Adolescent wellbeing in humanitarian and fragile settings: moving beyond rhetoricBMJ 2023; 380 doi: https://doi.org/10.1136/bmj-2021-068280 (Published 20 March 2023) Cite this as: BMJ 2023;380:e068280
- Neha S Singh, associate professor1,
- Jocelyn DeJong, professor2,
- Kimberley Popple, research consultant1,
- Chi-Chi Undie, technical director3,
- Rozane El Masri, research consultant4,
- Ritah Bakesiima, lecturer5,
- Mariana Calderon-Jaramillo, PhD student6,
- Ellen Peprah, clinical and public health research intern7,
- Saha Naseri, technical officer8,
- Nadine Cornier, head of programme support unit9,
- Karl Blanchet, professor10
- 1Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
- 2Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- 3Population Council, Nairobi, Kenya
- 4War Child, Beirut, Lebanon
- 5Department of Epidemiology and Biostatistics, Faculty of Public Health, Lira University, Lira, Uganda
- 6Asociación Profamilia, Centre d’Estudis Demografics, Universitat Autònoma de Barcelona, Barcelona, Spain
- 7STOP NCDs, Ghana College of Physicians and Surgeons, Accra, Ghana
- 8World Health Organization, Kabul, Afghanistan
- 9Humanitarian Response Division, United Nations Population Fund), Geneva, Switzerland
- 10Geneva Centre of Humanitarian Studies, University of Geneva, Geneva
- Correspondence to: N S Singh
The United Nations Refugee Agency (UNHCR) reported in May 2022 that 103 million people in the world had been forcibly displaced from their homes because of conflict and persecution.1 This number included 32.5 million refugees, over half of whom were under the age of 18. Adolescents, including unaccompanied minors, were at greater risk of forced displacement because of conflict between 2009 and 2017 than women and children under the age of 5 years, with the number of displaced adolescents increasing from 13 million in 2009 to 19 million in 2017.2
Although there are many types of humanitarian and fragile settings, we focus here on contexts affected by armed conflict and environmental disasters. Attention to the wellbeing of adolescents in such settings is essential because of the detrimental effects these contextual factors have on the physical, social, and cognitive changes experienced during this life stage. As humanitarian crises are often protracted, young people may spend much or all of their adolescence in such settings, with the resulting vulnerabilities continuing throughout their lives. Breakdown of family and supportive networks as populations are forced into displacement creates an unstable ecosystem for adolescents to form meaningful and emotional connections with others. These effects are often exacerbated by poverty, gender inequities, and human rights violations, as well as mental illness from the stressors derived from the crises themselves. These factors increase the vulnerability of adolescents to problems such as misuse of drugs and alcohol, sexual exploitation, academic underachievement because of interruption to schooling, reduced economic prospects, chronic poverty, poor psychosocial outcomes, and sexual and gender based violence.3
The covid-19 pandemic has exacerbated many of these challenges for adolescents in humanitarian and fragile settings, with the disease and its related response measures having long-lasting and often irreversible effects on their health and wellbeing.4 Economic deterioration associated with covid-19 and with the war in Ukraine has also had particularly drastic implications for adolescent wellbeing in humanitarian and fragile settings, and associated phenomena such as early marriage, early pregnancy, and adolescent or child labour are likely to rise.5 Yet, despite this greater need, humanitarian funding for these populations is increasingly squeezed. And while the current situation of adolescents in these settings is dire, the longer term implications of adverse experiences and outcomes of adolescents for future lives, as well as for the intergenerational transmission of disadvantage, must not be forgotten yet remain under-researched.6
Improving the wellbeing of these vulnerable adolescents requires greater investment in research and implementation of effective interventions to meet their specific needs. These include secondary education, which is often neglected but has critical implications for life chances and the health of this age group.
Lack of data and related ethical challenges
Despite the high number of humanitarian and fragile settings globally, evidence documenting the effects of such crises on adolescent wellbeing is limited.37 This lack of data cuts across all five domains in the 2020 framework conceptualising adolescent wellbeing8: good health and optimum nutrition; connectedness, positive values, and contribution to society; safety and a supportive environment; learning, competence, education, skills, and employability; and agency and resilience. Current indicators focus on physical health, education, fertility, and employment and overlook critical but difficult to measure aspects of wellbeing such as self-esteem, relationships and connectedness, resilience, stress, depression, and anxiety.3 In addition, most studies are cross sectional because the high mobility of these populations makes collecting longitudinal data difficult, and they therefore cannot assess causality.3
Even conducting cross sectional studies among representative samples is challenging in these contexts, as sampling frames usually do not exist, and refugees and displaced populations tend to be very mobile and may be living among local host communities. Data are often lacking on the situation before the crisis, making comparisons difficult. In the case of refugees, there are relatively few studies comparing their status with that of host population adolescents, although there have been promising moves in that direction.910
A World Health Organization report describes special ethical considerations that pose challenges when including young people in research on topics such as sexual and reproductive health and rights.11 Parental consent is recommended for participation of younger adolescents but can be difficult to obtain in humanitarian and fragile settings as families become separated. Although guidelines from the Council for International Organizations of Medical Sciences and WHO allow parental consent to be waived in certain circumstances, this recommendation is not evenly applied or followed globally.12 Other ethical challenges when collecting data from adolescents include the sensitivity around asking about traumatic events such as abuse, difficulties ensuring privacy and confidentiality, and concerns around the power relations between researchers and adolescents.3
Limited and poor quality evaluation of interventions
The effectiveness of current interventions that promote adolescent wellbeing in humanitarian and fragile settings is largely unknown because of a lack of evaluation. The quality of the evidence from the studies that have been done is often low, and they do not always sufficiently analyse the respective contributions of different components of the interventions. For example, a review of mechanisms of change for psychosocial interventions for children and adolescents in conflict settings found gaps in the testing of intervention mechanisms; nine of the 13 mechanisms had only moderate or poor quality evidence to support their use.13 Likewise, large evidence gaps still exist despite increasing research attention on the effectiveness of mental health interventions for young people affected by war. These gaps include evidence on prevention and maintenance, multilevel interventions, comorbidities, differential effects, measurement tools, and strengthening mental health services.14 Similarly, a stronger evidence base is needed to examine how sexual and reproductive health interventions with effectiveness data from stable settings work (or not) for different young people across varying humanitarian and fragile settings.15 For example, there is a lack of implementation and documentation of evidence based strategies that address the specific sexual and reproductive health needs of adolescents of varying age (eg, younger versus older), religion, gender, race, ethnicity, disability status, and sexual orientation in humanitarian and fragile settings.16
Although reaching adolescents is often challenging in any setting, many commonly used points of access may be inappropriate in humanitarian and fragile settings. For example, school based interventions, while cost effective, do not reach the high proportions of adolescents who are out of school or mobile in such settings; similarly, community based interventions such as safe spaces17 may fail to reach female adolescents, who often have restricted mobility in public spheres; finally, family based interventions, though promising,18 may face resistance or time constraints among families affected by conflict, disaster, or forced displacement.
