NHS Health Scotland and the Scottish Government established the YHISLG in 2012. Membership of the group includes strateg
Youth Health Improvement Consensus Statement
November 2014
Scottish Youth Health Improvement Strategic Leads Group
CONTENTS Page Summary of key issues and recommendations 1. Introduction
3
2. Key Issues and recommendations
3
2.1 Recognising the importance of adolescent health
3
2.2 Measuring the health of young people
4
2.3 Addressing health inequalities among young people
5
2.4 The importance of mental wellbeing
7
2.5 The importance of youth engagement
8
2.6 Taking an integrated approach
9
2.7 Taking a life course approach to healthy development
11
2.8 Delivering effective interventions
12
2.9 The need for cross sector multi agency responsibility for youth health improvement
13
2.10 Delivering youth friendly health services
14
3. Summary
15
References
16
1
Summary of key issues and recommendations 1.
2.
Key Issues Recognising the importance of adolescent health. Measuring the health of young people.
3.
Addressing health inequalities among young people.
4.
The importance of mental wellbeing. The importance of youth engagement.
5.
6.
Taking an integrated approach.
7.
Taking a life course approach to healthy development. Delivering effective interventions.
8.
9.
The need for cross sector multi-agency responsibility for youth health improvement.
10. Delivering youth friendly health services.
2
Recommendations The current commitment to health in the early years, nationally and locally, should be extended to adolescence. A more coordinated approach to youth health data collection is required. This should be led nationally, in partnership with local areas. More action should be undertaken across sectors, nationally and locally, to ensure the best possible health outcomes for those young people who are at risk of health inequalities. This should take account of the contribution made by fundamental, wider environmental and individual causes. Promoting mental wellbeing should be considered in all work with young people. Young people should be involved in all decisions that directly or indirectly affect their individual and collective lives. A holistic, young person-centred approach to healthy adolescent development should be developed at national and local level. National and local partnerships should contextualise youth health within a life course perspective. Work to improve youth health should always refer to the existing evidence base and use appropriate monitoring and evaluation of impact. Action on youth health improvement should be maximised by using a coordinated multisector and multi-agency approach. Local children’s services plans should include specific actions aimed at improving young people’s health Health services in Scotland should demonstrate that they are delivering youth friendly services
1. Introduction This Consensus Statement has been developed by NHS Health Scotland with, and on behalf of, the local Health Board Youth Health Improvement Strategic Leads Group (YHISLG). NHS Health Scotland and the Scottish Government established the YHISLG in 2012. Membership of the group includes strategic leads for youth health improvement (YHI) from each of the local NHS Boards in Scotland. The Scottish Government chairs the group whilst NHS Health Scotland provides secretariat support. Since its establishment, the group has focused its efforts on developing a shared understanding of the youth health improvement agenda in Scotland, including key issues and areas for improvement. This Statement sets out these key issues and makes recommendations for further action, nationally and locally. For the purposes of this Statement the terms youth, young people and adolescents are used interchangeably and refer to those aged 9-25 years. In this context, health improvement refers to any actions to promote wellbeing/good health and prevent health problems/illness. The term health refers to health and wellbeing.
2. Key issues and recommendations 2.1 Recognising the importance of adolescent health
Whilst the first few years of life are recognised as a crucial stage in child development, adolescence is a further time of significant growth and change. From the evidence, we know that this development happens on a number of fronts biological, cognitive, emotional, and social. For example:
Biological and physical changes occur during puberty which result in the capacity to reproduce.
Cognitive developments occur in advanced reasoning skillsa; abstract thinking skillsb and meta cognition (the ability to think about thinking) c.
Developments occur in young people’s ability to perceive, assess and manage their emotions and their capacity to sensitively and effectively relate to others.
