KNOWLEDGE SUMMARY:

2020 WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH 37 ADOLESCENT AND ENGAGEMENT FOR HEALTH AND WELL-BEING: strengthening capacities, opportunities and rights Photo: Flickr Creative Commons Brown License/UN Women/Ryan Flickr Photo:

The world’s 1.2 billion adolescents (aged 10–19 years) have a fundamental right to engage meaningfully in all matters that affect their lives (Box 1) (1, 2). This includes the right to engage in decision-making as equal and valuable partners, while being supported in their roles as adolescent leaders and advocates (3). When adolescents participate in decision-making, the resulting policies and programmes are more likely to respond to their diverse needs (4). Such engagement requires the empowerment of adolescents, by increasing their capacities, skills, autonomy and decision- making power, and by advancing their rights (5–7).

Box 1. Definition of meaningful adolescent engagement (1) Meaningful adolescent engagement is defined as an inclusive, intentional and mutually respectful partnership between adolescents and adults, whereby power is shared, respective contributions are valued, and young people’s ideas, perspectives, skills and strengths are integrated into the design and delivery of programmes, strategies, policies and funding mechanisms that affect their lives, communities and countries, and the wider world.

Hosted by the World Health Organization What do we know about engaging adolescents Box 2. Engaging adolescents to to improve health and well-being? improve HIV service delivery In recent years there has been an important shift away from Zvandiri is a multicomponent service viewing adolescents solely as passive beneficiaries of services, delivery programme for children and and towards considering them as powerful agents of change. adolescents living with HIV in Zimbabwe. The collective agency of adolescents is one of the most underused It integrates peer-led community resources for achieving global health and development goals. interventions and psychosocial support Their agency is epitomized by their current global activism with clinic-based government health concerning climate change (8). services (19). The programme was developed through the active It is widely recognized that meaningful engagement of adolescents engagement, training and leadership of helps to improve health policies and services for adolescents, which adolescents living with HIV (Community in turn improve health and broader societal outcomes (1, 9–11). Adolescent Treatment Supporters Much can be learnt from the efforts to meaningfully engage (CATS)) to ensure that adolescent- adolescents in the HIV response (5, 12–14). Greater engagement identified needs, values and perceptions by adolescents in their health and well-being is positively informed planning and implementation. associated with improvements in quality of care (15), overall The focus on shared experiences, role programme effectiveness and equity (5, 9, 16, 17). Respecting modelling and supportive friendship adolescents’ views and providing adolescent-responsive care and through CATS visits and support groups services ensures that more adolescents seek services and remain has improved adolescents’ lives. It has engaged in accessing them (Box 2) (9). Increasing access to digital also strengthened knowledge about HIV technologies is transforming adolescent engagement in education among adolescents and their caregivers, and learning, and also has wider societal implications (18). helping to improve treatment adherence Meaningful engagement enhances adolescents’ social capital and and increase adolescent self-esteem. connections with their peers. It enables the development of From one support group in 2004, leadership skills and the competencies and confidence needed in Zvandiri has been adopted by the adulthood (Box 3) (6). This positive influence on adolescent’s Ministry of Health and Care and social and emotional development can empower adolescents to scaled up across all 10 provinces of claim their rights and realize their full potential (9, 10, 21, 22). Zimbabwe, reaching 51 of its 63 Figure 1 shows the pathways leading from the engagement of districts (20). adolescents to the realization of their health and well-being.

