Realising the health and wellbeing of adolescentsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4119 (Published 14 September 2015) Cite this as: BMJ 2015;351:h4119
- Laura Laski, chief, sexual and reproductive health branch
- on behalf of the Expert Consultative Group for Every Woman Every Child on Adolescent Health
Adolescence is a critical stage of life characterised by rapid biological, emotional, and social development. It is during this time that every person develops the capabilities required for a productive, healthy, and satisfying life. In order to make a healthy transition into adulthood, adolescents need to have access to health education, including education on sexuality1; quality health services, including sexual and reproductive; and a supportive environment both at home and in communities and countries.
The global community increasingly recognises these vital needs of adolescents, and there is an emerging consensus that investing intensively in adolescents’ health and development is not only key to improving their survival and wellbeing but critical for the success of the post-2015 development agenda.2 The suggested inclusion of adolescent health in the United Nations secretary general’s Global Strategy for Women’s and Children’s Health is an expression of this growing awareness and represents an unprecedented opportunity to place adolescents on the political map beyond 2015. Ensuring that every adolescent has the knowledge, skills, and opportunities for a healthy, productive life and enjoyment of all human rights3 is essential for achieving improved health, social justice, gender equality, and other development goals.
We argue that the priority in the revised Every Women Every Child Global Strategy needs to be giving adolescents a voice, expanding their choices and control over their bodies, and enabling them to develop the capabilities required for a productive, healthy, and satisfying life. We call for a global, participatory movement to improve the health of the world’s adolescents as part of a broader agenda to improve their wellbeing and uphold their rights.
This paper is based on the review of evidence based inputs received from public consultations conducted by the Partnership for Maternal, Newborn and Child Health and expert meetings organised by the UN Population Fund (UNFPA) in 2015 as part of the UN secretary general’s Global Strategy for Women’s, Children’s and Adolescents’ Health. The consultations brought together leaders in adolescent health from governments, civil society organisations, UN agencies (including H4+, a partnership between UNAIDS, UNFPA, Unicef, the World Health Organization, UN Women, and the World Bank that helps countries improve their health services for women, children, and newborns), donors, academics and other researchers, private sector organisations, and young people and built consensus on priority actions needed to protect and promote the health of adolescents and youth.
Health challenges faced by adolescents
Adolescents have benefited less than younger children from the “epidemiological transition” that has reduced all causes of mortality among children.3 In 2012, an estimated 1.3 million adolescents died mostly from preventable or treatable causes.4 We set out the major health problems below.5
Injuries and violence
Unintentional injuries are a leading cause of mortality and morbidity during the second decade of life. Road traffic injuries are the top cause of death among adolescents, with some 330 adolescents dying every day.
An estimated 180 adolescents die every day from interpersonal violence.5 At least one in four boys aged 15-19 said they had experienced physical violence since age 15.6 Worldwide, up to 50% of sexual assaults are committed against girls under 16, and some 30% of girls aged 15-19 experience violence by a partner.4 Moreover, many girls’ first sexual experience is forced and coerced.
