Social determinants of adolescent health as reflected the SDG agenda
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Presentation by Dr Nicola Jones at the opening of the 4th IAAH MENA region Adolescent Health conference in Hurghada, Egypt
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Social determinants of adolescent health as reflected the SDG agenda
- 1. Social determinants of adolescent health as reflected the SDG agenda Dr. Nicola Jones GAGE Programme Director 4th IAAH MENA REGION Adolescent Health Conference December 2021
- 2. Overview The SDG framework, premised on the goal to leave no one behind, centres the global development agenda around the world’s most disadvantaged and overlooked populations – including adolescents. To understand the challenges faced by marginalised populations, SDGs call for robust and disaggregated data that captures inequalities faced by women, girls & young people more broadly, whose realities are often masked by reporting. GAGE has investigated what we can learn about adolescent and youth well-being based on available SDG data, and the extent to which data are usefully disaggregated in order to leave no one behind. If adolescent girls and boys are not visible in data then they will also be absent in policy priorities and so it’s key we leverage the potential of the SDGS to this end.
- 3. SRH, health and nutrition Data series for undernourishment (2.1.1) food insecurity (2.1.2) essential health service coverage (3.8.1) access to drinking water (6.1.1) and sanitation services (6.2.1) draw from indices that report on whole populations that often account for urban and rural divides but offer little insight into potential disparities associated with adolescent age or sex.
- 4. Adolescent SRH But adolescent birth rates are collected for 15-19-year olds, only; not for very young adolescents Girls who become pregnant in adolescence are at higher risk of a wide variety of adverse health outcomes for themselves and for their children including preventable causes of death
- 5. GAGE data find that the pandemic has exacerbated health risks, particularly in the most vulnerable communities. In Jordan, GAGE data shows that access to contraceptives was impeded in the initial months of COVID-19, and adolescent pregnancies increased. Across geographies, food insecurity increased – particularly in contexts of displacement. 31% boys and 39% of girls living in ITS in Jordan reported reduced dietary diversity during the pandemic. Adolescents also reported eating fewer meals and more food shortages. SRH, health and nutrition in COVID-19: GAGE data
- 6. Bodily integrity & freedom from violence SDG data from Jordan shows that adolescent girls are at greater risk of IPV than young women: 18% of girls aged 15-19 experienced IPV in last 12 months, compared to 15% of 20-24 year-olds. However, identifying country IPV trends over time is difficult due to lack of regularly collected and reported data.
- 7. Bodily integrity & freedom from child labour We analyze child labour data in this domain, as specific forms of child labour present a threat to adolescent bodily integrity Lumping age bands in child labour metrics is not helpful While Jordan reports on children under 18 years, Palestine and Tunisia only report for under 14 years.
- 8. Protection from violence in COVID-19: GAGE data Across contexts, many adolescents reported increased tensions at home, and greater risk of violence during COVID-19 In Jordan, GAGE qualitative data highlights that increases in intra-household conflict during the pandemic were due to economic downturn and male family members spending more time at home.
- 9. Psychosocial well-being and social connectedness There is a total absence of adolescent psychosocial well- being in the SDGs. We use 16.2.1 as a proxy of a lack of trusted adult support, i.e. adolescents who experience violent caregiver punishment and/or psychological aggression. 92% of Palestinian children and adolescents experience this physical or psychological aggression.
- 10. Voice, agency and community engagement This domain centres on a young person’s ability to meaningfully and safely participate in their household, school and broader community. Again, there is very little in the SDG framework. We use SDG Indicator 5.4.1 on time spent on unpaid domestic and care work as a proxy. Reporting on time use is very sparse.
- 11. Conclusions and implications 1 • Bodily autonomy, integrity and freedom from violence Focus data collection on specific age ranges to account for the variance in threats to bodily integrity. Share good practice examples of indicators employed among stakeholders across the region, including through the Arab Coalition on Adolescent Health network. 2 • SRH, health and nutrition Strengthen data collection on access to health services and infrastructure to identify gaps based on age &d sex. Provide guidance to Ministries of Health and Youth on appropriate indicators and publish an annual league table to promote progress & accountability. 3 • Psychosocial well-being and connectedness, voice and agency • Collect and report data more frequently and regularly on indicators for SDG targets 5.4 (unpaid care and domestic work), 16.2 (caregiver aggression) to establish observable trends in countries/ regions over time. • Complement this with efforts to promote data collection on adolescent girls’ psychosocial wellbeing (SDG 3) and voice and agency in the family, classroom and community as indicators of antecedents of women’s political empowerment (SDG 5.5).
