Now, more than ever, we need to invest in the health and wellbeing of young people. As the world faces threats of global health security, climate change and disruptive demographic shifts, young people are disproportionately affected. Yet, they are also at the frontline of solutions. In recent decades we have learnt that lasting and inclusive improvements in adolescent health and wellbeing need integrated, multifaceted approaches. These approaches mean moving young people centre stage.
Spotlight on youth
There are now over 1.2 billion youth aged 15-24 years worldwide, and it is projected that nine out of ten youth will be living in Africa and South Asia by 2050.1 Research suggests that globally young people face unprecedented economic challenges, largely due to inequitable economic policies, climate change and the impact of the COVID-19 pandemic. This means investing in the health and wellbeing of young people is both an obligation and a priority. Crucially, we need to ensure young people in low- and middle-income countries (LMICs) are not left behind – not least because the recent pandemic exposed our interconnectedness, and reminded us that universal health coverage is essential for the wellbeing of all.2
Indicators of adolescent health can be seen as a barometer of the health of societies. For example, rates of adolescent childbearing are sometimes regarded as a proxy indicator of the progress of multiple sectors, from health and education to social and gender equity and the economy.3 We know, too, that targeted investments in LMIC settings can open a window of opportunity for a democratic dividend - this window opens when fertility declines rapidly, and economic and social policies facilitate increased education and labourforce participation, especially for women and girls.4
Positive Youth Development (PYD) has become a cornerstone of contemporary adolescent health programmes. Indeed, evidence suggest that systematically building the agency, assets and contributions of adolescents within an enabling environment is one of the most effective strategies for nurturing healthy, productive and engaged young people.5 There is evidence, too, that investing in the health and positive development of adolescent girls can have a multiplier effect – although this can mean addressing social determinants of health, and tackling embedded social norms. Despite the complexity of this challenge, there is recognition that when interventions are youth-led, youthrelevant and youth-focused they can be especially impactful.4 In short, programmes are likely to be most effective if they are designed and delivered by, with and for youth
This Learning Brief reviews evidence and lessons on advancing adolescent health from Mott MacDonald’s project experience, an extensive desk review, and interviews with a panel of technical experts and country-based practitioners. The Learning Brief gives particular attention to how health interventions for adolescents can be delivered at scale in LMIC settings, spotlighting what successful projects do differently, especially for young women and girls.
Advancing adolescent health by youth, with youth, for youth
‘By youth’ approaches
We consider ‘by youth’ initiatives to be those that are youthled and where the primary participants are young people. Many of these initiatives have a communication, education, skills building and/or youth advocacy dimension. They are often delivered in spaces where young people gather (such as schools, clubs and religious, sports and music venues) and harness popular modes of communication, such as digital and social media; they may also tap into the peer networks and spheres of influence associated with trending music, fashion and charismatic performers and sports personalities. In some cases, ‘by youth’ initiatives enable the voices of young people to be represented in key governance and decision-making structures.
Youth-led organisations (YLOs), such as the Youth Café, Kenya6 and SERAC, Bangladesh7 are primarily defined by their youthled approaches. In PYD terms, there is generally an emphasis on creating an enabling environment to build the agency and assets of young people and facilitate their social contribution.
What do successful projects by youth do differently?
Evidence synthesis suggests youth-led projects can be especially successful in advancing adolescent health and wellbeing when they:
• Involve young people in the full project cycle –from formative research, project design and pretesting activities, to project delivery, monitoring, evaluation and implementation research.8 9
SERAC-Bangladesh: Community-based development led by young people
Established in 1991, SERACBangladesh is a youth-led, not-for-profit development organisation with over 5,000 youth volunteers across 28 districts of Bangladesh. In all its projects, SERAC ensures young women and men aged 18-35 years are directly engaged in project delivery and implementation. Using equitable, participatory and inclusive approaches, SERAC aims to build capacity, raise awareness, undertake advocacy, and create a human rightsoriented environment to improve access to healthcare, education and sustainable livelihoods for young people and their communities – especially the poorest and most vulnerable.
