alcohol and drug use, physical inactivity and poor nutrition);
1826 • harmful practices affecting adolescents (e.g. levels of child marriage and FGM);
1827 • sociocultural context of adolescents’ lives, including the protective and risk factors at various

1828 ecological levels (e.g. environmental exposures) and in different institutions (e.g. schools, health
1829 services and employment) that can influence the above issues; and
1830 • influence of gender norms, roles and relations on the health and well-being of both girls and boys
1831 during adolescence [116].
1832 • identify subgroups of adolescents who may be in the greatest need of services and
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1833 • programmes;
1834 • who are the stakeholders, and what are the data sources, that can provide more information on gaps
1835 identified and need to be accessed to finalize the needs assessment

1836 What are the data sources for needs assessment?

1837 Key methods and data sources for needs assessment are described in Figure XYZ.

Box XYZ
Methods and data sources for needs assessment

✓ Desk review of data sources (e.g. Health Information Management System (HIMS), Global
Health Observatory data, Demographic and Household Surveys (DHS), Multiple Indicator Cluster
Surveys (MICS), Global School-Based Student Health Survey (GSHS), The World Mental Health
Survey Initiative, Global Youth Tobacco Survey (GYTS), national disease surveillance records,
national vital statistics, educational records, reports from key ministries featuring adolescents,
reports from research studies, research from projects working with vulnerable groups or in
fragile settings etc.).
✓ Desc review of national, regional and global estimates from e.g. Global Health Estimates (e.g.
[397]) the Global Burden of Disease study (e.g. [398, 399]), or Global status reports (e.g.
[242]) Estimates are especially useful in countries where civil registration and vital statistics
systems are weak and required data is not readily available. WHO resource bank on adolescent
health includes database and resources for statistics across key health areas [400] that can be
used to extrapolate data in the absence of reliable national data
✓ Desk review of research such as national and subnational studies, peer-reviewed articles and
other country assessments
✓ Desk review of policy documents (e.g. data from projects’ evaluations).
✓ Interviews with key stakeholders from the health and other sectors, UN agencies (UNAIDs,
UNESCO, UNFPA, UNICEF, WHO, UN Women).
✓ Focus group discussions with adolescents and youth.
✓ It is suggested that data are presented disaggregated by age (10-14 years and 15-19 years)
and sex, as well as by geographic locations to show disparities.

1838

1839 Key stakeholders include adolescents and young adults; parents and families; community members; religious
1840 leaders; government representatives (e.g. from health, education and social protection sectors); national
1841 human rights institutions; NGO and civil society representatives; UN technical organizations; and bilateral and
1842 donor organizations. The needs assessment should establish a fair understanding of the most important
1843 health concerns and trends, even when it is not possible to compare and rank the rates of different conditions
1844 directly (e.g. road injury mortality and morbidity rates compared to HIV prevalence and teenage fertility rates).

Case Study 6
National ASHR Priority setting in Afghanistan

The WHO Adolescent and Youth Sexual and Reproductive Health and Rights Technical Assistance (TA)
mechanism support countries to implement effective interventions by coordinating the provision of high-
quality technical support using the growing commitment and resources for improving young people’s

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 Sexual and Reproductive Health and Rights. In 2019, the TA Mechanism received a request from the
Ministry of Public Health in Afghanistan (MOPH) to assess the situation of adolescents and youth in the
country and to review the outcomes of the Afghanistan National Reproductive, Maternal, New-born,
Child and Adolescent Health Strategy (2017-2021), in order to strengthen the adolescent health
component of the MOPH in Afghanistan.
The assessment was conducted in three consecutive phases. The first phase included a needs
assessment and a mapping exercise, based on a desk review and a landscape analysis. One of these
provided an external perspective, based on factors such as prevalence, severity, and the availability and
feasibility of evidence-based interventions to respond; and the other assessed in-country perspectives,
from people involved with policies and programming, using a Delphi technique, and community
consultations with young people. The second phase involved the prioritization of the problems and
interventions identified during phase one, incorporating additional efforts to obtain the perspectives of
people responsible for policies and programmes, and young people themselves. The third phase included
the synthesis of all the evidence from the desk review, landscape analysis, and prioritization exercise in
a summary report.

Based on the available data, adolescent pregnancy was the major health challenge for Adolescent Girls
and Young Women (and their children) in Afghanistan. Pregnancy and childbirth complications were
found to be a leading cause of death among girls 15–19 years of age and 20 and 24 years of age.
Ninety-three percent of women 15-19 years of age used no contraceptive method, which left them at
risk of early pregnancy. The determinants of high adolescent pregnancy rates included child marriage
and the early onset of sex without contraception in the context of marriage. The needs assessment
allowed for an evidence-based method for the MOPH in Afghanistan to set national priorities that
considered perspectives from a broad group of stakeholders including young people who are key in the
process.

Source: WHO WHO Adolescent and Youth Sexual and Reproductive Health and Rights (AYSRHR) Unit

1845 4.2 Landscape analysis

1846 What is landscape analysis?

1847 Landscape analysis is the analysis of the current national response to the needs identified in step 1, needs
1848 assessment. Its aim is to identify to which extent are the problems identified during needs assessment are
1849 covered in national plans, polices and services.

1850 What type of data should be analyzed during landscape analysis?

1851

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1852 The landscape analysis gives on overview of national (i) laws and policies and laws (ii) plans and strategies
1853 (iii) stakeholders (iv) implementation aspects of delivery of programmes (v) financing and (vi) evidence-based
1854 interventions currently in place (Box XYZ). These are analyzed against needs identified in step 1. By comparing
1855 what is currently available with what the needs are, gaps in national response are identified (see case study
1856 XYZ from Paraguay and XYZ from Thailand).

1857

Box XYZ
Checklist for landscape analysis

✓ Are the problems you identified in step 1 (needs assessment) covered to a sufficient extent in national plans
and polices? What is the extent to which the national health plan integrates adolescents in its goals and
programming?
✓ Are there specific laws or policies that may impede adolescents’ access to health services?
✓ What are the existing interventions and programmes? Do those programmes respond to social, economic
and other determinants of adolescents’ health and well-being across well-being domains?
✓ What are the gaps in the delivery of programmes and services?
✓ Who are the key stakeholders and organizations involved in planning, managing, implementing and
monitoring and evaluating these activities at the national and subnational level?
✓ What is the scale, scope, quality, coverage and evidence of impact of existing adolescent health
programmes in the country?
✓ What are the systems in place to support capacity development, supportive supervision, coordination and
other planning and management functions?
✓ How are interventions in relevant sectors targeted to reach particular groups of adolescents by age, sex,
location, educational level and other socio-demographic variables?
✓ What is the level of funding to existing programmes and how are the available funds allocated? Are
currently-funded activities aligned with the evidence-based practices recommended in the AA-HA!
guidance (see Section 3 of the AA-HA! guidance, main document)?
✓ Are youth involved in the design, implementation and monitoring of the specified programmes? Have those
marginalized such as the disabled, street workers, orphans and other vulnerable groups in humanitarian
settings, have equal opportunities to participate?
✓ What supply and demand barriers to access quality services and financial protection are experienced by
adolescents?
✓ What are the gaps (e.g. interventions that are currently not delivered but are recommended in section 3 of
the AA-HA! guidance, or certain needs identified in needs assessment do not have a reflection in national
or subnational response)?
✓ Who are the stakeholders, and what are the data sources, that can provide more information on gaps
identified and need to be accessed to finalize the landscape analysis?

1858

1859 Like needs assessment, the landscape analysis should explicitly elicit gender differences in access to services,
1860 and reasons for them (see the check list for gender analysis as part of needs assessment and landscape
1861 analysis, Box XYZ)

1862

Box XYZ
Types of questions to ask for a gender analysis of adolescent health programming:

▪ How do girls and boys get information about essential services, and what are their preferred

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 channels/methods/platforms/trusted sources? How do these differ for girls and boys, and for
girls and boys from urban/rural areas, different ages and ethnicities, and those with disabilities?

▪ Who makes decisions about adolescents’ access to essential and time sensitive services such as
contraception? What resources do parents/legal guardians need to be able to ensure their child
access to services (e.g., information, money, time, transportation)? Who has access to and
control over these resources?
▪ How the need to confidential services impacts differently boys and girls? For example do girls
and boys have different access to resources (e.g. freedom of movement, access to cash,
unsupervised time) that might impact their ability to care in confidence?

▪ In specific neighbourhoods or communities, who can access households for outreach activities
where house-to-house campaigns take place? Are there areas where only female health workers
or volunteers are permitted to enter households? How does access (or lack of it) impact planning
for frontline workers, such as social mobilizers and vaccinators?

▪ Are girls equally and meaningfully participating in programme design, implementation,

monitoring and evaluation at different levels? How? What could be done to further increase
their participation?

▪ What barriers exist for girls and boys to access health centres to seek services (related to, for
example, quality, safety, availability, access and space in waiting areas)? How could these
barriers be addressed most effectively?

▪ What are the possible barriers shaped by sociocultural and gender norms as well as laws/policies
that might hamper timely access to critical services or, for example, the effectiveness of
outreach services to reach out the most vulnerable?

▪ How are health workers recruited, trained and supported/supervised? What are their
opportunities to progress professionally and to be equally remunerated? Are there any issues
related to worker safety, workload or flexibility of working hours? Do health workers receive
gender training?

▪ Have girls and boys from different backgrounds been consulted and involved in designing,
monitoring and evaluating health care services? If so, in what ways?

▪ Are monitoring activities reaching equally boys and girls to hear their experiences and
perspectives?

Source: adapted from https://apps.who.int/iris/rest/bitstreams/1410774/retrieve

1863

1864 What are the data sources for landscape analysis?

1865 Key methods and data sources for landscape analysis are largely similar to those consulted for needs
1866 assessment, however the information gathered focuses on response (Box XYZ).

Box XYZ
Methods and data sources for landscape analysis
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 ✓ Desk review of existing interventions, programmes, legislation, policies and projects that
address adolescent health and well-being, as well as the results and outcomes of these
initiatives and their alignment with the evidence base in what works. Special attention should
be paid to what is being done by the government, NGOs and civil society organizations to
address inequities and respond to social, economic and other determinants of adolescents’
health problems.
✓ Desk review to map existing data sources (e.g. are there regular institutionalized mechanisms
to gather age and sex disaggregated data on adolescent health, well-being and risk and
protective factors)?
✓ Desk review of research such as national and subnational studies, peer-reviewed articles and
other country assessments
✓ Desk review of programme documents (e.g. data from projects’ evaluations).
✓ Field visits and interviews with key stakeholders to explain existing programme challenges and
achievements, perceptions of needs and services and the capacity and interest for expanded
work on adolescent health and well-being from the health and other sectors
✓ Focus group discussions with adolescents and youth, including with those marginalized such as
the disabled, street workers, orphans and other vulnerable groups in humanitarian settings, to
identify equity in response

1867

1868

Case study 7
Landscape analysis in Paraguay
Paraguay has made significant progress in advocating health and education services for adolescents
across the country. Despite the strong foundations for implementing school health policies, there are
still significant structural gaps that hinder the effective implementation of health programs for
adolescents and youth. In support of the Making Every School a Health promoting School initiative,
WHO and UNESCO have developed and promoted ]Global Standards for Health Promoting
Schools (9789240025059-eng.pdf9789240025059-eng.pdf). The initiative is meant “to provide a
resource for education systems to foster health and well-being through stronger governance” using
eight global standards. The standards include, government policies and resources, school policies and
resources, school governance and leadership, school and community partnerships, school curriculum,
school social– emotional environment, school physical environment, and school health services. .
In Paraguay, for effective implementation of the Global standards for health promoting schools, the
WHO and UNESCO in Partnership with the Ministry of Education, conducted a landscape analysis at the
national and local levels involving various stakeholders including public institutions, international
agencies, civil society organizations, and representatives at local communities where schools are
located. The landscape analysis sought to identify existing strengths and weaknesses of health
promotion strategies in schools. Using qualitative and quantitative data collection methods, data was
collected on each of the 8 global standards for HPs. Key recommendations from the landscape analysis
included the need for clarity of guidelines, strong leadership commitment, increasing and managing

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 resources for comprehensive school health programs, establish effective multisectoral and intersectoral
means of collaboration, and strengthen health promotion in educational settings through the provision
of adequate competent human resources and sustainable interventions. By conducting a landscape
analysis, Paraguay has positioned itself to set school health priorities specific to both national and local
contexts while considering existing systems that could be leveraged and those that should be
introduced, developed or supported for all schools in Paraguay to become health promoting schools.
Case Study 8
Rapid Assessment to Assess Adolescent Health in Thailand

In 2019, as part of the regional assessment of adolescent health (AH), Thailand has undertaken a rapid
assessment of the adolescent health situation in the country, and national response. By applying a
systematic approach recommended in the Global Accelerated Action for the Health of Adolescents (AA-
HA!), the country team systematically reviewed the health needs, strategy, policies, resources for
adolescent health programme implementation and coordination mechanisms. The findings showed that
there are gaps in existing policies and how they are implemented, access issues including poorly
supported youth friendly clinics, inadequate data infrastructure to support effective measurement and
evaluation of adolescent health programmes, and not enough support and resources for adolescent
groups.

The results of the assessment helped the country team to identify structural and programmatic gaps
that need to be addressed for effective implementation of adolescent health interventions.
Programmatic interventions such as HIV prevention among young populations most at risk, and
promotion of behaviors that prevent the onset of noncommunicable diseases in adulthood were
highlighted as key programmes needed for the improvement of AH. For example, the assessment
highlighted the need for Thailand to continue to strengthen the implementation of a National Strategy
to Prevent Teenage Pregnancy through a ‘genuine integration approach’, with realistic budget
integration. Also, by undertaken the analysis, the country identified the need to strengthen AH data
and research infrastructure by increasing the wealth of knowledge and research base about adolescents,
linking databases of adolescents between Ministries and agencies. By undertaking this assessment,
Thailand is in a position where responsible ministries and departments can identify a clear strategy to
implement school health programmes and initiatives such as sex education using appropriate channels,
messages and target groups.

Source: Rapid assessment of the implementation of adolescent health programmes in countries of

South-East Asia. New Delhi: World Health Organization, Regional Office for South-East Asia; 2021.
Licence: CC BY-NC-SA 3.0 IGO.
1869

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1870 4.3 Setting priorities

1871 All governments face resource constraints, so they must make difficult choices to ensure their adolescent
1872 health resources are used most effectively. A priority setting exercise is therefore necessary. Priority setting
1873 considers the high-priority adolescent conditions and populations identified in needs assessment, and the
1874 evidence-based and feasible interventions and delivery mechanisms to address them, as identified in
1875 landscape analysis. Prioritization of both key issues and interventions is therefore necessary. The prioritization
1876 process requires a systematic approach and a transparent set of criteria (ref.) (see Table XYZ); and should
1877 include meaningful participation and contributions by adolescents. All relevant stakeholders should be
1878 consulted (see case study from Sudan XYZ).

1879

1880 Table XZY

1881

1882 Guiding criteria to identify national priorities for adolescent health and well-being programmes

Criteria Explanation

Magnitude and public Resources should be directed at the main causes of death and illness or
health importance of injury, but, using a life-course approach, should also go beyond them to
the issue the address risk behaviours and exposures that could affect adolescents’ health
intervention now and, in the future, and strengthen overall well-being (e.g. resilience,
addresses connectedness, etc.)

Equity – is the All adolescents have health-related needs and can experience difficulties,
intervention likely but not all are equally vulnerable to health and social problems. Special
to address the consideration should be given to those interventions that are likely to
needs of vulnerable address the needs of the adolescents who are most vulnerable and/or need
populations/ them most
underserved
groups?
Availability of effectiv It is important that scarce resources are used to deliver interventions that
intervention(s) have the highest chance of effectiveness for the subpopulations of
adolescents that need them the most. All interventions listed in Section 3 of
this document are recommended by WHO and are known to be effective,
but not all of them will address the issue in the specific country context with
the same high impact.

Feasibility of Social, economic and cultural constraints, including lack of recognition of

delivering the adolescents’ rights, may make it difficult to deliver certain interventions.
intervention(s) Priority setting should be based on a careful and pragmatic analysis of the
feasibility of delivering each intervention at scale in the country context.
Acceptability of the intervention by the communities and political support for
it are important considerations when selecting interventions.

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 Potential to go to A realistic comparison is required of the current capacity to deliver each
scale intervention against the capacity that is necessary to deliver it with high-
quality and good coverage. Strong government and community ownership
and political will help drive scale-up (see case study XYZ from Jamaica).
Costing exercises can inform overall resource needs, and how plans can be
implemented in a phased approach.

1883

Case Study 9
Scale Up of small-scale program- Jamaica-
Jamaica has come a long way since the 1970s to maintain low pregnancy rates among adolescents and
provide better support systems for pregnant adolescents. Compared to 1977, where fertility rate among
girls 15-19 years was at 31%, current adolescent pregnancy rates in Jamaica stand at 7.2%.
(https://caribbean.unfpa.org/en/news/country-brief-jamaica). This decline has been sustained for
nearly 4 decades and some of the success could be attributed to innovative solutions and interventions
targeting adolescent girls with the goal of delaying pregnancy, and supporting pregnant adolescent girls
and mothers. One of those initiatives was the Programme for Adolescent Mothers (PAM) that was
launched by the Women’s Center of Jamaica Foundation and started as a small-scale initiative
implemented in 2 districts of Jamaica. The programme was designed to provide a plethora of interventions

primarily targeting pregnant adolescent girls by focusing on their return to school and capacity building,
as well as sexuality education meant to prevent repeat pregnancies. The programme was a first in
Jamaica, and with initial seed funding from international non-governmental organizations and in-kind
support from government, the pilot was successfully implemented in the two centers in Kingston and
Mandeville. The pilot showed that 73% of girls registered in the programme were enrolled in a secondary
school or vocational institution and more than 90% had accepted some form of contraceptive. These
promising results led to the programme receiving funding from the government and other partners for
an effective national scale-up. By 2018, PAM had been scaled up to 10 centers and 8 outreach centers
in 14 parishes across Jamaica. The PAM was able to achieve both vertical and horizontal scale-up due
to several factors including a supportive policy environment, political commitment, clarity, and relevance
of the programme. Having a clear funding strategy and funding stream that included both government
and non-governmental sources contributed as well to a successful scale-up of the program.

Source: https://doi.org/10.1080/15546128.2022.2093808
1884

1885 National priority-setting needs to take place even when it is not possible directly to compare and rank the
1886 rates of different conditions, and even when evidence of local programme effectiveness is limited. In many
1887 cases, this prioritization process will need to depend heavily on expert opinion, guided by relevant global
1888 evidence (see case study XYZ from Sudan).

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 Case Study 10
Sudan takes action to improve the health of its youth

Sudan’s adolescents make about a fourth of the total population, yet not much is known about their
diverse health needs. Although the country has a national health plan, it has so far not included
adolescents even though they represent a significant portion of the population with poor health and
wellbeing outcomes. Realizing the need to urgently address the problem, Sudan’s Directorate of
Maternal and Child Health of the Sudan’s Technical Ministry of Health used guidance from the Global
Accelerated Action for the Health of Adolescents (AA-HA!) document to mobilize stakeholders and work
together in a coordinated manner to improve and implement adolescent health strategy in the country.
Using an evidence-based process described in the AA-HA! document, Sudan was able to effectively
engage other government ministries, UN agencies and key civil society organizations to conduct a needs
assessment that highlighted critical health needs of country’s adolescents. Critical to the needs
assessment process was the engagement of youth groups on a variety of key health topics. Engaging
youth ensured that their needs are well understood and included in the National Strategy of Adolescent
Health and Wellbeing. In view of the gaps in knowledge about specific national indicators and
interventions, the list of evidence-based interventions provided in the AA-HA! guidance helped the FMOH
and stakeholders select national priority interventions relevant to Sudan’s context. This document was
the first national strategy document for adolescents aimed at creating a safe and supportive
environment that offers protection and opportunities for healthy development, and provision of much-
needed health information and skills for adolescents in Sudan. By employing an evidence-based
approach from the AA-HA! guidance, Sudan has positioned itself to better protect its youth and the
health of future generations in the country.

Source: [401]
ref
1889

1890 4.4 Additional considerations

1891 Critically, over time it is important for countries to re-visit this three-step process of needs assessment,
1892 landscape analysis and prioritization, to ensure that they meet changing adolescent health and well-being
1893 needs. New health trends and innovations in service delivery, economic development, employment, migration,
1894 urbanization, conflict, environmental degradation and technological innovations should all be considered. For
1895 example, an updated landscape analysis might identify new resources that are not being harnessed to

1896 their maximum potential – such as growth in rural telecommunications infrastructure – which could be

1897 exploited for telemedicine or rollout of e-health and m-health interventions.

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1898 In addition, there may be times when a country or region needs to implement rapid and focused adolescent
1899 health and well-being priority-setting exercises, such as in the event of a humanitarian crisis. Box XYZ provides
1900 an example of how an adolescent SRH situation analysis might be conducted in humanitarian and fragile
1901 settings.

1902

Box XYZ
An example of how an adolescent SRH situation analysis might be conducted in
humanitarian and fragile settings

In a humanitarian and fragile setting, it is important to conduct a needs assessment and landscape
analysis to understand the SRH situation of both male and female adolescents and in order to develop
a plan that responds to their priority needs. The 2009 Adolescent Sexual and Reproductive Health
Toolkit for Humanitarian Settings provides tools for initial rapid assessment, situation analysis and
comprehensive SRH surveys of adolescents in emergency situations.
Specifically:

• An initial rapid assessment should be conducted during the first 72 hours of an acute emergency
and be used to collect demographic information and identify life-saving issues that must be
addressed urgently to ensure the well-being of the beneficiary population.

• A situation analysis conducted after an emergency situation has stabilized will provide information
about the baseline status of SRH needs and services, and will help in the prioritization of
interventions when comprehensive SRH services are introduced. Situation analyses may use
several methods of data collection, including secondary data, in-depth interviews, focus-group
discussions (sex-separated, if culturally required), community mapping and facility assessments.

• Comprehensive SRH assessments are not often conducted in emergency situations because
they are time consuming and can place additional burdens on precious human and logistic
resources. After stabilization of an acute emergency, however, a comprehensive assessment of
SRH knowledge, beliefs and behaviours can provide valuable information that will help a
programme to design an SRH programme that responds to the specific gendered needs of local
adolescents.

Although the assessments and analyses above are valuable in a humanitarian crisis, it is important
to remember that the minimum initial service package should be the first SRH intervention to be
introduced, and should never be delayed.

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 Source: (287).
1903

1904

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1905 Section 5: programming: translating priorities into
1906 actions and plans
1907 Key messages

1908

1909 1. Most powerful gains for adolescent well-being result from multi-sectoral action. Countries should
1910 invest in inter-sectoral programmes for adolescent well-being to leverage the amplifying effect of join
1911 action, as well as capitalize on single sector action to normalize attention to adolescents’ needs in all
1912 aspects of their work, towards the progressive realization of the “Adolescent Well-being in All Policies
1913 Approach”.
1914 2. The science is clear: smartest of all investments are the coordinated investments in health and
1915 education that bring mutually reinforcing benefits. School health programmes - the most ubiquitous
1916 inter-sectoral programmes in public health - are cost-effective, feasible in all settings and deliver
1917 significant development gains. Realising the potential for every learner and every school will require
1918 transition towards health-promoting education systems that embrace the health and well-being of
1919 learners as a core mission of education. The WHO and UNESCO Global Standards for Health Promoting
1920 Schools provide a framework for countries to adopt this more holistic and system-oriented approach
1921 to school health at all levels of the education system.
1922 3. Adolescent-responsive health systems are key to achieving universal health coverage. To guarantee
1923 explicit ongoing, dedicated attention to adolescent health issues within the health sector, countries
1924 may consider mandating an adolescent health focal point in the Ministry of Health, with responsibilities
1925 for championing adolescent health within the ministry, coordinating systematic attention to adolescent
1926 needs in all health programmes and serving as a liaison person for multi-sectoral action.
1927 4. Countries should ensure that adolescents’ expectations and perspectives are included in national
1928 programming processes. Adolescent leadership and participation should be institutionalized and
1929 actively supported during the design, implementation, monitoring and evaluation of adolescent health
1930 programmes.
1931 5. Adolescents is a very diverse group with diverse needs. “Leave no one behind” should be a key
1932 principle in programming for adolescent health. An equity lens, with due attention to age, sex,
1933 disability and in particular; vulnerable groups of adolescents should inform all stages of programming
1934 from identifying goals, targets and objectives, through to defining indicators to monitor achievements
1935 and plan interventions, services and activities.
1936 6. To sustainably fund adolescent health programmes, the responsibility for funding adolescent well-
1937 being programmes should shift towards domestic resources, by including a focus on adolescents in
1938 national sectoral strategies, investment plans and budgets. Leveraging domestic resources for
1939 adolescent well-being will therefore require better advocacy, based in investment cases, for
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1940 adolescent health priorities within sectoral plans and budgets. External funding opportunities such as
1941 the Global Financing Facility and the applications for the Global Fund to Fight AIDS, Tuberculosis and
1942 Malaria (the Global Fund) provide additional opportunities to increase funding.

1943 Section’s overview

What is new in this section?

✓ A revised logical framework for programming, integrating well-being
domains
✓ A better description of the complementarity of different approaches to
programming for adolescent health and well-being
✓ New evidence from the global analysis of school health programmes
✓ Key implementation strategies in health and other sectors updated based
on the latest guidance
1944

1945 This section describes implementation areas and strategies to achieve the overarching goals of improving
1946 adolescent health and well-being and equity in health outcomes. The section starts by identifying the common
1947 elements of programming for adolescent health and well-being that are summarized in the logical framework
1948 (section XYZ). It then gives an overview of HOW TO design a programme, taking into consideration possible
1949 pathways (section XYZ), and various degrees of sectors working together (Section XYZ). Specific aspects of
1950 programming for adolescent health in humanitarian and fragile settings are described in section XYZ, and
1951 gender-transformative approaches in section XYZ. It then describes WHAT needs to be done, by proposing
1952 implementation areas and strategies in each of the key sectors (section XYZ). Throughout the section, practical
1953 examples are provided on how programming has been applied in various countries.

1954 There is some overlap between the implementation areas and strategies described in this section and some
1955 of the organizational, structural and macro-level interventions described in Section 3. This is because the
1956 complexity of interventions tends to increase the higher they are in the hierarchy of the ecological framework
1957 until some interventions (e.g. organizational level intervention of WASH in schools) are indistinguishable from
1958 a programmatic priority.

1959 For the convenience of the reader, when there is such overlap we list the implementation areas and strategies
1960 along with other priorities for programming, even if it has also been mentioned as an intervention area in
1961 Section 3.

1962 5.1 A logical framework for translating priorities into plans and programmes

1963 As described in Sections 2 and 3, the scope for adolescent health programming is large. It encompasses
1964 mental health, NCDs, SRH, road traffic injuries and violence, among others. It is difficult therefore to have a
1965 blueprint for the specific elements in the design and implementation of adolescent health programmes.

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1966 However, a unifying approach is possible. Recognizing that different levels of country capacity, and various
1967 well-being priorities and contexts will have implications for choosing interventions and key activities,
1968 programming for adolescent well-being has nevertheless common elements that are described by the logical
1969 framework (Fig. XYZ). The logical framework is a tool that provides a formalized approach to the planning,
1970 programming and evaluation of programmes and is a useful checklist of programme elements that need to
1971 be considered in planning a systemic response to adolescent health [402]. A logical framework makes explicit
1972 the links between the programmes’ goals, objectives, key interventions, implementation strategies and
1973 activities.