Notas do Editor
- Many thanks for the kind introduction So as to set the stage for the rich discussions that we will be having together these next three days my presentation focuses on the extent to which adolescent health and wellbeing is reflected in the Sustainable Development Goal agenda. We are now nearing the end of the 1st year of the so-called Decade of Action and as such it’s a critical moment to take stock of what progress has been made for young people aged 10-19 years, and what more needs to be done to enhance their prioritisation in policies and programmes.
- The SDG framework, premised on the goal to leave no one behind, centres the global development agenda around the world’s most disadvantaged and overlooked populations – including adolescents. To understand the challenges faced by marginalised populations, the SDGs call for robust and disaggregated data that capture inequalities faced by women, girls & young people more broadly, whose realities are often masked by reporting. It is critical to highlight that while adolescents make up an estimated one seventh of the global population, only 18 of the 232 SDG indicators explicitly call for disaggregation by gender and adolescent- or youth-specific age categories, meaning that too little data has been accrued on girls’ and boys’ lives, thereby concealing their specific needs and vulnerabilities. Bearing this in mind, GAGE has investigated what we can learn about adolescent and youth well-being based on available SDG data, and where key gaps are that require complementary data collection efforts in order to strengthen policy and programme agendas so that no young person is left behind. In this presentation I’m going to focus in on our findings about SDG targets relevant to adolescent health and related social determinants, and where possible draw on examples from countries in the Arab world including primary research findings from phone surveys that we conducted with approximately 4000 adolescents in Jordan and Palestine during the covid-19 pandemic.
- So let us begin with SDG goals related to nutrition and food security, physical health and wellbeing and access to clean water and sanitation. It is important to highlight that the data series for goals 2, 3 and 6 draw from indices that report on whole populations that often account for urban and rural divides, but offer little insight into potential disparities associated with adolescent age or sex. These gaps constitute limitations in the effort to achieve equitable health outcomes, especially given that adolescent girls in particular are frequently distinctly disadvantaged when it comes to accessing health and sanitation services.
- So if we look at Indicator 3.7.2 which measures the prevalence of adolescent mothers, the SDGs are providing an important window on to the risk of adolescent birth rates for 15-19 year olds. This is vital as it makes visible this highly vulnerable group who at higher risk of a wide variety of adverse health outcomes for themselves and their children, as well as risks of school drop out and truncated economic opportunities esp. given that 90% of births among adolescents take place within the context of marriage. What it omits however is the risk of adolescent births among very young adolescents – i.e. those aged 10-14 years who are the most vulnerable. Yet UNFPA estimates that 1 in 25 girls are married in the Arab World before their 15th birthday.
- With the Covid-19 pandemic adolescent health and nutrition risks have been exacerbated, putting SDG targets further in jeopardy. Findings from research that GAGE has undertaken in Jordan with adolescents in 2020 with support from WHO EMRO underscore that the most disadvantaged young people have been particularly affected. Access to contraceptives for married girls was impeded in the initial months of Covid-19 in Jordan in both host communities and refugee camps due to lockdowns and service closures, and adolescent pregnancies increased. Similarly, in terms of nutrition, adolescent experiences of food insecurity increased, especially for highly vulnerable Syrian refugees living in informal tented settlements and particularly for girls, 39% of whom reported reduced dietary diversity and eating fewer meals.
- Turning now to SDG 5 on gender equality, this goal emphasises the protection of adolescents from physical and sex- and gender-based violence, including child marriage, harmful traditional practices, and other forms of coercion – vulnerabilities that are often magnified for adolescents in the second decade of life – and impact their health and well-being. If we look at SDG indicator 5.2.1 on intimate partner violence we can see that adolescent girls are often especially at risk due to the lack of power that many adolescent girls face in contexts where social norms allow for child marriage. In Jordan, national data shows that adolescent girls are at greater risk of IPV than women aged 20-24: 18% of girls aged 15-19 experienced IPV in last 12 months, compared to 15% of 20-24 year olds. However, identifying country-level IPV trends, which could help establish progress (or lack thereof) over time, is difficult due to lack of regularly collected and reported data.