Social skills development occurs and may be influenced by the values, attitudes and behaviours of peers.1
In addition to these developmental changes, young people also experience changes in their relationships, responsibilities, levels of autonomy and their environments. All of these internal and external changes during adolescence bring new challenges Advanced reasoning skills include the ability to think about multiple options, to think hypothetically and to follow a logical thought process. b Abstract thinking skills help young people consider the future, judge options, solve problems and set goals. c Meta cognition enables young people to consider how they feel and what they are thinking as well as being able to think about how they are perceived by others a
3
and opportunities which influence health outcomes, either positively or negatively. Adolescence is therefore a time when:
Healthy development during the early years can be consolidated or compromised.
Unhealthy development during the early years can be compensated for or compounded.
Being healthy during adolescence matters. Health during this part of the life course can:
have an impact on a young person’s educational achievement, employability, relationships and contribution to societyd
influence how successful a young person will be as a future adult, parent, employer/employee, leader and individual
affect health outcomes in adulthood and later life
shape the health of the next generation.
However, we know that the health of some young people in Scotland is compromised2. Scottish data shows us that young people are not doing well in the following areas: wellbeing, obesity, sexual health, physical activity, mental health problems and violence.2 There is also clear evidence of inequalities in health among young people3. Despite this, improving young people health has a relatively low profile in Scotland’s current public health efforts. It needs to be given greater priority in national and local policy and action. Specifically the YHISLG believes that the current commitment to health in the early years should be extended to later childhood and adolescence. This would provide a continuum of action to ensure our early year’s investment fully achieves the level of improvement we seek and that young people have the best possible transition into adult life. Recommendation 1 The current commitment to health in the early years, nationally and locally, should be extended to adolescence. 2.2 Measuring the health of young people Describing and understanding the health of Scotland´s adolescent population and the factors that shape it is essential to improving youth health and reducing health inequalities. It enables the design of appropriate actions, targeting of resources and programme and policy impact assessment. In Scotland, there is room for improvement in the way youth health data is currently collected, coordinated and presented. The YHISLG have identified that: d
These areas can also affect adolescent health in a reciprocal relationship.
4
there are too many disparate surveys nationally and locally
comparability of data across surveys is a problem
sample sizes for key national surveys are too small for local usee
national surveys take too long to report and are not frequent enough
accessing some national datasets is problematic
data ownership is problematic for local areas
interrogating data for local health boards or partnership specific needs is difficult
data needs to be presented in one place in an easy to understand format
surveys need to also capture children not in mainstream education and provide better information on inequalities
current data does not reflect the whole health agenda.f
The YHISLG believes that a national survey with local bolt-on options, linked to local children’s services plans, could help address many of these issues and would present increased cost efficiencies for both national procurement and local purchasers. Recommendation 2 A more coordinated approach to youth health data collection is required. This should be led nationally, in partnership with local areas.
2.3 Addressing health inequalities among young people Inequalities in young people’s health are the consequences of systematic differences between young people occupying unequal positions in society. They are avoidable and unacceptable and an issue of social justice. Health inequalities are caused by underlying inequities in the distribution of income, power and wealth. This unequal distribution has an impact on young people’s opportunities for good quality education, leisure opportunities, housing, etc. In turn, these wider environmental factors shape young people’s individual experiences and ultimately influence inequalities in health (see Figure 1). Although there are limitations in our current ability to measure inequalities in youth health in Scotland there are clear indications of systematic differences in health behaviours and health outcomes between different groups of young people.2 Recent developments such as the need for Community Planning Partnerships to report on progress towards Single Outcome Agreements (SOAs) and requirements of the Children and Young People Act (Scotland) 2014 to report annually on children and young people’s outcomes through the GIRFEC SHANARRI wellbeing framework have further increased the need for local areas to have information specific to their communities. f There are notable gaps in current data, including mental health, the determinants of health, clustering of behaviours, data on 16-25 year olds, linkages between behaviours and wider determinants, data on health inequalities and local data in general. e
5
Figure 1: What causes health inequalities? NHS Health Scotland's Theory of Causation for health inequalities.