1974 With the renewed attention to adolescent well-being, defined by five interconnected domains [30], the revised
1975 logical framework recognizes the equal importance of well-being domains and integrates outcome level
1976 measures for each of the well-being domains.

1977 Notably, this logical framework is applicable not only to programmes led or implemented mainly by the health
1978 sector but also to programmes led or implemented mainly by other sectors.

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

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1995 A logical framework for national programming for adolescent health
1996 and well-being

1997
1998 Whereas programmes outcomes and impacts will always be related to one or another domain of well-being,
1999 depending on the programme’ main goals and objectives other domains might become determinants. For
2000 example, for a programme that has a primary intention to reduce child marriage, girl’s agency will be
2001 programme impact (Fig XYZ). However, for a programme that has its main goal to increase school enrolments
2002 of girls, girl agency will be a pre-requisite to achieve the main goal (Fig. XYZ).

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2003

2004 In programming, a holistic view on impacts across well-being domains is not only important but, in many
2005 instances, essential. Even for programmes that have a primary focus health outcome, approaches that
2006 promote other dimensions of well-being – e.g., connectedness, education and employability - should be
2007 considered [5]. A useful example is nutrition. To address key drives of adolescent malnutrition, programme
2008 design must consider the interconnectedness of protective and risk factors for adolescent malnutrition across
2009 multiple domains of well-being. These include macro-level policies (e.g., poverty reduction strategies and
2010 social protection measures), education (e.g., health and nutrition literacy, shared values and social interaction
2011 around food), life skills (e.g., making health lifestyle choices, ability to critically assess online content), agency
2012 and resilience (e.g., empowerment to question gender biases and oppose discriminatory practices), and safe
2013 and enabling food environments (e.g., regulation of marketing, food security, micronutrient supplementation,
2014 and food oriented social protection) [9].

2015 Another example is sexuality education that requires looking beyond mortality, morbidity and risks (e.g.
2016 reducing the risk of pregnancy or STIs) to developing a broader approach that addresses key issues such as
2017 young people’s self-confidence, self-expression, citizenship, sexuality and aspirations, and ability to think
2018 critically and make informed decisions [403]. Case study XYZ illustrates an example of a rights-based, gender-
2019 focused and citizenship approach to sexuality education.

2020 Programming for well-being means attention to all domains. In the regional consultations for adolescent well-
2021 being, Member States agreed that adolescent well-being to be included as a major implementation areas and

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2022 strategies in national and subnational implementation plans using a whole-of-government and whole-of-
2023 society approach [5].

Case Study 11
Comprehensive Sexuality Education Programme in Zambia

In 2016, in partnership with UNESCO, the government of Zambia launched a national comprehensive
sexuality education programme targeting young people including disabled and those living with HIV. The
goal of the programme was to increase access to age-appropriate comprehensive sexuality education (CSE)
for young people aged 10-24 years. Ultimately, the aim of the programme was to improve the health of
adolescents and young people by providing them with the opportunity to have better, appropriate, and
timely sexual and reproductive health education. The implementation of the programme was guided by the
International Technical Guidance on Sexuality Education developed by UNESCO and its partners
(https://www.unfpa.org/sites/default/files/pub-pdf/ITGSE.pdf). The International Technical Guidance on
Sexuality Education was developed to guide education stakeholders in the delivery of in-school and out-of-
school CSE programs. Several strategies were implemented in Zambia including curriculum reforms that
integrated CSE, revised curriculum in all government schools from grades 5 to 12, training teachers and
providing them with culturally appropriate and gender sensitive teaching materials. The delivery and
sustainability of the programme was ensured by collaboration across key sectors including the inclusion of
relevant government ministries, local government, UN Agencies, NGOs, and other partners. Ownership of
the programme at the local level was built by training and tasking Provincial Standards Officers to monitor
the delivery and quality of CSE at the school level.

A careful and systematic approach to implementing CSE that is evidence-based, age appropriate and
sustainable has so far resulted in positive results for schools implementing the programme. An evaluation
of the program in 2015 using the Sexuality Education and Review Tool showed positive results, with high
scores for key metrics including objectives, coverage, programme model, stakeholder analysis and
programme content. By 2016, nearly 77% of the programme coverage target had been met, reaching over
1.35 million learners, and 243 master trainers and 38,521 in-service teachers trained to deliver CSEs.
Lastly, an important milestone achieved by the programme is the implementation of CSE in all targeted
government schools across the country.

Source:
https://www.unwomen.org/sites/default/files/Headquarters/Attachments/Sections/Library/Publications/20
19/Promoting-gender-equality-in-SRMNCAH-Programming-guide-en.pdf
2024

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2025 5.2 Planning multi-sectoral action

2026 5.2.1 Two pathways for programming for adolescent well-being

2027 Translating national goals into actions and plans can happen in two ways. One is to establish an adolescent-
2028 specific programme, which entails a coordinated and comprehensive set of planned, sequential health
2029 strategies, activities and services designed to achieve well-defined objectives and targets. Health and social
2030 systems response to adolescent well-being is often hampered by vertical projects led by multiple actors, which
2031 complicate effective management [7, 19]. These projects often do not have domestic budgets and supervision,
2032 therefore institutionalizing them under a coherent programme with strong central leadership, greater decision
2033 space for district leaders, accountability mechanisms, and increased stewardship by local leadership instead
2034 of external partners, and the ongoing involvement of community and district actors, will ensure greater
2035 programmatic coherence and relevance to local needs [7].

2036 A national programme can be established within, and led by, one sector, or can be inter-sectoral (see section
2037 XYZ). It usually has national, subnational and local coordinators, and secured funding to support planned
2038 activities. The advantage of this way of programming is guaranteed attention and funding, enhanced by
2039 accountability. For the sustainability of the programme however, it is important that the funding source is
2040 coordinated/integrated with the overall health sector budget, and that the programme does not create
2041 separate organizational arrangements that may result in inefficient overlaps and duplications [6]. Ultimately,
2042 viable programmes are those that strengthen the core functions of the system to deliver for adolescents rather
2043 than create however perfectly parallel arrangements run.

2044 However programming for adolescent well-being may happen in the absence of a specific programme, as part
2045 of the sector's strategic and operational planning cycles, when adolescent-specific considerations inform
2046 planning decisions. Supporting actions within single sectors that form their core business (such as ensuring
2047 children attend school and learn well for the education sector, access to safe water for the water and sanitation
2048 sector, or access to clean power for the energy sector) produces arguably the greatest benefits when single
2049 sectors are doing their own core business well. For example, for the education sector, keeping adolescent
2050 girls in school and providing good education that enables their economic empowerment might have greater
2051 and longer term health impact than activities to increase health literacy or undertake school based health
2052 clinics [404]. This way of programming requires that decision makers involved in strategic and operational
2053 planning are sensitized to adolescent-specific needs and solutions. This is often not the case in many countries,
2054 especially with limited prior experience in implementing policies and plans for adolescent well-being, in which
2055 case establishing an adolescent-specific programme might be a preferred pathway to maintain dedicated
2056 attention to adolescent well-being. Ideally, this should be supported by actions within single sectors that
2057 form their core business [404].

2058 To sustain efforts, it is important that the programme is institutionalized (Box XYZ).

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 Box XYZ. Features of an institutionalized adolescent-health programme
A national adolescent health programme is a comprehensive set of planned and sequential strategies,
activities and services designed to achieve well defined objectives and targets. The terms project,
initiative and programme are often used interchangeably. Successful small-scale projects and initiatives
may mature into national programmes (see for example the Case study XYZ) [405]. In this document
we focus on institutionalized adolescent health programmes.

Their common features are:

• Having policy statements to support programme efforts
• Being a line item in a permanent health or education departmental budget
• Having a place in an organization chart
• Having permanent staff assigned to specific programme roles (e.g. National, subnational and
local coordinators)Having descriptions that include prevention functions and level of effort
• Having facilities and equipment for programme operations
• Developing an institutional memory for important agreements and understandings.

2059 Regardless of the pathway, programming efforts can achieve sustainable results only if efforts are contributing
2060 to strengthen the system’ response, e.g. by building adolescent-responsive health systems (see section XYZ),
2061 or health-promoting education systems (see section XYZ).

2062 5.2.2 Approaches to multi-sectoral action

2063 Depending on the programme goals, multi-sectoral action is usually required.

2064 Approximately 50 percent of the gains made in the health of women, children and adolescents result from
2065 investments made outside the health sector [2], particularly through efforts in reducing inequalities,
2066 education, nutrition, water and sanitation, technology and creating healthier environment [404]. Often, the
2067 health sector has neither a sufficient mandate nor the competence to address wider determinants of
2068 adolescent well-being. In these cases, collaboration with other sectors is essential [406]. Therefore
2069 interventions beyond the health sector should be considered as core to national strategies on adolescents’
2070 health [404].

2071 Multi-sectoral action includes two types of actions (Fig. 1). One is action within various single sectors (e.g.
2072 health, education, water and sanitation, environment and nutrition) which is appropriate when one sector has
2073 complete or near-complete control or influence over a given health or well-being problem.

2074 Implementation areas and strategies for individual sectors’ contribution to adolescent well-being are described
2075 in section XYZ. In this approach, each sector needs to normalize the attention to adolescent specific needs in
2076 all aspects of their work. If implemented with fidelity and with the lenses of Adolescent Well-being in All

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2077 Policies Approach (Fig.1), this approach leads long term to sustainable adolescent-responsive public policies
2078 in key sectors. These are described in section XYZ.

2079 The second approach is inter-sectoral action which is a joint action across and between sectors (e.g., between
2080 health and education sectors, environment and water and sanitation sectors). In some situations, especially
2081 if the programme goals cut across well-being domains, inter-sectoral approach can achieve outcomes in a
2082 way which is more effective, efficient or sustainable than might be achieved by the health sector working
2083 alone [406, 407]. In inter-sectoral action, a joint focus also facilitates ongoing mutually informed learning [7,
2084 406].

Action within single sectors and Adolescent Well-being Inter-sectoral action for adolescent well-
in All Policies Approach being

Health
Educatio
n

Telecom
munciati
ons
Social protection

Formerly known as Adolescent Health in All Policies Inter-sectoral action broadly refers to the
approach, with the advent of the well-being framework alignment of intervention strategies and
the Adolescent Well-being in All Policies (AWiAP) resources between actors from two or more
approach is defined here as an approach to public policy sectors in order to achieve
policies across sectors that systematically takes into complementary objectives that improve
account the implications of decisions on adolescent well- adolescent well-being or its determinants.
being, avoids harmful effects and seeks synergies in While inter-sectoral action is usually
order to improve adolescent well-being and health concentrated in government, it has also been
equity. It is a strategy that facilitates the formulation of taken to mean actions across other sectors
adolescent-responsive public policies in key sectors. including civil society and the private sector.
Adapted from. [148]

2085

2086 Unlike single-sector actions, inter-sectoral actions require public policies that involve two or more ministries
2087 performing different roles for a commonly agreed purpose. Such collaborations are much more complicated
2088 than merely involving other sectors in programme implementation through information exchange,
2089 coordination or cooperation. It is therefore important to build the necessary human and institutional
Page 142 of 259
2090 foundations for inter-sectoral action even before establishing a formal inter-sectoral programme [48]. This
2091 can be done systematically (Box XYZ).

2092

2093
Box XYZ. Practical considerations in planning and managing an inter-sectoral programme
• Raise awareness of the extent of the problem, and that prevention is possible. Because
ministries of health, both at national and local levels, generate much of the available data on
issues such as youth violence, self-harm, adolescent pregnancy and under-nutrition and oversee
the treatment of a substantial proportion of victims, they are well positioned to campaign for
more attention to these issues.
Three types of awareness generally need to be achieved: awareness within the ministry of
health and district health management teams, awareness among other sectors, and public
awareness. See the example Case study XYZ [408].
• Clarify the policy framework that mandates or enables inter-sectoral action for the issue at
stake. Identify policy documents, such as national strategies and plans of action that stipulate
the necessity of joint action across sectors for the problem in hand, or otherwise are important
for ensuring the good planning, coordination and implementation of inter-sectoral action.
• Invest in consulting with different sectors and in establishing a shared vision among key
stakeholders. Identify focal points for the issue(s) at stake from other sectors and organize an
informal meeting or meetings with other key sectors. Share information about your current work
and goals, identify common interests, and establish a mechanism to exchange information
regularly.
• Be aware of common barriers to inter-sectoral action and take anticipatory remedial actions.
Collaboration with other sectors brings specific communication challenges. These include lack
of understanding of the political agendas and administrative imperatives of other sectors, or
differences in the discourse between sectors in framing priorities and goals. Structural barriers
also exist. For example, budget allocations within each sector might be difficult to align with
the budget lines needed for inter-sectoral action. Effective inter-sectoral action will have to
anticipate these barriers (see Box XYZ. that presents a check list of behavioural and structural
impediments for inter-sectoral action) and plan remedial actions. Box XYZ describes challenges
that face adolescent sexual and reproductive health programmes in low- and middle-income
countries.
• Establish a formal partnership with clear governance structure and a mandate from the highest
level of the government, and strong representation of adolescents and the community (see
Case study XYZ). Appoint a national lead with a mandate from the highest level of the
government, who will be responsible for the overall delivery of the programme and engaging
with national and local organizations (see case study from Philippines XYZ). Develop and agree

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 the terms of reference for the national lead and each agency involved. Organizations and
individuals involved in partnerships need to have both the authority and the flexibility to engage
in mutual decision-making. Clarity about partners and stakeholders is key: who, how many,
their roles and responsibilities, and the need for consistency of participation and commitment.
• Consider an independent advisory group. Based on annual progress reports, this will ensure
independent scrutiny of progress and will highlight potentially neglected issues for the attention
of sectors involved.
• Invest early in organizational capability. A well-designed programme reaches and builds the
capacity of a wide variety of health professionals, programme administrators and policy-makers
to assist them in the development of local plans, service delivery and research. It provides
guidance materials and manuals to support local implementation and to facilitate fidelity in
programme implementation. Key areas where such resources might be needed include:
community and youth engagement; district planning; working across disciplines and
government sectors; public/research/practice partnerships; core indicators and measures; and
specific health issues. Such a programme collaborates with key national research centres and
institutions, and leverages their resources for intervention development and implementation
research. It also develops the core capacity of other ongoing adolescent health and
development programmes (e.g. national mental health programmes and HIV programmes).
• Ensure adequate financing for national, subnational and local activities. Decide on the approach
to co-financing (see Table XYZ). Consider allocation of funds to local areas through contracts
that are subject to conditions, such as appointing local coordinators and developing local plans
(Case studies XYZ).

• Create a mechanism for review. This should be informed by systematic collection of data
through the information system, and should facilitate adjustment of the response of the sectors
involved, as required, at regular intervals. Provide continuous support to the ongoing
monitoring, continuous quality improvement and rigorous evaluation of interventions and
policies.
• Plan for long-term sustainability from the outset [409], by aligning service delivery, financing,
generation of human and physical resources/inputs, and stewardship with system-wide
objectives [19], and by considering enablers and barriers to sustain co-financing (see Table
XYZ).

2094

Case Study 13
Management of the School Health Programme- in Philippines at the local level - Making
every school a health-promoting school

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 About a third of the population of the Philippines are of school age, and health in schools is considered
an important component of the country’s Department of Health’s agenda. Despite the country not having
a direct school health policy based on the World Health Organization’s (WHO) definition for Health
Promoting Schools (HPS), the country nevertheless has a school health and nutrition programme that
includes several interventions complementary to WHOs HPS. In July 2018, the Department of Education
launched the “Health in Schools” programme. The goal of the programme is to provide basic primary
health, nutrition, and dental care education in healthy lifestyle behavior for school staff and students,
and ensure the link between health service providers and local governments for child and adolescent
health services.

Despite the programme being led and implemented by the Department of Education, coordination of
the program mostly depends on local governments. Local governments are responsible for the
management and allocation of funds to schools for the implementation of the various programmes.
They receive and allocate funds from central government as well as provide additional funding to support
school improvement and other needed interventions not funded by the central budget. Local authorities
such as school officials and superintendents support school initiatives such as school health and nutrition
programmes and projects. They also provide other necessary administrative support needed for school-
based management of “health in schools programme”.

School management also contributes to the development of school level polices and the management
of the school environment. Although barriers still exist in school health programmme, the health in
schools’ strategy which includes local authorities as key stakeholders has contributed to the success of
some programs such as the WASH in schools’ program.

Source: Making every school a health-promoting school: country case studies. Geneva: World Health
Organization and the United Nations Educational, Scientific and Cultural Organization; 2021. Licence:
CC BY-NC-SA 3.0 IGO.
2095

2096 5.2.3 Build leadership within the Ministry of Health and across the government

2097 Good governance is a prerequisite for high-quality health systems [7], and leadership for adolescent well-
2098 being across the government is an essential foundation for successful programming [410]. A growing number
2099 of countries including Chile, England, Ethiopia and Thailand established strong leadership that led to put in
2100 place successful national government-led adolescent pregnancy prevention programmes (see also Case study
2101 XYZ from Scotland). Within the Ministry of Health, strong leadership for adolescent health is needed to
2102 mandate collaboration between different departments and to ensure an adolescent health focus in key policies,

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2103 including those related to financial risk protection; training and education of providers; quality improvement;
2104 health management and information systems; and infrastructure. As part of multicomponent programmes,
2105 over the last decade, they increased access to and uptake of contraception by adolescents by integrating
2106 adolescent-friendly health service elements into national health systems. To address other domains of well-
2107 being and their determinants, strong leadership is required at the highest level of both national and local
2108 government to mandate collaboration between different arms of government finance, gender, planning,
2109 statistics, social welfare, security, labour, health and education, working closely with communities, civil society,
2110 young people and the private sector.

Case Study 15
Leadership to Improve Pregnancy and Maternity conditions for Young People in Scotland

In Scotland, even though pregnancy rates have been on a steady decline in the last decade, pregnancy
rates among young people are still among the highest in Western Europe. In 2016, Scotland's ministries
of Children and Young People, and Public Health introduced the “Pregnancy and Parenthood in Young
People's” strategy. The goal of the strategy was to improve pregnancy conditions for girls under 18
years and those looked after up to age 26. The strategy provided action-oriented strategies to support
and improve the well-being and decrease deprivation among pregnant girls. Strengthening leadership
and accountability is at the core of the strategy.

Since the launch of the strategy concrete leadership and accountability actions have been implemented
both at the national and local levels. At the national level, the National Lead that was appointed for the
“Pregnancy and Parenthood in Young People” has been pivotal in increasing advocacy efforts,
coordination and engagement, especially with young people, and providing guidance on the
implementation of “Pregnancy and Parenthood in Young People Strategy”. At the local level, areas have
been supported to develop tailored action plans that support pregnancy and parenthood for young
people.

Strong leadership commitment also meant supporting improvements for young people to take more
control over their own lives through actions such as improvements to pregnancy information targeting
young people, publication of maternity documents specific to young people, increased funding to close
educational attainment gap, support for positive relationships and sexual wellbeing, supporting young
people with disabilities, etc. Looking ahead, there are plans for continued engagement and collaboration
between local and national governments, increased accountability at all levels through good practices
and trainings, and strategic partnerships with groups serving disadvantaged young people.

Source: https://www.gov.scot/publications/pregnancy-parenthood-young-people-national-progress-
report-no-2/

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2111

2112 Implementation areas and strategies to step up leadership for adolescent well-
2113 being within the Ministry of Health and across the government:

2114 1. Establish a national-level mechanism, or use existing platforms, to oversee and coordinate efforts for
2115 adolescent well-being across sectors and government ministries. Such a mechanism would facilitate
2116 engagement of relevant agencies and civil society organizations, including adolescents themselves. It
2117 would also identify and periodically review priorities for inter-sectoral collaboration, create incentives
2118 to expedite the work, coordinate action across government ministries, and promote related
2119 accountability at all levels.
2120 2. Mandate an adolescent health focal person in the Ministry of Health with the responsibility to:
2121 a. Work across departments within the Ministry of Health – i.e. financing, workforce, primary
2122 care and hospital care – to ensure that all health programmes have an appropriate focus on
2123 adolescent health
2124 b. Coordinate adolescent-specific programmes within the health sector or across sectors,
2125 depending on the mandate
2126 c. Work with other sectors during their routine strategic and operational planning cycles to
2127 ensure AHiAP (see Section XYZ).
2128 d. Liaise with other sectors through an inter-sectoral platform and ensure that there is strong
2129 leadership for adolescent health across government to mandate collaboration towards jointly
2130 owned health targets
2131 e. Plan and manage inter-sectoral action (see Box XYZ in Section XYZ)
2132 3. Build national and subnational (e.g. district-level) political and administrative capacity and leadership
2133 for adolescent health, through:
2134 a. development of adolescent-centered competencies in using data for decision-making
2135 b. essential skills in advocacy, negotiation, budgeting, building consensus, planning and programme
2136 management
2137 c. Collaborating across sectors
2138 d. Coordinating multi-stakeholder action
2139 e. Mobilizing resources
2140 f. Ensuring accountability

2141 5.2.4 Ensure meaningful adolescent and youth engagement

2142 Adolescent engagement must be made integral to the design, implementation, monitoring and evaluation of
2143 programmes and to decision-making that affects them in all spheres Error! Bookmark not defined.. The s
2144 ignatories of the Global Consensus Statement on Meaningful Adolescent and Youth Engagement define
2145 meaningful adolescent and youth engagement as “an inclusive, intentional, mutually-respectful partnership

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2146 between adolescents, youth, and adults whereby power is shared, respective contributions are valued, and
2147 young people’s ideas, perspectives, skills, and strengths are integrated into the design and delivery of
2148 programs, strategies, policies, funding mechanisms, and organizations that affect their lives and their
2149 communities, countries, and world” [53].

2150 Policies in key sectors should not be based exclusively on adults’ views of adolescents: too often, adolescents
2151 are tokenized, left out of discussions, or uncompensated for their time Error! Bookmark not defined.. H
2152 ealth and other ministries or governments have the responsibility not only to respect the right to participation
2153 but also to protect and fulfil it. It entails building adolescents’ capacity and providing them with meaningful
2154 opportunities for participation in leadership and financing decisions and in all phases of the programming
2155 cycle, including assessment, analysis, planning, implementation, monitoring and evaluation [411].

2156 Why meaningful adolescent and youth engagement in programmes is important?

2157 Engaging adolescents in decisions affecting their lives brings multiple benefits [271, 412].

2158 ● From a pragmatic perspective, adolescent participation ensures better decisions and policies [271,
2159 412]. It allows decision-makers to tap into adolescents’ unique perspectives, knowledge and
2160 experience, which brings a better understanding of their needs and problems and leads to better
2161 suited solutions. For example, upholding adolescents’ participation in health care helps create
2162 sustainable, acceptable, locally appropriate and more effective solutions, while also encouraging more
2163 adolescents to seek and remain engaged in care [413]. Having adolescent and youth perspectives in
2164 national policy has been linked to more coordinated responses from government, civil society
2165 organizations (CSOs) and donors. In addition, programmes can benefit from adolescents and youth
2166 playing an important role in tracking progress through giving their feedback on how the policy
2167 application is progressing.

2168 ● From a developmental perspective, meaningful engagement has an essential positive influence
2169 on social and emotional development [407]. It enhances adolescent-adult relationships, develops
2170 adolescents’ leadership skills, motivation and self-esteem, and allows them to develop the
2171 competencies and confidence they need to play an active role in society [414].

2172 ● From an ethical and human rights perspective, children’s right to participate in decision-making
2173 is enshrined in the United Nations Convention on the Rights of the Child and is a way to promote
2174 health equity. The underlying basis of inequities is the unequal distribution of power, money and
2175 resources, so empowering and involving vulnerable and excluded groups of adolescents through
2176 meaningful participation constitutes one of the mechanisms for the redistribution of power [415].

2177 5.2.4.1 What are the modalities and principles for effective and ethical youth
2178 engagement?

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2179 5.2.4.2 Adolescent participation can take several different forms including

2180 • Informing adolescents with balanced, objective information (e.g. Case study XYZ).

2181 • Consulting, whereby an adult-initiated, adult-led and adult-managed process seeks adolescents’
2182 expertise and perspectives in order to inform adult decision-making. See the case study XYZ from
2183 Cambodia.

2184 • Involving, or working directly with, adolescents in the communities.

2185 • Collaborating by partnering with affected adolescents in communities in each aspect of a decision,
2186 including the development of alternatives and identification of solutions.

2187 • Empowering by ensuring that adolescents in communities retain ultimate control over the key decisions
2188 that affect their well-being. This translates into adolescent-led participation where adolescents are
2189 afforded, or claim, the space and opportunity to initiate activities and advocate for themselves (see Case
2190 study XYZ from Malawi). Empowerment though shifting social norms, supporting policy change, fostering
2191 young women’s and girls’ leadership through effective partnerships is a strategy of particular importance
2192 in addressing the power imbalance resulting from unequal gender norms [416]

2193 Each of these modes of participation is legitimate and appropriate in a different context, if it complies with
2194 the five basic principles (Fig. XYZ).

2195

Case Study 12
Involving adolescents in formative research in Cambodia

Evidence from research have supported the inclusion of Adolescents in research to capture their
perspectives and viewpoints since they are better positioned to provide information on their health and
wellbeing. This realization has prompted many stakeholders to actively engage adolescents in
participatory research methodologies to inform programming.
In Cambodia, where Adolescents make up about a fourth of the population, the World Food Programme
(WFP) undertook research in Cambodia to contribute to the global evidence base on adolescents and to
guide future nutrition programmes. The research was conducted between 2016 and December 2017
and followed a participatory research methodology that included adolescents and their communities.
The objectives of the study were to assess adolescents’ nutrition needs and priorities, engagement
preferences for nutrition programs, understand current programmatic and policy environment and
establish recommendations for context and user-centered nutrition interventions for adolescents. Data
was collected from 280 participant in three provinces in Cambodia. Qualitative data collection
methodologies that ensured active engagement and participation of adolescents were used for data

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collection including focus group discussions, key informant interviews, workshops, and technology
surveys.

The research elicited perspectives directly from adolescents on how they view and define their
experience as adolescents, their food and nutritional needs, factors affecting their nutrition and how
they would like to be engaged by programmes. The active participation of adolescents led to key
recommendations for policy and programmatic considerations which included investments to increase
access to healthy and nutritious foods, providing healthier food options, food preparation and
consumption, improved land, and agricultural practices, keeping adolescents in schools, improve
maternal health awareness. An important consideration of the results from the research was the
attention to gender roles within communities and their influence on future programmes and
interventions.

Source: https://docs.wfp.org/api/documents/WFP-
0000064044/download/?_ga=2.155210803.907460398.1664883718-1710763202.1664883718
Case Study 16
Youth Group in Malawi equipped and empower young people

HeR Liberty, a youth-led agency established in 2017 in Malawi, has been working on adolescent focused
approaches to improve the health and wellbeing of adolescents locally. In partnership with key
stakeholders including the Global Financing Facility, the organization engaged meaningfully with youth
to co-create approaches with youth from the local communities. Young people are given the freedom
to develop a plan to improve their health and wellbeing based on their local needs and resources. The
organization provides youth leaders with training and toolkits so that they are empowered to complete
their own financial and narrative reports for projects they undertake. Youth leaders are also given
training on how to engage local leaders and government bodies on issues related to the health and
wellbeing of adolescents. The approach of HeR Liberty is to empower and support young people through
effective advocacy, so adolescents are better informed on key health and wellbeing issues affecting
them such as sexual health and reproductive rights.