Mental health and self harm
Although half of all mental health disorders in adulthood start by age 14, most remain undetected and untreated. Depression is the top cause of illness and disability among adolescents, and suicide is the leading cause of death among adolescent girls aged 15-19 and the third cause of death among all adolescents 10-19 globally.4
Communicable and non-communicable diseases
Childhood immunisation has brought down adolescent deaths and disability significantly,4 but common infectious diseases that have been a focus for action in young children are still killing adolescents. For example, diarrhoea and lower respiratory tract infections are estimated to rank second and fourth, respectively, among causes of death in 10-14 year olds globally.4 Adolescents who are sexually active have the highest rates of prevalent and incident human papillomavirus (HPV) infections, with 50-80% having infections within three years of initiating sexual intercourse.7
The health related behaviours that underlie major non-communicable diseases usually start during adolescence: tobacco and alcohol use and diet and exercise patterns potentially leading to overweight and obesity. These habits could affect the morbidity and mortality of adolescents later in their lives as well as of future generations. Anaemia, resulting from rapid growth during adolescence combined with a lack of iron, affects girls and boys and is the third cause of years lost to death and disability.4
Maternal mortality and morbidity
In low and middle income countries high adolescent birth rates reflect both a lack of opportunities available to girls and vulnerabilities they experience during adolescence and beyond. Every day in developing countries, 20 000 girls under age 18 give birth. Girls under 15 account for two million of the annual total of 7.3 million new adolescent mothers; if current trends continue, the number of births to girls under 15 could rise to three million a year in 2030.8
Pregnancy, whether intended or not, puts adolescents at risk of death and injury, including conditions such as obstetric fistula. Maternal mortality is the second leading cause of death among adolescent girls aged 15-19 years.4 Around 11% of births worldwide, or an estimated 16 million, are to girls aged 15-19,9 10 and very young mothers are the most likely to experience complications and die of pregnancy related causes.11 Adolescent girls have high rates of complications from pregnancy, delivery, and unsafe abortion.4 10 12 The consequences have implications for future generations, as newborns and infants of adolescent mothers are at higher risk of low birth weight and mortality.13 Gaps in the fulfilment of sexual and reproductive health undermine the achievement of gender equality, drain household incomes and public budgets, lead to poor health and educational outcomes, lower productivity and labour force participation, and result in missed opportunities for economic growth.14
Although there has been a 43% decline in new HIV infections among adolescents since 2000, globally, there are twice as many new infections as deaths from AIDS.14 In 2013, an estimated 2.1 million adolescents between the ages of 10 and 19 years were infected with HIV. In 2014, HIV/AIDS was estimated to be the second leading cause of death globally.4 Adolescents, especially adolescent girls, are the only population group for which AIDS related deaths are not falling.15 Young women and adolescent girls are disproportionately vulnerable and at high risk.16
Interventions to protect and promote health
In the past 20 years, governments and the international community have made clear commitments to adolescents and their health.1 4 5 8 9 10 17 18 Evidence shows that positive health outcomes for adolescents require intervention from not only health but other sectors, including education and workforce.
To ensure adolescents have a voice, choice, and control over their bodies and are enabled to develop the capabilities required for a productive, healthy, and satisfying life, global efforts should focus on reducing adolescent deaths and morbidity and creating a supportive legal and social climate for positive adolescent development. Key interventions need to span the health sector to social determinants of health, to other actors such as parents and community members. Based on an analysis of problems and opportunities, we suggest the following priority actions:
Health education, including comprehensive sexuality education—Adolescence is an appropriate time to learn about healthy diets, the consequences of alcohol and substance misuse, resisting peer pressure and bullying, healthy sexuality, sexual violence, respect for human rights, and promotion of gender equality. Promotion of and opportunities for physical activity should be also included in schools and communities
Access to and use of integrated health services—As adolescents become sexually active, they require an integrated package of services, especially sexual and reproductive health services. This includes access to an expanded mix of contraceptives, including emergency contraception and long acting reversible contraceptives; safe abortion where legal, and management of the consequences of unsafe abortion; maternity care; testing and treatment of sexually transmitted infections, including HIV testing, diagnosis, counselling, care, and post-exposure prophylaxis; and care after gender based or sexual violence