• Engage young people as partners, rather than beneficiaries. Successful projects by youth harness peer learning and networks, inclusive, participatory approaches, and avoid domination of more privileged youth leaders. Evidence indicates that well-managed youth-led organisations can help support sustainability and scale, while timely organisational capacity development inputs are also beneficial.8
• Address gender dynamics – by prioritising the participation of young women and girls, while continuing to engage boys, young men and key social gatekeepers. This often requires skilled consensus-building on gender equality and rights, and culturally-sensitive discussions on gender roles and norms10 (see next section).
• Recognise diversity – do not regard young people as a homogenous group; rather successful projects harness diversity and recognise the importance of differentiated approaches, for instance by targeting: different age cohorts with age-appropriate messaging;4 tailoring initiatives to different interests, contexts and settings – e.g. rural, urban and humanitarian settings; and developing strategies for meaningfully engaging marginalised and/or out-of-school youth.11 12
• Build young people’s capacity – by assisting young people to build abilities, assets and agency, including age-appropriate sexual and reproductive health and rights (SRHR) knowledge and skills.4 This can mean working alongside teachers to deliver approved SRHR curricula more effectively using participatory pedagogic approaches.13
• Innovate and connect – by working with young people to overcome the digital divide (including any gender divide), build digital literacy and ensure safe, secure and optimised internet access. This can, in turn, assist the uptake of digital solutions that support adolescent health and wellbeing, along with youth involvement in the development of meaningful SRHR messaging.8 14
• Do no harm – by ensuring youth-led initiatives receive training and support observe the highest standards of Safeguarding and mutual respect; this includes being alert to any issues that could lead to harm, exploitation or heightened vulnerability of individuals or groups.15
GEC: Empowering girls to end violence in schools
As a consortium lead for the UK-funded Girls Education Challenge (GEC) Fund, Mott MacDonald conductied a lessons synthesis on ‘ending violence in schols’. Adolescent girls are especially vulnerable to gender based violence (GBV) in many of the LMIC settings where GEC partners work. Programme partners have identified four key strategies for an effective response:
1. Supporting girls’ awareness of violence, including their rights and legal protections.
2. Encouraging girls to take the lead, using participatory methods to develop interventions based on lived experience of school-related GBV.
3. Creating a school culture that respects the rights of children and adolescents, regards their welfare to be of paramount importance, and ensures their needs are both listened to and met.
4. Developing zero-tolerance policies and codes of conduct for all school actors, with training to ensure knowledge/ acceptance of Safeguarding as both a legal and moral responsibility.
The GEC (2017-2025) covers 41 projects in 17 countries. EGC aims to ensure beneficiary girls to complete primary school, transition to secondary education, and progress onto technical vocational training or employment.
‘With youth’ approaches
Young people cannot thrive in isolation. They need the support of trusted adults, communities and wider social networks to acquire the knowledge, skills and resilience they need to meet their potential as healthy, productive and engaged adults. For young women, girls and other disadvantaged youth, this can mean challenging social and gender norms that are restrictive, or result in harmful outcomes, such as female genital mutilation (FGM), early marriage and childbearing, and reduced access to education, healthcare etc.
Transforming social and gender norms is complex and requires multisectoral approaches within a shared socio-ecological framework, and building of an integrated ‘enabling environment’. Addressing harmful social norms on adolescent SRHR typically requires interventions at every level, including information and life-skills education for young people; engagement and respectful dialogue with parents, key gatekeepers (community and religious leaders, elders etc.) and change agents (teachers, political leaders etc.); media campaigns and advocacy (e.g. for new laws and policies). All these activities need to be carefully monitoring for progress, and early identification of unexpected consequences or social backlash.16
What do successful projects with youth do differently?