The organization has successfully used music and short videos to develop advocacy toolkits and
roadmaps in partnership with Youth Networks, UN Agencies and other organizations. Using a clear
communication and media strategy, the organization uses social, online, and traditional media to share
SRHR messages to local radio stations and broadcast on TV channels. By 2019, their advocacy song,
“inu ndi ife” was played by 8 radio stations and 6 TV channels. In addition, downloads for the song via
the online platform “www.malawi-music.com” had reached 16202 by December 2022. In one campaign,
because the organization worked with youths to co-develop approaches and develop plans specific to

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 their context, the organization was able to reach 4000 youths in 30 days. Self-report by the organization
indicates that by December 2022, the organization had reached 8000 young people in 12 districts and
worked with 100 youth leaders and peer educators, and 80 clubs (https://herlibertymalawi.org/). The
organization has also organized intergenerational dialogues with over 20 community and traditional
leaders in 4 local districts in Zambia.

Source: https://apps.who.int/iris/handle/10665/362195
2196

2197 Figure XYZ describes the five principles for meaningful adolescent and youth engagement

Rights-based – Young people Transparent and Voluntary and free from

are informed and educated informative – Young people coercion – Young people must
about their rights and are provided with full, not be coerced into
empowered to hold duty evidence-based, accessible, participating in actions or
bearers accountable for age-appropriate information expressing views that are
respecting, protecting, and which acknowledges their against their beliefs and wishes
fulfilling these rights; diversity of experience and and must always be aware that
promotes and protects their they can cease involvement in
right to express their views any process at any stage
freely. There is a clear and
mutual understanding of how
young people’s information,
skills, and knowledge will be
shared, with whom, and for
what purpose

Respectful of young people’s views, backgrounds, and Safe – All adults and those in
identities – Young people will be encouraged to initiate ideas positions of authority working
and activities that are relevant to their lives, and to draw on their directly or indirectly with young
knowledge, skills and abilities. Engagement will actively seek to people in relation to issues at
include a variety of young people according to the relevant needs every level have a responsibility
or audience. Engagements will be culturally sensitive to young to take every reasonable
people from all backgrounds, recognizing that young people’s precaution to minimize the risk
views are not homogeneous, and they need to be appreciated for of violence, exploitation,
their diversity, free from stigma; tokenism, or any other
negative consequence of young
people’s participation.

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2198 5.2.4.3 What is the current status of youth engagement?

2199 Youth leaders are active in many countries, through community associations, school-based activities, youth
2200 councils, youth parliaments and other national or subnational youth advisory groups [417]. But much more
2201 needs to be done. In many setting the reasons for exclusion of adolescents and youth from decision-making
2202 process (Box XYZ) are still to be addressed.

Box XYZ
The dimensions of adolescents and youth exclusion from decision-making process

It is crucial to acknowledge that adolescents are a very heterogeneous group, and some forms of
inequity and privilege are entrenched, systemic and even intentional. Vulnerability and exclusion can
occur through one or multiple intersecting and overlapping dimensions of inequity, including, but not
limited to, age, gender (including gender identity/sexual orientation), ethnicity, disability, care status,
migration status, language and economic or social status. It can also be made worse by context (rural,
emergency, conflict, poverty, exclusion, lack of digital connectivity, etc.). Peer pressure or discrimination
can contribute to adolescents’ confidence or lack of confidence to express their views. Broader social
norms and cultural and organizational practices also help or hinder adolescents’ participation and civic
engagement. Within youth structures, younger adolescents are often marginalized in favour of older
youth. Information and participation methods are not always sufficiently adapted to adolescents of
different ages and abilities. When initiating consultations or forums for adolescents, many agencies find
it easier to reach and involve school-going adolescents (especially those who are doing well in school).
This, unintentionally, excludes more marginalized adolescents who may not regularly attend formal
schools.

Source: https://www.unicef.org/media/73296/file/ADAP-Guidelines-for-Participation.pdf
2203 As part of the accountability system for the Global Consensus Statement on Meaningful Adolescent and Youth
2204 Engagement (MAYE) [53], a survey of all 249 signatories of the statement was conducted to assess the
2205 progress made and the challenges identified during the first year of its implementation.

2206 Despite reports of strong progress and the establishment of specific mechanisms for MAYE, challenges remain.
2207 Structural barriers - such as racism, misogyny and ageism - rooted in privilege and hierarchy still prevent
2208 adolescents and young people from meaningful engagement in all processes that affect their lives and hamper
2209 the advancement of MAYE within the endorsing organizations. In terms of establishing equal partnerships
2210 with youth-led initiatives, almost half of those answering questions on this matter referred to the use of
2211 informal agreements, rather than formal memoranda of understanding (MoUs), contracts or terms of reference
2212 (ToRs).

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2213 Many organizations reported that they expect to increase their MAYE commitments in the near future. This
2214 would be achieved by internalizing MAYE guidance documents, including but not limited to seeking ways to
2215 financially compensate adolescents and young people, or by developing accountability mechanisms.

2216

2217 As for identified barriers preventing young people's access to decision-making bodies, the commonest
2218 response was that unrealistic requirements for qualifications was the main reason preventing young people's
2219 access to those spaces. Findings from the survey suggest that organizational mandates and internal advocacy
2220 were the main enablers of financial support for work done by young people, while restrictive internal financing
2221 policies and lack of donor requirements/ encouragement were found to act as barriers. This implies that, if
2222 those determining financial systems and policies worked closely with internal advocates and enablers, that
2223 would produce significant opportunities for progress. The organizations responding to the survey also
2224 commented on the support they would need to advance MAYE. In response, PMNCH and WHO have developed
2225 a MAYE Practical Guidance Resource which unpacks the checklist criteria of the MAYE Consensus Statement,
2226 including an assessment tool, recommendations and case studies.

2227

2228 Key implementation areas and strategies for MAYE in programming for
2229 adolescent well-being:

2230 1. Ensure that national policy frameworks recognize the importance of the meaningful engagement of
2231 adolescents and youth and establish mechanisms to guarantee it.

2232 2. Create forums for meaningful youth engagement and participation as leaders and key stakeholders at the
2233 national level (e.g. independent youth commissioners and a national youth council) with resources for
2234 independent oversight of government actions to promote adolescent well-being.

2235 3. Establish formal structures and processes to institutionalize adolescent meaningful participation in dialogues
2236 about relevant areas of public policy, financing and programme implementation (e.g. youth participation in
2237 the Civil Society Coordinating Group for the Global Financing Facility in Support of Every Woman Every Child
2238 ; youth participation in SDGs’ regular Voluntary National Review process and SDG-related reporting;
2239 systematic inclusion of young people through civil-society involvement in country platforms for reproductive,
2240 maternal, newborn, child and adolescent health).

2241 4. With the participation of adolescent and youth constituencies, adopt minimum standards for improved
2242 participation, inclusiveness and transparency and for the accountability of such country platforms. Ensure that
2243 policies for adolescent representation consider equity, addressing drivers of exclusion and barriers to
2244 participation of sub-populations (e.g., those with disabilities, poor access to internet, etc.). (see Box XYZ) to
2245 achieve greater parity, through adequate mechanisms for formal and informal youth representation, tailored
2246 capacity building and financial support.
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2247 5. Build mechanisms for youth participation at the local level, including taking advantage of technological
2248 platforms (e.g. mobile phones and social media) to facilitate youth engagement in problem identification,
2249 prioritization and solutions. Provide the resources to support these actions and ensure that the mechanisms
2250 allow the most vulnerable adolescents to participate.

2251 6. Train and mentor a diverse group of youth leaders to build their competencies to play an effective role in
2252 governance and accountability processes around their health and well-being. Ensure that youth-friendly and
2253 accessible information, resources and financial and technical support are available to support training and
2254 mentoring activities, and enable adolescents to share their experiences, good practices and models of
2255 successful adolescent-led interventions.

2256 7. Build legal awareness and literacy among adolescents about their rights under the Convention on the Rights
2257 of the Child, as well as about their legal entitlements (and limitations) under national laws and regulations.
2258 Ensure the existence of, and adolescents’ ability to use, functioning and accessible mechanisms for remedy
2259 and redress when violations occur. Ensure easy access for young people to present cases before regional and
2260 international judicial and human rights bodies.

2261 8. Put in place mechanisms and procedures to ensure adolescent participation in health services, including in
2262 their own care, in line with Standard 8 of the Global Standards for Quality Health-Care Services for Adolescents
2263 [413, 418].

2264 9. Identify clearly the objectives of adolescent participation and institutionalize the monitoring and evaluation
2265 of youth engagement with specific indicators. See Case study A5.26 from the Adolescent and Youth
2266 Constituency of the Partnership for Maternal, Newborn & Child Health on how establishing an 18-month
2267 workplan with clear objectives and expected results helped to demonstrate impact.

2268 10. Develop and implement internal policies and mechanisms that ensure proper recognition and
2269 compensation of adolescents and young people for their role in shaping policies, creating demand and
2270 providing services

2271 Sources: [53, 54, 271, 412, 413, 415, 419].

Resource bank for adolescent participation in programming for well-being

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2272

2273 5.2.5 Secure financing for adolescent well-being programmes

2274 As shown in section XYZ, investing in adolescent health and well-being is a good investment. Continuous
2275 advocacy is needed to persuade funding bodies about it. To meet the needs of adolescents, resources need
2276 to be allocated and purchasing decisions made within and outside the health sector. Depending on whether
2277 the programme is a single-sector programme, or inter-sectoral, the processes and opportunities to expand
2278 resource allocation will differ. Each sector has its own processes and mechanisms for the allocation of
2279 resources within the sector, and it is beyond the scope of this document to cover all of these. Because of this,
2280 for single sector programmes, we only use the example of the health sector; we then describe the approaches
2281 for funding inter-sectoral programmes.

2282 5.2.5.1 How to fund inter-sectoral programmes for adolescent well-being?

2283 Despite strong calls for ‘whole-of-government’ approaches, ‘health-in-all-policies’, and ‘inter-sectoral action
2284 for health’, financing for health and well-being is still dominated by a sectoral approach [48, 404]. Single
2285 sector financing is particularly problematic for the funding of structural interventions that address the social
2286 determinants of health and well-being. For example, gender equality has the potential to generate large health

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2287 gains and synergies across education, economic empowerment, service uptake and improved health -
2288 outcomes that “belong” to different sectors.

2289 However, health and other sectors rarely invest substantially in these inter-sectoral interventions, partially
2290 because of sectors’ specific paradigms that tend to undervalue co-benefits that are outside the sector’s
2291 mandate. The evaluation of the return on investment often excludes the consideration of a sector’s non-
2292 specific costs and impacts [48, 420]. In recent years, there has been increasing recognition that governments
2293 need to provide the incentives, budgetary commitments, and sustainable mechanisms to support multi-
2294 sectoral collaboration, and calls to mobilize financing at the global level, and incentivize multi-sectoral
2295 collaboration and action through existing partnerships and new financing mechanisms have been made [48,
2296 404]. Countries across income levels are beginning to explore how best to institutionalize these, and the
2297 funding flows that result from them [47].

2298 There is no one recipe for financing inter-sectoral programmes that will be fit for all situations, nor a single
2299 set of contextual characteristics necessary to support a co-financing approach between sectors. However, a
2300 starting point should be the consideration of all the benefits and harms to the adolescent of a programme,
2301 spanning all the five domains of adolescent well-being, rather than only considering benefits or harms within
2302 one domain or sub-domain. The implementation strategies listed below are based on emerging models for
2303 financing inter-sectoral action for health (Table XYZ), with the recognition that more research is needed to
2304 establish a credible evidence base on the impact of co-financing [48].

2305 Implementation areas and strategies;

2306

2307 1. Prepare a strategic and compelling plan for inter-sectoral investments in adolescents, making a strong
2308 case based on the triple dividend argument, and engage in negotiations with the Ministry of Finance
2309 over resource allocations.
2310 2. Consider various financial mechanisms to implement the co-financing approach, such as pooled
2311 budgets, aligned budgets, joint commissioning, cross-charging and transfer payments, and implement
2312 those that are most suitable to the context (e.g. the existence of enabling legislation of the maturity
2313 of partnership between sectors, grants’ conditionalities, etc.). Table XYZ describes the key features
2314 of inter-sectoral co-financing models and gives examples of their application in countries.
2315 3. Before deciding and implementing the co-finance model, anticipate barriers and enablers to uptake,
2316 implementation and continuation of the co-finance, and plan remedial actions from the outset. Table
2317 XYZ describes key barriers and enablers for co-financing
2318 4. Invest in programme managers´ specific skills that are required in the development stage of co-
2319 financing, including negotiation, resource mobilization, effective communication and public financial
2320 management.

2321
Page 156 of 259
2322 Table XYZ. Description of financial mechanisms used to implement the co-financing approach

2323

Financial Definition Example Country Description

mechanism
Pooled budgets At least two budget holders Children’s Trust England Local cross-
make contributions to a Pathfinders [421] sector
single pool for spending on partnerships
pre-agreed services or between ? and ?
interventions. promoting
greater
integration of
professionals
providing
children’s
services.

Aligned budgets Budget holders align The Interagency El Programme

resources, identify their Program for the Salvador providing an
own contributions towards Empowerment of integrated
pre-specified common Adolescent Girls response to the
objectives. (IPEAG) [422]. needs of
adolescent girls
Geracão Biz Mozambi Multi-sectoral
Program (PGB) que adolescent
[423]. sexual and
reproductive
health
programme
In-kind support Sectors contribute non- School Health & Zambia School-based
financial resources (e.g. Nutrition [424]. deworming,
human resources, micronutrient
infrastructure and/or supplementation
technology) towards the and health
joint provision of an education
intervention or programme

Page 157 of 259

 with a shared objective.

Kenya National Kenya School-based

School-Based deworming
Deworming
Programme [425].
Structural Full integration of cross- Integrated Health Northern Mechanism for
integration sector responsibilities, & Social Services Ireland joint health &
finances and resources Board social care
under single management (1973-present) planning,
or a single organisation. [68]. commissioning &
provision
Joint or lead Separate budget holders Contra Costa United Full-day full-year
commissioning jointly identify a need and County Community States integrated early
agree on a set of objectives, Services Dept. education &
then commission services coordinated funds support services
and track outcomes. for early education
[426].

Cross-charging The mechanism whereby a ADEL reform Sweden Local authorities

cross-sector financial (National Reform (responsible for
penalty is incurred for the of Elderly Care) social care) are
non-achievement of a pre- (1992- required to pay
specified target. county councils
(who run
hospitals) for
care delivered to
patients in
hospital once a
patient is
deemed fully
medically treated
by a hospital
doctor

Page 158 of 259

 Transfer payments Sectoral budget holders New York City United Community
make service revenue or Childhood Asthma States education on
capital contributions to Initiative [427]. asthma and case
bodies in other sectors to coordination
support additional services
or interventions in this other
sector.
Road Safety England Inter-sectoral
Partnership Grant projects
[428]. improving road
safety
2324

2325

2326 Adapted from: McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T, Remme M. Financing inter-
2327 sectoral action for health: a systematic review of co-financing models. Globalization and health. 2019
2328 Dec;15(1):1-8. [48]

2329

2330 Table XYZ: Barriers and Enablers to Uptake, Implementation and Continuation of Co-financing Models

Theme Barriers Enablers

Conceptual Buy-In Actor resistance due to perceived risk, Favourable political climate,
ambiguities, and threats client, actor and public
support

Model Design, Planning Unclear terms and unmatched Effective planning

Framing, and Implementation partnership

Context level for

implementation

Organizational Resources and Inadequate or incongruent resources Matched Partnership with

Capacity respect to resources,
capacity, decision-making
and implementation

Differences in human resources and Adequate Expertise and

ways of working Capacity

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 lack of leadership readiness, or Strong leadership, with
leadership buy in limited turnover, that
prioritises the co-financing

Insufficient time to produce impact Time to foster relationship

and achieve impact

uncertainties over long-term

sustainability beyond pilot or single
term

Relational and Organizational Non-constructive relational and work Established positive

Culture dynamics relational and work dynamics

Evidence, Output Data Insufficient result-focused practices Set targets

Monitoring and Evaluation
Evidence of success

Finance and Accounting Unmatched methods and capacity to Financial control

Practices adapt to needs

2331

2332 Adapted from: McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T, Remme M. Financing inter-
2333 sectoral action for health: a systematic review of co-financing models. Globalization and health. 2019
2334 Dec;15(1):1-8. [48]

2335

2336 5.2.5.2 How to expand resource allocation for adolescent health priorities in
2337 national health plans

2338 Historically, especially in low- and middle-income countries, adolescent health programmes and projects were
2339 largely funded through donor assistance for priority areas such as SRH and HIV that often led programmes to
2340 operate largely autonomously from the rest of the health system in seeking to optimize the achievement of a
2341 specific objective [39]. This dynamic has implications for how priority interventions are delivered and
2342 sustained, sometimes with separate organizational arrangements resulting in inefficient overlaps and
2343 duplications [19, 429]. When the funding source for adolescent programmes is not coordinated/integrated
2344 with the overall health sector budget, it can jeopardize the sustainability of programmatic activities in the case
2345 that funding sources dry up, change or shift, particularly related to donor assistance [19, 429]. Globally, only
2346 a minority of countries’ adolescent health programmes report having regular government budget allocation
2347 [430].

Page 160 of 259

2348 Whilst private financing plays a role in all health systems and in all kind of services, the evidence is clear that,
2349 where its role becomes large, it typically has a harmful impact on progress towards UHC [431]. Out-of-pocket
2350 payments are a particularly regressive way to fund health services and adolescents in particular are at risk of
2351 forgoing needed care if they have to rely on out-of-pocket payments. Private health insurance schemes can
2352 provide certain protections, however adolescents rarely have the necessary resources for private schemes´
2353 premiums.

2354 To make progress towards UHC, countries must move towards a predominant reliance on public funding for
2355 its health system in general [431], and for adolescent health programmes in particular. As contexts change,
2356 the responsibility for funding these programmes should shift more towards domestic resources, and the source
2357 of funding should come from the overall health sector budget [19]. Governments should include a focus on
2358 adolescents in national health strategies and investment plans for UHC [39]. Key actions therefore include
2359 better advocacy for adolescent health priorities within national health plans.

2360 While domestically raised funding should be the main financing source to be leveraged for investing in young
2361 people’s health, external funds can also play an important role in leveraging more resources for adolescent
2362 health in low-income countries. The Global Financing Facility is an important financing platform for the Global
2363 Strategy for Women´s, Children´s and Adolescents´ Health that is intended to support investment plans in
2364 selected countries that aim at smart, scaled and sustainable action for women’s, children’s, and adolescents’
2365 health [2]. The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) encourages countries
2366 to focus on adolescents in their applications [432-434] . See Case study XYZ.

Case Study 17
Global Fund invests in Adolescent Health Programmes

The Global Fund is a key funding partner investing in health and wellbeing initiatives specific to
adolescents and young people. Globally, they have funded several initiatives on important public health
issues affecting young people including HIV and Aids. One such initiative is the Linkages of Quality Care
for key young populations (LOLIPOP). LOLIPOP has been implemented in Indonesia since 2015 with the
goal of increasing HIV related services such as testing, treatment and adherence to Antiretrovirals
among vulnerable youth groups including men who have sex with men, transgender, sex workers, those
living with HIV, and those who inject drugs. The LOLIPOP programme supports strategic interventions
focused on creating an enabling legal and policy environment, increasing access and quality of HIV
services (supplies, health staff and commodities), encouraging young populations to use services, and
generation of strategic information to guide programmes.

The project is implemented in partnership with both national and local level partners. At the national
level, stakeholders involved in implementation are the Ministry of Health, UNICEF, National AIDS
Commission, and local organizations such as Spiritia Foundation and Inti Muda. At the local level,

Page 161 of 259

 stakeholders include community-based organizations, Department of Health, sub recipients of grants
from the Spriritia Foundation and District AIDS commissions. National level partners provide training
and coordination needed for the implementation of the project, while local partners implement projects
at the local level in coordination with the National level partners.

Pprogrammatic data from the first two semesters after implementation showed positive results for both
outreach and testing services in the three intervention regions, i.e., Denpasar, Surabaya and West
Jakarta. Improvements were observed in the number of people reached though outreach from 685
young people (15-24) in semester one to 1759 in semester two. Also, there was an over 50% increase
in the number of youths that were targeted for voluntary counselling and testing.

Source: https://www.aidsdatahub.org/sites/default/files/resource/youth-lead-assessment-gf-
investment-adolescent-and-ykp-2019.pdf
2367

2368 Implementation areas and strategies [19, 429, 435-438];

2369

2370 1. Prepare an investment case for a defined and costed national package of adolescent health
2371 interventions and use it as an instrument to guide purchasing decisions and benefit packages, giving
2372 particular attention to preventive services and adolescents’ rights to confidentiality. Estimate resource
2373 needs for the implementation of the priority package of interventions and associated programme
2374 costs, using tools such as the One Health Tool (ADD ref here).
2375 2. Ensure that adolescents and their advocates are represented in the process of developing national
2376 health financing strategies and defining the essential benefit package, and that their needs are well
2377 articulated and advocated for. Involve civil society and patient representatives in the benefit package
2378 selection process and strategic purchasing decisions so that adolescents’ representatives are
2379 consulted about the final decisions on ‘what’s in and what’s out’ through a formal hearing process, by
2380 access to an process for appeals or another structured participatory process.
2381 3. Participate and advocate for adolescents in the budgeting process at national and sub-national level,
2382 from the planning stage and throughout the budget preparation, the release of funds and the
2383 monitoring of expenditures [429].
2384 4. Ensure that adolescent needs are well articulated and advocated for in discussions about strategic
2385 purchasing of services in order to achieve the government’s strategic objectives related to adolescent
2386 health:
2387 a. Establish agreements with providers which make the expectations for the range, quantity and
2388 quality of services for adolescents explicit

Page 162 of 259

2389 b. Stimulate provider performance in providing adolescent-responsive care, e.g. by creating
2390 incentives, aligned with system-wide incentives, though performance indicators, provider
2391 payment methods such as fee-for-service of “pay for performance”, and clinical guidelines
2392 c. Improve the efficiency of the process for procurement of essential commodities for adolescent
2393 health services (e.g. menstrual kits)
2394 d. Promote equitable access of adolescents to these services, such as through offering higher
2395 payment rates in areas that are under-served.
2396 5. Build the capacity of adolescent health focal points in the ministry of health to apply the decision-
2397 making criteria used in defining essential health benefit packages to make evidence-based arguments
2398 in favour of adolescents (see Table XYZ).
2399 6. Build the agency and capacity of district and community managers to address adolescent health
2400 priorities when making local adjustments to central budgets.
2401 7. Build the capacity of national and district project managers to leverage external funds for adolescent
2402 health priorities using opportunities provided by the Global Financing Facility [436], and strategic
2403 investments by the Global Fund and GAVI the Vaccine Alliance, among others.

2404

2405 Table XYZ: Adolescent-specific application of criteria for essential health benefit package decision-making

2406

Criteria for decision The application of criteria in the context of adolescent health
making
Burden of disease The morbidity and mortality associated with diseases, injuries and risk factors
affecting adolescents
Balance of benefits The balance of health benefits and harms reflects the health impact of an
and harms intervention on adolescents, the cost of action
Cost-effectiveness of The value-for-money of the intervention (usually expressed as a ratio of the
interventions costs of the intervention to its benefits).
Equity and priority to A qualitative or quantitative measure of the ability of the intervention to address
the worse off existing health system inequities affecting various sub-populations of
adolescents including those with disabilities, the marginalized, displaced,
orphaned, poor and those living in hard-to-reach areas.
Financial risk The extent to which adolescents can afford the cost of the intervention and are
protection protected from catastrophic health expenditure and health-related financial risk
Budget impact and The overall financial implications, especially for additional costs, of
sustainability implementing the adolescent health and well-being interventions for the
available budget

Page 163 of 259

 Feasibility The extent to which adolescent health and well-being interventions can be
delivered through the existing health system taking into account available or a
realistic increase in human resources, infrastructure and other resources, and
whether it is socio-culturally acceptable to the public
Social and economic The societal consequences resulting from adolescent health and well-being
impact interventions, such as the triple dividend of health and well-being benefits,
economic benefits and enhancement of social capital (see section 1.XYZ)
Political acceptability Political dividends associated with supporting investments in adolescent health
(e.g. acceptability of a policy or programme to politically influential
constituencies, such as voters, donors, lobbyists)
2407

2408 Adapted from: WHO, 2021, Principles of health benefit packages [437].

2409

2410 5.2.6 A renewed attention to school health and mental health programmes

2411 Priorities for inter-sectoral programmes will be established during the process of national prioritization, as
2412 described in Section 4. They can be focused on a single issue or area of concern, such as adolescent pregnancy
2413 (Case study XYZ) or be broad-based (case study XYZ). It is beyond the scope of this document to attempt
2414 an exhaustive list of inter-sectoral programmes for adolescent health since the need for them is context
2415 specific. There is however one notable exception, and that is school health, which is a cost-effective
2416 investment and feasible in all contexts and settings. Health promotion in schools is one of the three most
2417 common policy areas when multi-sectoral and inter-sectoral action is undertaken [41]. Importantly, when
2418 designed well, school health programmes act at the interconnectedness of protective and risk factors across
2419 multiple domains of well-being (Figure XYZ. well-being) [9]. This is perhaps why globally, 90% of countries
2420 have some form of SHN programme. SHN is one of the most widely implemented approaches to delivering
2421 health and social protection.

2422 In the past five years, including due to the lessons learned from the COVID-19 pandemic when school closures
2423 prompted massive disruptions of critical services to school-age children [439], there has been a renewed
2424 attention to school health [6, 41, 43-45, 440]. The rationale is clear. Globally, over 90% of children of primary
2425 school age, and over 80% of children of lower secondary school age are enrolled in school [441]. On average,
2426 children and adolescents spend ‘7,590 hours in the classroom over 8–10 years during primary and lower
2427 secondary school [441].

2428 This makes schools a unique setting for preventive interventions, and school years an important period to
2429 establish healthy behaviours that will contribute to a lifetime of health promotion [439]. Looking after the
2430 health and well-being of learners is one of the most transformative and cost-effective ways to improve
2431 education outcomes and make education systems more inclusive and equitable. Investing in school health
Page 164 of 259
2432 systems is a smart way for countries to improve the health and education prospects of today’s learners and
2433 tomorrow’s leaders. Concurrently, there have to be strategies put in place to reach the “out-of-school
2434 adolescents” who are also more likely to face the added health risks. For instance, adolescents with disabilities
2435 are 49% more likely to have never attended school and may be missed if the focus is only on school-based
2436 health programmes (see Box).

