Understanding Social Determinants of Adolescent Health

SOCIAL DETERMINANTS OF ADOLESCENT HEALTH Updated July 2016 1

WHO COMMISSION ON THE SOCIAL DETERMINAN TS OF HEALTH, 2008 (SDH)

EXECUTIVE SUMMARY Our children have dramatically different life chances depending on where they were born And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality . In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the poorer the health. It does not have to be this way and it is not right that it should be like this.

understanding and enhancing health requires a focus upstream away from an individual s risk or protective factors to the social patterns and structures that shape people's chances to be healthy

the conditions in which people are born, grow, live, work and age shaped by the distribution of money, power and resources at global, national and local levels influenced by policy choices at each of these levels

SOCIAL DETERMINANTS Nations present young people with structures of opportunity as they grow up Structural determinants generate social stratification, such as national economic, political and social welfare systems and education systems. Intermediate determinants flow from the configuration of underlying social stratification determine differences in exposure and vulnerability to health compromising conditions. family environment, availability of food, recreation and education

LIFE-COURSE EFFECTS OF SDH (AFTER HERTZMAN .) Latent biological or developmental early life experiences which influence adult health independent of intervening experience Pathway experiences that set individuals onto life trajectories that influence health, well-being, and competence over the life course Cumulative accumulation of advantage or disadvantage due to exposure to unfavourable environments over time)

ADOLESCENT DEVELOPMENT: UNIQUE OPPORTUNITIES FOR SOCIAL DETERMINANTS TO INFLUENCE HEALTH Central Nervous System (CNS) and pubertal development, driving identity formation adoption of behaviours (e.g. smoking, drug use, sex) life stage transitions and changes in personal and social responsibilities and relationships entailed. World Bank: 1. learning: transition from primary to secondary to higher education 2. work: transition from education into workforce 3. health: transition to responsibility for own health 4. family: i.e. transition from family living to autonomy, early marriage and parenthood. 5. citizenship: transition to responsible citizenship

Transition to experience of unequal chances related to gender, ethnicity, education, employment and socioeconomic status These transitions may represent critical points for preventing the accumulation of health risk...

ADOLESCENCE MAY BE A SECOND CRITICAL PERIOD FOR SDH cumulative effects of early childhood development modified by new latent and pathway effects in adolescence new latent effects puberty & CNS development Initiate transitions in family, peer and educational domains new pathway effects related to transitions adoption of health behaviours

10-20 years = 17.7%

Mortality among males in Switzerland 1970-2008 200 180 160 140 120 1-4y 5-9y 10-14y 15-19y 20-24y 100 80 60 40 20 0 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2006 2004

VARIATIONS BETWEEN COUNTRIES

there are dramatic variations in adolescents health BETWEEN countries Teenage birth rate 15-19 yr Male smoking amongst 15 yo Timor-Leste Mozambique Georgia Guinea Czech Republic Cameroon Russian Federation Equatorial Guinea New Zealand Swaziland 52 PNG Gambia Namibia Dominican Republic Argentina Cape Verde Mauritania 199 Niger Togo El Salvador Syrian Arab Republic Bahrain Ghana Uruguay Antigua and Barbuda Congo Puerto Rico Barbados Grenada Jordan Turkey United Arab Emirates Bhutan Lebanon Rwanda Paraguay Kiribati Mongolia Trinidad and Tobago Fiji Singapore Jordan Equatorial Guinea United Kingdom Serbia Turkmenistan Myanmar Lithuania Kosovo Myanmar Fiji Tonga Viet Nam Maldives Nepal Maldives 0.9 Korea 2 Kuwait Cambodia France Tanzania Italy Iraq Slovenia Antigua and Barbuda Hong Kong SAR Maldives Korea (North) Democratic 0% 20% 40% 60% 0 50 100 150 200 Births per 1000 women 15-19yr % smoked in last month

VARIATIONS EXIST DESPITE SIMILAR ADOLESCENT DEVELOPMENTAL ISSUES SDH approaches focus upstream individual factors structures that shape people's chances to be healthy social patterns & national

EVIDENCE FOR THE SDH INFLUENCING ADOLESCENT HEALTH Review of literature Structural SDH Intermediate/proximal SDH Effect of structural SDH on intermediate determinants, influencing exposure Quality of data LMIC data Analyses of variations between nations Reflect variation within nations Informative re generalisability to LMIC

MALE MORTALITY RATE & GROSS DOMESTIC PRODUCT 250 Brazil Venezuela Ukraine Male all-cause mortality (15-19yr) & GDP Guatemala Colombia South Africa 200 Russian Federation Saint Kitts and Nevis mmort1519 Belarus Belize Kazakhstan Tajikistan 150 Lithuania Uzbekistan Estonia Argentina Latvia Uruguay Mexico 100 Panama Suriname Trinidad and Tobago Philippines United States of America Barbados Cyprus Portugal Slovenia New Zealand Kyrgyzstan Moldova, Republic of Kuwait Costa Rica Romania Saint Lucia Antigua and Barbuda Chile Croatia Czech Republic Dominica Georgia Grenada Hungary Austria Canada Finland France Spain United Kingdom Bahrain Greece IsraelItaly Korea, Republic of Poland Slovakia Ireland Bulgaria Mauritius Serbia Maldives Norway Australia Belgium Denmark Germany Iceland Japan Netherlands Sweden Luxembourg Azerbaijan Macedonia, TFYR Malta 50 Switzerland Singapore 0 20 40 GDP 60 80