Call to action
Adolescent wellbeing in humanitarian and fragile settings will continue to be largely neglected unless all relevant actors identify and prioritise the specific needs of this age group by calling for appropriate investments. Efforts to monitor and evaluate
and improve this important population’s wellbeing require urgent attention. Financial commitment to developing health services and programmes that are designed to be receptive to adolescents is essential, and ensuring engagement requires involving adolescents in the design and evaluation of interventions.7 We outline four key policy and programmatic recommendations below.
Prioritising investment in research, monitoring, and evaluation
Data are critically needed both to evaluate existing programmes and to promote the routine collection and use of age and sex disaggregated data. Such data collection should include rigorous evaluations of existing programmes to examine both process and the short, medium, and long-term effects on adolescents, and to establish any causal links between humanitarian interventions (eg, the transition to cash-based assistance) and adolescent outcomes. With donors’ support, programme implementers must prioritise and allocate resources for working with evaluators and researchers either within or external to their organisation, to include systematic evaluations of the effectiveness and cost effectiveness of their programmes
Adolescent specific modules must also be added to routine data collection systems (eg, Health Management Information System) and ad hoc surveys such as those assessing demographic and health characteristics, living standards, and violence against children. Such modules are being piloted within Unicef’s multi-indicator cluster surveys.3
Implementation research on improving post-conflict resilience
This type of research, focusing on context specific interventions, should be conducted at all stages of humanitarian response, from preparation to evaluation. Implementation research and preparations before interventions are particularly important to prevent resistance from the community, especially for those concerning girls’ and women’s rights and the sexual and reproductive health of adolescents. Interventions should also be focused on increasing adolescents’ resilience. Greater resilience developed during traumatic experiences within humanitarian and fragile settings can be of lifelong benefit.
Bridging the humanitarian-development divide
Given the protracted and cyclical nature of many conflicts, it is important to ensure care for affected adolescents continues throughout their lifespan and meets their diverse needs. To deliver this, humanitarian and development sectors must work together in a timely manner. This requires strengthening the links between sectors, including health, protection, education, and livelihoods, to create a holistic, multisectoral response (including monitoring and evaluation) for adolescents using existing structures in humanitarian and fragile settings.
Engaging meaningfully with adolescents
Delivering meaningful engagement entails including adolescents in design, implementation, and evaluation of interventions and considering them as full actors with diverse needs. This requires prioritising the support of local adolescent led initiatives and organisations. Additionally, there is a need to build sustainable systems for adolescent participation in decision-making (especially for girls) and to invest in gender-transformative approaches to improve adolescent girls’ agency and leadership at community, provincial, national, and global levels. Investing in systems where adolescents work on current and future challenges faced by humanitarian and fragile settings will result in positive outcomes for them, their families, and communities in the short, medium, and long term.
● Adolescents are particularly vulnerable in humanitarian and fragile settings, where they often face high risk situations and may be forced to take on adult roles
● Data are lacking on the specific needs of adolescents in these settings and how to improve their wellbeing
● Greater investment is needed in adolescent specific strategies and in collecting disaggregated data by age, gender, sexual orientation, and disability status
● Humanitarian and development sectors must work together to support the diverse needs of adolescents throughout their lives
●Adolescents must be involved in the design, implementation, and evaluation of interventions to ensure meaningful engagement
NSS received salary support from the Centers for Disease Control and Prevention of the US Department of Health and Human Services as part of financial assistance award U01GH002319. The article does not represent the official views of, or an endorsement by, CDC/DHHS or the US government.
Contributors and sources:The authors include young people and represent a diversity of world regions. The analysis is based on experiences and evidence from varied humanitarian and fragile settings. NSS and JD led on the conceptualisation, writing of the original draft, and reviewing and editing of the manuscript. KB, KP, CCU, REM, RB, RCJ, EP, SN, and NC reviewed, edited, and contributed to the manuscript. NSS and JD contributed equally and are joint first authors. NSS is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.
Patient and public involvement: Young people from humanitarian and fragile settings (REM, EP) were involved in reviewing, editing, and contributing to the manuscript.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a collection proposed by the Partnership for Maternal, Newborn, and Child Health. Open access fees were funded by the Bill and Melinda Gates Foundation. The BMJ commissioned, peer reviewed, edited, and made the decision to publish these articles. Emma Veitch was the lead editor for The BMJ.
This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.