2437 Box XYZ: School health and nutrition programmes are a cost-effective investment, feasible in all
2438 settings, and deliver significant development gains

School health and nutrition programmes are a cost-effective investment, feasible in all
settings, and deliver significant development gains

• Schools reach millions of children and adolescents and SHN programmes are a cost-effective
way to improve both health and education outcomes. For example, school feeding programmes
deliver US$9 in returns for every US$1 invested. School programmes that address mental health
can potentially provide a return on investment of US$21.5 for every US$1 invested over 80
years.
• Whole-school approaches have large effects on school climate, depressive symptoms, bullying,
violence perpetration and victimization, attitudes towards gender, and knowledge of
reproductive and sexual health [442].
• Investing in SHN benefits multiple sectors in addition to education, including health, social
protection and local farmers where school meals are linked to local procurement. It delivers
immediate, lifelong and inter-generational benefits for individuals and contributes to the
creation of human capital and the sustainable growth of nations.
• Despite this, only US$2 billion is invested each year in addressing the health needs of school-
age children and adolescents, whereas some US$210 billion is spent on educating this age group
in low- and lower middle-income countries. As well as education expenditure, resources for
school-age children and adolescents’ health and well-being must increase substantially to
maximize investments [41].
2439 Despite the fact that clearly governments in many countries are already investing in the health and well-being
2440 of school-age children and adolescents through school health programmes, more needs to be done to ensure
2441 that these programmes are comprehensive and embedded into education systems to make them sustainable
2442 and serve every learner in every school [9]. Global data suggest that SHN programmes are not always
2443 comprehensive in scope, that coverage of essential components of SHN remains low, particularly in low-
2444 income countries, and that interventions are not consistently implemented at both primary and secondary
2445 school level [41].

2446 The UNESCO and World Health Organization (WHO) Global Standards for Health Promoting Schools is one
2447 important vehicle through which countries are being supported to build health promoting education systems

Page 165 of 259

2448 (Figure XYZ) in order to adopt a more holistic and sustained approach to school health, and Make Every School
2449 a Health Promoting School.

2450 What is a health-promoting education system?

2451 A health promoting education system is one that constantly strengthens its capacity as a healthy setting for
2452 living, learning and working, achieved through active engagement between health and education officials,
2453 teachers, teachers' unions, students, parents, health providers and community leaders [443]. In line with the
2454 WHO's Global School Health Initiative, health promoting education systems aim to improve the health and
2455 well-being of students, school personnel, families and other members of the community through schools.
2456 Guidance on Health promoting schools was developed jointly by UNICEF and UNESCO [41] along with eight
2457 global standards and indicators [6]. The eight standards for a health-promoting education system and their
2458 relationship, are as shown in Figure XYZ.

2459

2460

2461 Figure XYZ Global standards for health-promoting schools and their relationship. Adapted from [6]:

2462

2463 Implementation areas and strategies to improve school health are described in section XYZ

2464

Case Study 14
Building Teacher Capacity supports student inclusion in Scotland

In 2021, Scotland embarked on work to increase teacher capacity so that schools across the country
can be more inclusive of Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) students. The LGBTI

Page 166 of 259

 inclusive education policy is complementary to other policies in the country such as the national anti-
bullying initiative, Gender expression and Respect for all. The focus of the LGBTI inclusion education
policy was in line with a national policy that aims to provide both students and teachers with the requisite
skills and training so that they are adequately informed on LGBTI issues at both Primary and Secondary
school levels. Teachers and staff in primary and secondary schools across Scotland were provided with
toolkits and resources that geared towards increasing their competencies on LGBTI issues. The toolkits
and resources also provided them with information and tools on how to implement a curriculum that
includes considerations specific to the LGBTI community. In addition to the resources, teachers and
staff were offered in-person and virtual training sessions and a certificate of completion. According to
preliminary data from the Time for Inclusive Education in Scotland, almost all teachers who participated
in the trainings reported increased knowledge on the implementation of the strategy of inclusive LGBTI
in primary and secondary schools. In addition, some teachers are also reporting increased confidence
in their ability to manage LGBTI issues.

Source: 91775206-en.pdf (oecd-ilibrary.org)

2465

2466 Mental health is another area for inter-sectoral action that came into spotlight during the COVID-19 pandemic
2467 (Box XYZ) [444], and practical guidance for programming became available since the first edition of the AA-
2468 HA! [11, 445].

2469 BOX XYZ: Child marriage and intersectoral action

2470 BOX XYZ: COVID-19 and adolescent mental health and well-being

COVID-19 and adolescent mental health and well-being

• The social and economic effects of COVID-19 including nationwide school closures posed many
mental health challenges for adolescents [445].
• Unmet mental health need soared during the pandemic with adolescents reporting difficulties
accessing services, and providers reporting some of their lowest attendances [88, 446].
• Prior to COVID-19, mental health disorders accounted for 13% of global burden of disease
among adolescents, with self-harm, depressive disorders and anxiety disorders among the top
6 contributors of disability adjusted life years [447].
• During the pandemic, more adolescents reported depression, anxiety and behavioural disorders
compared to prior years [88, 444].
• Some studies reported that rates of suicide among youth increased during the pandemic
compared to pre-pandemic status [444].
• During the pandemic, mental health and well-being difficulties were more likely to be reported
by adolescents with the following characteristics [214].

Page 167 of 259

 o female
o older (≥16 years)
o disadvantaged
o with special educational needs and disability

2471 For a more integrated approach, a focus on mental health in school health programs is recommended.
2472 However the Helping Adolescent Thrive toolkit describes core principles that should guide programming efforts
2473 for adolescent mental health, as well as key implementation strategies and approaches that can be
2474 implemented in any programming context. (BOX XYZ)

Page 168 of 259

2475
BOX XYZ
Helping Adolescents Thrive Toolkit: evidence-based strategies to promote and protect
adolescent mental health and reduce self-harm and other risk behaviours

The Helping Adolescents Thrive (HAT) toolkit, has been developed to improve programming for
adolescent mental health promotion and prevention and to support the implementation of the WHO HAT
guidelines on mental health promotive and preventive interventions for adolescents. The toolkit describes
evidence-informed approaches for promoting positive mental health, preventing mental health
conditions, and reducing engagement in self-harm and risk behaviours.

2476 5.2.7 Addressing adolescent well-being in humanitarian and fragile settings

2477 Addressing adolescent well-being in humanitarian and fragile settings is another example of multi-sectoral
2478 and inter-sectoral action for adolescent well-being. While child protection actors play a central role, all sectors
2479 need to be involved in preventing and responding holistically to the risks and vulnerabilities that affect girls
2480 and boys in crises [448].

Page 169 of 259

2481 A recovery programme in a humanitarian and fragile setting should be guided by development principles that
2482 seek to generate self-sustaining, nationally owned, resilient processes for early post-crisis recovery [449-451].
2483 Therefore, the core implementation strategies as outlined in the logical framework (Figure XYZ) will be the
2484 same in humanitarian and fragile settings. They will encompass addressing laws and policies, human resource
2485 capacity, adolescent-responsive service delivery and financial risk protection, and promote adolescent
2486 participation in leadership and governance arrangements for accountability.

2487

2488 The key principles and standards for accountable and high-quality humanitarian action are described in The
2489 Core Humanitarian Standard on Quality and Accountability (CHS) that sets out Nine Commitments that
2490 organizations and individuals involved in humanitarian response can use to improve the quality and
2491 effectiveness of the assistance they provide [452]. In this section we only describe the adolescent-specific
2492 aspects of planning and delivering the humanitarian response, aligned with evidence-based interventions
2493 described in section 3.

2494

2495 All actions described below should be implemented by upholding the principles of child participation, non-
2496 discrimination, best interest of the child, the right to survival and physical, psychological, emotional, social
2497 and spiritual development; safety, dignity and rights to information, confidentially and privacy [448, 452, 453].

2498

2499 Implementation areas and strategies [448, 453, 454].

2500 1. Coordinate:
2501 a Establish a child and adolescent health working group to integrate CAH priorities into the
2502 humanitarian response plan and actively engage partners from key sectors to ensure an
2503 integrated multi-sectoral response
2504 b Advocate for child and adolescent health to health and humanitarian authorities
2505 c Participate in humanitarian structures to effectively integrate child and adolescent health into
2506 humanitarian action
2507 d Identify key humanitarian actors and reach out to partners and work to establish common systems
2508 and avoid duplication

2509 2. Engage:
2510 a Establish systems for adolescent participation in decision-making (especially for girls and those
2511 with disabilities and other vulnerabilities), in developing and implementing responses at
2512 community, provincial and national levels [455].

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2513 b Ensure that mechanisms for adolescent participation encompass engagement across the
2514 humanitarian programme cycle, including needs assessment and analysis, strategic planning,
2515 resource mobilization, implementation and monitoring, and peer review and evaluation [453].

2516 3. Communicate:
2517 a Develop a communication strategy for child and adolescent well-being, communicate without
2518 delay urgent messages to the affected population
2519 b Implement, update and coordinate internal, multi-sectoral and multiagency communications and
2520 advocacy policies and processes to ensure all messages support children’s and adolescents’ needs
2521 for protection and well-being. Avoid messages that re-traumatize children and adolescents or
2522 create fear, division or violence

2523 4. Assess and prioritize:

2524 a Ensure a systematic, objective and ongoing assessment of the context and its impact on child and
2525 adolescent health, nutrition and well-being and assessing the safety and security of affected,
2526 displaced and host populations of children and young people to identify threats of violence and
2527 any forms of coercion, denial of subsistence or denial of basic human rights
2528 b Assess existing resources and capacity and their adequacy to ensure access of children and young
2529 people to critical interventions and services
2530 c Prioritize child and adolescent health interventions confronting the biggest causes of death and
2531 morbidity with the most cost-effective tools and providing extra attention to populations at high
2532 risk

2533 5. Train staff

2534 a Train staff, including clinical staff (community health workers, nurses, midwives, doctors,
2535 paramedics, national and international volunteers) in providing care with respect to adolescents’
2536 right to information, dignity, best interests, safety, autonomy and self- determination, and
2537 participation
2538 b Develop the capacity of child protection workers and all health and humanitarian workers to
2539 prevent, detect and respond appropriately to child protection issues.

2540 6. Provide services:

2541 Health services
2542 a Adapt, improve or establish adolescent-responsive service delivery structures such as flexible and
2543 integrated adolescent-friendly health services, temporary clinics that are community-based and
2544 mobile, provision of comprehensive sexual and reproductive health services for adolescents at a
2545 single site, home-based care, education and outreach through non-health facilities and safe
2546 spaces.
2547 b Use innovation to enhance the capabilities of existing service delivery platforms:
2548 o Use of social media to promote access to quality health information and information sharing

Page 171 of 259

2549 o Flexible outreach strategies, including transportation budgets that consider the difficulty of
2550 reaching adolescents in insecure environments and otherwise hard-to-reach areas
2551 c. Provide services to tackle key health concerns in adolescents:
2552 i. Preventive care: contraception, condoms, emergency contraception, prevention of sexual and
2553 gender-based violence, mental health, sexuality education, life skills, maternal health care
2554 including family planning counselling, voluntary counselling and testing for HIV, iron and folic
2555 acid supplements
2556 ii. Treatment: treatment of traumas and orthopedic surgery, emergency obstetric and neonatal
2557 care services, contraception, nutrition, comprehensive abortion care, clinical care for survivors
2558 of sexual violence, treatment of sexually transmitted infections, emergency skilled birth
2559 attendance, postnatal care including for postpartum depression, antiretroviral treatment
2560 iii. Supplies: Ensure the availability and provision of menstrual hygiene kits (dignity kits), post-
2561 rape kits, sexually transmitted infection kits, contraception kits

2562 Education and recreation

2563 a Ensure safe spaces for education that are disaster resilient, safe, dignified and accessible to all
2564 children and adolescents
2565 b Address barriers to enrolment and issues related to school retention for specific groups, such as
2566 girls and child mothers and children and adolescents with disabilities.
2567 c Provide targeted support for schooling options (safe passage, financial support to families e.g.
2568 cash and voucher assistance) and vocational training, and access to life skills and comprehensive
2569 sexuality education in and out of schools
2570 d Ensure safe spaces, especially for girls, for recreation and play and barriers that might prevent
2571 inclusion of adolescents with disabilities.
2572 e Ensure safe access to and use and maintenance of toilets; and materials and facilities for
2573 menstrual hygiene management.

2574 Nutrition
2575 a Ensure safe, adequate and appropriate nutrition services, especially for pregnant and lactating
2576 women and girls
2577 b Implement integrated response interventions for households at risk of malnutrition
2578 c Develop and implement child- and adolescent-friendly, multi-sectoral referral mechanisms and
2579 standard operating procedures for malnutrition cases.

2580 7. Protect:
2581 a Map existing protection services, identify and address gaps.
2582 b Support the most at-risk children and adolescents.
2583 o Sexual violence. Recognize that sexual violence is common. Seek to understand local
2584 perceptions and reactions. Disseminate sexual violence prevention messages. Educate health

Page 172 of 259

2585 and allied staff to look, recognize, and respond to sexual violence sensitively. Report
2586 information in line with national laws and international norms.
2587 o Armed forces. Assess involvement of children and adolescents in armed forces, community
2588 perceptions, and demobilization and reintegration activities. Support schools and other
2589 institutions protecting children. Share prevention, reporting and survivor care information.
2590 o Survivors. Develop age-appropriate survivor assistance that includes medical care, physical
2591 rehabilitation, psychosocial support, legal support, economic inclusion, and educational and
2592 social inclusion. Include non-stigmatizing support for those who need additional attention
2593 (e.g. those involved in armed forces, pregnant girls, sexually exploited children and
2594 adolescents, girls who are pregnant as a result of rape).
2595 o Child labour. Prioritize action on the worst forms of child labour, including forced/bonded
2596 labour, armed conflict, trafficking, sexual exploitation, illicit work, unsafe work. Involve
2597 affected families and other local stakeholders in responses.
2598 o Unaccompanied and separated children. Assume all children have a caring adult with whom
2599 they can be reunited, until tracing proves otherwise. Review existing legal systems and
2600 procedures for family tracing and reunification. Assess the scope, causes and risks of family
2601 separation. Take practical steps to prevent separation (e.g. reception registers, ID cards). Re-
2602 establish community support networks and structures for orphans and vulnerable children,
2603 and ensure that adolescents who have lost their parents or carers have consistent, supportive
2604 care-giving. Avoid unintentionally encouraging abandonment (e.g. advertising special
2605 assistance to unaccompanied and separated children).
2606 o Justice system. Strengthen child-friendly spaces in courts and police stations. Identify children
2607 in detention (especially arbitrary detention), and patterns of violations. Promote diversion
2608 activities to resolve issues without the trauma of the justice system.
2609 c. Establish procedures for informed consent/assent
2610 i. supports participants’ ownership over their personal information and its use
2611 ii. prevents possible conflicts of interest between data collectors and respondents

2612 8. Monitor and evaluate

2613 a Monitor programme quality, outputs, outcomes and, where possible, impact. Monitor changes in the
2614 adolescent well-being situation and adjust programme implementation accordingly.
2615 b Collaborate with children and adolescents and other stakeholders to design, implement and monitor
2616 adolescent-friendly confidential and gender-, age-, disability- and culturally sensitive mechanisms to
2617 gather and process feedback and reports from children, families and communities that:
2618 i. Allow flexibility in the programme design to incorporate feedback in a timely manner
2619 ii. Immediately address any safeguarding issues

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2620 c. Share findings and learning from assessments, monitoring, feedback and accountability
2621 mechanisms with all stakeholders, including Children and families. Ensure they understand how
2622 their efforts have contributed to programmes.
2623

2624 5.2.8 Gender transformative approaches in programming

2625 Gender is a powerful determinant of adolescent well-being as sex and gender intersects with other drivers of
2626 inequalities such as income, age, gender-based violence, stigma, discrimination and child marriage to
2627 exacerbate the vulnerability and susceptibility of adolescent girls and boys to health and social risks [22, 60].
2628 Sex and society, nature and nurture, genetics and environment interact in complex ways to determine
2629 adolescent well-being outcomes. Gender inequality is explicitly recognized as an important determinant of
2630 health outcomes, with women and girls often at a societal disadvantage. Adolescents and young adults facing
2631 discrimination based on their sex, gender identity, gender expression or sexual orientation have unequal
2632 access to, and uptake of, health services and resources. Gender inequalities exacerbate the problem for
2633 adolescent girls, who in some settings bear the consequences of low value that families place on their
2634 education, expectations about domestic chores, unequal food allocation within households, increasing the risk
2635 of malnutrition for them and any future children, especially in countries with high rates of early adolescent
2636 pregnancy [16, 441]. To achieve the goal of gender equality, programmes need to apply the process and
2637 strategy of gender mainstreaming (Box).

2638 Box XYZ: Gender mainstreaming and why it matters

What is gender mainstreaming and why does it matter in adolescent health programming?

Gender mainstreaming is a process of assessing the implications for adolescent boys and girls of any planned
action, including legislation, policies and programmes, in all areas and at all levels. The starting point for gender
mainstreaming is gender analysis described in section 4. As a strategy it involves integrating the concerns and
experiences of girls and young women, as well as boys and young men into the design, implementation,
monitoring and evaluation of adolescent well-being policies, budgets and programmes. It matters not only
because diverse adolescent boys and girls have different needs, but also because the different roles and
expectations within a society for boys and girls dictate what it means to be male and female and consequently,
shapes context and the situation in which programming is conducted. By applying gender mainstreaming
programmes are more effective in promoting equality and not perpetuating inequality.

Adapted from: World Health Organization. Why gender matters: immunization agenda 2030 [60].
2639

2640 Without gender mainstreaming programmes risk to be gender unequal or gender-blind. Adolescent health
2641 programmes and interventions should, at a minimum, be gender-specific, and ideally and when possible,
Page 174 of 259
2642 gender-transformative. Fig. XYZ provides an overview of each level, with illustrative examples related to
2643 adolescent health programming.

GENDER-RESPONSIVE
Gender- Gender-blind Gender-sensitive Gender-specific Gender-transformative
unequal
Perpetuates Ignores gender Shows an awareness Intentionally Addresses the causes
gender roles, norms and of gender roles, norms targets a of gender inequality;
inequalities, relations, and the and relations while not specific group transforms harmful
reinforces differences in necessarily addressing of girls or boys gender roles, norms
stereotypes, opportunities and inequality generated for a specific and relations;
and privileges resource by them; no remedial purpose; promotes gender
boys over girls allocation. action developed. doesn’t equality.
(or vice versa). challenge
gender roles
and norms.
Examples: Examples: Examples: Director of Examples: Examples: Community
Intentionally Informing the a national adolescent Organizing an programme
only youth in the health programme information supporting families to
disseminating community about acknowledges gender campaign to value girls’ education;
vaccination the HIV issues; programme prevent injuries cash-plus transfer
leaflets to men; prevention only assessment includes from burns programmes that
promoting through youth gender analysis which targeting girls directly address social
harmful, clubs when 80% is not followed up in in households norms--including in
traditional of visitors there implementation. with traditional relation to domestic
stereotypes are boys; setting stoves, and and care work within
about boys’ and up an HPV boys in sport the household, access
girls’ roles in vaccination point clubs, with to income and asset-
information, only at a messages generation
education and marketplace adjusted for opportunities;
communication where girls are different encouraging boys to
materials. not allowed to causes of burns question established
visit. in boys and stereotypes on
girls. masculinity (see Box
XYZ); establish
mechanisms for
adolescent girls and
boys equally

Page 175 of 259

 participate in
programme design
and implementation at
different levels.
Source: Adapted from WHO’s Gender Responsive Assessment Scale [456]
2644

2645

Box XYZ: Progressive masculinities

Programmes aimed at encouraging kinder, gentler forms of masculinity are increasingly common in
LICs and MICs and a small number have been linked to cash transfers in Latin America and sub-Saharan
Africa. The Bolsa Familia Companion Programme, run by the NGO Promundo, which was among the
first to directly tackle masculinities, has been found to make men’s beliefs about their responsibilities
for childcare, cooking, and domestic chores more equitable. In Ethiopia, the BMGF-funded Act with Her
programme is following a multi-faceted design and in partnership with the DFID-funded GAGE
longitudinal research programme will be able to tease out the effects of cash in combination with classes
on progressive masculinities for boys and life skills for girls in comparison to an intervention without
cash in both the short and longer term.
Source: [457]
2646

2647

2648

2649

Page 176 of 259

 Resource bank for gender mainstreaming into adolescent health programmes

2650

2651 Demands for social and gender transformative approaches are building across areas such as HIV [15, 58],
2652 mental health [59], and SRMNCAH [22]. Countries have implemented several comprehensive best practice
2653 programmes focused on increasing the agency, economic empowerment and improving access to HIV and
2654 sexual and reproductive health and reproductive rights (SRH&RR) services for adolescent girls and young
2655 women [58], such as the DREAMS, SASA, HER programme and She Conquers with positive outcomes reported
2656 [15].

2657

Page 177 of 259

2658 5.3 Implementation areas and strategies in key sectors

2659 As stated earlier, accountability for contributing to adolescent well-being lies within various sectors and
2660 branches of the government. Health, education, social protection, labour, criminal justice, telecommunication,
2661 urban planning, energy and environment sectors have an important contribution to make to adolescent well-
2662 being, and to do so effectively, they need to normalize the attention to adolescent specific needs in all aspects
2663 of their work. In this section, implementation areas and strategies are described for the sector specific
2664 contributions to adolescent well-being.

2665

2666 5.3.1 Health

2667 The COVID-19 pandemic has slowed progress on the SDGs for both universal health coverage and health
2668 determinants, for which the rate of progress is one quarter or less of what is needed to achieve 2030 targets
2669 [458]. The pandemic has disrupted adolescents’ access to mental health, SRH, child protection, immunization
2670 and nutrition services, with potentially substantial reversals of preventing child marriage, adolescent
2671 pregnancy and FGM [95]. But even before the pandemic, adolescents access critical services less frequently
2672 than do any other age group, and when available, services are of poor quality [7]. When they do access
2673 services, their experience is often far from optimal, especially for adolescents who are sexually active,
2674 pregnant, unmarried, have a disability, or are from low-income families, and who commonly face disrespect
2675 and mistreatment. Adolescents are less likely to report having a usual source of care than are older individuals
2676 in LMICs. Adolescent girls are less likely to use modern contraceptives than are older women. Compared with
2677 adolescents in HICs, far fewer adolescents in LMICs report being somewhat or very confident in their ability
2678 to receive the care they needed from their health system [7].

2679 One important lesson learned from the COVID-19 pandemic, is that strengthening health systems, with a
2680 focus on primary health care, provides the foundations for both UHC and health security . Therefore not only
2681 investing in adolescent- responsive health systems is a way to achieve UHC for the world 1.2 billion
2682 adolescents, but it is also a measure to ensure that should another public health emergency occur in future,
2683 health systems will be able to continue providing critical services to adolescents. Another lesson was that
2684 many critical services are depending on schools remaining open when the COVID-19 pandemic forced 190
2685 countries to close schools, 1.6 billion learners lost access to critical services such as psychosocial support,
2686 school meals and child protection. It is important therefore to invest more in integrating services across health,
2687 education and other sectors, in ways that are responsive to the needs of communities.

2688 To achieve universal health coverage, health systems need to become adolescent-responsive, meaning that
2689 they need to normalize the attention to adolescent-specific needs in all aspects of their work (Fig. XYZ).

2690 Figure XYZ

2691 What is an adolescent-responsive health system?

Page 178 of 259
2692 An adolescent-responsive health system is the one that includes this group in the overall health systems
2693 strengthening efforts:

2694 • Invests in leadership for health including for adolescent health

2695 • Ensures adequate financing of the priority package of health services and interventions inclusive of
2696 adolescents’ needs, and ensures financial risk protection of adolescents
2697 • Builds an adolescent-competent workforce at all levels of care
2698 • Ensures that the quality of health services responds to adolescents’ specific needs and invests in
2699 service platforms that maximize coverage (e.g. primary care, school-based and school- linked health
2700 services, outreach in communities, and e-health)
2701 • Invest in making adolescents visible in health management and information systems, in analytical
2702 capacity and reporting of age- and sex- disaggregated data

2703 Adolescent-responsive health systems is the strategy to achieve the UHC.

2704

Box XYZ: What does UHC means for the world’s 1.2 billion adolescents?

Universal health coverage means that all adolescents can use the promotive, preventive, curative,
rehabilitative and palliative health services they need – of sufficient quality to be effective – while also
ensuring that the use of these services does not expose them to financial hardship [39]. UHC embodies
three programmatic objectives [437]:
1. Equity in access to health services – every adolescent who needs services should get them, not
only those who can pay for them;
2. The quality of health services should respond to adolescents’ specific needs, to improve the health
of those receiving services;
3. Adolescents should be protected against financial risk, ensuring that the cost of using services does
not prevent them from using services and put them at risk of financial harm.

2705

2706 5.3.1.1 Ensure financial risk protection of adolescents

2707 An important function of high-quality health systems is to reduce financial hardship from care seeking [7, 40].
2708 Financial barriers are among the key barriers for adolescents to access services. According to a recent WHO
2709 policy survey, adolescents in many countries do not have access to services that are free at point of use
2710 (Figure XYZ based on latest data) [39].

Page 179 of 259

2711

2712 There are many reasons why adolescents face specific vulnerabilities in relation to financial access [39, 459]:

2713

2714 • Adolescents and young adults have the poorest insurance rates when compared with children and
2715 adults older than 24 years old, particularly if they are not in school, are older than 18 years, are not
2716 employed or live in low-income households.
2717 • Second, adolescents are disproportionally deterred from seeking care by out-of-pocket payments.
2718 This is because of their limited access to money; either their own or their family’s.
2719 • Third, adolescents have limited capacity to access services independent of their parents, although
2720 they have a greater need for confidentiality than younger children.
2721 • Fourth, not all services needed by adolescents are adequately covered by prepaid pooled funding
2722 arrangements. For instance, contraceptives for adolescents or HPV vaccine might not be covered in
2723 the benefit package.
2724 • Fifth, mechanisms for paying providers are not always aligned with service requirements for
2725 adolescents. In fee-for-service schemes, providers might be discouraged from spending sufficient time
2726 consulting an adolescent client – who may need more time than an average adult or child, especially
2727 in a first consultation. It is therefore important that mechanisms for paying providers are aligned with
2728 the needs of adolescents.

2729

2730 Although insurance can reduce financial hardship, little evidence is available about its effects on adolescents
2731 [7]. Removal or fee exemptions for health system users in Africa resulted in immediate increases in care
2732 use; however, in many cases, informal, drug, and transport payments still caused substantial financial hardship
2733 [7].

2734

Page 180 of 259

2735 Implementation areas and strategies to ensure financial risk protection of
2736 adolescents [7, 40, 64, 435, 437, 460]:

2737 1. Communicate the basic benefit package clearly to beneficiaries for adolescents to understand their
2738 entitlements, and ensure monitoring of the boundary between the benefits package and privately
2739 financed services to prevent providers from diverting adolescents to private services
2740 2. Ensure that adolescents and youth are covered by mandatory, prepaid and pooled funding to access
2741 the services they need.
2742 3. Assess the impact of out-of-pocket payments at the point of use for adolescents accessing key
2743 services. Use data to advocate for reduction or elimination of adolescents’ out-of-pocket payments at
2744 the point of use.
2745 4. Design and implement measures for adolescent financial risk protection (e.g. waivers, vouchers and
2746 exemptions or reduced co-payments) so that health services and commodities, including
2747 contraceptives, are free or more affordable to adolescents at the point of use. See Case study XYZ on
2748 5. Identify subgroups of adolescents that are not covered by mandatory, prepaid and pooled funding
2749 arrangements, and design mechanisms to maximize their coverage. This can take different forms,
2750 e.g. an explicit insurance programmes; access to facilities that are financed by prepaid pooled funds;
2751 or adequate subsidization for vulnerable adolescents and their families. Consider cash transfer
2752 schemes to increase adolescents’ access to critical services and advise welfare and social protection
2753 sectors on this issue. See Case study XYZ on cash transfer schemes as a vehicle to achieve public
2754 health objectives.
2755 6. Monitor facilities to ensure that payment exemption policies are observed.
2756 7. Provide financial, such as pay-for-performance, or non-financial, such as recognition and awards,
2757 incentives that motivate health workers to implement quality interventions that are essential for
2758 adolescent health and development

2759

2760 5.3.1.2 Reinforce adolescent-protective laws and policies

2761 Laws and policies should protect, promote and fulfil adolescents’ right to health. Legal and regulatory
2762 frameworks should be based on internationally recognized and accepted human rights principles and
2763 standards. See the case study XYZ from South Africa on how international and national legal instruments were
2764 used to uphold the fundamental rights of children to health, education and nutrition during the COVID-19
2765 pandemic.