TEENAGE BIRTH RATE & GROSS DOMESTIC PRODUCT Niger Chad Mali Mozambique 200 Uganda Gabon 150 Equatorial Guinea Venezuela teenpreg Mexico 100 Panama USA NZ UK 50 Australia UAE Qatar Luxembourg Tunisia 0 0 20 40 GDP 60 80

WEALTH AND GROSS DOMESTIC PRODUCT Poorer health Better health Smoking mental health Behaviour & Bullying Violence Injuries Female Teenage pregnancy Sexual health Male HIV prevalence All-cause mortality Mortality Injury mortality Non-communicable disease mortality Communicable disease mortality -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8

Equality line The Gini coefficient is calculated as the area A divided by the sum of areas A and B. 0= absolute equality 1= absolute inequality

ACCESS TO WEALTH: INEQUALITY HARMS AND KILLS Teenage birth rate 15-19 yr and Gini coefficient 250 Each 10 increase in Gini increases teen births by 30 per 1000 Niger 200 Mali Mozambique Malawi births per 1000 women Guinea-Bissau Uganda Guinea Sierra Leone Tanzania Burkina Faso Zambia Madagascar Gabon 150 Bangladesh Central African Republic Nigeria Somalia Benin Cote d'Ivoire Swaziland Gambia Kenya Venezuela Senegal Guyana Mauritania Yemen Ghana Jamaica Laos Ethiopia Honduras Zimbabwe Ecuador Lesotho 100 Colombia Panama Guatemala Mexico Papua New Guinea Haiti Argentina Puerto Rico Peru Philippines Bahamas Rwanda United States of America Burundi Fiji Kyrgyzstan Jordan Turkmenistan LithuaniaMorocco PolandMalaysia Greece Italy Tunisia Japan Namibia Brazil Cambodia Botswana South Africa EgyptIndia Bulgaria New Zealand United Kingdom Belarus 50 Cuba Romania Ukraine Hungary Slovakia Iceland Czech Republic Sweden Slovenia Singapore Cyprus China Algeria Gini coefficient 0 20 30 40 50 60 70 80

TEENAGE BIRTH RATE AND INEQUALITY 1990 1995 2000 2005 2010

GINI AND MALE ALL-CAUSE MORTALITY 250 Brazil Ukraine Venezuela Guatemala Colombia South Africa 200 Russian Federation mmort1519 Belarus 150 Kazakhstan Tajikistan Lithuania Uzbekistan Estonia Argentina Mexico Suriname United States of America Uruguay Bahamas Philippines 100 Panama Trinidad and Tobago Latvia Barbados Kyrgyzstan Moldova, Republic of Portugal Romania Serbia United Kingdom New Zealand Cyprus Costa Rica Slovenia Austria Cuba Finland France Luxembourg Malta Croatia Chile Poland Ireland Spain Bulgaria Greece Italy Korea, Republic of Switzerland Mauritius Canada Norway Slovakia Georgia Israel Macedonia, TFYR Australia Belgium Czech Republic Denmark Germany Hungary Iceland Netherlands Sweden Azerbaijan 50 Japan Singapore 20 40 60 80 Gini1

BULLYING AND INEQUALITY IN FEMALES 80 Zambia 60 Egypt Ghana Kenya Botswana Zimbabwe Lithuania Philippines Namibia Malawi Greece Indonesia fbully Benin 40 Chile Ukraine Swaziland Venezuela Guyana Turkey Jordan Mauritius Portugal Romania Tanzania Belgium Djibouti Pakistan Austria France Germany Luxembourg Norway Latvia Yemen Colombia Estonia Switzerland Sri Lanka Tunisia Canada Macedonia, TFYR Morocco Russian Federation Thailand Trinidad and Tobago Argentina Suriname Ecuador Bulgaria Ireland Mongolia United States of America Uruguay United Kingdom 20 Costa Rica China Hungary Netherlands Poland Czech Republic Denmark Finland Iceland Slovenia Sweden Italy Spain Tajikistan Croatia Malta 0 20 40 60 80 Gini1