Young people at particular risk of health inequalities include (but are not limited to) those:
who have experienced domestic abuse
who are looked after
who are at risk of homelessness
who are not in education, employment or training
with chronic long term health conditions
with disabilities, sensory impairment
in contact with the justice system
who experience extreme poverty.
The YHISLG believes that any work with young people (e.g. education, youth work, youth justice work, youth unemployment work) should seek to improve health and reduce health inequalities. Action may be direct or via advocacy (depending on an individual or organisation’s sphere of influence) and should include work to: 6
mitigate the impact of social inequalities on different individual young people or groups of young people through equitable provision of services and programmes, sensitive to the local context
affect wider environmental influences (e.g. affordable transport and leisure opportunities for young people)
create fairer fiscal, legislative and cultural change in order to address the fundamental causes of health inequalities (e.g. engagement of young people in local decision making).
Recommendation 3 More action should be undertaken across sectors, nationally and locally, to ensure the best possible health outcomes for young people who are at risk of health inequalities. This should take account of contributions made by fundamental, wider environmental and individual causes.
2.4 The importance of mental wellbeingg
Young people often identify mental wellbeing as being especially important to them. Mental wellbeing is a complex construct. It is conceptualised in various ways but it is generally agreed that it encompasses more than the absence of mental health problems and has two distinct components covering experience and functioning:
subjective experience of affect (happiness) and life satisfaction (often referred to as emotional or subjective wellbeing)
psychological functioning covering concepts such as confidence, energy, clear thinking, creativity, self acceptance, personal growth and development, purpose in life, competence, autonomy, good relationships with others and self realisation (often referred to as psychological wellbeing). This covers a wide range of cognitive aspects of mental health and links to social wellbeing.4
Mental wellbeing has a range of influences. It helps protect young people against behavioural problems, violence and crime, teenage pregnancy and the misuse of drugs and alcohol. It can also influence educational attainment5 and youth unemployment6, two areas of significant priority in Scotland. Research also shows positive correlations between mental wellbeing and healthy behaviours such as physical activity and a good diet and negative correlations with drug misuse, smoking and alcohol consumption. 7 The YHISLG believes that mental wellbeing should form the basis of any work with young people - promoting, enhancing and protecting mental wellbeing should be a key aspect of all work with young people in all sectors and settings.
The term mental wellbeing is often used interchangeably with positive mental health, and in the education field ‘emotional and social wellbeing’ is a frequently used. g
7
Recommendation 4 – Promoting mental wellbeing should be considered in all work with young people.
2.5 The importance of youth engagement We get lots of opportunities to give our views and we know that we are listened to and taken seriously. Respect is a two-way thing and when it is given a chance it really works. Young person aged 14
How can they make all the decisions about me? They don’t know me, I do. Child aged 10
It’s our community too. Why shouldn’t we get to say what things we might want where we live, and The staff here help us to get involved. It is so much fun and I love it. They listen to us and help us understand what it all means so that we can make changes to things. They really care about us and tell us all the time that it is important that we say what we think and that they will listen. Young person aged 15
what we think about schools that are closing? We are the ones who feel it most when adults make decisions that are going to mean changes for young people. Why don’t they just listen instead of nodding their heads and then totally ignoring us? We don’t find anything out until it has already happened, and they say that it is the best decision for us. How can they know that? Child aged 11
Figure 2: The views of young people on being engaged8
If we are to meet the health needs of young people, we must understand what their needs are. Young people themselves should therefore be at the heart of the planning, delivery, monitoring and evaluation of youth health improvement work both nationally and locally. In addition, meaningful youth engagement by any service or organisation can contribute to improvements in youth health, even if the topic of engagement is not ‘health’. Youth engagement can enhance a young person’s sense of connectedness, belonging and feeling of being valued, which can contribute to good mental wellbeing.9 Under the United Nations Convention on the Rights of the Child children have the right to have their opinions taken into account. In Scotland, under the new Children and Young People (Scotland) Act 2014, Scottish Ministers will have to consider children’s rights whenever they take decisions and will have to promote children’s rights. There is also a duty on Scottish Ministers and other organisations that support children to report on what they are doing to encourage and support children’s rights. In line with addressing the fundamental and wider environmental causes of health inequalities, the YHISLG believes that any decisions that affect young people’s lives should be informed by young people’s views and that more needs to be done in this regard.
