Improving adolescent health: an evidence-based call to action
Authors: Helen A Weiss, Rashida A Ferrand
Journal: The Lancet (2019)

Adolescent health is coming of age, with the number of young people aged 10–24 years at an all-time high globally and projected to increase in the coming decades.1United Nations Department of Economic and Social Affairs Population DivisionWorld Population Prospects: 2015 revision, key findings and advance tables. United Nations, New York, NY2015Google Scholar The greatest increase will be in low-income countries where there have been remarkable decreases in the under-5 mortality and child mortality rates, but where fertility often remains high.2Bundy DAP de Silva N Horton S Patton GC Schultz L Jamison DT Investment in child and adolescent health and development: key messages from Disease Control Priorities.Lancet. 2017; 391 (3rd Edition): 687-699Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar Health indicators often focus on burdens of disease or mortality; however, indicators for health and wellbeing in adolescents need to focus on morbidity and risk behaviours. This broadened scope is necessary because several key health conditions,3Kotchick BA Shaffer A Forehand R Miller KS Adolescent sexual risk behavior: a multi-system perspective.Clin Psychol Rev. 2001; 21: 493-519Crossref PubMed Scopus (430) Google Scholar, 4Santelli JS Sivaramakrishnan K Edelstein ZR Fried LP Adolescent risk-taking, cancer risk, and life course approaches to prevention.J Adolesc Health. 2013; 52: S41-S44Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 5WHOHealth for the world's adolescents: a second chance in the second decade. World Health Organization, Geneva2014Google Scholar, 6WHOGlobal accelerated action for the health of adolescents (AA-HA!). World Health Organization, Geneva2017https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf?sequence=1Date accessed: January 28, 2019Google Scholar including over half of mental health disorders,7Kessler RC Amminger GP Aguilar-Gaxiola S Alonso J Lee S Ustün TB Age of onset of mental disorders: a review of recent literature.Curr Opin Psychiatry. 2007; 20: 359-364Crossref PubMed Scopus (1781) Google Scholar and risk factors for morbidity and mortality in later life start in adolescence, such as tobacco and alcohol use, unhealthy diet, lack of physical activity, or risky sexual behaviours, and many have social determinants.4Santelli JS Sivaramakrishnan K Edelstein ZR Fried LP Adolescent risk-taking, cancer risk, and life course approaches to prevention.J Adolesc Health. 2013; 52: S41-S44Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 8Mokdad AH Forouzanfar MH Daoud F et al.Global burden of diseases, injuries, and risk factors for young people's health during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2016; 387: 2383-2401Summary Full Text Full Text PDF PubMed Scopus (576) Google Scholar In The Lancet, Peter S Azzopardi and colleagues9Azzopardi PS Hearps SJC Francis KL et al.Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(18)32427-9Summary Full Text Full Text PDF Scopus (139) Google Scholar report country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing10Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1539) Google Scholar from 1990 to 2016, and discuss the current and future health and wellbeing of adolescents. Data were provided for almost all countries and territories using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 and other datasets. The authors focus on three aspects of current and future adolescent health: health outcomes (ie, communicable, maternal, and nutritional diseases [group 1 conditions]; injuries; and non-communicable diseases); health risks (tobacco smoking, binge alcohol use, overweight, and anaemia); and social determinants of health (fertility; secondary education; not in education, employment, or training [NEET]; child marriage; and satisfaction of demand for contraception with modern methods). The data illustrate the changes in adolescent health and wellbeing from 1990 to 2016, with two prominent aspects being clearly shown: the demographic transition, with an increase in the number of adolescents (aged 10–24 years) from 1·53 billion in 1990 to 1·8 billion in 2016; and the epidemiological transition, which has seen a decrease in the number of countries classified as multiburden countries. In multiburden countries, characterised by a high degree of poverty, adolescents face a heavy and complex burden of diseases including group 1 conditions, injuries, and non-communicable diseases. Notably, a substantial increase was seen in the number of countries classified as non-communicable disease predominant (those with relatively low rates of both group 1 conditions and injuries). The demographic transition means that, although fewer countries are classified as multiburden, these countries were home to an additional 250 million young people in 2016 compared with 1990. Young people living in these countries (which are largely in sub-Saharan Africa and south Asia) face not only the highest burden of communicable diseases but also of non-communicable diseases globally. In particular, young women in multiburden countries are being left behind. Young women tend to have worse health outcomes than men in the same multiburden countries, and compared with males and females in other country groups, these women have