2766

2767 However currently, national legal frameworks are highly heterogeneous, for example for issues related to age
2768 limits for adolescents to provide consent that vary by marital status and by the type of health service. A

Page 181 of 259

2769 greater number of countries have legal age limits for unmarried adolescents as compared to married
2770 adolescents [119]. This makes it more difficult for unmarried adolescents to access services, particularly SRH,
2771 HIV as well as mental health services.Error! Bookmark not defined.

Case Study 18
Balancing the rights to education, health and basic nutrition during COVID-19 in South
Africa

In the midst of the Covid-19 pandemic, schools in South Africa closed, limiting the delivery of the
National School Nutrition Programme (NSNP), which provides a daily meal to all pupils in South Africa
who are eligible based on economic need. The government announced that schools would reopen on 8
June, 2020 and the NSNP would be restored, but when the time came to reopen schools to some pupils,
the NSNP meals were not delivered as promised.
The NSNP was explicitly introduced to address both the right to basic education under section 29(1)(a)
of the Constitution and the right of children to basic nutrition under section 28(1)(c), and consequently
the authorities had a constitutional duty to provide basic nutrition to pupils. Therefore, the suspension
of the NSNP program during the pandemic, and the delay in its restoration, was a failure in upholding
this duty, and has infringed upon the right of pupils for basic nutrition.
The case was brought to Court for a violation of constitutional and statutory duties to achieve full
implementation of the NSNP program. The Court has considered the fundamental rights involved such
as the right to education, right of every child to have basic nutrition, and the legal instruments such as
the right to have access to sufficient food and water, art. 27(1)(b) of the South African Constitution, the
right of every child to have basic nutrition, shelter, health care, and social services, art. 28(1) of the
South African Right to a basic education, art. 29(1)(a) of the South African Constitution.
The Court held that the government has a “negative” obligation not to impair a right protected in the
Constitution and concluded that the suspension of the NSNP had diminished the constitutionally
protected rights by delaying the implementation of the NSNP program. The court argued that all eligible
pupils are entitled to a daily meal from the NSNP, and ordered a restoration of the program and progress
report every 15 days on the implementation of the NSNP.

Source: COVID-19 litigation, Open access case law database.https://www.covid19litigation.org/case-

index/south-africa-high-court-south-africa-gauteng-division-pretoria-225882020-2020-07-17
2772

2773 Implementation areas and strategies [11]:

2774 Adolescents are in need of protective policies, as described in Section 3. Parents or legal guardians, health
2775 and social workers, teachers and other adults have a role to play in ensuring a safety net for them. However,
2776 this should not mean that adolescents are seen as incompetent and incapable of making decisions about their

Page 182 of 259

2777 lives (Figure XYZ. in Annex XYZ). Protection and autonomy may seem to be conflicting principles – because
2778 protective measures tend to restrict adolescents’ autonomy – but in fact they can be balanced and are mutually
2779 reinforcing. Fostering autonomy, for example by empowering adolescents to access health services, is a
2780 protective measure, since timely access to services could protect them from potential harm. Laws and policies
2781 should therefore ensure that all the various rights of every adolescent are afforded equal priority.

2782 In seeking to provide an appropriate balance between respect for the emerging autonomy of adolescents and
2783 sufficient levels of protection in national policies, consideration needs to be given to: the level of risk involved;
2784 the potential for exploitation; an understanding of adolescent development; how competence and
2785 understanding do not develop equally across all fields at the same pace; and individual experience and capacity
2786 (15). The section below presents key areas that need to be considered in designing laws and policies that
2787 treat the rights to health, protection and autonomy as universal, indivisible and interrelated.

Compliance of legal and • Develop laws and policies that promote sexual health and
regulatory frameworks with reproductive rights
internationally recognized and • Develop laws and policies that eliminate harmful practices
accepted human rights inflicted on young people without consent, including female
principles and standards genital mutilation and early and/or forced marriage.
• Develop policies and laws that protect and support vulnerable
adolescents (e.g. adolescents with disabilities, children involved
in armed conflict, refugees and migrants, orphans, adolescents
in detention and/or with incarcerated caregivers).
• Assess and update the legal and regulatory frameworks that
mediate adolescents’ access to services to ensure compliance
with internationally accepted human rights principles and
standards, e.g. by using the WHO toolbox for examining laws,
regulations and policies [461].
Equity • Review and amend laws and policies to ensure access to the
required health and well-being service package by adolescents
regardless of gender, income, rural living, disability, sexual
orientation and other groups known locally to face
discrimination.
o Ensure gender-responsive programming to mitigate specific
barriers faced by adolescent girls and boys in accessing
services.
o Enforce policies to redress inequalities and discriminatory
practices (both real and perceived) in adolescents’ access to
services.

Page 183 of 259

Privacy and confidentiality • Establish procedures to be followed in health facilities to ensure
that:
o information about clients is not disclosed to third
parties;
o personal information, including client records, are held
securely;
o there are clear requirements for the organization of the
physical space of the facility, and actions to ensure
visual and auditory privacy during registration and
consultations with a service provider.
• Specify in health-care guidelines that consultations with
adolescent clients accompanied by parents or guardians should
routinely include time alone with the adolescent.
• Review national laws and policies to indicate situations, clearly
and unambiguously, when confidentiality may be breached,
with whom and for what reasons (e.g. disclosure of sexual
abuse of a minor, significant suicidal thoughts or self-harm or
homicidal intent).
• Establish standard operating procedures for situations in which
confidentiality might be breached due to legal requirements.
Consent and assent to health • Train health care providers to assess and support adolescent
treatment or services capacity for autonomous decision making in line with WHO
protocol [120].
• Determine appropriate age limits for consent or refusal of
health treatment or services without parental or guardian
involvement. The following are common considerations:
o In most settings adolescents aged 15 years and above
are able to give oral or written informed consent, while
for the younger, decisions should be made on a case-
by-case basis in the best interest of the adolescent.
o Age limits informed by developmental stage, evolving
capacity, and careful evaluation of risks, security and
other issues in the local context.
• Adopt flexible policies to allow specific groups of adolescents to
be considered “mature minors”. For example, locally
established procedures should not impede unaccompanied

Page 184 of 259

 adolescents or those who do not have parents or carers from
accessing services.
• Remove the need for parental or guardian consent when an
adolescent is seeking counselling and advice services. The right
to counselling and advice is distinct from the right to give
medical consent and should not be subject to any age limit.
• Remove the need for mandatory third-party (e.g. parental,
guardian or spousal) authorization or notification in the
provision of SRH services, including contraceptive information
and services. Adopt a legal presumption of competence that an
adolescent seeking preventive or time-sensitive SRH goods and
services (e.g. contraception or safe abortion) has the requisite
capacity to access such goods and services.
• Establish standard operating procedures for obtaining informed
consent. Consent forms and other information tools (e.g.
posters) should be developed in line with internationally agreed
guidelines, consultation with trusted community members and
designed specifically for the age groups to be included in the
activity.
• Enforce a policy that in all cases – whether or not the consent
of the parent or carer is required – an adolescent’s voluntary,
adequately informed (using language appropriate for age,
education level and culture), non-forced and non-rushed assent
for services and participation in a data-gathering activity is
obtained.
• Adopt policies to protect the rights of adolescents with
disabilities, including demanding that their views be given due
weight in accordance with their age on an equal basis with
others. Adolescents with disabilities may face particular barriers
and require opportunities for supported decision-making.
• Where legal, modify legislation to include provision for
adolescents easily to access safe abortion care, without
parental or spousal consent requirements.
• Ensure elimination of harmful practices inflicted on young
people without consent, including FGM and early and/or forced
marriage.

Page 185 of 259

 BOX XYZ
How to assess and support adolescents’
capacity for autonomous decision-
making in
health-care settings?

Evaluation of decision-making capacity

is not straightforward for HCPs, many
of whom lack training and tools in
conducting such evaluations.

The new WHO tool and its

accompanying algorithm provides a
step-by-step guidance for assessing
and supporting adolescents’ capacity
for autonomous decision-making.
2788

2789

The tool is based on shared decision-making and thus considers the perspectives of the individual, families
and communities to assess and support adolescents in making decisions about their health. Its aim is to
move from a vertical, paternalistic, unilateral view of assessment to a much more horizontal, integrated
process, with the adolescent as a partner at the centre of the process [119, 120]..
2790

Page 186 of 259

2791 5.3.1.3 Build an adolescent-competent workforce at all levels of care

2792 Adolescents are not simply older children or younger adults. Returning to the ecological model described in
2793 Section 1, individual, interpersonal, community, organizational, environmental and structural factors make
2794 adolescent clients unique in the ways that they understand information, in what information and which
2795 channels of information influence their behaviours, and in how they think about the future and make decisions
2796 in the present [135, 270]. Therefore, achieving the ambition of universal health coverage for the world 1.2
2797 billion adolescents requires a health workforce that is equipped to provide services in a way that is cognizant
2798 of adolescent specific needs and vulnerabilities.

2799 Competency-based education is the most effective approach to ensuring preparedness for practice [462]. The
2800 Global Competency and Outcomes Framework for Universal Health Coverage identifies six domains of health
2801 worker competencies towards the achievement of UHC: people-centeredness, decision-making,
2802 communication, collaboration, evidence-informed practice and personal conduct [462]. Whereas these are
2803 entirely valid for adolescent health care, their contextualization for the specifics of adolescent health care is
2804 described in the WHO Core competencies for adolescent health and development for primary care providers
2805 [463]. All health workers who are in places that adolescents visit (e.g. hospitals, primary care facilities and
2806 pharmacies) should develop these competencies (Fig. 5.3).

2807

2808 Figure XYZ. Domains for core competencies in adolescent health care

2809
Page 187 of 259
2810 Source: [463]

2811 Core competencies can be taught in both pre-service and in-service education [269, 462]. A progression
2812 across this spectrum of education is necessary to ensure lifelong learning [270, 462]. Many countries,
2813 however, do not have sustainable forms of continuous professional education [463]. Therefore, improving the
2814 structure, content and quality of the adolescent health component of pre-service curricula is very important.
2815 Making competency-based education in adolescent health-care mandatory in pre-service curricula and
2816 postgraduate education is one of the key actions towards a workforce that is competent in adolescent health
2817 [39, 269].

2818 To support countries in building an adolescent- competent workforce, WHO developed Core Competencies in
2819 Adolescent Health and Development for Primary Care Providers, which includes a tool to assess the adolescent
2820 health and development component in pre-service education, and develop recommendations [463].

2821 Case study

2822 Implementation areas and strategies to build an adolescent-competent

2823 workforce [135, 269, 462, 463].

2824

2825 1. Create a common understanding about the importance of investing in an adolescent-competent

2826 workforce among key players, such as the ministries of health, education and youth; the national
2827 board of licensing and certification; curriculum development agencies; professional associations; and
2828 other civil society organizations.
2829 2. Define core competencies in adolescent health and development in line with WHO Core Competencies
2830 for Adolescent Health and Development for Primary Care Providers [463]. Where relevant, include
2831 competency in adolescent health in job descriptions and policies related to human-resource capacity.
2832 3. Create and implement competency-based training programmes in pre-service and continuing
2833 professional education. To inform the development of such programmes, assess the structure, content
2834 and quality of the adolescent health component of existing pre-service curricula at key educational
2835 and training institutions. Identify opportunities to strengthen the adolescent health component. The
2836 WHO tool to assess the adolescent health and development component in pre-service education [463]
2837 may inform this process.
2838 4. Support institutions teaching adolescent health to assess the quality of teaching and learning, and to
2839 evaluate the progress of implementation of adolescent health competencies. Apply the quality
2840 assessment conceptual framework [269] to support such assessments.
2841 5. Establish a mechanism to consult health-care providers on their training and education needs in
2842 adolescent health-care, and conduct capacity-building activities at national and district levels that are
2843 aligned with reported needs. Facilitate providers’ access to online free-of-charge courses, and use

Page 188 of 259

2844 other effective pedagogy, such as peer education, simulation, reflection, blended learning etc.
2845 recommended for adolescent health and education [269].
2846 6. Develop and review information and training materials, practice guidelines and other tools to support
2847 decision-making in adolescent health-care.
2848 7. Strengthen the capacity of community health workers in reaching adolescents, especially those out of
2849 school, with health education and services.
2850 8. Set up a system for supportive supervision of adolescent health-care, and provide collaborative
2851 learning opportunities as a key strategy to improve providers’ performance.

2852

2853 5.3.1.4 Improve quality of services and service delivery platforms that maximize
2854 coverage such as digital health and school health services

2855 Global initiatives are urging countries to prioritize quality of care as a way of reinforcing rights-based
2856 approaches to health and achieving universal health coverage [464, 465]. However, evidence from high-,
2857 middle- and low-income countries shows that adolescents experience many barriers to receiving information
2858 and quality health-care, and that services for adolescents are often fragmented, poorly coordinated and
2859 uneven in quality [7, 403, 466-468]. Quality of services for adolescents is substandard across both health and
2860 social systems. Health systems have deficits in care competence (e.g., diagnosis and management), system
2861 competence (e.g., timeliness, continuity, and referral), user experience (e.g., respect and usability), service
2862 provision for common and serious conditions (e.g., cancer, trauma, and mental health), and service offerings
2863 for adolescents [7].

2864 Recognizing the problems, many countries have moved towards a standards-driven approach to improve
2865 quality of care for adolescents (Case study XYZ). However, the success and sustainability of such efforts will
2866 be dependent on the effective alignment and integration with the national direction for quality of health
2867 services informed by facility- and district-level realities, and considerations for a systems approach to enhance
2868 quality of care, and long-term national aspirations [469]. The WHO planning guide for quality health services
2869 describes actions required at the national, district and facility levels to enhance quality of health services,
2870 providing guidance on implementing key activities at each of these three levels [469]. It is important therefore
2871 that adolescent specific aspects of quality of care are well articulated and embedded in these activities.

A critical consideration in national adolescent health programming is integrating services at the delivery
level. For example, integrating treatment of the presenting complaint with a broader assessment using the
HEADSSS check list (home, education, activities/employment, drugs, suicidality, sex) is an opportunity to
provide a context for anticipatory guidance and preventive interventions [135]. For example, to extend the
reach of deworming interventions to all adolescent girls, it is recommended to integrate deworming with
other programmes targeting this age group, such as human papillomavirus vaccination, iron and folic acid

Page 189 of 259

 supplementation, and school health and nutrition programmes. [198, 470]. To combat TB and HIV, it is
required in most settings for TB and HIV to be addressed through maternal, newborn and child health
(MNCAH) programmes Error! Bookmark not defined. [471]. Integration of services is important from t
he point of view of both maximizing efficiency and improving responsiveness to adolescents’ needs.
2872

Case Study 19
Using Web-based Platform to Measure the quality of health-care services for adolescents

The Global standards for quality health-care services for adolescents developed by the WHO and other
stakeholders has been used by countries since 2015 (A guide to implement a standards-driven approach
to improve the quality of health care services for adolescents (who.int)). The aim of the document is to
assist policymakers and health service planners in improving the quality of health-care services so that
adolescents find it easier to obtain the health services that they need to promote, protect and improve
their health and well-being. In collaboration with stakeholders, eight global standards focusing on
adolescent health literacy, community support, appropriate package of services, providers
competencies, facility characteristics, adolescents’ participation, equity and non-discrimination, and data
and quality improvements were proposed. Periodic monitoring of the implementation of standards was
a key component of the document but required time consuming and expensive surveys for data
collection. The World Health Organization has developed a web-based platform to digitally monitor and
evaluate national quality standards. Ghana was among the first early adopter countries to pilot the Web
platform to monitor the Global standards for quality health-care services for adolescents. In 2019, the
platform was introduced by WHO to the Adolescent Health and Development Programme of Ghana
Health Service. A total of six facilities in the Cape Coast Municipal and Abura Asebu Kwanmankese
district in the Central region were selected for the pilot. These were predominantly school clinics
including; Aggrey Memorial Senior High School Clinic, Cape Coast School for the Deaf and Blind School
Clinic, St Augustine’s School Clinic, Wesley Girls High School Clinic, Holy Child School Clinic., and Planned
Parenthood Association of Ghana Clinic (Standalone private health facility).

School Nurses are provided with mobile phone tablets and source of internet to facilitate regular access
to the web application. Using guidance from the Global AA-HA document, the first step in the
implementation of the web-based platform was the adaptation of the Global Standards for quality
healthcare services to the national context followed by orientation of stakeholders on the utility of the
web platform. Staff in participating facilities, districts and national focal points were given access to their
respective dashboards through specific user accounts. Training sessions on adolescent health and
development were held with both trainers and providers. Supervisory visits to facilities were made to
support and motivate staff as well as resolve ongoing issues. Review meetings at district and national
levels provided feedback on project implementation.

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 After three months of project implementation, six facilities had access to the web platform and have
collected information on the quality of care from more than 3000 adolescents and health care staff.
Staff had been extensively trained in adolescent health and development, adapted the user manual for
the web platform to suit local content including translations. Evidence and feedback from Ghana show
that the implementation of the web platform has already had a positive impact on the facility, district
and national management environment, and, importantly, increased awareness of the unique health
needs of adolescents, by both health care personnel and adolescents themselves. Improved
communication, enhanced professional competencies, standardized tools and materials - such as TORs
and guidance - have resulted from the implementation of the project to date. The Country subsequently
adopted the use of the platform with support from UNFPA as part of the Joint UN Programme for
Adolescent Girls. The number of implementing schools were scaled up to 12 in 2020, 28 in 2021 and 33
in 2022 with support from FCDO through WHO. Plans for 2023 include improving data management for
planning, decision-making and advocacy, provision of learning materials to improve school health
teaching and learning, sensitization of staff and students in focal schools, training for service providers
on the use of the platform, etc.

Source: WHO AYH Unit internal report

2873

2874 Implementation areas and strategies to ensure adolescent health services are of
2875 high quality:

2876 1. Develop a shared understanding of adolescent health and the need to improve the quality of health
2877 services for adolescents in the context of national quality improvement efforts [469, 472].
2878 2. Develop and implement national quality standards and monitoring systems in line with the WHO and
2879 UNAIDS Global Standards for Quality Health-Care Services for Adolescents [274]. Position standards-
2880 driven quality improvement within national adolescent health programmes [473], where such exist,
2881 or within overall national platforms for quality improvement. As part of standards’ implementation,
2882 empower adolescents to raise their expectations of health systems [7].
2883 3. Implement e-standards to automate the processes of data collection and analysis, and to improve
2884 adolescent participation in providing feedback to facilities by using IT.
2885 4. Establishing performance-based incentives (financial and non-financial) to stimulate performance
2886 measures related to adolescent health care, as part of a robust quality improvement programme
2887 5. Establish local, sub-national and national learning platforms for quality improvement.

2888 Ever since the Declaration of Alma-Ata of 1978, and later reconfirmed in the Declaration of Astana in 2018,
2889 health promotion and disease prevention was recognized as central to the role of primary health care [474,
2890 475]. However, despite longstanding and widespread agreement on the centrality of prevention to the public
Page 191 of 259
2891 health agenda, the health sector remain challenged to meaningfully include prevention, focusing more on
2892 conspicuous health issues. This has meant preventive interventions were not translated into viable models for
2893 service delivery. ref

2894 This is changing with new attention to well-child and well-adolescent visits, integrated into primary care.
2895 These visits move beyond common screening tests for common conditions towards integrating other well-
2896 being dimensions through broader evaluation of social risks, emotional state, as well as individual and family
2897 resources delivered with context-specific recommendations through key moments during the first two decades
2898 of life (see Box XYZ).ref.

Box XYZ What is a well-adolescent visit and what is its added value?

A well-adolescent visit is a system-supported (e.g. guaranteed in the basic benefit package) or system-
initiated (i.e. scheduled) encounter between the adolescents and health care provider(s) at pre-
established age (e.g. 10 and 15 y.o.). The visits allow the health care provider or the team to examine
the adolescent holistically, assess their physical and emotional needs, support their growth and
development, and intervene quickly if any issues arise.
Whereas such visits are well established during pregnancy and for small children, they are less common
in adolescents. While many countries have routine check-ups, usually as part of their school health
services, only few use these contacts at the critical junctions in adolescent life to move beyond screening
towards a more holistic focus on well-being including psychosocial assessment and anticipatory guidance
[476].
The services provided during the visit include
• Health and development assessments
• Psychosocial assessment of the adolescent, their environment and needs, as well as the
strengths and needs of the family
• Brief interventions and referrals to services that operate within the context in which the
adolescent lives in response to identified problem
• Anticipatory guidance based on the developmental stage

WHO is investing in generating evidence for a model of these visits across the first two decades of life
that encompasses detection of morbidities and risk factors for future disease as well as preventive
interventions. Ref
2899

2900

2901 Implementation areas and strategies to expand service delivery models that
2902 maximize coverage [10, 477-480]

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2903 1. Improve primary- and referral-level care capacity to deliver integrated, adolescent-centered services
2904 (e.g. train providers in conducting a HEADSSS assessment using pre-visit psychosocial assessment
2905 tools [477] to detect any health and development problems that the adolescent has not presented
2906 with (see Box XYZ))
2907 2. Invest in well-child, well-adolescent visits to ensure universal health coverage with health promotive,
2908 preventive and anticipatory guidance and care interventions (see Box XYZ).ref
2909 3. Implement and strengthen comprehensive school health services (school-based and school-linked)
2910 and their linkages with health services to facilitate adolescents’ access to preventive services, and
2911 promptly manage conspicuous health problems [10]. See the menu for school health services
2912 interventions in the WHO guideline [10].
2913 4. Invest in telehealth consultations for adolescents to address problems of distance and access and
2914 exploit other benefits (see Box XYZ), by setting up a teleconsultation service, integrated and aligned
2915 with national vision for telehealth [480].
2916 5. Explore the potential of digital and mass communication platforms, including radio, television, mobile
2917 phones, and the internet to provide information through use of social and digital media, helpline
2918 support, text messaging for health education and appointment reminders, and online prescription.
2919 See for example the WHO VMMC app that provides access to up to date Voluntary Medical Male
2920 Circumcision (VMMC) for HIV prevention guidelines and resources from WHO's Global HIV, Hepatitis
2921 and STIs Programmes. WHO VMMC app makes it quicker and easier to view the guidance on
2922 smartphones and tablets, online or off, everywhere and at any time [481]. Other examples include
2923 the WHO MyopiaED and WHO mSafeListening handbook, which are toolkits to assist policy- and
2924 decisions-makers and implementers to establish national or large-scale myopia and hearing loss
2925 prevention programmes, built on a smartphone technology platform [482, 483]. (ref.)
2926 6. Conduct regular assessments of services delivered through digital technology and mobile phones
2927 before they are expanded, or before current care models are replaced, to identify effects on outcomes,
2928 care processes, cost, and equity, as well as both beneficial and detrimental system-wide effects (e.g.,
2929 reductions in needed in-person care) [7].
2930 7. Invest in “activated adolescent patients” - defined as having “the skills and confidence that equip
2931 patients to become actively engaged in their health care” [7], and build self-care skills for pregnant
2932 adolescents, adolescents with HIV, and other chronic physical or mental health conditions, as part of
2933 school health and other programmes, while paying attention to coordination with existing services, a
2934 supportive local sociopolitical context, and an enabling environment [13].
2935 8. Engage community health workers in reaching adolescents, especially those out of school, with health
2936 education and services.
2937 9. Establish mechanisms for formal engagement of NGOs in service delivery on behalf of the government
2938 to strengthen community-based platforms for service delivery, and to reach underserved populations
2939 of adolescents in coordination with other health providers. See Case study XYZ.

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2940

A focus on School health services [484, 485]

What are School health services?

School health services (SHS) are health and well-being services provided by professionals to healthy
or chronically ill pupils enrolled in education institutions [484]. SHS programs have been operational
in many countries for decades [485].

What are the benefits SHS?

With at least 90 per cent of children attending primary school and over 50% attending secondary
school, schools are the only institution with the most contact with adolescents and children [486].
Schools therefore offer a unique platform for delivery of health and well-being services. The
widespread attendance also makes schools a unique opportunity to reach underserved, low-income
and high-risk populations thereby addressing some of the health and well-being inequalities during
adolescence.

What services do SHS offer?

Many health and well-being programs are being offered in schools. Focusing Resources on Effective
School Health (FRESH), a United Nations framework promoting health-related school policies lists
provision of safe water and sanitation, skills-based health education and school-based health and
nutrition services, as the four pillars of SHS [487]. Other health and well-being issues such as oral
health and malaria, are also included based on local needs.
2941

The promise of pre-visit multi-domain psychosocial assessments [477]

What is a pre-visit psychosocial screening?

Pre-visit psychosocial assessment is a self-assessment using a questionnaire completed by the

adolescent client before the planned contact with a professional (health, education, or social
service). The assessment is done to detect and prioritize potentially problematic issues beyond the
presenting complain, which the adolescent would normally not have otherwise considered to bring
up, making consultations more holistic. Psychosocial assessment increases the possibility of early
detection and timely intervention for health and well-being issues, improving prognosis. This is
especially important because during adolescence there is a high burden of psychosocial issues,
risky behaviours and corresponding disease burden in adult life.

Page 194 of 259

 What are the benefits of conducting multi-domain psychosocial assessments before
the (clinical) consultation?
Psychosocial assessments are recommended as a routine practice during each visit. However often
providers do not have sufficient time, and validated tools to conduct them. Moving the assessment
outside the consultation has several benefits. The self-administration allows for greater disclosure
and timely interventions for sensitive topics which during adolescence include emerging sexual
and reproductive health challenges. It will free provider’s time to focus during the consultation on
detected issues, and provide brief intervention on the spot, or organize a referral, as appropriate.

What tools exist to facilitate pre-visit psychosocial screening?

An overview of pre-visit multi-domain psychosocial screening tools has been published in a recent
systematic review [477]. The most included health and well-being domains across these tools are
denoted using the acronym HEEADSSS, and include: Home environment, Education and
employment, Eating, peer Activities, Drugs, Sexuality and Suicide/depression, Safety and security,
Screens and Strengths. The tools have been shown to be acceptable, and to detect health and
well-being issues similar to when the assessment is done by the practitioner. Their ease of
deployment and utility mean that they can be accessed widely, opening room for interventions to
adolescents in settings with limited provider time. Digital versions of the tools – completed by the
adolescents and results being available immediately to providers – have additional advantages.

2942

2943

The promise of teleconsultations [479, 480]

Teleconsultation is the use of information and communication technologies by a professional, to

provide health and well-being services to a remotely located client. The main benefits of
teleconsultation are summarized in the figure below.

Teleconsultation with adolescents requires that practitioners are aware of and accommodate the
necessary conditions to ensure adolescents’ rights to autonomy, participation, safety, and
developmentally appropriate information, and confidentiality. Practitioners also need to take into
account adolescents’ limited ability to communicate or engage effectively, and biological or illness
related concerns such as potential for rapid deterioration. A detailed WHO guideline has been
developed to support the planning and conduct of teleconsultations with children and adolescents
[480].