Figure 1. Pathways from adolescent engagement to health and well-being

Improved adolescent-adult relationships

Increased self-efficacy and empowerment

Adolescents have Increased Improved Meaningful Improved identity and evolving capacities, decision-making health and adolescent sense of purpose resources, agency in health and well-being engagement and skills well-being outcomes Increased social capital and peer connections

Improved competencies and confidence

Supportive laws, policies and structures; Institutionalization Equitable policies; responsive adults/decision-makers of engagement quality health care Why do we need to draw attention to adolescent Box 3. Adolescent engagement for health and well-being? Participation Forums The right of adolescents to take part in and influence processes and Argentina’s Adolescent Participation decisions that affect their lives was enshrined in the 1989 United Forums enable adolescents to engage Nations Convention on the Rights of the Child and related General in developing public policy proposals Comments on the right to be heard and on the rights of adolescents to address their critical health (6, 28, 29). Upholding this right supports adolescents’ attainment of challenges (23). In 2018, 13 Forums voice and agency to engage meaningfully in decision-making, were held in four provinces of regardless of their socially determined circumstances. Argentina, at which 2800 adolescents discussed and developed Despite binding international obligations, there is global institutional recommendations for tackling underinvestment in the development of robust adolescent engagement adolescent pregnancy, suicide and strategies (9, 30). As shown by recent climate change activism, mental health challenges. The adolescents have the energy and optimism needed to influence Forums also served as accountability governance and demand accountability. However, despite some mechanisms: adolescents interacted progress (28, 30) few governments or organizations have made the with the authorities and demanded necessary commitments, in terms of budgets, legal and policy answers to their concerns. The frameworks, and programmes, to support adolescents’ right to Forums were complemented by engage. For example, although 84% of national health policy Adolescent Health Advisory Services documents from 109 countries included some reference to (AHAS), established in secondary adolescents, only 15% of these specified support for adolescent schools, health centres and hospitals engagement as a specific goal, indicator or target (31). to promote adolescent engagement To support further investment in adolescent engagement, more and leadership (24). In 2018, the research is needed to systematically examine the effects of adolescent number of AHAS increased from 68 engagement on health and well-being (6, 15) and to conceptualize to 1148, with participation by measures and methodologies appropriate for adolescents of different 64 000 adolescents. The Ministry of ages and genders (11, 32, 33). However, adolescent engagement Health convened a National Advisory should not be evaluated only in terms of impact indicators. The Board on Adolescents to ensure quality of the engagement should also be measured, as well as other systematic engagement of adolescent factors, such as the context of the engagement, social change and representatives in national policy. gender dynamics (11, 34). Such efforts would take into account the Showing what can be achieved by continuum of adolescent engagement (Figure 2) and include the increasing adolescent participation engagement of adolescents in the research process itself (32, 35). and adolescent-led accountability mechanisms, two provinces have now extended national policy by Figure 2. Continuum of adolescent engagement developing specific protocols to assist pregnant adolescents, particularly those under age 15, who currently suffer the greatest rights violations (25–27). The enhanced partnership between adolescents and service Inform Consult Influence Partnership Empowerment providers generated integrated Adolescents Adolescents Adolescents Adolescents Adolescents policies and interventions on may be may be are are in joint have full informed but consulted, but systematically control with control and adolescent health education and do not impact it is often ad consulted and adults. Tasks this is adolescent-friendly health services decisions. hoc, and they their inputs are jointly recognized do not impact are taken negotiated formally. and the expansion of AHAS in Adults are in full control. decisions. seriously. and Typically but secondary schools. The process of Typically Information delegated. not always adolescent participation and their adults’ sharing is adolescent agenda takes two-way. initiated and exchanges with local authorities was precedence. directed. documented in the publication Voices that Matter (23). Increasing impact on decisions Challenges to meaningful Adolescent engagement ranges from tokenistic participation to initiatives that are wholly adolescent-led adolescent engagement (Figure 2) (11, 37). Limited efforts to include To enable a positive pathway from adolescence to adolescents in decision-making reinforce their distrust, adulthood, adolescents must be able to express their apathy and despondency (6). Consideration must also views to service providers and decision-makers, as well be given to uneven dynamics within adolescent as practice their evolving capacities and decision-making movements, especially those which disadvantage girls. skills within their families, communities and beyond (4, Adolescents who see benefits resulting from their 5). However, adolescents in some settings have far influence on decisions are likely to become more fewer opportunities than others to engage meaningfully committed, engaged and motivated (34). in the conceptualization, design, delivery and evaluation Many adolescents lack the capacity, resources, agency of programmes that affect them (36). and skills to influence decisions affecting their health Power dynamics must be realigned to ensure more and well-being, or are unaware of their right to do so, egalitarian relations among adolescents, and between which reduces their demands for services and them and decision-makers, to enable meaningful engagement (7, 10, 28). This is particularly the case for engagement (10). Systems and structures must be put adolescents experiencing poverty, disabilities or chronic in place to institutionalize adolescent engagement, illnesses, and those marginalized because of their including a supportive legal and policy environment. sexual orientation, HIV status, gender identity, ethnicity, This includes addressing legal and regulatory barriers, class or other sociocultural factors, as well as those such as those relating to privacy, confidentiality and living in humanitarian and fragile settings (21). Unequal evolving capacities to give informed consent. It also social and gender norms also result in adolescent girls requires the removal of bureaucratic structures that experiencing structural, cultural, economic and political prevent adolescent engagement (31). Currently, constraints that impede their autonomy and agency decisions in the home, school and community are often (39, 40). This poses significant barriers to their taken by adults, without giving due consideration to meaningful engagement in both private and public life. adolescents’ views (10). While adults can be allies in The heterogeneity of adolescents (for example in age, amplifying adolescents’ perspectives, they can only level of maturity) and the role of caregivers must also encourage or enable genuine engagement if they have be considered when determining their ability to the understanding and skills necessary to carry out independently engage for better policy decisions and participatory practices (5). programmes, especially for those aged 10–14 years (9). Photo: Flickr Creative Commons License/U.S. Embassy Penh Phnom Flickr Photo: What actions are needed? Adolescents, especially those living in challenging circumstances, need support in developing the knowledge, skills and capacities necessary to play an active role in society. This requires a conducive environment, with institutions across sectors that are responsive to the ideas and priorities of adolescents. Digital platforms are important for facilitating engagement. As policy-makers, champions and members of PMNCH constituencies, we must draw on existing efforts (9) to galvanize global commitment to mainstreaming adolescent engagement through advocacy, learning and sharing best practices. We must work together to undertake the following actions in an integrated way.