Evidence synthesis suggests projects ‘with youth’ can be especially successful in advancing adolescent health and wellbeing when they:
• Include effective social and behavioural change communication to reinforce adolescent health interventions and engage social support. Coordinated mass media, social media and community-based communication have proved useful, especially when designed by and with young people using diverse formats – e.g. edutainment via television series, films, radio dramas and interactive theatre. Participatory and reflective community-based dialogue using mixed methods can also be effective – with message uptake being highest where girls and their families have actionable options.17
• Provide Safe Spaces and opportunities for girls’ empowerment – for example through girls’ clubs. Safe Spaces that offer girls knowledge, life skills, ‘social and emotional learning’18 and access to peer networks under the supervision of a proficient mentor can help girls stay healthy, avoid early marriage, know their rights and where to get help.4 19 Uptake of health services can be improved with the support of community-based
female outreach workers, while partnerships with women’s rights organisations often provide girls with additional role-models, referral pathways, and linkages to an enabling environment.20 8
• Provide appropriate information from an early age. There is a growing evidence-base to suggest that curriculum-based SRHR education is most effective and protective when it begins with ‘very young adolescents’ (VYAs) by providing targeted age-appropriate information and activities for those 10-14 years old.21
• Address men and boys. Initiatives to change harmful gender norms and practices, such as GBV, are often more effective when they address men and boys in their specific gender roles and behaviours. These interventions tend to be most impactful when they enlist respected men as trainers and role-models, and when they are aligned to interventions for women and girls.22
• Link girls’ education to economic incentives and skills. Cash transfers can be an effective tool for postponing the marriage of adolescent girls – although they are rarely sufficient for changing gender norms. Complementary programming that offers vocational and financial skills training for adolescents is also beneficial.23 24
• Invest in continuous monitoring from the outset to assess the effectiveness of messaging, adapt programming, assess progress to results that are meaningful to beneficiaries and communities,25 promote shared learning and identify/mitigate any backlash. Inclusive community-based feedback mechanisms help keep key stakeholders fully engaged and surface alternative views and perspectives.16 Digital platforms can be used to support ‘social listening’ and tracking shifts in social discourse.26
GEC: Supporting Girls Clubs and Safe Spaces
Lessons from the GEC programme show that school-based girls clubs bring adolescent girls together in a place seen as legitimate by parents and community members. This legitimacy means parents are more supportive and the risk of community backlash is limited. In weekly ‘safe spaces’, girls catch up in subject areas, learn about their sexual and reproductive health rights, form friendships and share experiences. Content covered within the GEC girls’ club tends to respon to gaps in girls; knowledge or skills that are not met elsewhere at home or at school.
1. Inviting parents, caregivers and community members to participate from the outset helps improve buyin and community support.
2. Being inclusive by extending access to girls with disabilities and other disadvantaged groups helps reduce marginalisation and stigma.
3. Including ‘social and emotional learning’ (SEL) curriculum can help to improve mental health and psychosocial support (MHPSS).
4. Adopting a pragmatic, flexible approach helps support regular attendance and access, particularly for vulnerable girls.
GEC_learning_brief_girls_clubs_final. pdf (girlseducationchallenge.org)
‘For youth’ approaches
In its global report on Adolescent Health, WHO refers to adolescents as ‘the Missing Population in Universal Health Coverage’. Yet, adolescence represents a critical “window of opportunity” since investments in adolescents can deliver a “triple dividend” by improving health now, enhancing it throughout the life course and contributing to the health of future generations. In addition, healthy adolescents can fuel economic growth by contributing to increased productivity and reduced health expenditure.2 Similarly, the UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) with its ‘Survive, Thrive and Transform’ agenda warns that multiple SDGs
pertaining to health, education, poverty, climate change and peaceful and inclusive societies, will not be achieved without further investments in transformative initiatives and policies for youth.27
What do successful projects for youth do differently?