Immunisation—HPV vaccination for 10-14 year olds protects them from developing cervical cancer as adults. HPV vaccination is also an opportunity to reach adolescents with other interventions such as menstrual hygiene, deworming, and malaria prevention. Other critical vaccines include tetanus booster, rubella, and hepatitis B (if not previously vaccinated), measles, and meningococcal disease (depending on epidemiology)
Nutrition—Developing healthy eating and exercise habits at this age are foundations for good health in adulthood and protect against overweight and obesity. Nutritional supplementation, particularly iron and folic acid, is important to prevent anaemia and protect the health of their future offspring (should they choose to have children)
Psychosocial support—Mental health problems in adolescence should be detected and managed by competent health workers.5 Schools and other community settings can also help in promoting good mental health
Creating health systems suited to adolescents
Availability of good quality care and healthcare workers trained to deal with adolescents is critical for delivering effective health interventions. Efforts to improve adolescent health require health systems that are responsive to adolescents.4 Stigma, discrimination, judgmental treatment, lack of confidentiality, and inability to physically access services have been shown to be important barriers to care.19 Evidence from both high and low income countries shows that services for adolescents are highly fragmented, poorly coordinated, and uneven in quality.4 Outreach and non-facility based services are important to reach adolescents who otherwise will not come to the services. Variability in quality can be minimised by setting standards and supporting their achievement.4
Individual, interpersonal, community, organisational, and structural factors affect how adolescents access care, how they understand information, what information they receive, which channels of information influence their behaviours, and how they think about the future and make decisions in the present. To improve acceptability and quality of health services, health workers, particularly primary care workers, need to be trained and supported in protecting adolescents’ privacy and confidentiality and in treating them with respect and without judgment.4
Financial and legal barriers also need to be tackled. Adolescents may not be covered by an effective prepaid pooling arrangement, such as insurance schemes, or be able to meet out of pocket expenses.20 Financial protection to cover the services needed by adolescents should be part of universal health coverage.4 In some countries, governments restrict access of adolescents to health services, especially sexual and reproductive services, by requiring the consent of parents, or spouses if they are married.
Non-health sector interventions
Numerous factors outside the health sector protect or undermine the health of adolescents.21 Short and long term risks arise from economic (poverty, inequality), sociocultural (gender, early marriage), biological (prevalence of malaria, water borne helminths, HIV, etc) physical, environmental (such as road conditions, housing, and pollution), legal, and policy factors, but education is the principal socioeconomic determinant of adolescent health.
A good education gives young people the skills and knowledge to enable them to mitigate health risks and to seek health and social services when faced with these problems. The longer a girl stays in school, the greater the chances that she uses modern contraception if she has sex, and the lower her chances of giving birth as an adolescent.17 Early (and often forced) marriage is a serious contributing problem to school retention and health. Fifty one countries have rates of early marriage (before age 18) that are above 25%, and nine out of 10 adolescent births take place in the context of early marriages.18 Schools must become a safe place for girls and should enable pregnant girls to pursue their education in a supportive environment.
Adolescents need quality education and schooling at least to secondary level. Younger adolescent girls in particular may need extra support to stay in school, and all adolescents need a range of economic and social assets such as financial literacy, life skills, safe spaces, social networks, and economic capital. Vocational training is also important to prepare adolescents for decent paid employment and self employment after they reach working age.
Communities and schools must be equipped with safe water and sanitation, which promotes good hygiene, and particular challenges for menstruating girls must be addressed. Appropriate spaces and facilities for physical activity need to be in place to promote and enable safe and healthy exercise practices.
Parents and tutors have a critical role in raising healthy children. In the challenging adolescent years, parents need support, information, skills, and resources to function effectively. Investment in support activities for parents is an important component of programmes for adolescents, to prevent interpersonal violence and promote good mental and sexual health.22 Support (both practical and legal) also needs to be provided for those affected by harmful traditional practices and violence, including trafficking. Over the next five years, interventions must be prioritised for places where child marriage is prevalent, including keeping girls in school and equipping them with the knowledge and ability to exercise their rights as adolescents. Finally, adolescents must be given the opportunity to participate in decision making and be encouraged to participate in the political process once they have reached the legal age.