8
Recommendation 5 Young people should be involved in all decisions that directly or indirectly affect their individual and collective lives.
2.6 Taking an integrated approach Many health risk behaviours are established during adolescence, and often maintained into adulthood. Consequently, both policy and practice in youth health improvement has traditionally focused on health behaviours, especially health risk behaviours (e.g. substance misuse and risky sexual health behaviours). Such an approach raises a number of concerns. In particular, it is at odds with a person-centred approach and the reality of young people’s lives – young people themselves do not consider their lives in terms of discrete health behaviours. An approach focused on health risk behaviours can also contribute to:
insufficient attention being paid to behaviours that are protective to health e.g. a good diet
problematising young people
competing agendas between individual health topics, a silo approach in terms of policy and practice and duplication
uncoordinated approaches cascaded from policy makers and practitioners to youth work, community work and school settings
a focus on behaviours and behaviour change at the expense of looking at wider environmental and fundamental causes of health and health inequalities (such as poverty, unemployment and neighbourhood conditions).
Furthermore, growing evidence indicates that many risk-taking behaviours in youth tend to co-occur.h The likelihood of this co-occurrence needs to be taken into account when considering individual risk taking behaviours. It should not be assumed they happen in isolation. There is also growing evidence that different health-promoting and health-risk behaviours have shared influences. For example, risky sexual behaviour and smoking, alcohol misuse and cannabis use have low income and poor housing as a shared risk factor and school connectedness as a shared protective factor.10 Acting on these shared influences rather than on individual behaviour may therefore have an impact on several behaviours at once and be a more efficient and effective approach.11 This does not however negate specific actions for certain health behaviours. While some factors do seem to be common to several behaviours there are also some that appear uniquely associated with a particular health risk or health promoting behaviour. Activity focused on the unique influences on specific behaviours will therefore still need to be a part of approaches to youth health improvement but they should include or connect to (in a coordinated way)
h
Many young people who engage in one risk taking behaviour are more likely to engage in others.
9
actions aimed at addressing wider aspects of young people’s health (including support for healthy development more generally and work on contextual issues). This is highly relevant to health inequalities. Young people experiencing greater deprivation are more likely to be engaged in more health risk behaviours and less health promoting behaviours. Health behaviours are often influenced by the context of young people’s lives such as the price of basic commodities (food, rent, fuel, etc.), community capacity, availability of affordable transport, food and leisure opportunities, the unequal distribution of income, power and wealth, and poverty, marginalisation and discrimination. Efforts to be more holistic are evident across Scotland (e.g. Getting it Right for Every Child (and Young Person), Curriculum for Excellence, examples of adolescent health services and activities at local level which aim to promote a holistic approach). Despite these efforts, the YHISLG believes that more needs to be done to provide support for all young people in an integrated way, to maximise their health outcomes. With regards to Government policy the YHISLG believes that Scottish policy to optimise the health of adolescents is currently fragmented, overly focused on health risk behaviours and lacks clarity about preventative action.12 No single Scottish Government Directorate has policy responsibility for young people’s health and wellbeing and there is no overarching framework that sets out the Scottish Government’s approach to youth health and youth health improvement. The policy landscape for youth health is therefore complex and fragmented and it can be difficult for service providers and practitioners to navigate their way through this.13 Despite policy drivers around a person centred (e.g. the NHS Quality Strategy) and holistic approach (e.g. Getting It Right For Every Child), much of current youth health improvement policy focuses on issues resulting from distinct public health policies (and related targets) e.g. smoking, physical activity, alcohol and sexual health. It is increasingly being argued in the international literature on adolescent health14,15 and by local health boards16, voluntary sector youth organisations and researchers in Scotland10 that policy makers should move away from this kind of siloed, single issue approach to addressing youth health, to one which takes an integrated life course approach (see 2.7). 17 Evidence would therefore suggest that Scottish Government policy on youth health improvement might helpfully be strengthened to reflect a focus on well-being, prevention and person centeredness. The approach suggested by the YHISLG is more integrated, combining specific health topics and clearly articulating the determinants of health which are shared and those which are unique to each topic. Associated resourcing, targets and actions should also be restructured to reflect those areas that are common across topics and those which are topic specific.