Evidence synthesis suggests that projects ‘for youth’ can be most effective when they successfully engage governments, donors and development partners to prioritise adolescent health and wellbeing at scale with investments to:
• Improve adolescent health services using a ‘gender lens’. Governments must reach adolescents with high quality, well-coordinated and well-integrated services underpinned by continuum of care approaches. Evidence suggests this needs to include mental health and SRHR services that adopt a rights-based approach to specific gender and sexual health needs. This often needs concerted advocacy efforts complemented by laws guaranteeing accessible, quality, nonjudgemental health services for adolescents.2
• Improve health financing at each health system level to ensure adolescent health strategies are adequately and predictably resourcedwith both human and financial resources - to reach the most vulnerable and marginalised adolescents and their families at scale.2
• Improve health governance and evidence-based decision-making. Promoting good health sector governance must involve inclusion of mandated youth representatives in key governance structures at each system level so they can contribute to, influence and act upon the issues that affect their health and development. This decision-making should be informed by reliable flows of quality age and sex disaggregated data.2
• Improve resilience to social, economic, health and climate shocks. We know that the social, emotional and physical environments in which adolescents live and learn have significant influence on their health. From climate change to armed conflict, migration, demographic change, pandemics and economic downturns, adolescents are often disproportionately affected – either directly or as a result of coping strategies such as early child marriage. Youthfocused investments in resilient health and social systems and ‘One Health’ approaches are necessary to assist preparedness, mitigation, adaptation and rapid recovery of young people and their communities.4 27
•
Strengthen robust digital and data governance
New technologies and social media provide adolescents with opportunities for better access to educational information and services, but can also reinforce vulnerabilities and expose them to bullying, sexual exploitation, scams and mental health harms. Artificial intelligence may have profound implications for the lifestyles, livelihoods, career pathways and security of young people. Timely investments are needed to ensure young people remain active and informed contributors to civic engagement platforms, and influence the development of legal, regulatory and safeguarding frameworks on these key issues.4 28
Health young people contributing to sustainable, resilient livelihoods in Bangladesh
Some of Mott MacDonald’s most exciting work on advancing adolescent health has been taking place in the context of wider initiatives on social development and climate change. Since 2022, we have been helping to build sustainable, climate resilient livelihoods in Chattogram Hill Tracts region of Bangladesh by strengthening physical, human, social, natural and financial capital.
The human capital component of this project focuses on improving the access of marginalised women and girls to quality health services, education and vocational skills. This component is linked, in turn, to efforts to strengthen livelihoods through improved infrastructure and connectivity, participation in governance structures, and community-based iniatives on management of natural resources.
Although the project is in the early stages, there are already indications that, by working collaboratively to build the assets and agency of young people, the project is contributing to reduced gender inequality, while also contributing to sustainable, resilient rural development and improved food security.
https://www.adb.org/projects/54047-001/main
References
1 United Nations. (2015). Population Facts. Youth population trends and sustainable development. Available at: https://www.un.org/esa/socdev/ documents/youth/fact-sheets/YouthPOP.pdf
2 WHO et al. (2019). Adolescent Health: The Missing Population in Universal Health Coverage. Available at: https://pmnch.who.int/resources/ publications/m/item/adolescent-health---the-missingpopulation-in-universal-health-coverage
3 United Nations.(2018) World Youth Report: Youth and the 2030 Agenda for Sustainable Development. Available at: Youth and the 2030 Agenda for Sustainable Development | United Nations For Youth
4 USAID. (2022). Youth in Development Policy: 2022 Update. Available at: Youth in Development Policy | Strategy and Policy | U.S. Agency for International Development (usaid.gov)
5 USAID and Youth Power Learning. Examples of Adolescent and Youth Reproductive Health and Positive Youth Development Program Activities Aligned with PYD Features, Mapped to a Socio-Ecological Model. Available at: https://www.youthpower.org/sites/default/files/YouthPower/ files/resources/PYD%20MATRIX%20AYRH_final%20edit.pdf
6 The Youth Café: The Youth Cafe | Youth Empowerment in Africa | Creating a Better Future
7 SERAC-Bangladesh: SERAC Bangladesh – A youth focused rights and development organization (serac-bd.org)
8 Oxfam. Youth as Active Citizens: 12 ways towards youth-led programming. Available at: 12 ways towards youth-led programming (oxfam.org.uk)
9 Gibbs, L. et. Al. (2020). Using Technology to Scale up Youth-Led Participatory Action Research: A Systematic Review, Journal of Adolescent Health, Volume 67, Issue 2, Supplement, 2020, pp. S14-S23.
