This publication on WHO recommendations related to adolescent health is one of four in a series; the others relate to maternal, newborn and child health. The objective of this document is to make available WHO recommendations on adolescent health in one easy-to-access document for WHO staff, policy-makers, programme managers, and health professionals. The compilation can also help better define gaps to prioritize guideline updates.
This document is meant to respond to the questions:
  What health interventions should the adolescent receive and when should s/he receive it?
  What health behaviours should the adolescent practise (or not practise)?
Sections in this compilation either reflect adolescent-specific recommendations only or these and adolescent-relevant recommendations.
Adolescent-specific recommendations: Recommendations that specifically address adolescents and are different from recommendations for other population groups e.g. adults or children Adolescent-relevant recommendations: Recommendations that apply to adolescents as well as other population groups (e.g. adults or children)
WHO produces guidelines according to the highest international standards for guideline development. The main principles are transparency and minimizing bias in every step of the process. The process of developing guidelines is documented in WHO Handbook for guideline development. 1 The development process includes the synthesis and assessment of the quality of evidence, and is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. GRADE categorizes the quality (or certainty) of the evidence underpinning a recommendation as high, moderate, low or very low.
  High: further research is very unlikely to change our confidence in the estimate of effect;   Moderate: further research is likely to have an impact on our confidence in the effect;   Low: further research is very likely to have an important impact on our confidence in the effect and is likely to change the estimate of effect;   Very low: any estimate of effect is very uncertain.
Once the quality of the body of evidence on benefits and harms has been assessed, an expert group formulates the recommendations using a structured evidence to decision framework. When determining whether to recommend an intervention or not, the expert group carefully considers the balance of benefits and harms of an intervention, and other factors such as values and preferences of persons affected by the recommendation, stakeholders' perceptions of the acceptability and feasibility of the options and interventions, resource implications, the importance of the problem, and equity and human rights considerations.
The expert group then decides on the strength of the recommendation -strong or conditional. A strong recommendation is one where the desirable effects of adhering to the recommendation outweigh the undesirable effects. Recommendations that are conditional or weak are made when the expert group is less certain about the balance between the benefits and harms or disadvantages of implementing a recommendation. Conditional recommendations generally include a description of the conditions under which the end-user should or should not implement the recommendation.
The quality of evidence and strength of the recommendation, as well as the link to the source, are included in this publication. Different expert groups may employ different terminology in the guideline processes. We suggest the Reader refer to the Source where more details are available.
The current publication includes updates and new guidelines up until 2017.
Prevent/promote/protect adolescent health

# PREVENTING EARLY PREGNANCY AND POOR REPRODUCTIVE OUTCOMES AMONG ADOLESCENTS IN DEVELOPING COUNTRIES
Reduce marriage before the age of 18 years

# Strong recommendations:
  Encourage political leaders, planners and community leaders to formulate and enforce laws and policies to prohibit marriage of girls before 18 years of age. Source

# Undertake research to:
  identify effective interventions that result in the formulation, enforcement and monitoring of laws and policies, including unintended harmful consequences; Source   determine the feasibility, effectiveness and long-term impact of economic incentives to adolescent girls and their families as a means of delaying the age of marriage until 18 years of age; Source
Rubella-containing vaccines are administered subcutaneously or intramuscularly, usually at age 12-15 months, but may be administered to children aged 9-11 months and to older children, adolescents and adults. Although one dose of rubella vaccine probably induces life-long protection, in most countries using the measles-rubella or measles-mumps-rubella vaccines a second dose is offered at 15-18 months or 4-6years, as indicated for protection against measles and mumps. (Strong recommendation, high quality evidence). Source Commonly used RCVs are combinations with vaccines against measles (MR), measles and mumps (MMR), or measles, mumps and varicella (MMRV). Each dose of an RCV contains a defined number of infectious units (1000 PFU or CCID50). Source

# Tetanus vaccine booster
Serological survey data suggest that booster doses in adolescents and adults are critical in maintaining high antibody levels, which can persist for decades. Pre-adolescent and adolescent booster doses are also programmatically feasible and align with the human papillomavirus (HPV) immunization schedule. Source

# HIV PREVENTION 3
The use of antiretroviral drugs for treating and preventing HIV infection 2016
Comprehensive condom and lubricant programming   Adolescents' emotional, intellectual and social capacities are continuously evolving. Young people from key populations, perhaps more so than their peers in the general population, experience power imbalances in sexual relationships that limit their ability to use condoms.
Peer-led and outreach approaches may help to distribute condoms and lubricants, increase knowledge, develop skills and empower adolescents from key populations to use condoms and lubricants correctly and consistently. Source

# Creating an enabling environment
Health sexuality across the life course

# VOLUNTARY MEDICAL MALE CIRCUMCISION
Voluntary medical male circumcision for HIV prevention   Countries with hyperendemic and generalized HIV epidemics and low prevalence of male circumcision should increase access to male circumcision services as a priority for adolescents and young men. Source

# SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS 4

# Contraceptive services
  In order to meet the educational and service needs of adolescents, it is recommended that sexual and reproductive health services, including contraceptive information and services, be provided for adolescents without mandatory parental and guardian authorization/ notification.
  To act in the best interest of adolescents, health services may need to prioritize their immediate health needs, while being attentive to signs of vulnerability, abuse and exploitation. Appropriate and confidential referral, if and when requested by the adolescent, can provide linkage to other services and sectors for support.
Safe abortion and post-abortion care   Adolescents may be deterred from accessing health services if they think they will be required to obtain permission from their parents or guardians; this can increase the likelihood that they will go to providers of unsafe abortion. Source