10
Topic specific Topic specific
Topic specific
Generic youth health improvement
Topic specific
Topic specific
Topic specific
Figure 3: Putting generic youth development issues at the heart of youth health improvement
Recommendation 6 – A holistic, young person-centred approach to healthy adolescent development should be developed at national and local level.
2.7 Taking a life course approach to healthy development
A life course approach to youth health18 offers one way of taking a more integrated approach as it combines traditional approaches focused on aspects of health/illness, health topics/behaviours, settings (e.g. school, home, health service) and life stages. It:
looks collectively at all aspects of health at any one time in the life course as well as across the life course
includes a health topic/behaviour perspective but contextualises these at times across the life span when they may negatively impact on health and considers them jointly rather than in isolation
includes life stages but highlights the interrelated nature of these rather than considering them discretely, recognising that each life stage both influences the next and is influenced by what has gone before
incorporates settings but combines them in recognition of the fact that the lives of young people often straddle different settings at any one time and that different settings can have relevance at different parts of the life course (See Figure 5 for further detail).
Taking a life course approach to youth health is in keeping with other policy drivers in Scotland around prevention, being person centred, looking at the whole person and focusing on efficiencies and effectiveness. The YHISLG believes that this approach is a better way to provide support, which is needs led, age and stage appropriate, context relevant and builds on work in the early years.
11
A life course approach to health improvement – main points: Health develops across the whole life course, cumulatively and longitudinally. A life course approach represents the development of health by health trajectories that an individual follows from birth to death. These can be upwards, downwards or mixed and are built or diminished over the life span A person’s or a population’s current health outcomes and health trajectories are the result of cumulative inputs across the life course. Inputs can be risk or protective factors. There are sensitive periods of health development- while adverse events or environments can have a negative impact at any point in a person’s life course the impact can be greatest at specific sensitive periods of development (e.g. during foetal development). Both health status and health trajectories can be affected. The development of health as an adaptive process- outcomes are considered to be the result of multiple, complex and continuous transactions between interrelated layers of influence on health (e.g. genetic, biological, social, and economic contexts) that change as a person develops and have different effects at different stages of the life course, with certain types of determinants having special relevance at certain stages. Lives are linked and effects can be intergenerational. Understanding the ways in which health is transmitted from generation to generation - economically, socially and developmentally – is an important part of developing strategies to ensure that current patterns of advantages and disadvantages are not reinforced in adult life. Continued, repeated or varied risks across the lifespan can result inequalities of outcome
Figure 4: A life course approach to health improvement
Recommendation 7 National and local partnerships should contextualise youth health within a life course perspective.
2.8 Delivering effective interventions Highly processed evidence sources, systematic reviews and major Scottish evaluations18 indicate that:
Structural interventions in areas such as education and employment are more likely to reduce health inequalities than those addressing individual health behaviours.
Services which take a settings based approach to youth health improvement planning can be more effective in terms of cost and impact.
Evidence of effectiveness for targeting vulnerable groups of young people is limited; there is a need for robust evaluations of current initiatives and interventions. 12
Evidence from studies addressing multiple risk behaviours suggests there is a need to strengthen protective factors such as resilience by intervening early enough and working simultaneously across individual, family, school and community domains.
Evidence supporting an asset-based approach is limited, but may have the potential to complement traditional (effective) approaches being used to improve the health of young people in Scotland.
