From policy to action
While knowing about the number of policies on adolescent health is useful, exploring the national context of policies and the stakeholders and processes involved in their development and implementation provides a deeper understanding of the path from policy to action.10
The potential impact and costs of an intervention are just two of many considerations for governments deciding how to address health issues. Another is the attitude of the public towards an intervention, as this will influence the success of implementation.
The Nuffield intervention ladder. A tool to assist in thinking about the acceptability and justification of different policy initiatives to improve public health is the “Nuffield intervention ladder”.11 This tool depicts the range of options available to government and policy-makers as a ladder of choices, with progressive steps from individual freedom and responsibility to state intervention as one moves up the ladder. Considering which policy “rung” is appropriate for a particular public health goal involves weighing benefits to individuals and society against the erosion of individual freedom. Economic costs and benefits also need be taken into account alongside health and societal benefits.Nuffield
Public opinion matters. A recent systematic review synthesized evidence on public opinion regarding policy measures to influence four behaviours of particular importance to adolescents’ health—alcohol consumption, tobacco smoking, diet and physical activity. The public acceptability of interventions depended on the behaviours, the intervention type (e.g. information provision; incentives; penalties), the target group of the intervention and whether the intervention had already been implemented. The review showed that the interventions on smoking were supported. Those interventions that were considered not to infringe on individuals’ behaviour and that targeted children and young people also generally received more support.12
Implementing marketing restrictions
Systematic monitoring of the implementation of some policy measures provides an indication of the actual protection of adolescents’ health in countries. Globally, 169 countries have adequately implemented at least one tobacco demand-reduction measure. Data on national tobacco policies indicate that, worldwide, 16% of adolescents are protected by comprehensive smoke-free laws, and only 10% are protected by bans on tobacco advertising, promotion and sponsorship.13
In the WHO Europe Region, most countries restrict or prohibit marketing of food and non-alcoholic beverages to children and adolescents.14 However, a study in the WHO Africa Region found that most countries had not implemented any of WHO’s recommendations on regulation of advertising of food and non-alcoholic beverages. Barriers to implementation included inadequate regulation of advertising in general, lack of institutional mechanisms to monitor regulation and, typically, lack of awareness of the issues.15 While 7 of 12 countries in the Eastern Mediterranean Region have some level of awareness of the need for measures to restrict food marketing, only 2 countries have implemented any16. In the Americas Region, there are 3 countries with government policies restricting food marketing. There are examples of self-regulation by food and advertising industries in other countries.17
Restricting marketing is becoming increasingly complicated as the number of media platforms increases. In addition to domestic television and radio, satellite and cross-border transmissions and, in particular, social media present new challenges. Social media may have limited reach on a per capita basis, but, nonetheless, very large populations are online, and industry is increasingly using social media to advertise. Advocates should themselves be using these new channels to warn communities and individuals about the marketing of dangerous or harmful products.18 This is particularly notable as very few adolescents involved in WHO global consultation recognized the role of the media in their health even though they acknowledged obtaining health information through social media (32%) and the Internet (44%).
Another policy measure important in addressing road traffic injuries, a major cause of death among adolescents, is the setting of lower blood alcohol concentration limits (≤0.02g/dl) for young drivers. This policy has been shown to be an effective means of reducing crashes related to drunk-driving among this age group19 and has been applied to date in 42 countries (23%).20Youth and alcohol: Legal blood alcohol concentration limits, by country
The example of HIV policy
As noted, attention to adolescents in national health policies has focused on improving access to health information and services, especially concerning sexual and reproductive health (SRH). Attention to pregnancy among adolescents is long-standing.21 With the advent of the HIV epidemic and realization of the high incidence of infections among young people, the focus now combines SRH and HIV. Millennium Development Goals (MDGs) 5 and 6 reflect these concerns. These MDGs in turn have given countries further impetus to take action. This stimulated the development of explicit age-specific policies and programmes in countries. Crucially, the establishment of these policies is monitored periodically.22
Concerted advocacy, development of technical guidance and increased technical and financial support for policy development and implementation in countries has taken place over the past several decades regarding adolescent sexual and reproductive health. WHO and other United Nations organizations, notably the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF), have been active. The participation of national and international civil society organizations, as stakeholders in the policy process, also has been crucial. One example is the International Planned Parenthood Federation, which monitors government commitment to developing policies on sexuality education and sexual and reproductive health services for adolescents.
More monitoring needed
Monitoring the implementation of national policies and strategies can lead to improvements and readjustment. Unfortunately, implementation of policies for adolescent health often is not monitored. For example, in the responses to the external evaluation of the implementation of the 2001–2007 plan for adolescent health of the WHO Americas Region,23 22 of 26 Member States reported establishing national adolescent health programmes. However, only 30% of the countries have national surveillance systems that cover adolescent and youth health indicators, and only 27% monitor and evaluate their programmes. The 2010–2018 plan sets targets to address various health issues for adolescent boys and girls and also establishes monitoring mechanisms.24
A law that criminalizes abortion, and if I have the need to end a pregnancy I could go to jail.
female, 15-17, Mexico
Improvement of the environmental situation in the country and the world. The tightening of laws on tobacco smoking and alcohol. As well as high quality medical service at any time.
female, 15-17, Republic of Moldova
’Many laws have rules about nutritional content and the fabrication of food in general, forbidding products that are dangerous to our health. Laws about not selling alcohol to minors and not smoking in public also help to preserve our health.
male, 15-17, France
I know government guidance is to eat 5 fresh fruit and vegetables per day and up to 2000 calories per day. I also understand that it is unhealthy and illegal to use cigarettes, drugs or alcohol.
male, 12-14, United Kingdom
These laws should be enforced with greater strength. Although I have chosen to abstain from such, I have friends my age and younger that are able to purchase alcohol, cigarettes and drugs and such on a regular basis.
female, 15-17, Switzerland