Page 195 of 259

2944

2945

2946 5.3.1.5 Make age- and sex-disaggregated data on adolescents visible in health
2947 management information systems

2948 National health management information systems rarely report data specific to adolescents. Even when these
2949 data are captured at the facility level, the reported data are often aggregated with data from other age groups
2950 as they move up from facility to district or national level. Age- and sex-disaggregated data on adolescents are
2951 rare in countries that most need them, i.e. those with large adolescent populations, high adolescent disease
2952 burdens and relatively weak infrastructures. Instead, data are typically compiled in ways that obscure
2953 adolescents’ particular experiences; for example, using 5–14 year, 15-24 year 15–49 year age bands [328].
2954 There are other weaknesses beyond age- and sex-disaggregation. Data on young adolescents (10–14 years)
2955 are mostly available from school-based data collection systems that have limited utility where absenteeism is
2956 high and retention is low. Programmes should review all national systems for health-data collection and find
2957 ways to incorporate a focus on adolescents, including on young adolescents and those out of school. Ideally,
2958 some data need to be disaggregated by sex and five-year age bands for the entire life period.

2959

Page 196 of 259

2960 Implementation areas and strategies for adolescent-responsive health
2961 management and information systems [3]: add newest reference to this topic,
2962 e.g., GAMA papers

2963 1. Identify and respond to specific weaknesses in national data collection systems, including a review of
2964 sources and mechanisms for data collection on impact, outcome, output, process and input indicators
2965 (see Section 6).
2966 2. Improve the capacity of national and subnational statistics agencies to report regularly on the health,
2967 development and well-being of adolescents, disaggregated by age and sex. At a bare minimum, data
2968 should be disaggregated by age and sex, and wherever possible other relevant stratifiers should be
2969 included, e.g. disability, education, rural or urban. Ensure that this information is easily accessible to
2970 constituents.
2971 3. Implement participatory monitoring approaches to engage adolescents themselves in designing
2972 monitoring and evaluation systems, to capture the user perspective (i.e. service quality and policy
2973 implementation), and to ensure that mechanisms are in place to hear the voices of young adolescents
2974 (10–14 years).
2975 4. Ensure that facility data collection and reporting forms allow for an explicit focus on adolescents
2976 (including young adolescents), cause-specific utilization of services, and quality of care (see Box
2977 XYZ.).
2978 5. Ensure that district and national reports address adolescents including cause-specific utilization of
2979 services and quality of care.
2980 6. Develop national capacity to conduct standardized surveys on key adolescent behaviours and social
2981 determinants, and conduct such surveys at regular intervals. Examples include the Global School-
2982 Based Student Health Survey (GSHS), the Global Youth Tobacco Survey (GYTS), and the Health
2983 Behaviour in School-Aged Children (HBSC) survey.
2984 7. Ensure that data-collection systems are available for out-of-school adolescents.
2985 8. Develop national capacity to conduct standardized surveys to monitor inputs, processes and outputs
2986 within national school health programmes, for example School Health Policies and Practices Survey
2987 (G-SHPPS) . Conduct such surveys at regular intervals.
2988 9. Strengthen the availability of disaggregated data and information to expose inequities. Use data to
2989 plan remedial actions to address inequities.
2990 10. Strengthen the capacity to conduct qualitative research to understand the underlying causes of trends
2991 (e.g. in health-related behaviours or use of services).
2992 11. Synthesize and disseminate the evidence base for action.

2993

2994 5.3.2 Education

Page 197 of 259

 Why actions by the education sector for adolescent well-being?
Cross reference with the other Box in section XYZ

2995

2996 Implementation areas and strategies:

2997 1. Reinforce inter-sectoral government and multi-stakeholder coordination.

2998 Establish structures and processes to facilitate and implement communication and coordination within and
2999 between all relevant sectors (education, health, social services, agriculture), and local and national
3000 government departments and development partners. Establish a committee with a clear structure, roles and
3001 responsibilities for Health Promoting Schools (HPS).

3002 2. Develop or update the school health policy

3003 Review and update existing policies, strategies and plans for school health and well-being following a
3004 systematic multi-stakeholder consultative process of identifying, defining, and prioritizing health and education
3005 needs and targets including how HPS can address them.

3006 3. Strengthen school leadership and governance practices.

3007 Define and implement an inclusive model of school leadership for HPS and governance structure with
3008 representatives from students, school management and local community members and subnational and
3009 national government.

3010 4. Allocate resources

3011 Establish mechanisms for predictable and sustainable financing of school health programmes:

3012 • Identify domestic resources dedicated to support long term and predictable financing of school health
3013 programmes
3014 • Maximize investments by using available resources including staff, information and infrastructure, and
3015 by exploiting synergies between programmes and projects
3016 • Embed flexibilities in the use of national funds for health promotion in the form of grants and other
3017 mechanisms that schools can access according to their needs and contexts.
3018
3019 5. Use evidence-informed practices

3020 Generate context-specific evidence to inform the initial design, continuous update, monitoring and evaluation
3021 of HPS activities in all policies and plans. Support evidence generation and sharing culture by routinely
3022 facilitating research and evaluation of HPS activities and establishing communities of practice or information-
3023 sharing networks for school communities and stakeholders.

Page 198 of 259

3024 6. Strengthen school and community partnerships.

3025 Maintain an active partnership between school and community (e.g. community members, local businesses,
3026 health services) with formal, well documented, and regularly reviewed roles, responsibilities, and
3027 accountability for contributions to collaborative activities.

3028 7. Invest in school infrastructure.

3029 Establish a set of national infrastructure requirements for maintenance of school physical and social–emotional
3030 environments in line with international guidelines. Support local government, school leaders, and communities
3031 in maintaining and improving existing infrastructure to align with requirements.

3032 8. Develop the curriculum and associated resources and ensure its implementation.

3033 Develop, review and implement the curriculum (including content and pedagogy) and associated resources
3034 (e.g. assessment tools, sample lesson plans, audio-visuals) to promote health and well-being in all subject
3035 areas (all scholastic and co-scholastic domains)

3036 9. Ensure access to teacher training and professional learning.

3037 Ensure inclusion of students’ health and well-being, and principles of HPS in pre-service teacher education,
3038 professional learning for in-service teachers, and in graduate and in-service teacher standards and
3039 certification.

3040 10. Ensure access to comprehensive school health services

3041 Deliver comprehensive school health services in line with WHO guideline [10], based on a formal agreement
3042 between schools (or local education departments) and health service providers, and ensure competency-
3043 based professional education and development of school health personnel.

3044 11. Involve students.

3045 Include students on school councils and governance boards and on school health/HPS design teams, with
3046 parents, caregivers and local community members, and create equal opportunities for all students to be
3047 ethically and meaningfully involved in the governance, design, implementation and evaluation of school
3048 health/HPS programmes.

3049

3050

3051 12. Involve parents, caregivers and the local community.

3052 Include parents, caregivers and representatives of the local community on the school council or governance
3053 board and on HPS design teams, and create opportunities for parents, caregivers and local community

Page 199 of 259

3054 members to participate meaningfully in the governance, design, implementation and evaluation of school
3055 health/HPS programmes.

3056 13. Monitor and evaluate

3057 Design, develop and share practices and tools for local, subnational and national approaches for collecting,
3058 storing and analysing data, generating reports, disseminating findings, and adapting school health/HPS
3059 programmes accordingly. Invest in capacity development activities on monitoring, evaluation and quality
3060 improvement to all those involved in HPS design, planning, and implementation and monitoring.

3061

3062 Implementation strategies for each of the 13 implementation areas are described in more details in the
3063 implementation guidance for Global Standards for health promoting Schools [6].

3064

3065 5.3.3 Social protection

Why actions by the social protection sector for adolescent well-being?

Government-led social transfers have positive and significant impact on adolescents’ school
attendance and enrolment, food security and nutrition, a protective, negative impact on paid or unpaid
labour activities outside the households, a potential to delaying sexual debut and reducing the
prevalence of multiple sexual partners and depend on context, short-term protective effects against
early marriage with increase in the age of marriage and reducing migrate for marriage purposes, and
depending on context a positive effect on mental health outcomes [16, 21, 29].
3066

3067 Implementation areas and strategies in social protection:

3068

3069 1. Scale up general social protection and anti-poverty coverage so that more adolescents in poor and
3070 vulnerable households are covered.
3071 2. Expand targeting to include adolescents including through expansion of age-related eligibility cutoffs
3072 of child grants, while improving the adolescent-responsiveness of social protection programmes by
3073 exploring how payment schedules and modalities might be adapted to improve adolescent outcomes.
3074 3. Strengthen civil registration programmes to ensure adolescents have legal identity documents to claim
3075 benefits for which they are eligible.
3076 4. Design programme components to respond to adolescent-specific vulnerabilities, including:
3077 a. Increase transfer amounts to households with adolescents to offset opportunity costs of
3078 attending school;
Page 200 of 259
3079 b. Strengthen linkages to health services to address sexual and reproductive health needs and
3080 prevent sexually transmitted infections and adolescent childbearing, including through supply-
3081 side training (to make services more adolescent-friendly), premium fee waivers for enrolment
3082 in health insurance schemes, and improved access to information about available services;
3083 c. Strengthen linkages to social services, including through case management whereby social
3084 workers can identify adolescents’ needs and connect them to available services.
3085 5. Implement conditional and unconditional cash transfer programmes that create incentives to increase
3086 specific health-promoting behaviours (e.g. nutrition, school attendance, medical check-ups and
3087 vaccinations). Make cash transfer payments sustained, large enough, and predictable and on time,
3088 and maintain their real value, so households can invest in the health and education of adolescents
3089 and delay their transitions to adulthood (in terms of sexual debut, pregnancy and marriage).
3090 6. Invest in gender-transformative cash-plus approaches that support programme beneficiaries and their
3091 families with cash while simultaneously linking them to complementary programming, including health
3092 and social information and services.Error! Bookmark not defined. These can include linkages to h
3093 ealth services through supply-side strengthening, community health workers outreach, income
3094 generation and vocational training, or fee waivers for enrolment in health insurance schemes (see
3095 Case study XYZ). Design cash-plus approaches in a way so they focus directly on adolescents’ age-
3096 and gender-related needs – such as safe-space empowerment programming for girls, masculinities
3097 programming for boys, and broader norms interventions aimed at communities and parents.
3098 7. Design demand-side interventions to increase adolescents’ access to health services, which may
3099 include reimbursing user fees and the costs adolescents incur in transportation.
3100 8. Increase the portability of social protection benefits so that health coverage is more responsive to the
3101 needs of increasingly mobile populations of older adolescents and young adults who may also be
3102 subject to more frequent changes of employer.
3103 9. Tailor health and nutrition interventions to the developmental needs of adolescents at various ages,
3104 e.g. ensure that in-kind transfers to improve nutrition take into consideration recommended calorific
3105 intake for adolescent boys and girls.
3106 10. Invest in more research on the following under-researched areas:
3107 • Impact and outcome evaluations, age-disaggregated by subgroups of adolescents, on the
3108 following under researched outcomes: use of health services, sickness, mental health,
3109 psychosocial well-being, transitions from school to the labour market, community/civic
3110 participation, depression, alcohol and drug abuse, unprotected sex, early pregnancy, HIV, early
3111 marriage, violence and transactional sex; and measure pathways of impact (for example, stress,
3112 time spent in unpaid care, social support, etc.).
3113 • Impacts of integrated social protection programming (sometimes referred to as ‘cash plus’),
3114 especially between health and social protection
3115 • Longitudinal studies to understand whether impacts are sustained into early adulthood.

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3116

Case study 20
The Adolescent Girls Initiative-Kenya
The Adolescent Girls Initiative-Kenya (AGI-K) investigated the effect of a multi-sectoral cash plus
interventions targeting the community and household level, combined with interventions in the
education, health, and wealth-creation sectors on fertility, sexual and reproductive health, and
education outcomes. The AGI-K study randomly assigned 2,075 girls aged 11 to 14 years to the
following four intervention packages:
• community dialogues on unequal gender norms and their consequences (violence prevention),
• violence prevention and a cash transfers conditional on children attending school (education)
• violence prevention, education and health and life skills training (health)
• violence prevention, education, health and financial literacy training and savings activities
(wealth)
The interventions were implemented between 2015 and 2017, and participants were followed through
to 2019. The primary outcomes were fertility (ever having sex, pregnancy, or delivery) and herpes
simplex virus-2 infection. Secondary outcomes were violence prevention, education, health
knowledge, and wealth creation.

The study demonstrated that multi-sectoral cash plus interventions targeting the community and
household level, combined with interventions in the education, health, and wealth-creation sectors
that directly target individual girls in early adolescence, generate protective factors against early
pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on
the longer-term health and economic outcomes of girls residing in impoverished settings.

Source: [21]
3117

3118

Resource bank

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3119

3120

3121 5.3.4 Criminal justice system

Why action in criminal justice systems is important for adolescent well-being?

1. More than one million children worldwide are deprived of their liberty by law enforcement
officials. Most have committed petty crimes or minor offences such as truancy, begging
or alcohol use. Often, children who engage in criminal behaviour have been used or
coerced by adults.
2. Even one day in detention and incarceration has devastating impact on a child’s physical,
emotional and mental development
3. Child victims themselves have limited knowledge of their rights. And they are often
dependent on the adults around them to bring violators to justice.
4. Child-friendly justice systems can operate in the best interest of the child and take into
account the child’s age and development stage, by establishing processes and procedures
that are child-friendly and gender-sensitive and ensure cooperation between Justice, child
protection and allied systems to respond to violence, abuse and the exploitation of children
[24, 488].
3122

3123

3124

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3125 Implementation areas and strategies

3126 1. Put in place programmes for prevention of child offending, including early intervention directed at
3127 children below the minimum age of criminal responsibility:
3128 a. Implement intensive family and community-based prevention and early intervention
3129 programmes focused on support for families, in particular those in vulnerable situations or
3130 where violence occurs. Provide support to children at risk, particularly children who stop
3131 attending school, are excluded or otherwise do not complete their education.
3132 b. Provide early intervention for children who are below the minimum age of criminal
3133 responsibility though child-friendly and multidisciplinary responses to the first signs of
3134 behaviour that would, if the child were above the minimum age of criminal responsibility, be
3135 considered an offence.
3136 c. Decriminalize minor offences such as school absence, running away, begging or trespassing,
3137 which often are the result of poverty, homelessness or family violence. Remove status
3138 offences from countries’ statutes.
3139 2. Establish a minimum age of criminal responsibility that recognizes the evolving nature of maturity and
3140 the capacity for abstract reasoning in adolescence. It is recommended to increase the minimum age
3141 of criminal responsibility to at least 14 years of age, and if higher minimum ages are currently
3142 established, for instance 15 or 16 years of age, not to reduce them under any circumstances. Abolish
3143 systems with exceptions to the minimum age, for example, for serious offence, and set one
3144 standardized age below which children cannot be held responsible in criminal law, without exception.
3145 3. If there is no proof of age and it cannot be established that the child is below or above the minimum
3146 age of criminal responsibility, the child is to be given the benefit of the doubt and is not to be held
3147 criminally responsible.
3148 4. Establish comprehensive child justice systems with specialized units within the police, the judiciary,
3149 the court system and the prosecutor’s office, as well as specialized services such as probation,
3150 counselling or supervision and specialized defenders or other representatives who provide legal or
3151 other appropriate assistance to the child.
3152 5. Apply child justice system to all children above the minimum age of criminal responsibility but below
3153 the age of 18 years at the time of the commission of the offence, and extend its protection to
3154 children who were below the age of 18 at the time of the commission of the offence but who turn 18
3155 during the trial or sentencing process.
3156 6. Ensure systematic and continuous multidisciplinary training to all the professionals involved in the
3157 child judiciary system on a variety of fields on, inter alia, the social and other causes of crime, the
3158 physical, psychological, mental and social development of children and adolescents teams, the special
3159 needs of the most marginalized children such as children belonging to minorities or indigenous
3160 peoples, the culture and the trends in the world of young people, the dynamics of group activities
3161 and the available diversion measures and non-custodial sentences, in particular measures that avoid

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3162 resorting to judicial proceedings. Consideration should also be given to the possible use of new
3163 technologies such as video “court appearances”, while noting the risks of others, such as DNA
3164 profiling.
3165 7. Develop competencies of police officers and prison staff to identify mental health problems and
3166 provide timely, culturally-appropriate first-line care to children [489].
3167 8. Avoid resorting to judicial proceedings for children above the minimum age of criminal responsibility
3168 by giving preference to diversion - referral of matters away from the formal criminal justice system,
3169 usually to programmes or activities - in dealing with children (see case study XYZ from Zambia).
3170 Extend the range of offences for which diversion is possible, including serious offences where
3171 appropriate. Make opportunities for diversion available from as early as possible after contact with
3172 the system, and at various stages throughout the process, and implement it according to the principles
3173 outlined by the Committee on the Rights of the Child [490].
3174 9. When judicial proceedings are necessary, apply the principles of a fair and just trial and provide ample
3175 opportunities to apply social and educational measures, and to strictly limit the use of deprivation of
3176 liberty, from the moment of arrest, throughout the proceedings and in sentencing. Put in place a
3177 probation service or similar agency with well-trained staff to ensure the maximum and effective use
3178 of measures such as guidance and supervision orders, probation, community monitoring or day
3179 reporting centres, and the possibility of early release from detention.
3180 10. Put in place safeguards against discrimination from the earliest contact with the criminal justice system
3181 and throughout the trial, and active redress mechanisms if discrimination occurs against any group of
3182 children. In particular, gender-sensitive attention should be paid to girls and to children who are
3183 discriminated against on the basis of sexual orientation or gender identity. Accommodation should be
3184 made for children with disabilities, which may include physical access to court and other buildings,
3185 support for children with psychosocial disabilities, assistance with communication and the reading of
3186 documents, and procedural adjustments for testimony.
3187 11. Enact legislation and ensure practices that safeguard children’s rights from the moment of contact
3188 with the system, including at the stopping, warning or arrest stage, while in custody of police or other
3189 law enforcement agencies, during transfers to and from police stations, places of detention and courts,
3190 and during questioning, searches and the taking of evidentiary samples.
3191 12. Ensure that child’ rights to effective participation in the proceedings are upheld by providing support
3192 by all practitioners to comprehend the charges and possible consequences and options in order to
3193 direct the legal representative, challenge witnesses, provide an account of events and to make
3194 appropriate decisions about evidence, testimony and the measure(s) to be imposed. Proceedings
3195 should be conducted in a language the child fully understands or an interpreter trained to work with
3196 children is to be provided free of charge at all stages of the process. Proceedings should be conducted
3197 in an atmosphere of understanding to allow children to fully participate. Developments in child-friendly
3198 justice provide an impetus towards child-friendly language at all stages, child-friendly layouts of

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3199 interviewing spaces and courts, support by appropriate adults, removal of intimidating legal attire and
3200 adaptation of proceedings, including accommodation for children with disabilities.
3201 13. Ensure child’ access to legal or other appropriate assistance, and support by a parent, legal guardian
3202 or other appropriate adult during questioning. Police officers and other investigating authorities should
3203 be well trained to avoid questioning techniques and practices that result in coerced or unreliable
3204 confessions or testimonies, and audiovisual techniques should be used where possible.
3205 14. Take measures to ensure that deprivation of liberty is used only as a measure of last resort. In the
3206 minority of cases when deprivation of liberty is deemed necessary, it should be conducted in
3207 accordance with the principles and procedural rights as stipulated by the Committee of the Rights of
3208 the Child [490].
3209 15. Children with developmental delays or neurodevelopmental disorders or disabilities (for example,
3210 autism spectrum disorders, fetal alcohol spectrum disorders or acquired brain injuries) should not be
3211 in the child justice system at all, even if they have reached the minimum age of criminal responsibility.
3212 If not automatically excluded, such children should be individually assessed.
3213 16. Systematically collect disaggregated data, and ensure regular evaluations of national child justice
3214 systems, preferably carried out by independent academic institutions, in particular of the effectiveness
3215 of the measures taken, and in relation to matters such as discrimination, reintegration and patterns
3216 of offending. Involve children is this evaluation and research in line with existing international
3217 guidelines.

3218

Case study 21
Zambia’s National Diversion Framework

The National Diversion Framework was developed by the Ministry of Community Development and
Social Services, supported by UNICEF, following an initial assessment of diversion and alternative
sentencing practices in Zambia. The assessment found that diversion was being carried out across
Zambia in an informal, ad hoc manner, typically by police officers mediating with the accused child
and complainant (and their families). It also found that more intensive and rehabilitative ‘diversion’
programmes were being implemented through a number of CSOs and NGOs. However, the vast
majority of referrals into these programmes were coming from the Courts, and were not strictly
diversion, but rather, constituted community-based sentencing alternatives. These measures were
limited to parts of the country in which links had been established to appropriate service providers
(notably, Lusaka and Kitwe).
Stakeholders consulted in the process of developing the Framework identified a need for
standardization of approaches to diversion and consistency in the implementation of diversionary
measures. There was general agreement that a National Framework on Diversion was needed.

Page 206 of 259

 The Framework aims to assist all stakeholders, including the law enforcement agencies, Social Welfare,
Public Prosecutors, Magistrates and NGO service providers to respond to child offending by way of
diversion out of the formal court proceedings, in accordance with the UN Convention on the Rights of
the Child (UNCRC). The Framework sets out the scope, criteria, process and options for the use of
diversion in Zambia, such as warnings, restorative measures (mediation, family group / community
conferencing, restitution), and rehabilitative programmes.

Source: [491]
3219

Resource bank

3220 5.3.5 Labour

3221

Page 207 of 259

 Why actions by the labour sector for adolescent well-being?

3222

3223 Implementation areas and strategies:

3224 1. Sustain youth employment measures put in place during COVID-19 pandemic (e.g. training
3225 bonuses) with broader policy support and recovery strategies including demand-side policies to
3226 increase the number of decent work opportunities that are available to young people, supported
3227 by supply-side interventions to give young adults the competencies needed to take advantage of
3228 new opportunities in the labour market [492].
3229 a. promoting education and reducing the number of school drop-outs;
3230 b. extended access to vocational training, reskilling and up-skilling for youth, and career
3231 guidance and mentoring
3232 c. job search support and youth-adapted job search infrastructure
3233 d. job creation through public employment programmes for youth and the provision of
3234 subsidies for private sector work
3235 e. youth-targeted wage subsidies and other hiring incentives
3236 f. investments in youth entrepreneurship
3237 2. Implement youth employment policies following good practicesError! Bookmark not defined. s
3238 uch as ;
3239 a. Early intervention (addressing the labour market risks faced by young people at the
3240 earliest stage of human capital formation);
3241 b. Support rather than compulsion (supporting the self-employment and youth
3242 entrepreneurship);
3243 c. Individualized, tailored support (shaping the support according to the individual needs of
3244 the young participants)
3245 d. Integrated approach (providing a combination of measures)
3246 e. Human capital development (improve the employability of young people by equipping
3247 them with business- and market-relevant knowledge and skills via career counselling,
3248 vocational guidance and training components)
3249 f. Creation of better opportunities (enhance the existing opportunities e.g. though
3250 employment services provision through financial support to direct job creation)
3251 3. In collaboration with social protection, contribute to the design, implementation and evaluation
3252 of active youth labour policies so that policies provide unemployed youth with opportunities for
3253 re-training and job-seeking support, as well as schemes for income security to protect young
3254 adults from being disproportionally affected by unemployment.

3255

Page 208 of 259

3256 4. Monitor the impact on youth psychosocial and physical health of labour market transformation
3257 underpinned by new technologies and growing prevalence of flexible, temporary and irregular
3258 work among young workers, long working hours and blurred boundaries between home and work;
3259 and mitigate negative health and safety implications of new work practices [493].

3260

3261 5. Engage in public-private partnerships to combat child labour in countries where a large number
3262 of children are involved in labour (e.g. farming), by enhancing coordination with national child-
3263 labour committees and supporting the development and extension of community-based
3264 monitoring systems

3265

Resource bank

3266

3267 5.3.6 Telecommunications

3268 “We grew up with the Internet. I mean, the Internet has always been here with us. The grown-ups are like
3269 ‘Wow the Internet appeared’, while it is perfectly normal for us.” – Boy, 15 years, Serbia [494] .

3270

Why actions by telecommunications for adolescent well-being? [132, 495, 496]

Adolescents today spend an increasing part of their lives online: since 2011, the number of 12- to 15-
year-olds who own smartphones has increased by more than 50%. With 69 per cent of young people
online in 2019, and one in three children with Internet access at home, the Internet has become an
integral part of adolescents’ lives.

Page 209 of 259

 The digital environment offers tremendous benefits to adolescents, opening new channels for education,
creativity and social interaction including for political and civic participation. The digital environment
facilitates daily interactions in a number of contexts, including formal and informal education, formal
and informal health services, recreation, entertainment, maintaining links to culture, socializing,
expressing themselves and their identity through the creation of digital content, engagement with
political issues, and as consumers.

But it also presents serious risks, including cyberbullying, extortion and risks to privacy. These risks
have become particularly acute amid the COVID-19 crisis and the surge in screen time it has
precipitated. Children and adolescent might be more vulnerable than adults to content, contact, and
conduct risk, as well as risks related to them as consumers, product safety, digital security, data
protection and privacy. Those who are more vulnerable offline are also more vulnerable online, and
protective offline factors can also reduce exposure to online risks.

Governments have a key role in mitigating these risks, and in responding to the needs of children in the
digital environment by putting in place policies and regulation to establish a safer digital environment
by design. Since adolescents’ capabilities vary by age, maturity, and circumstances, actions and policies
for adolescents in the digital environment should be age-appropriate, tailored to accommodate
developmental differences, and reflect that adolescents may experience different kinds of access to
digital technologies based on their socio-cultural and socio-economic backgrounds and the level of
parental, guardian, and carer engagement.
3271

3272

3273 Implementation areas and strategies:

3274 1. Develop an inclusive multi-stakeholder national child online protection strategy that aims to ensure a
3275 safe, inclusive, and empowering digital environment. The strategy should be fully integrated with
3276 policy frameworks relevant to children’s rights and complement national child protection policies by
3277 offering a specific framework for all risks and potential harms for children in the digital environment.
3278 2. Address the online risks by implementing the following policy actions:

3279 Child rights

3280 • Standardize the definition of a child as anyone under the age of 18 in all legal documents
3281 • Build on and collaborate with independent human rights institutions for children to ensure children’s
3282 protection online through specialized expertise, investigation and monitoring, promotion, awareness
3283 raising, training and education, and with children’s participation.

Page 210 of 259

3284 • Include direct consultation with children into the development, implementation, and monitoring of
3285 any kind of child online protection framework or action plan.

3286 Legislation

3287 • Review the existing legal framework to determine that all necessary legal powers exist to enable and
3288 assist law enforcement and other relevant actors to protect persons under the age of 18 from all types
3289 of online harms on all online platforms.

3290 Establish that any illegal act against a child in the real world is, mutatis mutandis, illegal online and that the
3291 online data protection and privacy rules for children are adequate.

3292 • Align legal frameworks with existing international standards, laws, and conventions related to
3293 children’s rights and cybersecurity, facilitating international cooperation through the harmonization of
3294 laws.
3295 • Encourage the use of appropriate terminology in the development of legislation and policies
3296 addressing the prevention and protection of sexual exploitation and sexual abuse of children

3297 Law enforcement

3298 • Ensure that cases of children who harm others online are dealt with in line with child rights principles,
3299 appropriately inscribed in national legislation, strongly favouring tools other than the criminal law.
3300 • Provide appropriate financial and human resources, as well as training and capacity building to fully
3301 engage and equip the law enforcement community.
3302 • Ensure international cooperation between law enforcement agencies around the world, allowing a
3303 quicker response to online-facilitated crimes.