The YHISLG believes that, where evidence exists, it should be used to inform actions to promote adolescent health. Appropriate monitoring and evaluation (process and impact) should also be used, particularly in those areas where there is an absence of evidence. Recommendation 8 Work to improve youth health should always refer to the existing evidence base and use appropriate monitoring and evaluation of impact.
2.9 The need for cross sector multi-agency responsibility for youth health improvement The role of the NHS during adolescence is important but is particularly challenging as contact with health services may be less frequent than during early childhood and adult life. In addition to their role in health care and treatment, health services (provided by any sector) play an important role in youth health improvement by promoting health and preventing disease and illness such as sexually transmitted infections, poor mental health and problems associated with drug and alcohol use. However, as health and health inequalities are largely influenced by underlying inequities in the distribution of income, power and wealth and by factors in the wider environment (see Figure 1), the role of the NHS, as a direct influencer is therefore limited without partnership approaches. Furthermore, effective partnership working leads to improved service delivery. The YHISLG believes that in order to address the fundamental causes and wider environmental influences of adolescent health and health inequalities a coordinated multi-agency approach is required when planning services and developing both national and local policy. At local level, Community Planning Partnerships should ensure collaborative working takes place. Existing Children’s’ Services Plans and Health Improvement Plans are ideal vehicles for this cross-sector work. Curriculum for Excellence, GIRFEC and the requirements of CEL16 to improve health outcomes for looked after children provide a number of opportunities to ensure an appropriately connected focus on the health of adolescents. For example, the YHISLG believes that in order to reflect evidence of the wider factors which influence health, the role of the NHS (organisationally and at professional and practitioner level) in delivering on the SHANARRIi Indicators in the GIRFEC wellbeing wheel has to be extended beyond the ‘Health’ indicator to iSHANARRI
13
outcomes include: Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible and Included.
consider the NHS’s responsibilities and contributions to all the other indicators. Equally, the ‘Health’ indicator should not be regarded by other sectors as solely the responsibility of the NHS but also as their responsibility in terms of the contribution they can make. In addition, with the introduction of Health and Social Care Partnerships, this is an opportune time to consider how Community Planning Partnerships are working collaboratively to address the health (and wider) needs of young people. Recommendation 10 – Action on youth health improvement should be maximised by using a coordinated multi-sector and multi-agency approach. Local children’s services plans should include specific actions aimed at improving young people’s health.
2.10 Delivering youth friendly health services It is internationally recognised19 that health improvement and health care services need to be “youth-friendly” if young people are to be appropriately supported. To be youth friendly these services need to be welcoming and helpful in meeting need, respecting confidentiality, promoting wellbeing and providing care, treatment and support. This is relevant whether these health services are provided in a clinical setting, in a school or youth centre, at a workplace or through outreach to informal venues within communities. Not just to kind of look at it as a clinical thing but overall, consider maybe other issues that are going on in their life as well. Young female
I also think more initiatives directly aimed for young people like C cards and things like that would help young people feel more comfortable. Young male
What would make a good health service for young people?
Just one that will relate to young people and that have involved young people when they're creating the services. Young male
It's very important for all young people to know that they can go and speak to someone in a confidential environment. Young male
Figure 5: Young people’s views on youth friendly health services
Young people in Scotland have identified that there are barriers preventing or deterring them from using health services. These barriers include accessibility,
14
acceptability and confidentiality. Health services should therefore assess how youthfriendly they are and respond to any findings around improvement. Youth friendly health services should include youth engagementj as a core part of their service delivery and service developments should be designed in coproduction with young people. They should take into consideration the specific needs of young people in areas such as: communication; provision of information; service location, environment and opening times; and issues related to consent and confidentiality. They should be clear about how they will engage with young people and the outcomes they wish to achieve. The YHISLG believes that health services (NHS and non-NHS services) should demonstrate they are delivering youth friendly services. To achieve this it will be necessary to implement Recommendation 5 (see above) regarding the engagement of young people, Recommendation 11 – Health services in Scotland should demonstrate that they are delivering youth friendly health services.
