A second chance in the second decade

Strategic information to guide the health sector response


Outcome data: use of health services

Special surveys. WHO has supported a number of countries to carry out national and district-level representative household coverage surveys of adolescents to assess their use of public and/or private health services. Additional topics covered include factors related to the use of such services, such as parental support, perceived barriers to accessing and using services, and satisfaction with aspects of services received—for example, privacy and confidentiality.

Such surveys in Bangladesh, Honduras, India, Malawi, the Republic of Moldova and Ukraine have provided important strategic information for planning and monitoring services for adolescents. For example, in India gender differences were apparent: Both adolescent boys and girls use government and private facilities, but boys also use pharmacies; more girls than boys use qualified doctors.

In the State of Haryana, India, quality improvement interventions for providing health services to adolescents were implemented at facility level and community-level support was generated for these services. Health-care providers received training and managers received orientation to the national standards for quality health service provision. In the surrounding communities the health-care providers advocated with gatekeepers the necessity of adolescent services and of trained community extension workers and adolescent peer educators to support adolescents in healthy and health seeking behaviours. Assessments supported by WHO headquarters and South-East Asia Regional and Country Offices showed that 55% of adolescents reported using government facilities where these interventions took place, compared with 36% reporting use of comparison facilities (WHO and SWACH Foundation: Adolescent Friendly Health Services Coverage Survey in Haryana, unpublished data).

In Malawi, the Republic of Moldova and Ukraine, it was possible to show increases in adolescents’ use of health services following interventions to implement standards, although no data were collected from comparison facilities.

Tanahashi diagram
Tanahashi diagram with definitions of levels of coverage

Health authorities undertake ad hoc reviews of facility data to shed light on issues, for example, the increasing prevalence of HIV among adolescents in Uganda stimulated a baseline assessment of service delivery.

Peter Elyanu

Health impact data

Health impact data include information on health status, mortality and morbidity. As discussed below, these data are not readily available for the adolescent age groups.

Mortality data from vital registration. Cause-specific mortality data are available from vital registration for 119 countries.19 These data are disaggregated by sex and age group. Countries reporting include almost all those in the Americas and Europe, close to half in the Eastern Mediterranean and Western Pacific regions and about one-third in South-East Asia but less than 10% of countries in the African Region. Country-level mortality data on adolescents are available to varying degrees.

Mortality data from estimations. WHO assesses the vital registration data assessed for their level of completeness and quality. Those that are classified as useable are used to estimate cause-specific mortality rates for WHO Member States. The most recent estimates available are for the years 2000 and 2012 (Global Health Estimates 2013)20 for Member States with a population of 300,000 or over in 2012.

For countries without useable vital registration data, WHO Global Health Estimates for causes of death are based on the results of the IHME-developed covariate-based estimation models for a large number of single causes. These estimates are used as inputs to overall estimation of numbers of deaths by country, cause, age and sex for the years 1990–2010 in the Global Burden of Disease 2010 study.

In addition, WHO Global Health Estimates included estimates on some specific diseases or causes as derived by its technical programmes.

However, these WHO country-level estimates are presented in broad age-group disaggregation (0–4, 5–14, and 15–24 years) and are therefore not specific for adolescents.

Mortality data from household surveys. In countries with inadequate vital registration systems, national household surveys can provide information on some causes of mortality during adolescence. For example, the DHS surveys report on maternal mortality in 15–19 year olds for 80 countries without vital registration data.

Disease surveillance. Most countries maintain disease surveillance systems, and their data often are disaggregated by sex and age. For example, in the countries of the Commonwealth of Independent States and in the Central Asian Republics, national-level data on STIs, HIV, abortions and pregnancies are available for the adolescent age group.

Data on non-health system determinants

In general, very little strategic information is available on individual-level determinants external to the health system. The household and school-based surveys discussed above provide some data on determinants of health outcomes for adolescents. The GSHS and HBSC surveys provide data on two important protective factors: connection to a trusted adult and regulation by a trusted adult. Both of these are included in the WHO proposed list of health indicators for adolescents.

DHS, AIS and MICS provide data on the prevalence of correct knowledge for the prevention of HIV, another indicator in WHO’s proposed list.


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

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

I just found out that my school has a nurse (two years after getting there).

female, 18-19 Peru

I do not find enough time to perform sports and I find unhealthy food in front of me.

female, 18-19 Saudi Arabia

Barriers to using services- Negative / judgmental attitude of health care providers, long waiting periods, lack of trust in diagnosis.

female, 18-19 Romania

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