- Another aspect of adolescent bodily integrity that we explore in the report refers to adolescent freedom from child labour. However, SDG indicator 8.7.1 on child labour is neither disaggregated by adolescent nor youth age but instead reports data for all children aged 5–17. This is a prime example of the problems associated with a lack of systemic and nuanced data disaggregation as clearly comparing the diverse capacities and development trajectories of a 5 year old with a 17 year old is not illuminating for policy makers or programme designers. It is also important to note that data included in this series does not capture the worst forms of child labour including human slavery, recruitment of children as child soldiers or into prostitution – thus exacerbating the invisibility of these highly vulnerable children from policy and programming priorities
- In the context of Covid-19, our findings highlight that risks to adolescent bodily integrity and freedom from violence have become heightened. In Jordan we found that almost half (49%) of adolescents surveyed described increased levels of intra-household conflict. Our qualitative research findings identified the economic downturn and the fact that male family members were spending more time at home with associated greater time burdens on women and girls having to cater to their needs as key drivers of these tensions.
- Adolescent psychosocial wellbeing and social connectedness is another critical aspect of adolescent health. But there is a total absence of indicators to assess adolescent psychosocial wellbeing in the SDG framework. We looked at: SDG indicator 16.2.1 as a proxy for lack of support from a trusted adult – i.e. the percentage of children and adolescents who experience violent caregiver punishment or psychological aggression. In Palestine for example, findings show that 92% of Palestinian children and adolescents experience caregiver violence or aggression. However, of the countries we examine here, none have data points from more than a single year, making the degree of progress over time difficult to ascertain.
- In terms of adolescent voice, agency and community engagement all of which are critical to adolescent health and wellbeing again we find no specific indicators in the SDG framework As a proxy, we analyse SDG indicator 5.4.1: Proportion of time spent on unpaid domestic and care work, by sex, age and location for this domain, and find that reporting on this domain is sparse From the list of countries examined in our report, only Palestine reports data for 15-24 year olds. To the extent that data is available, it clearly show that girls are disadvantaged over their male peers when it comes to negotiating their own time use, with girls 7x as likely to be burdened by unpaid care and domestic work – but as you can see by the low rates – 14% for girls and 2% for boys these figures likely suggest significant rates of under-reporting.
- So what are the implications of these findings? Broadly speaking our report underscores that the data needed to raise the profile of adolescents in the policy agenda at a global and regional level are significant and urgent. If young people aged 10-19 years are not visible in the data underpinning progress reports towards the SDGs, they are likely not to be accorded the priority in funding and policies that this life-stage merits with implications for this cohort now and over the life-course. More specifically, in terms of a data and research agenda, our findings point to three key priority actions: First, in terms of Bodily autonomy, integrity and freedom from violence: It is critical to focus data collection on specific age ranges to account for the variance in threats to bodily integrity pertaining to different ages. For example, younger adolescents may be more vulnerable to violent methods of discipline from parents, whereas the threat of GBV is magnified in the mid-adolescent stage given high rates of IPV in the context of child marriages. In this regard, sharing good practice examples of indicators employed among stakeholders across the region will be important, including through the Arab Coalition on Adolescent Health. Second, in terms of SRH, health and nutrition: In addition to collecting much needed data on adolescent birth rates for very young adolescents, it is key to sharpen the focus of data collection on access to health services and infrastructure to identify gaps based on age and sex in addition to more generalised parts of the population. Providing guidance to Ministries of Health and Youth on appropriate indicators and publishing an annual league table to promote progress & accountability could be a helpful first step. Finally, in terms of psychosocial well-being and connectedness, voice and agency: Given the dearth of adolescent-specific indicators in the SDGs for these key domains, collect and report data more frequently and regularly on proxy indicators including SDG targets 5.4 (recognise and value unpaid care and domestic work) and 16.2 (ending caregiver aggression) in order to establish observable trends in countries and regions over time. This needs to be complemented with efforts to promote data collection on adolescent girls’ psychosocial wellbeing ( in line with SDG 3) and voice and agency in the family, classroom and community as indicators of antecedents of women’s political empowerment (SDG 5.5). You can find more detail and data in our report online here as well as on GAGE research on adolescent capabilities and wellbeing more broadly – about which my colleagues Dr Bassam Abu Hamad and Sarah Alheiwidi will be presenting in sessions later today.