Outcome data: behaviours
Outcome data measure health behaviours as well as the coverage of health services for adolescents. Data on outcome indicators are available from multi-country household surveys supported by the United States Agency for International Development and United Nations agencies, including school-based surveys supported by WHO.
Nationally representative household surveys. These surveys—the Demographic and Health Surveys,11 the AIDS Indicators Surveys (AIS)12 and the Multi-Indicator Cluster Surveys (MICS)13 —include a focus on adolescents. However, in general, these surveys provide data only on 15–19 years olds, not younger ages, and mostly for married females and for indicators relating to sexual and reproductive health and HIV. They give little attention to boys. (Some countries include the modules for men and the modules on tobacco and alcohol use.) Data on adolescents from these surveys since 2005 are available for 103 countries.
One advantage of these data is that they are representative of the general population of adolescents and not just those in school. They can be analysed by rural/urban residence, educational status and wealth quintiles. Also, the co-prevalence of certain behaviours, such as smoking, alcohol use and violence, can be assessed. These surveys provide data on specific health-related behaviours that are included among the WHO proposed list of health indicators for adolescents: age at first sex, pregnancy, prevalence of sexually transmitted infections (STIs), HIV, HIV testing and counselling and skilled attendance at childbirth.
WHO’s STEPwise approach to surveillance (STEPS)14 is a population-based household survey that gathers self-reported information on risk factors for noncommunicable diseases. In some of the STEPS surveys, body mass index (BMI), waist circumference and blood pressure are measured as are, where possible, fasting blood glucose and total cholesterol. Such biological measurements have great value because self-reports of health status and health-compromising behaviours can sometimes be inaccurate. STEPS surveys have been undertaken in 90 countries, although in only 21 countries are data available separately on 15–19 year olds, and not all studies include biochemical measurements.
The STEPs dataset includes a number of indicators in the WHO proposed list of health indicators for adolescents, namely, those assessing obesity, tobacco and alcohol use, physical activity and consumption of fruit and vegetables.
The Global Adult Tobacco Surveys (GATSs) provide tobacco use data for 15–19 year olds from nationally representative household surveys.15 It would be informative to compare smoking rates among 15-year-olds from household and school-based surveys in the same country. However, the household and school-based surveys have not collected data in the same year. Even if this were the case, the small sample of 15-year-olds, particularly in the household surveys, would make meaningful comparisons difficult.
Nationally representative school-based surveys. Various countries carry out a number of school-based surveys: the Global Youth Tobacco Survey (GYTS),16 the Health Behaviour of School Children survey (HBSC),17 and the Global School-based Student Health Survey (GSHS).18 These surveys collect information about health-related behaviours during adolescence. They help countries identify gaps in existing policies and programmes. The surveys focus on 13–15 year olds. The HBSC also collects data on 11-year-olds. In addition to the information on risks factors for noncommunicable diseases, these school-based behavioural surveys report on the prevalence of underweight, interpersonal violence and substance use, all of which are proposed in WHO’s list of health indicators for adolescents.
Limitations and strengths. School-based surveys have their limitations. In some countries many children are not enrolled in school, retention rates are low, and absenteeism is high. Therefore, adolescent girls and adolescents who are marginalized and vulnerable are likely to be under-represented. Still, school-based surveys provide data on adolescents less than 15 years of age, which can complement the household survey data available mostly for older adolescents. With increasing school enrolment and retention and decreasing gender gaps in enrolment, school-based surveys are likely to become more useful.
Valuable information in routinely collected on adolescent behaviours in high income countries as well, e.g. Australia, Netherlands and United States used in policy and programme development.
Netherlands
Adolescents on what stops them from using health services: Delays in public services, like at the hospital; often they attend to your needs but it’s already too late, and they can be very rude, which is psychologically damaging.
female, 18-19 Mexico
Adolescents on what stops them from using health services: Long distance from the health center, lack of information on available health services and lack of money to pay for health services like STI's treatment
female, 18-19 Uganda
Barriers to using services- Negative / judgmental attitude of health care providers, long waiting periods, lack of trust in diagnosis.
female, 18-19 Romania
I do not find enough time to perform sports and I find unhealthy food in front of me.
female, 18-19 Saudi Arabia
I just found out that my school has a nurse (two years after getting there).
female, 18-19 Peru
I don’t sleep well often; sometimes I don’t eat enough because I’m scared of gaining weight and sometimes I just don’t feel the need. I am also enormously stressed.
female, 18-19 France
Adolescents on what stops them from using health services: Fear, distance, not being aware that they (health services) are available in your region
female, 15-17 Switzerland