the largest increases in risky behaviours (including tobacco smoking, binge drinking, and the prevalence of overweight or obesity); the highest prevalences of anaemia, NEET, adolescent livebirths, and child marriage; and the lowest prevalences of secondary education completion and demand for modern contraceptive need being met. Additionally, non-communicable diseases caused more disability-adjusted life-years (DALYs) than group 1 conditions in multiburden countries for both sexes. For example, over half of DALYs for females in these countries were related to non-communicable diseases (8259·2 [51%] of 16 071·4 DALYs per 100 000 population) compared with 39% (6334·5 DALYs per 100 000) due to group 1 conditions, and 9% (1477·7 DALYs per 100 000) due to injuries. This finding, alongside the increases in risky behaviours in this age group, is likely to cause non-communicable diseases in later life. The data used in this study raise questions that are not addressed in the current Article. For example, the authors identified only four multimorbidity countries, all in southern Africa (Lesotho, South Africa, Swaziland, and Zimbabwe), with increases in group 1 conditions between 1990 and 2016. This finding might be driven by the high prevalence of HIV infection. Further disaggregation by age is also needed because causes of morbidity and risky behaviours among adolescents aged 10–15 years are different from those for adolescents aged 20–24 years. As with any synthesis, the quality of the data depends on the primary data collected, and ten of the 12 indicators were populated using modelled data, with wide uncertainty estimates indicating the lack of primary data, especially for binge drinking, child marriage, and injuries associated with conflict and war. Nonetheless, the Article is based on data with far higher coverage than previous estimates.11Patton GC Coffey C Cappa C et al.Health of the world's adolescents: a synthesis of internationally comparable data.Lancet. 2012; 379: 1665-1675Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar This study is an evidence-based call to action to the global health community in several ways. First, the 12 indicators defined in the Lancet Commission10Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1539) Google Scholar and populated in this Article9Azzopardi PS Hearps SJC Francis KL et al.Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016.Lancet. 2019; (published online March 12.)http://dx.doi.org/10.1016/S0140-6736(18)32427-9Summary Full Text Full Text PDF Scopus (139) Google Scholar identify important health outcomes, health risks, and social determinants of health that should be targets of policy and programming. These clearly defined indicators are aligned with the framework for the Sustainable Development Goals and with current global policy documents from UN agencies and major funders, such as the Global Strategy for Women's, Children's and Adolescents' Health (2016–30) with the Survive, Thrive, Transform agenda12Every Woman Every ChildGlobal strategy for women's, children's and adolescents' health (2016–2030).https://www.who.int/life-course/publications/global-strategy-2016-2030/en/Date: 2015Date accessed: January 31, 2019Google Scholar focusing on longer-term health and wellbeing for adolescents. These indicators can be used systematically in future studies to advocate for measuring and reporting the needs of adolescents globally. Second, the Article highlights the need to focus on screening, counselling, and treating adolescents for common morbidities and risk behaviours that can affect current and future health and wellbeing. The multimorbidity seen in all settings calls for a shift away from focusing on single health problems in adolescent health care and research, and instead focusing on strategies to improve prevention, diagnosis, treatment, and referral in integrated adolescent health programmes. For example, a strong theoretical case has been made that health check-up visits, similar to the check-up visits for infants and younger children, in which adolescents are screened for multiple conditions and risk behaviours could be highly cost-effective in low-income and middle-income countries;2Bundy DAP de Silva N Horton S Patton GC Schultz L Jamison DT Investment in child and adolescent health and development: key messages from Disease Control Priorities.Lancet. 2017; 391 (3rd Edition): 687-699Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar empirical evidence of the effectiveness of such visits is urgently needed.13Salam RA Das JK Lassi ZS Bhutta ZA Adolescent health interventions: conclusions, evidence gaps, and research priorities.J Adolesc Health. 2016; 59: S88-S92Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 14Bright T Felix L Kuper H Polack S Systematic review of strategies to increase access to health services among children over five in low- and middle-income countries.Trop Med Int Health. 2018; 23: 476-507Crossref PubMed Scopus (15) Google Scholar Finally, the study illustrates the crucial need for intersectoral strategies—particularly, investment not only in health but also in educational, economic, and social sectors to promote and protect the health and wellbeing of current adolescents, future adults, and their children. We declare no competing interests. Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries. Full-Text PDF Open Access