10 Bill & Melinda Gates Foundation. (2018). Youth Clubs, Girls’ Empowerment and Gender Equality: Implementation lessons from the WGCD Grand Challenge. Available at: https://www.ungei.org/sites/ default/files/Youth-Clubs-Girls%27-Empowermentand-Gender-Equality-Implementation-lessons-fromthe-WGCD-Grand-Challenge-2018-eng.pdf
11 UNFPA. (2020). International Technical and Programmatic Guidance on Out-of-School Comprehensive Sexuality Education. Available at: https://cdn.who.int/media/ docs/default-source/hrp/9780897140454.pdf
12 Mott MacDonald/Cambridge Education. (2023). Girls Education Challenge. Community-based education: informal and invaluable. Available at: https://girlseducationchallenge. org/media/b54hvxmn/gec_learning_brief_cbe_final.pdf
13 Wangamati, C. K. (2020) Comprehensive sexuality education in sub-Saharan Africa: adaptation and implementation challenges in universal access for children and adolescents, Sexual and Reproductive Health Matters, 28:2
14 Ross, K.M., Tolan, P.H. (2021). Positive Youth Development in the Digital Age: Expanding PYD to Include Digital Settings. In: Dimitrova, R., Wiium, N. (eds) Handbook of Positive Youth Development. Springer Series on Child and Family Studies. Springer, Cham
15 National Youth Agency. Safeguarding for Youth Work. Available at: Safeguarding for Youth Work – NYA
16 The Social Norms Learning Collaborative. Monitoring Shifts in Social Norms. A Guidance Note for Program Implementers. Available at: https://www.alignplatform. org/sites/default/files/2021-04/lc_monitoring_shifts_ in_social_norms_a_guidance_note_eng.pdf
17 High-Impact Practices in Family Planning (2022). SBC Overview: Integrated framework for effective implementation of the social and behavior change high impact practices in family planning. Available at: SBCOverview_HIPbrief_2022.pdf (fphighimpactpractices.org)
18 Mott MacDonald/Cambridge Education. (2023). Girls Education Challenge. More than grades: The importance of social and emotional learning in girls’ education. Available at: https://girlseducationchallenge.org/ media/nqkbm2nk/gec_learning_brief_sel_final.pdf
19 Mott MacDonald/Cambridge Education. (2023). Girls Education Challenge. A space of their own: What we have learned about Girls’ Clubs. Available at: https://girlseducationchallenge.org/media/t4zlxkbp/ gec_learning_brief_girls_clubs_final.pdf
20 High-Impact Practices in Family Planning (2014). Mobile Outreach Services: Expanding access to a full range of modern contraceptives. Available at: https://www. fphighimpactpractices.org/briefs/mobile-outreach-services/
21 WHO. Global Early Adolescent Study Training Suite: A resource for research and programming with very young adolescents. Available at: GEAS Training Suite — Global Early Adolescent Study (geastudy.org)
22 High-Impact Practices in Family Planning. Engaging Men and Boys in Family Planning: A Strategic Planning Guide. Available at: https://www.fphighimpactpractices.org/ guides/engaging-men-and-boys-in-family-planning/
23 High-Impact Practices in Family Planning. (2017). Economic Empowerment: A Potential Pathway for Women and Girls to Gain Control Over Their Sexual and Reproductive Health. Available at: Economic Empowerment | HIPs (fphighimpactpractices.org)
24 Mott MacDonald/Cambridge Education. (2022). Girls’ Education South Sudan: Cash Transfers update!. Available at: https://girlseducationsouthsudan. org/cash-transfers-update/
25 Mott MacDonald/Cambridge Education. (2023). Girls Education Challenge. Effective education for girls in emergencies and protracted crises: A different measure of success. Available at: https://girlseducationchallenge. org/media/bg4mivy3/gec_learning_brief_fcas_final.pdf
26 Sommariva, Silvia, et al. “Social listening in Eastern and Southern Africa, a UNICEF risk communication and community engagement strategy to address the COVID-19 infodemic.” Health security 19.1 (2021): 57-64.
27 United Nations. (2015). The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030). Available at: EWEC_globalstrategyreport_200915_FINAL_WEB.pdf
28 UNICEF. The future of youth participation online: Understanding recent trends in digital civic engagement by adolescents and young people. Available at: https://www.unicef.org/globalinsight/ stories/future-youth-participation-online