Social norms, skills and capabilities for engagement (5, 9, 22, 28, 39–43) We must address the social context for adolescent engagement and support adolescents in building the knowledge, skills and self-confidence required to engage meaningfully in decision-making for their health and rights. • Challenge discriminatory norms. Unequal power relations between adolescents and adults need to be addressed at the individual, relational, resource and structural levels. This includes training adults to listen, and making activities gender-sensitive and participatory, for example by training health service providers, including community health workers, in adolescent friendly service global standards. It requires tackling discriminatory social and gender Photo: Flickr Creative Commons License/UN Women/Khristina Godfrey norms that lead to the subordination and disempowerment of adolescent girls and other vulnerable adolescents, while promoting norms - access to information (e.g. about what to expect which foster positive outcomes. from schools and health services) and peer counselling about rights and opportunities; • Build adolescent knowledge, skills and agency to engage in dialogue and action for their health and - social and life skills training, including rights. Strengthening adolescent competencies and communication and leadership skills; leadership skills enables adolescents to engage more - comprehensive sexuality education to improve effectively in decision-making. Younger adolescents knowledge, skills, attitudes and values relating to should be allowed to learn at their own pace. adolescent health, well-being and dignity; Funding should be made available for training, especially for those living in poverty. Knowledge and - safe and friendly social platforms (e.g. school, sports awareness must be built among adolescents, and arts clubs, peer networks and digital hubs); families and communities about adolescents’ rights, - community-based support groups to facilitate as well as their policy and legal entitlements (and learning, goal setting, confidence building and limitations) under national laws and regulations. socializing; Illustrative examples from the HIV response, sexual formal platforms (e.g. roundtable discussions, and reproductive health and rights, education and - symposiums and panels); and positive development programmes, among others, include: - family and community mobilization and dialogue. Photo: Flickr Creative Commons License/Unicef Ethiopia