Policies and laws protecting the health of adolescents
Adolescents are neither children nor adults; their needs can be easily overlooked in policies. Health interventions for adolescents cannot be effectively implemented without the appropriate policy and legal environment and its effective application. In this regard countries need to take the following actions:
Enable access to health services—Examine and potentially revise current policies to remove mandatory third party authorisation for sexual and reproductive health services and adopt flexible policies to allow adolescents to be considered “mature minors”
Control exposure to unhealthy products—Enact and enforce laws on use of tobacco, alcohol, and illegal substances and food policies to reduce exposure to dangerous and unhealthy substances (such as raising taxes on tobacco and alcohol, prohibition of sale to people below an appropriate minimum age, prohibiting smoking in public spaces, setting lower maximum blood alcohol concentration levels for young drivers, and regulating marketing of foods high in saturated fats, trans-fatty acids, sugar, or salt)
Revise and implement laws on child marriage—The minimum age at marriage should be universally set at 18 for both boys and girls. Exceptions to marry with consent from parents should not be included in marriage laws. As part of civil registration and vital statistics efforts, birth and marriage registration should be made mandatory
Make adolescents visible in policy formulation and monitoring—Use existing data on adolescents from censuses, demographic and health surveys, and multiple indicator cluster surveys to formulate policy and deliver programmes. Dedicated surveys such as the global school-based student health surveys are needed to overcome the lack of data, especially on younger adolescents and other subpopulations of adolescents, such as head of households, those living without their parents, domestic workers or migrants, refugees, those living with disabilities, and trafficked adolescents.
Building a new monitoring framework
We need a unified platform that allows countries to come together and pursue a contextually relevant yet common agenda on adolescent health. The Global Strategy presents just such a platform, convening and leading countries in a global call to action on indicators related to adolescent health in the sustainable development goals accountability framework. Four of the sustainable development goals include clearly stated targets for adolescent health (see appendix on thebmj.com for details).
Given the extent of change across adolescence, these health targets must be measured separately in adolescents aged 10-14 and 15-19 years so that we can monitor countries’ progress.
The inclusion of adolescent health in the UN secretary general’s Global Strategy for Women’s and Children’s Health and targets directly linked to adolescent health in the post-2015 sustainable development goals agenda represent an unprecedented opportunity to step up efforts to adopt policies for adolescents. By developing programmes to provide them with the skills they need for their health and development countries can ensure adolescents will contribute fully to their societies and develop the judgment, values, behaviours, and resilience they need to be safe, to end discrimination and violence, and to help create and sustain national and global peace. In turn, this healthy generation will nurture the next so that it can participate effectively in a rapidly changing globalised world.
Adolescents aged 10-19 years have specific needs and health systems need to take into account their biological, emotional, and social development
Interventions to support adolescents to attain a productive, healthy, and satisfying life are critical to the success of the sustainable development agenda
Priorities for action include health education, access to health services, immunisation, nutrition, and psychological support
Action is also needed in other sectors, particularly education
Cite this as: BMJ 2015;351:h4119
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Contributors and sources: The members of the expert consultative group for Every Woman Every Child on Adolescent Health were L Laski, United Nations Population Fund, New York; Z Matthews and S Neal, University of Southampton, UK; G Adeyemo, Save the Children, Nigeria; G Patton, University of Melbourne; S Sawyer, Centre for Adolescent Health, Royal Children’s Hospital, Parkville, Australia; N Fuchs-Montgomery. Family Planning Program at the Bill and Melinda Gates Foundation; A Capasso, Family Care International, New York; S Gold, International Women’s Health Coalition, New York; S Petroni, International Center for Research on Women; L Say, R Khosla, and V Chandra Mouli, Department of Reproductive Health and Research, WHO; B J Ferguson, Department for Maternal, Newborn, Child and Adolescent Health, WHO; M Melles, United Nations AIDS agency; S Kasedde, T Oyewale, N Yasrebi, and S Lehtimaki, United Nations Children’s Fund; D Engel, S Chalasani, P Awasti, and L Sharaf, United Nations Population Fund.
Provenance and peer review: Not commissioned; externally peer reviewed.
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