# Global Recommendations on Physical Activity for Health
Recommended levels of physical activity for health

# 5-17 years old
For children and young people of this age group physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities.
In order to improve cardiorespiratory and muscular fitness, bone health, cardiovascular and metabolic health biomarkers and reduced symptoms of anxiety and depression, the following are recommended:
  Children

# Use of multiple micronutrient powders for point-of-use fortification of foods consumed by pregnant women
  Routine use of multiple micronutrient powders during pregnancy is not recommended as an alternative to standard iron and folic supplementation during pregnancy for improving maternal and infant health outcomes (strong recommendation, very low quality of evidence).

# WHO RECOMMENDATIONS ON ADOLESCENT HEALTH Vitamin A supplementation in postpartum women
Vitamin A supplementation in postpartum women is not recommended for the prevention of maternal and infant morbidity and mortality (strong recommendation). Source
Fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders Restricting caffeine intake   For pregnant women with high daily caffeine intake (more than 300 mg per day), lowering daily caffeine intake during pregnancy is recommended to reduce the risk of pregnancy loss and low-birth-weight neonates. (Context-specific recommendation). Source
Vitamin A supplementation during pregnancy for reducing the risk of mother-tochild transmission of HIV   Vitamin A supplementation in HIV-positive pregnant women is not recommended as a public health intervention for reducing the risk of mother-to-child transmission of HIV (strong recommendation). Source

# WHO Recommendations on health promotion interventions for maternal and newborn health

# Birth preparedness and complication readiness (BPCR)
 BPCR interventions are recommended to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications. Source

# Male involvement interventions for MNH
 Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of women, improved home care practices for women and newborns, improved use of skilled care during pregnancy, childbirth and the postnatal 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. Source
Partnership with traditional birth attendants (TBAs)
 Where TBAs remain the main providers of care at birth, dialogue with TBAs, women, families, communities and service providers is recommended in order to define and agree on alternative roles for TBAs, recognizing the important role they can play in supporting the health of women and newborns.
 The use of lay health workers including trained TBAs is recommended for promoting the uptake of a number of maternal and newborn-related health care behaviours and services, providing continuous social support during labour in the presence of a skilled birth attendant and administering misoprostol to prevent postpartum haemorrhage.
 The use of lay health workers including trained TBAs to deliver the following interventions is recommended, with targeted monitoring and evaluation: the distribution of certain oral supplement-type interventions to pregnant women (calcium supplementation for women living in areas with known low levels of calcium intake; routine iron and folate supplementation for pregnant women; intermittent presumptive therapy for malaria for pregnant women living in endemic areas; vitamin A supplementation for 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. Source
Providing culturally appropriate skilled maternity care  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. Source
Companion of choice at birth  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.
  Community mobilization through facilitated participatory learning and action cycles with women's groups   The 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.
The 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   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 and implementation   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. Source

# Maternity waiting homes (MWHs)
  MWHs 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.

# (Conditional recommendation) Source
Community-organized transport schemes   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. (Conditional recommendation) Source

# Management of adolescent conditions

# HIV TESTING AND COUNSELLING FOR ADOLESCENTS LIVING WITH HIV 9

# HIV testing and counselling
In all epidemic settings accessible and acceptable HTC services must be available to adolescents and provided in ways that do not put them at risk. Countries are encouraged to examine their current consent policies and consider revising them to reduce age-related barriers to access and uptake of HTC and to linkages to prevention, treatment and care following testing. Young people should be able to obtain HTC without required parental or guardian consent or presence.    When G6PD status is unknown and G6PD testing is not available, a decision to prescribe primaquine must be based on an assessment of the risks and benefits of adding primaquine.
(Good practice statement)
Treatment of severe malaria First-line support includes:
being non-judgmental and supportive and validating what the woman is saying providing practical care and support that responds to her concerns, but does not intrude asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved)
helping her access information about resources, including legal and other services that she might think helpful

# MANAGEMENT OF ADOLESCENT CONDITIONS
assisting her to increase safety for herself and her children, where needed providing or mobilizing social support.
Providers should ensure:
that the consultation is conducted in private confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting)
If health-care providers are unable to provide first line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.
Infants less than 5kg body weight   Treat infants weighing less than 5kg with uncomplicated P. falciparum malaria with ACT ant the same mg/kg bw target dose as for children weighing 5kg. Preventing relapse in P. vivax or P. ovale malaria   The G6PD status of patients should be used to guide administration of primaquine for preventing relapse. (Good practice statement)   To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants aged < 6 months, women breastfeeding older infants unless they are known not to be G6PD defcient, and people with G6PD defciency) with a 14-day course (0.25-0.5 mg/kg bw daily) of primaquine in all transmission settings. (Strong recommendation, high-quality evidence)  start the regimen as soon as possible and before 72 hours provide HIV testing and counselling at the initial consultation ensure patient follow-up at regular intervals two-drug regimens (using a fixed dose combination) are generally preferred over threedrug regimens, prioritizing drugs with fewer side-effects the choice of drug and regimens should follow national guidance.