EDUCATION

ACCESS TO EDUCATION: THE BEST HEALTH INTERVENTION Male 15-19 year all-cause mortality by education participation 250 Brazil Ukraine Each 10% rise in education decreases deaths by Venezuela Guatemala Colombia mortatliy per 100,000 pyo South Africa 20 per 100,000 200 Belarus Saint Kitts and Nevis Belize Kazakhstan 150 Tajikistan Lithuania Uzbekistan Trinidad and Tobago Estonia Argentina Mexico Bahamas Panama Philippines United States of America Uruguay 100 Kyrgyzstan New Zealand Suriname Kuwait Cyprus Portugal Chile Slovenia Saint Lucia Poland Romania Croatia Ireland Greece Maldives Georgia Norway Australia Spain France Malta Hungary Iceland Luxembourg Korea, Republic of 50 Switzerland Japan Netherlands Sweden % boys in secondary education 0 30 40 50 60 70 80 90 100

EDUCATION & TEENAGE BIRTHS 200 Niger Chad Mozambique Mali Liberia Malawi Guinea-Bissau Uganda Angola 150 Afghanistan Guinea Madagascar Sierra Leone Tanzania Zambia Bangladesh Burkina Faso Nigeria Benin Cote d'Ivoire Ethiopia teenpreg Lao People's Democratic Republic Nicaragua Swaziland Gambia Guatemala Sao Tome and Principe Vanuatu 100 Kenya Zimbabwe Venezuela Dominican Republic Ecuador Lesotho Colombia Marshall Islands Senegal Cape Verde Belize Mexico Panama Bolivia Mauritania Togo Eritrea Yemen Namibia Syrian Arab Republic Saint Vincent and Grenadines Suriname Uruguay Solomon Islands Ghana Iraq El Salvador Saint Kitts and Nevis Cayman Islands Grenada Saint Lucia United States of America Paraguay Argentina Brazil Cuba Georgia Kiribati Kyrgyzstan Lebanon Mongolia Saudi Arabia Switzerland Jamaica Peru South Africa Seychelles Philippines Cambodia Botswana Egypt Indonesia Turkey 50 Chile Dominica Bhutan Bahamas Romania Bulgaria Netherlands Antilles New Zealand Serbia Spain Aruba Azerbaijan Fiji Iran (Islamic Republic of) JordanKazakhstan Macedonia, TFYR Malta Portugal Tonga Mauritius Samoa Tajikistan United Arab Emirates Trinidad and Tobago Ukraine Djibouti Armenia Australia Bahrain Belgium Cyprus Denmark Italy Korea, Republic of Macau SAR Netherlands Slovenia Moldova, Republic of Uzbekistan Brunei Darussalam Estonia Hungary Iceland Ireland Israel Japan Sweden United Kingdom Belarus Croatia Greece Kuwait Luxembourg Pakistan Lithuania Poland Qatar Morocco Myanmar Albania Malaysia Oman Tunisia Maldives Canada Finland France Norway Algeria Hong Kong SAR 0 0 20 40 60 80 100 fseced % females in secondary education

EDUCATION & HEALTH OUTCOMES Poorer health Better health Behaviour & mental Smoking Bullying health Violence Female Injuries Male Teenage pregnancy Sexual health HIV prevalence All-cause mortality Mortality Injury mortality Non-communicable disease mortality Communicable disease mortality -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8

LITERACY & HEALTH OUTCOMES Poorer health Better health Behaviour & mental Smoking Bullying health Violence Female Injuries Male Teenage pregnancy Sexual health HIV prevalence All-cause mortality Mortality Injury mortality Non-communicable disease mortality Communicable disease mortality -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8

INTERMEDIATE/PROXIMAL DETERMINANTS Smoking Alcohol Drugs Risky sex + Depression Violence Parental connectedness + + + + + School connectedness + + + + + + Peer (prosocial) connection + + + + + + IOM 2010 (Hawkins)

SDH APPROACHES FOR ADOLESCENT HEALTH

SDH APPROACHES FOR ADOLESCENT HEALTH 1. Build upon existing risk and protective factor models in adolescent health 2. Help us identify and intervene on the causes of the causes 3. May help us understand how determinants get under the skin

TAKING ACTION ON THE SOCIAL DETERMINANTS Action needed is different to that for children or adults A. Intervene on malleable proximal determinants B. Policy actions on structural determinants 1. Improve access of young people to wealth -youth access to employment -taxation policies re youth employment -microfinance initiatives 2. Improve access to secondary education -boys as well as girls

TAKING ACTION 3 Improve the conditions of daily life -gender equity; young mothers focus on injury prevention -transport policies, road safety -firearm, knife, pesticide control 4 Recognise adolescence as a second critical period in the life-course in which social determinants of health act to program health life-long

RESEARCH QUESTIONS Lifecourse issues Latent effects: How strong are the latent effects of puberty and CNS development Pathway effects: Can a good adolescence put children back on trajectory And how much does a bad adolescence throw children off good trajectory Cumulative effects: Is adolescence important?

STRATEGIES 1. measure the problem 2. evaluate action 3. expand the knowledge base 4. develop a workforce that is trained in the social determinants of health 5. raise public awareness about the social determinants of health, advocate 37

The Lancet, 2016 Lancet commission on adolescent health and wellbeing 39