Policies, programming and service delivery (5, 6, Accountability (6, 9, 10, 34, 39) 9, 13, 43, 44) We must reach and support the engagement of the It is the obligation of the state, through adult duty-bearers, most marginalized adolescents to ensure that the to create the conditions for the meaningful engagement causes of discrimination against them and their lack of of adolescents, in collaboration with other stakeholders. engagement are fully addressed. • Ensure that national policy frameworks recognize • Create forums of accountability for meaningful the importance of meaningful engagement in public adolescent engagement, with a focus on adolescent and private life and establish mechanisms to girls and other vulnerable groups, as leaders and key guarantee it. This requires addressing, across all stakeholders at the national and sub-national levels sectors, structures that constrain adolescents, for (e.g. independent youth commissioners; youth example by reforming laws, policies and institutions councils). Adolescent advocates have the motivation that disadvantage them, particularly adolescent girls. to challenge corruption and harmful traditional This includes ensuring access for adolescent girls to practices, and to advocate for good governance and primary and secondary education and policies that accountability. Resources must be available for protect them from early marriage. Funders should independent oversight of government actions. invest in earnest and provide core long-term support • Ensure national and sub-national processes and to adolescent-led and adolescent-driven initiatives. mechanisms for remedy and redress. When • Avoid ad hoc and occasional engagement. adolescents are prevented from enjoying their rights, Systematic opportunities for adolescent engagement such as the right to participate in decisions about must be created across sectors. A minimum their health and well-being, they should have access standard for structures and processes should ensure to mechanisms offering effective remedies and equitable representation of the most marginalized redress. This could be through subnational complaint adolescents in relevant areas of public policy, mechanisms, children’s/adolescents’ ombudspersons, financing and programme implementation. This courts and/or national human rights institutions, as includes building mechanisms into programmes and well as regional and international judicial and human services to facilitate adolescent engagement in rights bodies. identifying, prioritizing and finding solutions to problems. 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Acknowledgements Scientific writer: Rachael Hinton, RHEdit. Editor: Joanne McManus. Technical contributions (in alphabetical order): Wole Ameyan, World Health Organization; Avni Amin, World Health Organization; Vicky Camacho, UNFPA; Nazneen Damji, UN Women; Karen Devries, London School of Hygiene and Tropical Medicine; Joshua Dilawar, Institute for Social and Youth Development (Pakistan); Danielle Engel, UNFPA; Regina Guthold, World Health Organization; Alan Jarandilla Nuñez, International Youth Alliance for Family Planning; Tamar Kabakian-Khasholian, American University of Beirut; Chisina Kapungu, WomenStrong International; Joanna Lai, UNICEF; Joweri Namulondo, Uganda Youth and Adolescents Health Forum; Sarah Onyango, International Planned Parenthood Federation; Suzanne Petroni, Gender Equality Solutions, LLC; Meghna Ranganathan; London School of Hygiene and Tropical Medicine; Emily Sullivan, FP2020; Linda Weisert, Children’s Investment Fund Foundation; William Yeung, Reach Out (Australia). Coordinated by: Anshu Mohan and Meheret (Mimi) Melles-Brewer (PMNCH). Design: Annovi Design.

PMNCH Knowledge Summaries synthesize recent evidence into a clear, concise and user-friendly format to support advocacy, policy and practice on issues related to sexual, reproductive, maternal, newborn, child and adolescent health and well-being. Each Knowledge Summary is targeted at policy-makers, champions and PMNCH constituencies. PMNCH works actively with partners from different organizations and constituencies, not only to develop the series, but also to ensure that the summaries reach key stakeholders.

ISBN 978-92-4-000572-3 (electronic version) ISBN 978-92-4-000573-0 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. ISBN 978-92-4-000572-3 Available on-line at http://www.who.int/pmnch/knowledge/publications/summaries/en/