3304 Regulation

3305 • Consider the development of a regulatory policy (co-regulatory policy development, full regulatory
3306 framework).
3307 • Place an obligation on businesses to undertake child-rights due diligence and to safeguard their users.
3308 • Establish monitoring mechanisms for the investigation and redress of children’s rights violations, with
3309 a view to improving accountability of ICT and other relevant companies.
3310 • Strengthen regulatory agency responsibility for the development of standards relevant to children’s
3311 rights and ICTs.

3312 Monitoring and evaluation

3313 • Establish a multi-stakeholder platform to steer the development, implementation, and monitoring of
3314 the national digital agenda for children.

Page 211 of 259

3315 • Develop time bound goals and a transparent process to evaluate and monitor progress and ensure
3316 that the necessary human, technical, and financial resources are made available for the effective
3317 operation of the national child online protection strategy and related elements.

3318 ICT industry

3319 • Engage industry in the process of elaborating child online protection laws and common metrics to
3320 measure all relevant aspects of child online safety.
3321 • Establish incentives and remove legal barriers to facilitate the development of common standards and
3322 technologies to combat content risks for children.
3323 • Encourage industry to adopt a safety and privacy by design approach to their products, services, and
3324 platforms, recognizing respect for children’s rights as a core objective.
3325 • Ensure that industry uses rigorous mechanisms to detect, block, remove, and proactively report illegal
3326 content and any abuse (classified as criminal activity) against children.
3327 • Ensure that industry provides suitable and child-friendly reporting mechanisms for their users to report
3328 issues and concerns and where users can obtain further support.
3329 • Collaborate with industry stakeholders to promote awareness in order to support industry to identify
3330 hazards in development and correct existing products and services. This includes considering other
3331 stakeholder concerns and the risks and harms to which the end users are being exposed.
3332 • Support industry stakeholders to provide age-appropriate family friendly tools to help their users to
3333 better manage the protection of their families online.

3334 Reporting

3335 • Establish and widely promote mechanisms to easily report illegal content found on the Internet.
3336 • Establish a national child helpline with the necessary capacity on online facilitated risks and harms or
3337 child hotline/child helpline to facilitate reporting of child online safety concerns by victims.
3338 • Establish safe and easily accessible child-sensitive counselling, reporting, and complaint mechanisms.

3339 Social services and victim support

3340 • Ensure that universal and systematic child protection mechanisms are in place that oblige all those
3341 working with children (e.g. social care, healthcare professionals and educators) to identify, respond
3342 to and report any sort of harm to children that occurs online.
3343 • Ensure social services professionals are trained both for preventative action and response to online
3344 harms to children, identifying child abuse and providing adequate specialized and long-term support
3345 and assistance for child victims of abuse. – Develop child abuse prevention strategies and measures
3346 based on scientific evidence.
3347 • Provide appropriate human and financial resources to ensure the full recovery and reintegration of
3348 children and to prevent re-victimization of child victims.

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3349 • Ensure that children have access to adequate health care (including mental health as well as physical
3350 well-being) including in the event of victimization, trauma, or abuse online.

3351 Data collection and research

3352 • Invest in and align the development, monitoring and evaluation of frameworks and activities.
3353 • Undertake research of the spectrum of national actors and stakeholders to determine their opinions,
3354 experiences, concerns and opportunities with regard to child online protection.

3355 Education

3356 • Ensure educators and school administrators/ professionals are trained to identify and adequately
3357 respond in suspected or confirmed cases of child victims of abuse.
3358 • Develop a broad digital literacy programme that is age-appropriate and focused on skills and
3359 competencies to ensure that children can fully benefit from the online environment, are equipped to
3360 identify threats, and can fully understand the implications of their behaviour online. Such a programme
3361 can be built upon existing educational frameworks.
3362 • Develop digital literacy features as part of the national school curriculum that is age-appropriate and
3363 applicable to children from an early age.
3364 • Create educational resources outside the school curriculum that emphasize the positive and
3365 empowering aspects of the Internet for children and promote responsible forms of online behaviour.
3366 • Avoid fear-based messaging.
3367 • Consult children, as well as parents and carers on the development of educational programmes, tools
3368 and resources.

3369 National awareness and capacity

3370 • Develop national public awareness campaigns, covering a wide variety of issues that can be linked to
3371 the digital environment and tailored to all target groups.
3372 • Enlist public institutions and mass media for the promotion of national public awareness campaigns.
3373 • Harness global campaigns, as well as multi-stakeholder frameworks and initiatives to build national
3374 campaigns and strengthen national capacities on child online protection.

Resource bank

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3375

3376 5.3.7 Road and transportation.

Why Action by road and transportation for adolescent well-being? [280]

Over 500 children and adolescents under the age of 18 years are killed on the world’s roads each day
and thousands more are injured. Road traffic injury is a leading killer of adolescents and the vast
majority (95%) of child road traffic fatalities are in low- and middle-income countries. Limited by their
physical, cognitive and social development, younger adolescents are more exposed to risk in road
traffic than adults due to developmental factors such as judgment of proximity, speed and direction
of moving vehicles; older adolescents may be more prone to take risks including as drivers, such as
speeding.

The road and transportation sector has an important role to play since most road traffic injuries are
largely preventable by child- and adolescent specific measures directed at speed management,

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 supervision, infrastructure design and improvement, enforcing vehicle safety standards and traffic
regulation laws, and prompt trauma response measures after crash.

3377

3378

3379 Implementation areas and strategies:

3380 Speed management

3381 • Implement low-speed zones (30 km/h limits) around schools and other locations with high volumes
3382 of child pedestrians by applying road design solutions (road narrowing, traffic calming, speed bumps,
3383 signalized crossings, etc.). Enforce speed limits with measures such as automatic speed cameras in
3384 areas with high volumes of child pedestrians.

3385 Leadership on road safety

3386 • Improve data collection to develop effective policies and target interventions. Disaggregate data by
3387 age and collect data to identify high-risk areas where children are exposed to high traffic speed and
3388 where safe infrastructure is lacking.
3389 • Ensure collaboration and coalition building among institutions and stakeholders, and between diverse
3390 sectors (e.g. education, health, local government, transport and police), to improve protection for
3391 children on the roads.
3392 • Engage schools and students in road safety policy decision-making. Establish supervision schemes,
3393 with the involvement of parents, teachers and caregivers, for protecting children on the roads,
3394 particularly in poorer communities and complex and risky road environments. Establish partnerships
3395 between local communities, schools and the police to manage school crossing patrols and walking-
3396 bus initiatives, particularly when parents are at work and unable to supervise children.

3397 Infrastructure design and improvement

3398 • Prioritize safe infrastructure provision (sidewalks, safe crossings, traffic calming measures, speed
3399 bumps, etc.) for protecting children on the school journey. Design or reconfigure the built environment
3400 in schools and densely populated neighborhoods to prioritize pedestrians and cyclists as part of
3401 policies to promote child health and tackle obesity.

3402 Vehicle safety standards

3403 Improve vehicle safety for child passengers, by applying the UN minimum safety regulations to new vehicles
3404 and including measures such as ISOFIX child restraint anchorage points. Promote consumer awareness and
3405 demand for higher standards of safety for all car occupants including children.

3406 Enforcement of traffic laws

Page 215 of 259
3407 • Strengthen and enforce legislation to protect children on the roads by enacting and enforcing laws
3408 addressing the use of child restraints, helmet legislation focused on child passengers as well as adults;
3409 laws and regulations to ensure seatbelts on school buses and the safety of school vehicles; and
3410 enforcement of speeding and drink–driving legislation.
3411 • Employ communication and social marketing strategies focused on the need to protect children to
3412 promote public support for road safety enforcement.

3413 Survival after a crash

3414 • Improve trauma response to accommodate the needs of children by training teacher and school
3415 transport drivers in safe immediate stabilization of injuries; equipping emergency vehicles with child-
3416 sized medical equipment and supplies; and improving paediatric-specific rehabilitation services for
3417 children [280].

3418

3419

3420

3421

3422

3423

3424

3425

3426

3427

3428

3429

3430

3431

3432

Resource bank

Page 216 of 259

3433

3434 5.3.8 Housing and urban planning.

Why actions by the housing and urban planning sector are important for adolescent well-being?

Young women and men are flocking to cities more than ever before. It is expected that by 2030
more than 50% of urban populations will be under 35. Despite this, young people have little voice
in decision-making and face major obstacles to education, employment and safety.
UN-Habitat https://unhabitat.org/topic/youth

3435 Implementation areas and strategies:

3436 1. Ensure a participatory formulation of a national or city urban youth strategy, which encompasses skills
3437 development, creation of decent jobs and livelihoods for youth, sports, and recreation [497]. Gather
3438 youth perspectives in urban planning to inform such strategies [27].
3439 2. Consider the adolescent-specific and gender-responsive aspects of the four dimensions of planning
3440 for health in urban and territorial planning [498-500], and healthy recovery from COVID-19 [501]:
3441 a. Basic planning and legislative standards to avoid risk to health

3442 Examples

3443 • Design, implement and maintain, public spaces for children are safe from physical hazards (such as pollution,
3444 waste, and traffic) and social risks (such as crime, exclusion, and bullying), and are easily accessible by
3445 children irrespective of age, physical abilities, economic status, gender, or race.

Page 217 of 259

3446 • Develop and implement design guidelines for recreational and sports facilities that optimize location
3447 to ensure equitable, safe and universal access by adolescents of all ages and abilities, and access by
3448 walking and cycling with provision of appropriate end of trip facilities [367].
3449 • Enforce water and sanitation standards in housing, schools, sport clubs and recreational facilities
3450 visited by adolescents
3451 • Ensure adequate storage of chemicals and other hazardous substances
3452 • Legislate equal access to urban resources by both men and women, and by youth
3453 • Secure non-discriminatory and equitable access, use and control of land for all, through the
3454 development and utilization of pro-youth and gender-responsive land tools [499].
3455 • Ensure the long-term affordability of housing for youth through measures such as housing price caps,
3456 rent vouchers and social housing [498]
3457 b. Planning codes to limit environments that detract from healthy lifestyles or exacerbate inequality

3458 Examples

3459 • Restrict “hot food takeaways” near to schools

3460 • Limit car-oriented, isolated developments;
3461 • Prevent urban physical degradation and design for defensible space that enhances openness and
3462 promotes social interaction and community surveillance to prevent youth violence
3463 • Provide good-quality, low-cost homes for vulnerable families in the places with accessible schools and
3464 health care facilities
3465 c. Spatial frameworks to enable healthier lifestyles

3466 Examples

3467 • Encourage city compactness and development near to transport hubs

3468 • Provide citywide access to safer walking to enable “walking school buses”, improve cycling
3469 infrastructure and cycle paths to schools with provision of appropriate end of trip facilities, as well as
3470 reliable and safe - for boys and girls - public transport
3471 • Improve access to safe playgrounds and recreational areas for adolescents, green spaces around
3472 schools to provide shade and improve air quality
3473 • Ensure women and girls’ safe and autonomous access to quality city services, public spaces and all
3474 forms of mobility [499].
3475 d. Urban and territorial processes to capture multiple co-benefits of “building in” health

3476 Examples

3477 • Improve urban governance through accountable, inclusive, democratic, gender-responsive institutions
3478 and systems, including by strengthening local institutions to enable women and girls’ active and
3479 meaningful participation in urban planning, management and governance [499].

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3480 • Track policy decisions using urban health equity indicators that capture the social determinants of
3481 health (e.g. percentage of subsidized enrolment in youth after school programmes housing,
3482 percentage of youth participating in cultural programmes) to inform efforts to promote greater urban
3483 health equity for youth [502].
3484 • Work with multiple partners to strengthen co-benefits through systemic holistic approaches. Examples
3485 include: active travel, slow city, age-friendly or child-friendly initiatives; peri-urban, urban and school
3486 food systems, and regional economic resilience strategies

3487

3488

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3489 Resource bank

3490

3491

3492 5.3.9 Energy

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 Why actions in the energy sector are important for adolescent well-being?

Women and youth face structural disadvantage in the energy sector

Despite the barriers that women and youth face, they continue to provide creative sustainable energy
solutions and strive for a more sustainable future. Young women and men are at the forefront of
creating innovative approaches and demanding tangible actions from policy makers and world leaders.
However, they face structural education barriers related to a mismatch between what the education
system offers and what the market needs. The market also favors experience over creativity and
diversity, which puts youth at a disadvantage. Due to the multiple barriers that young women and
girls can face due to their age and gender, they are often exposed to double discrimination in the
energy sector [503].

Reliance on polluting fuels and technologies is associated with significant chore and time loss for
children – especially girls.
Women and girls are the primary procurers and users of household energy services, and bear the
largest share of the health and other burdens associated with reliance on polluting and inefficient
energy systems. In sub-Saharan Africa, household air pollution exposure is the single greatest health
risk for women and girls. The never-ending job of feeding the stove prevents many girls from
attending school, and robs them of time to spend in rest and socializing [284].

3493

3494

3495 Implementation areas and strategies:

3496 1. Champion Youth Mainstreaming in Energy Compacts to accelerate a just, inclusive and sustainable
3497 energy transition [504]:
3498 a. Assess and strengthen national and regional ecosystems to promote and support youth
3499 empowerment and leadership, including meaningful youth participation in policy- and decision-
3500 making in the energy sector
3501 b. Support youth in developing competencies relevant to clean energy transition and the job markets
3502 of tomorrow, including in the fields of science, technology, engineering and mathematics (STEM)
3503 [4].
3504 c. Ensure girls equal access to relevant technical skills and digital literacy to be able to take
3505 advantage of the essential technology and digital tools for clean energy transition [4].

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3506 d. Provide equitable access to productive resources, such as finance, technical knowledge,
3507 entrepreneurial training, technical skills development and business development services for
3508 youth-led enterprises
3509 e. Elevate youth participation in the sustainable energy workforce through the provision of career
3510 advancement avenues and the increase of entry-level jobs in the energy sector and training—
3511 designed with a youth-centric approach
3512 f. Provide equal access to affordable financial mechanisms as well as tenders and other business
3513 opportunities for women and youth-led enterprises, nonprofit projects, and other initiatives, e .g.
3514 through gender-responsive procurement and budgeting [4].
3515 g. Put women and youth at the center of economic recovery. Integrate incentives into program
3516 funds and green recovery packages to encourage employers to employ, retain and advance more
3517 women and youth in the clean energy sector [4].
3518 h. Generate knowledge, monitor and evaluate implemented measures of youth involvement in the
3519 energy sector and the energy transition
3520 i. Champion diversity, gender equality, women's empowerment and inclusion in decision-making

3521 Ensure access to clean energy for cooking, heating and lighting in homes [284], schools and health facilities.
3522 Disseminate information on how safely to install, manage and maintain improved cooking stoves.

3523 2. Support initiatives to implement energy-efficient public transport and cycle and pedestrian routes.

3524

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 Resource bank

3525

3526

3527

3528

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3529 5.3.10 Environment

3530 Adolescents face many environmental risk factors for poor health and well-being [505], which if addressed
3531 would avert as much as a quarter of the global burden of disease [506]. The necessary changes for minimizing
3532 the impact of environmental risk factors include ensuring access to safe household water, better hygiene
3533 measures, improved management of waste and toxic substances, and improved urban air and household
3534 quality, and minimized impact of adverse climate change [505]. These actions require coordinated actions
3535 from energy, environment, transport, agriculture, industry and health sectors.

3536

Why actions by the environment sector for adolescent well-being?

Schools are ill-equipped to provide healthy and inclusive learning environments for all children

Globally, 29 per cent of schools still lack basic drinking water services, impacting 546 million
schoolchildren; 28 per cent of schools still lack basic sanitation services, impacting 539 million
schoolchildren; and 42 per cent of schools still do not have basic hygiene services, impacting 802
million school children [507].

Smaller hands, cheaper labour: the crisis of e-waste affects children’s health

An estimated 152 million children aged 5–17 years are involved in child labour, including 18 million
children (11.9%) in the industrial sector, which includes waste processing. Some 73 million children
worldwide engage in hazardous labour, with unknown numbers in the informal waste recycling sector.
Children are particularly vulnerable to some of the toxicants found in, or produced by, e-waste and e-
waste recycling activities [139].

More than 90% of the world’s children breathe toxic air every day

Every day around 93% of the world’s children under the age of 15 years (1.8 billion children) breathe
air that is so polluted, it puts their health and development at serious risk. 1 billion children under 15
years are exposed to high levels of household air pollution from mainly cooking with polluting
technologies and fuels. Air pollution affects neurodevelopment, leading to lower cognitive test
outcomes, negatively affecting mental and motor development.

Children and adolescents are particularly vulnerable to ill health due to exposure to chemicals

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 Chemicals such as heavy metals, pesticides, solvents, paints, detergents, kerosene, carbon monoxide
and pharmaceuticals lead to unintentional poisoning at home and in the workplace. Children are
particularly vulnerable to these exposures because of their developing systems and behaviours [136].
Exposure to certain chemicals, such as lead, is associated with reduced neurodevelopment in children
and increases the risk for attention deficit disorders and intellectual impairments [140].

Climate change has increased levels of uncertainty about our future for the world’s 1.8 billion young
people

Young people are not only victims of climate change. They are also valuable contributors to climate
action. They are agents of change, entrepreneurs and innovators. Whether through education, science
or technology, young people are scaling up their efforts and using their skills to accelerate climate
action [26].
3537

3538

3539 Implementation areas and strategies:

3540 1. Assess and mitigate the impact of e-waste on children and adolescents [139]:
3541 a. Eliminate child labour and incorporate adult e-waste workers including youth into the formal
3542 economy with decent conditions across the value chain of collection, processing and recycling,
3543 and resale by transitioning informal workers to the formal economy
3544 b. Raising awareness of e-waste recycling health risks to women and children and encourage
3545 responsible recycling with policy-makers, communities, waste workers and their families
3546 c. Pursue better data and further research about women, children and adolescents involved with
3547 e-waste
3548 2. Prepare schools for future pandemics and provide disability inclusive WASH services in schools [136,
3549 508]:
3550 a. Build and upgrade education facilities that are child, disability and gender-sensitive and
3551 provide safe and effective learning environments that includes availability and sustainable
3552 management of safe drinking water, sanitation and hygiene services
3553 b. Improve coverage of disability-inclusive WASH services in schools
3554 3. Improve air quality and minimize children’s exposure to polluted air and chemicals [136, 332]:
3555 a. Adopt measures to ensure exclusive use of clean technologies and fuels for household
3556 cooking, heating and lighting activities, including by making clean fuels and technologies
3557 affordable, available and accessible to low-income families through social transfers
3558 b. Ensure better waste management to reduce the amount of waste that is burned within
3559 communities and thereby reducing ‘community air pollution’.

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3560 c. Train health professionals to recognize air pollution as a major risk factor for their young
3561 patients, understand the sources of environmental exposure in the communities they serve,
3562 “prescribe” solutions to air pollution-related problems, such as switching to clean household
3563 fuels and devices, and advocate solutions to other sectors, policy- and decision-makers.
3564 d. Implement lead paint hazard control in homes, and ensure safe management of chemicals in
3565 the home, schools and community.
3566 4. Climate action [509]
3567 a. Develop age-appropriate and engaging multimedia content and interactive features to inform,
3568 engage, educate, and lead to youth climate action [509].
3569 b. Promote social and behavioural change and support sustainable education and youth-led
3570 action with outreach campaigns and public engagement and by engaging with formal and
3571 non-formal education activities that shift knowledge, attitudes, behaviours and norms to
3572 address the indirect drivers of biodiversity loss and the degradation of nature [510].
3573 c. Enforce standard-setting and eco-labelling schemes to promote and improve existing
3574 consumer information tools by including criteria of the effect of key products on biodiversity,
3575 and promote adolescents’ literacy in eco-labelling [510].
3576 d. Strengthening environmental digital literacy and e-governance capacities of youth to engage
3577 in the environmental dimensions of digital transformation [510].
3578 e. Leverage on youth activism, and amplify youth voices, to gain support for positive
3579 environmental change, reducing and preventing pollution and promoting sustainable,
3580 healthier living [510].
3581 f. Collaborate with health and education ministries to integrate sustainable living (e.g. lifestyle
3582 changes to reduce greenhouse gas emissions).

3583

3584

3585

3586 Resource bank

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 What is new in this section

✓ The Global Action for Measurement of Adolescent health (GAMA) proposes a set of priority
indicators for adolescent health measurement, building on previous efforts
✓ A measurement approach for adolescent well-being is being developed
✓ Good practices and key principles for the meaningful inclusion of adolescents in monitoring,
evaluation and research of adolescent health and wellbeing programmes are introduced.
✓

3587 SECTION 6:
3588 Monitoring, Evaluation and Research

3589

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3590 Key messages

3591 • To focus measurement on the most important adolescent health issues, the Global Action for
3592 Measurement of Adolescent health (GAMA) Advisory Group proposes 52 priority indicators. These
3593 indicators draw from and complement those included in the monitoring frameworks of the Sustainable
3594 Development Goals (SDGs) and the Global Strategy for Women’s, Children’s and Adolescents’ Health.
3595 Building on existing systems, countries should – as much as possible - collect and use the data on
3596 these indicators to monitor progress towards improving the health of their adolescents.
3597 • An adolescent well-being measurement approach is currently being developed. The approach will be
3598 designed for use at global, regional and country levels, encompassing multiple domains beyond health
3599 to provide a broad perspective of adolescent well-being.
3600 • The rapid physical, emotional and social changes across the adolescent period pose special challenges
3601 for adolescent health programmes, making it essential to disaggregate data by age (five-year age
3602 groups) and sex.
3603 • It is essential for adolescent health programmes to monitor the full range of indicators from inputs
3604 and processes to outputs, outcomes and impact – they answer different questions and are useful for
3605 different purposes. Periodic evaluations of adolescent health programmes are essential and should
3606 build on routinely collected monitoring data.
3607 • Over the last decade, WHO has conducted a number of priority-setting exercises in areas of adolescent
3608 health. These exercises can help researchers and research funders to identify and prioritize areas of
3609 research that require particular attention.
3610 • Monitoring, evaluation and research designed to improve the health of adolescents should include the
3611 opinions of adolescents themselves. Increasingly, youth-led participatory methods are being used,
3612 including engaging adolescents as active evaluators and in participatory research.
3613 • Key principles for engaging adolescents in monitoring, evaluation and research include: Balancing
3614 their participation with the safety of their engagement; Paying attention to the evolving capacity of
3615 adolescents to make informed decisions; Gender and equity considerations should always be included;
3616 Including disadvantaged, vulnerable or marginalized adolescents; and if possible, integrating
3617 adolescents in evidence generation activities as advocates, data collectors, analysts and researchers.

3618

3619 6.1 Global adolescent health measurement

3620 6.1.1 Overview of global frameworks and the Global Action for Measurement of
3621 Adolescent health (GAMA)

3622 In 2015, all United Nations Member States adopted the 2030 Agenda for Sustainable Development [511]. It
3623 sets out 17 Goals, which include 169 targets that are being tracked by 232 unique Indicators [512]. Together,

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3624 the goals aim to transform our world and call to action to end poverty and inequality, protect the planet, and
3625 ensure that all people enjoy health, justice and prosperity. Adolescents have been repeatedly mentioned to
3626 be a crucial population group to achieving many of the Sustainable Development Goals (SDGs) [513]. Yet,
3627 they are largely invisible in the Global indicator framework, including due to a lack of age- and sex-
3628 disaggregated details to measure progress for 10-19-year-olds [407, 514].

3629

3630 The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) (Global Strategy) [513]
3631 emphasizes that children and adolescents must be at the heart of the SDGs and strives for a world in which
3632 every woman, child and adolescent can thrive to realize their full potential. Its objectives and targets as well
3633 as 34 of its 60 indicators are aligned with the SDGs, while an additional 26 indicators have been drawn from
3634 established global initiatives for reproductive, maternal, newborn, child and adolescent health. A total of 43
3635 of the Global Strategy indicators relate to adolescent health [515].

3636

3637 In addition to the indicator frameworks of the SDGs and the Global Strategy, a recent mapping has identified
3638 another 14 global and regional initiatives including adolescent health indicators [516]. They include, for
3639 example, The Lancet Commission on Adolescent health and Well-being [517], Countdown to 2030 [518], and
3640 the Measurement of Mental Health among Adolescents at the Population Level initiative [519].

3641

3642 With the overarching aim to improve and harmonize national and global adolescent health measurement,
3643 WHO in collaboration with United Nations (UN) H6+ partner agencies established the Global Action for
3644 Measurement of Adolescent Health (GAMA) Advisory Group, consisting of 16 global adolescent health experts
3645 [520]. The objectives of the GAMA Advisory Group are to [521]:

3646 • provide technical guidance to WHO, UN H6+ agencies and other relevant measurement groups to
3647 define a core set of adolescent health indicators, for the purpose of harmonizing efforts around
3648 adolescent health measurement and reporting;
3649 • promote harmonized guidance for adolescent health measurement, supporting countries and technical
3650 organizations in collecting useful data to track progress in the improvement of adolescent health.

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3651 In line with the first objective, a consensus list of priority indicators with metadata was developed with
3652 structured inputs from a broad range of stakeholders [3] (Figure 6.1). The list builds on indicators promoted
3653 by other initiatives, including the SDGs and the Global Strategy, and ensures to cover the most important
3654 health issues for adolescents. Notably, several indicators were adopted from other initiatives and only modified
3655 by restricting the age range to 10-19 years. While the list of priority indicators proposed by the GAMA Advisory
3656 Group is currently being further harmonized and tested for feasibility in countries, it may already be used to
3657 orient national adolescent health monitoring efforts and to identify measurement gaps. Table 6.1 shows the
3658 short names of the indicators included in the list of priority indicators recommended by GAMA as well as how
3659 it complements the SDG and the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030)
3660 indicator frameworks.

Step 1. Identification of 16 global and regional measurement initiatives including adolescent health
indicators

Step 2. Selection of 33 core areas for adolescent health measurement, considering four inputs:

✓ Adolescent health burden (by region, adolescent age group and sex)
✓ Areas covered by existing initiatives
✓ Inputs from country adolescent health stakeholders
✓ Inputs from youth group representatives

Step 3. Mapping of 413 indicators assessing any aspect of the selected core measurement areas

Step 4. Definition of indicator selection criteria

Step 5. Selection of 52 priority indicators

Step 6 (on-going). Assessment of feasibility of indicators and harmonization of their measurement

3661 Figure 6.1. Process of selecting priority indicators for adolescent health measurement used by the GAMA
3662 Advisory Group.

3663

3664 Table 6.1. The priority indicators (short names) for adolescent health measurement proposed by the GAMA
3665 Advisory Group and how they complement the SDG and Global Strategy indicator frameworks.

