The wellbeing of young people is rarely top of the healthcare agenda. This matters deeply as much of the cost and care, particularly of the elderly, is spent on combatting non-communicable diseases (NCDs) that often have their roots in behaviours acquired in childhood or adolescence. As children or adolescents make up a majority of the population in the 48 least developed countries and there are 1.8 billion young people globally aged between 10 and 24 this is a huge current and future problem.
This kind of issue is best addressed through health promotion, but this receives only a very small part of already stretched healthcare budgets, if any at all. In 2015 OECD countries allocated on average 2.8% of healthcare expenditure to health promotion and disease prevention.
Precise breakdowns of these limited funds are not widely available, the data for Scotland in 2017/18 may, however, be indicative. Activity on obesity, smoking and alcohol misuse for all age groups accounted for just 8% of ‘Health Improvement and Protection’ expenditure. For poorer countries the resources available are even smaller or non-existent.
This shortage of funds extends into research and with our partners we have been working to fill some of the resulting knowledge gaps about adolescent health. Our research aims to understand youth behaviour better; to identify and quantify the challenges; and to assess the effectiveness of some potential solutions to ensure that scarce resources are deployed as effectively as possible.
Our first major work contributed funding to a wide-ranging and ground-breaking study by the Johns Hopkins Bloomberg School of Public Health into the Well-being of Adolescents in Vulnerable Environments (WAVE), with five papers published in a special supplement of the Journal of Adolescent Health. This compared the health profiles of 15- to 19-year-old youth in similarly disadvantaged circumstances in five cities across the globe (Baltimore, Ibadan, Johannesburg, New Delhi, and Shanghai). The experience of these young people is likely to be aligned to, if more extreme than, that of other youth.
The study showed that negative perceptions of local environments and the absence of social capital (for example support from family, friends and neighbourhoods) was associated with ill health and especially mental ill health, and hindered young people from obtaining the resources they needed to secure good health.
“Physical health was simply not a top priority” said Dr Kristin Mmari of Johns Hopkins. The young people did, however, still have health concerns, primarily about sexual and reproductive health for girls, and tobacco, alcohol and drug consumption for boys, but they had little access to support mechanisms to resolve them. “Few adolescents sought any kind of healthcare services” resulting at least in part from “lack of trust in the formal healthcare system”. The family, “either the lack of it or being overprotected”, could be central to their trust in, and usage of, healthcare support.
These findings demonstrated the need to look at the issue in the round: addressing underlying psychosocial causes and the accessibility and acceptability of support, rather than just negative behaviours themselves.
The study helped to focus the YHP on developing mechanisms to support behaviour change away from NCD risk behaviours – especially smoking, alcohol misuse, poor diet and lack of exercise – and the underlying psychosocial issues such as lack of supportive peer groups and positive role models.
A second strand has been research to provide accurate and useful data to help guide policy. A series of studies by the Population Reference Bureau has brought together statistics from a range of sources to give an authoritative overview of NCD risk factors for adolescents across Africa, Asia and the Middle East, creating a traffic-light chart of the risk factors for young people by country. These underlying data have been supplemented, and made more accessible, in the Youth and NCDs Data Center where the data can also be interrogated using interactive maps. Dr Toshiko Kaneda, a senior research associate at PRB and project director points out that “the Data Center will help policymakers and others monitor risk behaviour trends around the world and inform effective responses to this growing public health problem.”
Research conducted by Imperial College London, supported by the YHP and published in The Lancet, focused on obesity, drawing together an information pool of 2,416 population-based studies including over 30 million young people aged 5–19 years. This magisterial study highlighted not just the general rise in childhood obesity, but compared and contrasted the incidence between regions. It has quickly become a key resource for researchers and policymakers – being cited over 300 times in other papers in the first year since its release and becoming the 7th most discussed journal article of any type in 2017.
Our third strand is to investigate and evaluate a variety of approaches to assisting positive behaviour change in young people through on-the-ground programmes. At the moment there are sixteen such YHP programmes in operation, with a further ten successfully completed and others in the pipeline. These have ranged from individual mentoring to large-scale engagement programmes involving hundreds of thousands of young people. This very diversity presents a challenge in how to evaluate them objectively and fairly.
Whilst we share statistical outputs on our YHP website this only tells part of the story and so we have experimented with Social Return on Investment (SROI) to investigate what the longer-term outcomes could be in terms of lives improved and extended.
To date we have evaluated four programmes on a common methodology from Brazil, Canada, India and Romania all of which are slightly larger scale and employ a variety of approaches. We have published the analysis which suggests that they have generated a very positive social return for the money invested. There are, however, many uncertainties in such an analysis as it projects behaviour and outcomes many years into the future and some of the underlying data are not as strong as we would like.
By publishing the report and sharing our methodology we hope to illuminate how change can occur and how it can be evaluated. This process has helped and encouraged us to capture our own data more effectively and we hope it will inform the monitoring and evaluation of others too.
We are more than aware that our efforts are dwarfed by the scale of the healthcare challenges that young people face; but by engaging other thought leaders and civil society organisations in discussions based on our evidence and working with local and national regulators, we are helping to get this information shared more widely and used more effectively.
 UNFPA, 2014, The Power of 1.8 Billion- Adolescents, Youth and the Transformation of the Future. Available at https://www.unfpa.org/sites/default/filespub-pdf/EN-SWOP14-Report_FINAL-web.pdf , accessed 4 April2018
 Gmeinder, M., D. Morgan and M. Mueller (2017), “How much do OECD countries spend on prevention?”, OECD Health Working Papers, No. 101, OECD Publishing, Paris. http://dx.doi.org/10.1787/f19e803c-en
 British Medical Association, 2017, Funding for ill-health prevention and public health in the UK.
 Altmetric, Top 100 articles 2017. Available at https://www.altmetric.com/top100/2017/#list [accessed 3 December 2018]