3. Summary There is clearly a strong rationale for taking action to promote the health of young people in Scotland. This Consensus Statement makes a number of recommendations based on evidence and it is hoped that their implementation will make a positive contribution to improving health during this second important life stage. Author This Consensus Statement was written by Emma Hogg (Health Improvement Programme Manager -Youth Health), NHS Health Scotland on behalf of the local Health Board Youth Health Improvement Strategic Leads Group. Contact details For further information, contact Emma Hogg at
[email protected].
Examples of youth friendly health service work in Scotland can be found at http://www.walk-the-talk.org.uk/casestudies/index.aspx j
15
References 1McNeely
C, Blanchard J. The Teen Years Explained: A Guide to Healthy Adolescent Development. Baltimore: Centre for Adolescent Health at Johns Hopkins Bloomberg School of Public Health; 2009 2NHS
Health Scotland. Youth Health in Scotland: an epidemiology briefing. Edinburgh: NHS Health Scotland; 2012. http://www.healthscotland.com/documents/5899.aspx. Marmot Review. Fair society, healthy lives: the Marmot review: strategic review of health inequalities in England post 2010. Marmot Review: London; 2010 3
NHS Health Scotland. Establishing a core set of national, sustainable mental health indicators for children and young people in Scotland: Final Report. Edinburgh: NHS Health Scotland; 2012 4
5The
Scottish Government. Health and wellbeing literature review – examining the links between health and wellbeing and educational outcomes, including attainment, Edinburgh: The Scottish Government; 2013 6Anand
N. Young people, Unemployment and Health Improvement- Quick high level evidence review. Unpublished briefing. NHS Health Scotland; 2012 NHS Health Scotland. Warwick-Edinburgh Mental Well-being Scale (WEMWBS) acceptability and validation in English and Scottish secondary school students (The WAVES Project). Edinburgh: NHS Health Scotland; 2012 7
8
NHS Health Scotland. Promoting Youth Friendly Health Services. Edinburgh: NHS Health Scotland; 2011
Advocates for Youth. Youth Involvement in Prevention Programming http://www.advocatesforyouth.org/storage/advfy/documents/involvement.pdf 9
Scottish Collaboration for Public Health Research and Policy. Adolescent and Young Adult Health in Scotland. Edinburgh: Scottish Collaboration for Public Health Research and Policy; 2010 10
11Hale
D, Fitsgerald-Yau, Viner R. Systematic Review of Effective Interventions for Reducing Multiple Health Risk Behaviors in Adolescence. American Journal of Public Health 2014; Vol 104(5) : e19-e41 NHS Health Scotland. Youth Health Improvement: A summary of local NHS health board views. Edinburgh: NHS Health Scotland; 2013 12
13Scottish
Government. Supporting Young People’s Health & Wellbeing: A Summary of Scottish Government Policy. Scottish Government: Edinburgh; 2013 14Lancet.
Putting Adolescents at the centre of health and development. Lancet Editorial 379 1561.Lancet; 2012 15Journal
of Public Health. Supplement on Multiple Risk Behaviour in Adolescence. 34 (Suppl 1): i1 - i56. Oxford: Journal of Public Health; 2012 16NHS
Health Scotland. Youth Health Improvement: A summary of local NHS Health Board views. NHS Health Scotland: Edinburgh; 2012 NHS Health Scotland. (2013) A life course approach to youth health improvement. NHS Health Scotland: Edinburgh; 2012 17
NHS Health Scotland. Using Evidence to Inform Youth Health Improvement Planning. NHS Health Scotland: Edinburgh; 2012 18
World Health Organisation Europe. http://www.euro.who.int/en/health-topics/Life-stages/child-andadolescent-health/adolescent-health/5s-approach/service-delivery-models-that-are-youth-friendly 19
16