Domain No. Indicator (short name) proposed by Corresponding SDG indicator Corresponding Global Strategy
the GAMA Advisory Group indicator
Social, 1.01 Adolescent population proportion
cultural, 1.02 School completion rate 4.1.2
economic, 1.03 Poverty (national reference) 1.2.1*
educational, 1.03- Poverty (international reference) 1.1.1*
environmental ALT
determinants 1.04 Food insecurity 2.1.2*
of health 1.05 Sexual and reproductive health 5.6.1* Thrive*
decision-making among older
female adolescents
1.06 Not in education, employment or 8.6.1* Transform*
training
A1.01 Foundational learning skills 4.1.1 Key indicator 14 - Transform
Health 2.01 Overweight and obesity
behaviours 2.02 Thinness
and risks 2.03 Heavy episodic drinking 3.5.2* Survive*†
2.04 Psychoactive drug use

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 2.05 Tobacco use 3.a.1* Survive*
2.06 Fruit and vegetable consumption
2.07 Physical activity Thrive*
2.08 Bullying 4.a.2 (thematic indicator)*
2.09 Early sexual debut
2.10 Condom use at last sex
2.11 Skilled birth attendance 3.1.2* Survive*
2.12 Modern contraceptive use at last sex
2.13 Met need for modern contraception 3.7.1* Thrive*
A2.01 Alcohol use
A2.02 Sugar-sweetened beverage
consumption
A2.03 Pre-menarche menstruation
awareness
A2.04 Electronic cigarette use
Policies, 3.01 National adolescent health
programmes, programme
and laws 3.02 National standards for adolescent
health service delivery
A3.01 Health service user fee exemptions
for adolescents
A3.02 Legal restrictions for accessing
health services
Systems 4.01 Health services use
performance 4.02 HPV vaccine coverage 3.b.1* Survive*†
and 4.03 Health data disaggregation by age
interventions and sex
A4.01 Comprehensive school health
services
A4.02 Schools offering HIV and sexuality 4.7.2 (thematic indicator) Thrive*†
education
Subjective 5.01 Social connectedness
well-being A5.01 Parental/guardian connectedness
Health 6.01 Mortality rate (all-cause) Key indicator 5 – Survive
outcomes and 6.02 Mortality rate (cause-specific) Survive†
conditions 6.03 Incidence of HIV infections SDG 3.3.1* Survive*
6.04 Incidence of sexually transmitted
infections (STIs)
6.05 Suicide attempt
6.06 Depression/anxiety symptoms Survive*†
6.07 Incidence of injuries
6.08 Physical violence experience 16.1.3*
6.09 Contact sexual violence experience 16.1.3*
6.10 Adolescent birth rate 3.7.2* Key Indicator 7 – Thrive*
6.11 Anaemia Thrive*
A6.01 Physical violence perpetration
A6.02 Sexual violence experience by age 16.2.3 Transform
18
A6.03 Suicidal thoughts
A6.04 Care seeking for depression/anxiety
A6.05 Female genital mutilation/cutting 5.3.2* Transform*
3666 *Indicator proposed by GAMA has been modified †Global Strategy for WCAH notes indicator is for development

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3667

Measuring adolescent well-being

In 2020, the UN H6+ Technical Working Group on Adolescent Health and Well-being developed an
adolescent well-being definition and conceptual framework. The proposed definition, “Adolescents thrive
and are able to achieve their full potential”, is underpinned by five domains: 1. Good health and optimal
nutrition; 2. Connectedness, positive values and contribution to society; 3. Safety and a support
environment; 4. Learning, competence, education, skills and employability; and 5. Agency and resilience.
To move the adolescent well-being agenda forward, WHO, in collaboration with PMNCH and UN partners
and with the support of an expert consultative group, is leading the development of a measurement
approach for adolescent well-being. As part of this effort, priority indicators will be identified, building on
and adding to the adolescent health indicators prioritized by the GAMA advisory group. The measurement
approach will be designed for global, regional, and country levels, with the primary aim of supporting
countries to gather the most important data for improving the well-being of their adolescents.

3668

3669 6.1.2 Data collection systems for adolescent health indicators

3670 Data for adolescent health indicators may come from a variety of sources. Table 6.2 provides an overview of
3671 common data sources.

3672 One of the main data sources for many of the adolescent health-related indicators are nationally representative
3673 household surveys, such as the Demographic and Health Surveys [522] (DHS) or the Multiple Indicator Cluster
3674 Surveys (MICS) [523] (though these usually do not include adolescent boys and young men), or school-based
3675 health surveys, such as the Global School-Based Student Health Survey (GSHS) [524], the Health Behaviour
3676 in School-Aged Children (HBSC) [525] survey and the Global Youth Tobacco Survey (GYTS) [526]. While
3677 sources such as DHS and MICS do not explicitly focus on adolescents, older adolescent girls, and sometimes
3678 boys aged 15–19 years, are usually included.

3679 Another important source for adolescent data is the Civil registration and vital statistics (CRVS) system. A well-
3680 functioning civil registration and vital statistics (CRVS) system registers all births and deaths, issues birth and
3681 death certificates, and compiles and disseminates vital statistics, including cause of death information. It may
3682 also record marriages and divorces [527].

3683 National Health Information Systems (NHIS) serve multiple users and a wide array of purposes that can be
3684 summarized as the ‘generation of information to enable decision-makers at all levels of the health system to
3685 identify problems and needs, make evidence-based decisions on health policy and allocate scarce resources
3686 optimally. They include Routine Health Information Systems (RHIS) involving regular collection of data and
3687 reporting from health facilities [528].

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3688 Health policy surveys collect information on policies that may be relevant to adolescent health. An example of
3689 a policy survey at the school level is the Global School Health Policies and Practices Survey (G-SHPPS) that
3690 enables countries to generate credible school-level data describing characteristics of school health policies
3691 and practices nationwide [529].

3692 Data collection systems need to ensure that monitoring data can and will be used for management at all levels
3693 of the health system, such as the district or subdistrict levels. Systems are also needed to allow for data to be
3694 used for monitoring at regional and national levels.

3695

3696 Table 6.2. Common data sources for adolescent health-related indicators

INDICATOR DOMAIN DATA SOURCES EXAMPLES

Determinants of health • CRVS • Adolescent population proportion

• Nationally representative household • Not in education, employment or
surveys such as DHS, MICS training
Health behaviours and • Nationally representative household • Overweight and obesity
risks surveys such as DHS, MICS • Tobacco use
• School surveys
Policies, programmes • Policy surveys, including school • National adolescent health programme
and laws policy surveys • National standards for adolescent
• Key informant interviews health service delivery
• Self-reported by governments
Systems performance • National Health Information System • HPV vaccine coverage
and interventions • Health facility surveys • Health services use
• Policy surveys, including school • Schools offering HIV and sexuality
policy surveys education

Health outcomes and • CRVS • Mortality rate (all-cause)

conditions, subjective • National Health Information System • Incidence of HIV infections
well-being • Nationally representative household • Sexual violence experience by age 18
surveys such as DHS, MICS • Suicide attempt
• School surveys
3697

3698 6.1.3 Global adolescent health databases

3699 WHO’s Maternal, Newborn, Child and Adolescent health and Ageing Data portal [530], UNICEF’s Adolescent
3700 Data Portal [530, 531], and UNFPA’s Adolescent and Youth Dashboard [532] bring together and display global
3701 adolescent health and well-being data for some of the most important indicators, drawing from common data
3702 sources.

3703

3704 Through these data portals, up-to-date global, regional and country data can be accessed, visualized in a
3705 variety of ways, including in country profiles, and downloaded [533]. Where no data exist, the data portals
Page 233 of 259
3706 also highlight these data gaps. The NCD Microdata Repository [534] holds unit record data from Global School-
3707 based Surveys (GSHS) done in over 100 countries around the world.

3708 6.1.4 Monitoring of inequality and disaggregation of health data

3709 Health determinants, risk and protective factors and outcomes are rarely distributed equally in populations,
3710 and health programmes reach different subpopulations to different degrees. For example, one of the indicators
3711 proposed by the GAMA Advisory Group and the Global Strategy is the prevalence of insufficient physical activity
3712 among adolescents. Insufficient physical activity differs substantially between young adolescents and older
3713 adolescents, by sex within each of these age groups, by rural or urban residence, and by in-school versus
3714 out-of-school adolescents [250]. Ignoring these differences may mean that the needs of particular
3715 subpopulations remain unaddressed.

3716

3717 Few surveys collect data on a representative sample of all adolescents. Global school surveys, such as Global
3718 School-based Student Health Survey (GSHS), the Health Behaviour in School-aged Children (HBSC), or the
3719 Global Youth Tobacco Survey (GYTS) aim to include a representative sample of school-going adolescents
3720 within specified age ranges. The biases introduced by excluding out-of-school adolescents will vary by country,
3721 as the proportion of adolescents who are in school differs considerably. However, accessing out-of-school
3722 adolescents may be more problematic, as there is no one setting where they can be reached easily.

3723

3724 Furthermore, in adolescent programmes, it is often harder to reach those at the greatest risk, both in terms
3725 of health behaviours and ill-health, as those adolescents might also be the least likely to attend school or seek
3726 health services.

3727

3728 Monitoring of equity and adolescents’ rights is critically important, and the Innov8 technical handbook provides
3729 a useful tool for this [535]. WHO guidance on health inequality monitoring is also relevant to monitoring of
3730 adolescent health [536].

3731

3732 As part of monitoring inequality, the 2030 SDG agenda [512, 515] as well as the Global Strategy call for
3733 disaggregation of data, including by age, sex, disability, socioeconomic status and other dimensions as
3734 appropriate. The work of the GAMA Advisory Group has further highlighted the great importance of
3735 disaggregation of reported data for adolescents [3], and a recent article suggests age disaggregation by 5-
3736 year age groups across the life course [537]. It is however acknowledged that – despite these global
3737 recommendations for standard age disaggregation, different disaggregation might be needed on the basis of
3738 local context, specific health programmes, policies, and specific diseases.
Page 234 of 259
3739

3740 6.2 Monitoring and evaluation of adolescent health programmes at

3741 country level

3742 6.2.1 Monitoring adolescent health programmes

3743 Programmatic monitoring is the systematic collection of data to check on the progress of a programme. It
3744 aims to answer the question, are we doing what we planned to do? It is an essential component of
3745 programmes to guide efforts and investments and to act as the basis to accelerate and reinforce progress. It
3746 is also a critical tool for advocacy to redouble programme efforts. Section 5 of this report sets out the logical
3747 framework (Figure XYZ) required to translate priority adolescent policies and interventions into programme
3748 implementation. Monitoring the success and challenges of implementation is important not only for
3749 demonstrating progress, but also for identifying areas where corrective action is needed for the programme
3750 to be able to meet its objectives.

3751

3752 The International Health Partnership (IHP+) Common Monitoring and Evaluation Framework [538, 539]
3753 classifies indicators for monitoring health programmes into five categories (see logical framework in section
3754 5): inputs (e.g. financing, human resources); processes (e.g. supply chain and mechanisms for sharing
3755 information); outputs (e.g. availability of services and interventions and their quality); outcomes (e.g.
3756 intervention coverage and prevalence of risk behaviours); and impact (e.g. health impact and system
3757 efficiency). The IHP+ Framework is useful for thinking about the processes that will be needed to monitor
3758 and evaluate adolescent health programmes (Table 6.3).

3759

3760 Most of the globally proposed indicators either measure health outcomes or impact [3, 512, 515], with
3761 relatively few indicators measuring inputs, processes or outputs. In the national context, selected indicators
3762 for monitoring inputs, processes and the outputs unique to a country’s context need to be added to drive
3763 improvements in programme effectiveness, efficiency and sustainability.

3764

3765 This section on adolescent health programme monitoring builds on the previous sections of the document by
3766 adding examples of indicators needed to measure the extent to which a programme is facilitating an
3767 adolescent-responsive national health system. It also provides an example of monitoring an adolescent
3768 nutrition programme to illustrate key principles of how countries can monitor the success of their chosen
3769 programmes to improve the health of adolescents (Table 6.3).

3770

Page 235 of 259

 3771

3772 Table 6.3. Examples of indicators to monitor a programme designed to ensure that the national health system
3773 is adolescent-responsive, and an adolescent nutrition programme

Programme Inputs and processes Outputs Outcomes Impact

(see Section
5)
Programme National adolescent Adolescent health training Health services Improved
to ensure the health policy provided to health-care providers acceptable to adolescent
national • National • Number and percentage of adolescents health
health system adolescent health health-care providers trained in • Proportion outcomes
is adolescent- policy available the provision of health services to of • Adolescent
responsive adolescents adolescents mortality
Programme funding • Proportion of target education and reporting rate (by sex
and resources training institutions that have an satisfaction and age
available adolescent health component in with care group)
• By source their curriculum in line with WHO • Adolescent
• Number of health core competencies in adolescent Coverage birth rate
workers by 10,000 health for primary-care providers • Percentage (by age
population by of 15-19 group)
categories, Adolescent-responsive health year-old
geographical services available and accessible females who
distribution, place • Number and proportion of health have their
of employment, facilities with adolescent-friendly need for
etc. accreditation family
• Number and proportion of health planning
Appropriate workers with adolescent-friendly satisfied
processes in place to accreditation by category with modern
support adolescent Teachers trained to provide methods
health adolescent health education
• Governance • Proportion of target education and
structures for the training institutions that have their
adolescent health faculty trained in recommended
programme are approaches to adolescent health
defined at national, education and training
subnational and
local levels
• Mechanisms in
place to ensure
that health system
is adolescent-
responsive

Page 236 of 259

Programme Policy, legislation, Procurement and distribution (to Improved Short-term
to improve and/ or regulations subnational level) of educational impact:
adolescent • Guidance on commodities/materials outcomes improved
school health operationalization of • Number of vaccine/ supplements/ • Improved health,
and nutrition ASHN policy/program meals/ counseling materials delivered attendance nutrition, and
(ASHN) at subnational level • Improved education
• Training curricula for ASHN package delivered (coverage academic outcomes
teachers and/or ASHN of the intervention) performance among
providers, including • Number of schools implementing the adolescent
comprehensive ASHN package Improved populations
sexuality education • Number of [male/female] students health, • Reduction in
available who received interventions from the nutrition, and adolescent
• Monitoring and ASHN package learning pregnancies
supervision tools and outcomes • Reduction in
mechanisms available Improved health and nutrition among malnutrition
knowledge and behaviors among adolescents among
Funding available adolescents • Years of adolescents,
(national and • Improved knowledge on health and education particularly girls
subnational level) nutrition topics covered by ASHN completed • Reduction in
• By source package • Delayed sexual childhood
• Improved access to health and debut stunting
Operational nutrition services by adolescents • Increase in
modalities agreed contraceptive Long-term
and established use impact:
• MoU with relevant • Improved • greater
local entities to enable energy and employment
referral system nutrient intake and earning
• Human resources to • Improved opportunities;
implement ASHN nutritional status economic
services (teachers/ growth
health workers/school
nurses) identified and
recruited
3774

3775 The indicators that are suggested in Table 6.3 are not intended to be either prescriptive or exhaustive, but
3776 are used as examples to demonstrate the importance of different types of indicators for day-to-day
3777 programme monitoring and evaluation. The choice of indicators depends on the specific strategic priorities of
3778 the programme and is limited by practical considerations and available data sources. Countries will need to
3779 select relevant indicators to complement the generic indicators recommended by the GAMA Advisory Group
3780 that are specifically tailored in order to give a clear picture of whether the programme is doing what is planned.

3781

3782 These indicators will also provide information to support day-to-day programme management and decision-
3783 making. To run a programme effectively, monitoring needs to be addressed at every stage of the programme,
3784 including programme planning. Each step in the logical framework (described in Section 5) needs to be
3785 considered separately, and each important activity should be monitored. In the short term, the most useful
3786 data will come from indicators that monitor progress in the first half of the results chain from inputs and
3787 process to outputs, since these should change relatively rapidly. However, outcomes and impact indicators
3788 should also be monitored from the start to ensure that a baseline is established to track progress over time.

Page 237 of 259

3789

3790 Adolescent health programmes have specific features relative to those for other age groups and these must
3791 be considered when designing systems to monitor them. Prominent among these is the fact that many of the
3792 health needs of young adolescents are very different from those of older adolescents. The developmental
3793 changes during adolescence are rapid and, unlike in younger children, they differ substantially between the
3794 two sexes. As a result, detailed age and sex disaggregation of monitoring data is needed to a greater degree
3795 than for any other age group.

3796

3797 6.2.2 Evaluation of adolescent health programmes

3798 While monitoring is the systematic collection of data to check on the progress of a programme or the
3799 implementation of an intervention, evaluation is the critical assessment of the degree to which the programme
3800 fulfils its stated goals and objectives. It aims to answer questions such as, Is the programme achieving its
3801 objectives, goals and associated targets? and is it run in an effective and efficient way? Evaluations contribute
3802 to the overall evidence-base for the effectiveness of interventions and can be used to improve or redirect
3803 implementation and for subsequent programme planning. They can either be conducted by internal
3804 programme staff or by external evaluators. Monitoring data is a major resource for any programme evaluation.

3805 Programme evaluations should follow the Development Assistance Committee criteria [540], which include
3806 measurements of programme:

3807 • relevance – consistency with the overall programme goal and its desired impact;
3808 • effectiveness – reasons for achievement (or not) of the programme’s main objectives;
3809 • efficiency – whether the least costly resources were used to achieve results;
3810 • impact – measures that the programme made a real difference to its beneficiaries; and
3811 • sustainability – likelihood that the programme benefits will continue in the absence of external
3812 support.

3813 This document will not cover the basics of programme evaluation in general. Good guidance on that can be
3814 found elsewhere [538, 539]. The aim here is to highlight issues that are particularly important considerations
3815 for evaluations of adolescent health programmes.

3816

3817 Countries should conduct periodic evaluations of the degree to which their adolescent health programme is
3818 meeting its goals and targets related to the Global Strategy. An example of an evaluation of the Healthy
3819 Communities programme in Uganda Case study 22.

Case Study 22

Page 238 of 259

 Process Evaluation of USAID’s Communication for Healthy Communities programme in
Uganda

USAID’s “Accelerating the rise in contraceptive Prevalence” implemented in Uganda between 2016-2017
targeted adolescent girls between 15-24 and their partners as part of the Communication for Healthy
Communities programme. The programme was implemented in five districts of Uganda and also targeted
other groups including adolescent boys and men between 15-24 years, parents/guardians of adolescents
and other groups such as religious leaders and healthcare workers. To do a real-time assessment and
progress of the programme, type of intervention activities, context, personnel, audience and effort, a
process evaluation was undertaken to understand the effect of current interventions for future
programming. Using a socio-ecological model, undertaking a process evaluation provided opportunities
on learning and improving effectiveness of interventions across various levels including interpersonal,
institutional, community and policy environments. Even though undertaking a process evaluation does
not equate to a comprehensive impact assessment of the entire Communication for Healthy Communities
adolescent programming, results from the evaluation were helpful in informing context of programming,
areas of programme success including coverage and reach, dose delivered and received, and areas for
strengthening adolescent health programing. Undertaking such an evaluation allowed for the
identification of key influencers such as linking “income-generating activities to health promotion
programmes” with reputable and reliable implementation tools.

Source [541]:
3820

3821 For a programme evaluation to be meaningful and useful, it must be both rigorous and objective. It should
3822 go beyond a superficial checklist that reveals little about the quality or coverage of an implemented
3823 programme. For example, an evaluation of a national comprehensive sexuality education (CSE) programme
3824 should go further than simply documenting that sex education is in the national curriculum. The evaluation
3825 should review whether each aspect of the CSE curriculum is in line with the topics and approaches proposed
3826 in the UNESCO International Technical Guidance on Sexuality Education [114], particularly any topics which
3827 may be sensitive or controversial. The evaluation should assess the quality and coverage of related aspects
3828 of teacher-training programmes. It should also include an assessment of the quality and coverage of CSE
3829 programme implementation. Ideally, such an evaluation would include the participation of external CSE
3830 experts, to ensure there is the technical capacity rigorously to evaluate the programme and to reduce the
3831 potential for bias – as education sector representatives may have a conflict of interest.

3832

3833 Planning for evaluations should be an integral part of programme planning and should be included in the initial
3834 programme plan so that adequate budget is allocated for the evaluations. Evaluation planning also helps

Page 239 of 259

3835 clarify the specific goals and targets of the programme, making it easier to anticipate and avoid the challenges
3836 that would otherwise be detected by the evaluators.

3837

3838 The main function of a monitoring and evaluation system is to produce information on which to base
3839 management decisions. If programmes are evaluated, the information obtained should feed directly and
3840 promptly into programme planning and priority- setting. Periodic programme reviews are a way to make sure
3841 that the findings of evaluations are used rather than gathering dust on bookshelves. These reviews should
3842 include an assessment that takes into account the findings from both internal and external programme
3843 evaluations. Programme reviews should also take account of available monitoring data and stakeholder
3844 opinions, which should include the opinions of adolescents themselves and of youth-led and youth-serving
3845 organizations. The assessment findings should feed into participatory review processes where programme
3846 priorities, approaches and targets are re-evaluated, and changed where necessary.

3847

3848 6.2.3 Country support for monitoring adolescent health programmes

3849 Many countries will have empirical data on some but not all of the adolescent health indicators recommended
3850 by the GAMA Advisory Group. The World Health Organization, the Health Data Collaborative and other entities
3851 are working with countries to improve the availability, quality and use of data for local decision-making and
3852 tracking of progress toward the health-related Sustainable Development Goals (https://www.
3853 healthdatacollaborative.org/). For monitoring and evaluation of adolescent health programming, countries will
3854 need to ensure that they include a focus on age and sex disaggregation.

3855

3856 6.3 Advancing research for adolescent health and wellbeing

3857 Research aims to systematically investigate and study important questions in order to increase current
3858 knowledge through the discovery of new facts. The earlier sections of this document have demonstrated that
3859 much is known about the burden of disease and injuries in adolescence and the risk factors for future adult
3860 burden; what adolescent health interventions are effective; and how best these interventions might be
3861 prioritized and then implemented within adolescent health programmes.

3862

3863 Further research will be essential to push progress forward for adolescent health in order to achieve the
3864 ambitious health-related Sustainable Development Goals. Key areas of focus will include research to develop
3865 evidence on which interventions should be implemented and under what conditions (research on the what
3866 and the how of adolescent health programming). Emerging threats and opportunities, such as online use,
3867 climate change and pandemic risk, will also necessitate research investments.
Page 240 of 259
3868

3869 Research focused on child and adolescent development has been conducted primarily in high-income countries
3870 in North America and Western Europe [542, 543], neglecting developmental issues that are unique to the
3871 majority who live in low- and middle-income countries. This leaves a gap in basic research addressing
3872 normative development during adolescence in a range of cultural, social and environmental contexts.
3873 Interdisciplinary approaches and collaborations between academic researchers and those working in applied
3874 settings provide much potential to fill research gaps.

3875

3876 To strengthen programs and policy action, further investment is needed to unpack the challenges and
3877 opportunities of multisectoral programs for adolescents; and conceptual and measurement advances are
3878 particularly needed with respect to studying adolescent voice and agency, connectedness, civic and social
3879 participation and engagement. In addition, household surveys often capture the situation of adolescents 15
3880 years and older, but 10- to 14-year-olds remain particularly understudied. Last, but not least, inclusion should
3881 be a priority for data collection and research. A recent review of evidence gap maps collated the highest
3882 quality evidence on adolescent wellbeing and noted that less than one in five studies analyzed gender as a
3883 variable of interest. Disability was seen in only 3% of studies [544].

3884

3885 Unfortunately, relative to the research capacity for maternal, newborn and child health, adolescent research
3886 capacity is weak, especially in LMICs where it is needed most [407]. Investment in research capacity
3887 strengthening will need to involve multiple disciplines and is likely to bring a substantial return on investment.

3888

3889 Undeniably, the number of important research questions is large. Priorities will need to be selected for
3890 investment. Over the last ten years, WHO has conducted a number of priority-setting exercises in areas of
3891 adolescent health to help countries prioritize their research investments [545-549]. These use versions of the
3892 Child Health and Nutrition Research Institute (CHNRI) methodology [550], in which experts propose potential
3893 research questions and then score them based on explicit criteria related to clarity, answerability, importance,
3894 potential for implementation and relevance for equity. Exercises showed that priorities have shifted away from
3895 basic questions on the prevalence of specific health conditions towards questions about how best to scale-up
3896 existing interventions and testing the effectiveness of new ones.

3897 6.4 Involving adolescents in monitoring, evaluation and research

3898 Ideally, the monitoring, evaluation and research of programmes designed to improve the health of adolescents
3899 should always include the opinions of adolescents themselves. There is also the increasing potential for
3900 adolescents or young people to be engaged as active evaluators rather than only as subjects of the evaluation.
3901 Increasingly, youth-led participatory action research is being undertaken to advance research particularly in
Page 241 of 259
3902 community settings. Adolescents engaged in such research identify issues they want to improve, conduct
3903 research to understand the issues and possible solutions, and advocate for changes based on research
3904 evidence. Using such collaborative models helps to increase the power of marginalized groups to effect
3905 change. Youth- led participatory action research has four phases: issue selection, research design and
3906 methods, data analysis and interpretation, and reporting back and taking action for change. Involving young
3907 researchers can strengthen the validity of research by applying their unique expertise and insider experience
3908 to develop research questions, instruments and interpret findings. Dissemination among adolescents may also
3909 be perceived to be more credible if their peers participated in generating the evidence.

3910 Unfortunately, adolescents can be excluded from research in part because of confusion about whether they
3911 should be regarded as children or adults [551]. Adolescents’ rapidly evolving capacity to make informed
3912 decisions is important related to their consent and assent in data collection, and the role that adolescents can
3913 have in actively being involved in the design, implementation, analysis and interpretation of programme
3914 evaluations. The capacity of a 19-year-old will be very different from that of a 10-year-old. Furthermore, all
3915 adolescents of the same age will not have the same capacity. In order to achieve a proper ethical balance,
3916 researchers need to achieve the twin goals of including adolescents in research and protecting them from
3917 research risk (ibid). Data collection methods and study instruments may need to vary across adolescence, and
3918 special data collection approaches may be required to overcome shyness or to ensure understanding,
3919 especially among young adolescents.

3920

3921 Different data collection instruments may be needed for young versus older adolescents, or for adolescents
3922 with disabilities. Extra consultation is often required with adolescents, their parents, families and communities
3923 prior to data collection. An example of this would be if a questionnaire survey is to be used that will require
3924 asking sensitive questions to adolescents who are under the legal age of majority (usually under 18 years),
3925 such as questions to unmarried adolescents about their sexual behaviour or use of illegal drugs. Also,
3926 appropriate consent from parents or legal guardians, in addition to assent from adolescents themselves, is
3927 required for underage adolescents. Legal and ethical provision of protection and ensuring access to services
3928 also need to be considered.

Page 242 of 259

 BOX: Key principles for involving adolescents in monitoring, evaluation and research [552]
• Adolescents of all ages should not be excluded from research or data collection unless there is
a risk to their safety or there is no benefit from their inclusion.
• The evolving capacity of adolescents to make informed decisions should be central to
considerations about adolescent research involvement and who should provide informed consent
for adolescent participation.
• Inclusion of adolescents in research and protection from research risk can both be achieved. To
achieve this, research and data collection require nuanced understanding of adolescent
development and their social contexts.
• Gender and equity should always be considered. This means including appropriate age (10-14
and 15-19) and sex disaggregated data, as well as ensuring research is gender and age sensitive.
• Disadvantaged, vulnerable or marginalized adolescents should be included in research and data
collection by prioritizing sex- disaggregated sampling of marginalized adolescents and by
including them through inclusive community-based participatory approaches.
• To the fullest extent possible, integrate adolescents as local advocates, data collectors, analysts
and researchers in evidence generation activities.

3929

3930

3931

3932

3933

3934

3935

3936

3937

3938

3939

Page 243 of 259

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