Youth: the future is ours!

Youth: The future is ours!

Youth: The future is ours! Abstract Following the adoption of resolution EUR/RC67/R3 (2017), and the Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy framework for health and well-being, the WHO Regional Director for Europe was asked to provide a core package of technical resources, knowledge and tools related to the Sustainable Development Goals. This brochure, as a part of this core package, is intended to inspire youth and highlight the overall importance of health and well-being for achieving the 2030 Agenda. It focuses on health-related issues that most probably concern youth in the WHO European Region and provides options for addressing these. The information is provided in a format intending to stimulate curiosity and empower the advocates for health and well-being. Educational institutions and civil society organizations can use the brochure to engage youth leaders to address gaps in their knowledge and to support advocacy activities in health and well-being. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2020-5566-45331-64875 © World Health Organization 2020 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Design by Mark Pellegrini Edited by Jane Ward Printed in 2020 CONTENTS Acknowledgements ............................................................. iv About this brochure ......................................................................1 A bit more on sustainable development ................................ 3 The SDGs at a glance ............................................................. 5 Health and well-being in the SDGs ............................................ 8 Road safety ...............................................................................11 Youth violence ........................................................................ 15 Mental health ...........................................................................19 Substance abuse ..................................................................... 23 Sexual and reproductive health and rights .............................. 27 Nutrition and physical activity ................................................ 33 Youth-friendly health services ................................................ 37 Climate change and air pollution .......................................... 41 Chemicals and waste ............................................................. 47 Education and employment .................................................... 51 Digital technologies and health ............................................. 55 Moving forward .......................................................................... 61 Youth in action ....................................................................... 61 Meaningful participation for youth in governance ................. 63 WHO .......................................................................................... 66 References .................................................................................69 iv This brochure was written by Amine Lotfi, Julie Desmet, Dovile Adamonyte, Viktor Jósa and Daniel van Wyngaarden, under the guidance of Dr Bettina Menne (Coordinator of the Sustainable Development and Health programme). The authors wish to thank the following staff members and consultants from the WHO Regional Office for Europe whose knowledge and expertise made this brochure possible: Emilia Aragon de Leon, João Breda, Christine Brown, Angela Ciobanu, Carina Ferreira- Borges, Vittoria Gemelli, Valentina Grossi, Dorota Jarosinska, Jo Jewell, Veronika Knebusch, Joana Madureira Lima, Pierpaolo Mudu, Govin Permanand, Carrie Peterson, Oliver Schmoll, Juan Tello, Julianne Williams, Hanna Yang, Yongjie Yon and Irina Zastenskaya. ACKNOWLEDGEMENTS

Fig. 1. The 5Ps of sustainable development There is no universally agreed international definition of the youth age group. For statistical purposes, however, the United Nations defines our group as those people between the ages of 15 and 24 years (1). Today, there are 1.2 billion of us aged 15–24  years, accounting for 16% of the global population (1). Never has a generation been more concerned about their future than our generation. A Youth  Speak global survey of 180  000 young people from 126 countries showed that 68% of us believe the world will be a better place by 2030 (2). Our generation could be the one to eliminate poverty, halt climate change and create a fair world for everyone! Implement the agenda through a solid global partnership Foster peaceful, just, and inclusive societies Ensure prosperous and fulfilling lives in harmony with nature End poverty in all its forms and ensure dignity and equality Protect our planet’s natural resources and climate today and for all future generations ABOUT THIS BROCHURE PEOPLE PLANET PARTNERSHIP PEACE PROSPERITY “The future of humanity and of our planet lies in our hands. It lies also in the hands of today’s younger generation who will pass the torch to future generations.” 2030 Agenda for Sustainable Development, paragraph 53 The 2030  Agenda is the United Nations’ post- 2015 vision to protect the planet and bring peace and prosperity to all human beings. It focuses on each and everyone of us, and in partnership (Fig. 1). Sustainable development is a “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (3). The success of this agenda will depend on us, on our dreams, action and participation in politics, business, academia and civil society. We are the critical agents for change and a driving force for innovation. We have the energy and enthusiasm to shape and change the world for the better! As young leaders of today and tomorrow, there is a lot we can do, from changing our daily habits to raising awareness around us. This brochure doesn’t pretend to cover all the things we can do to achieve the Sustainable Development Goals (SDGs). It is more of a guide to help in understanding why the SDGs matter to us all and to our health. We hope it will help you to discover what you are passionate about and to get some ideas of how to become actively engaged and innovative health advocates in your communities. 2 3A BIT MORE ON SUSTAINABLE DEVELOPMENT The SDGs • The 17 SDGs are the biggest attempt in the history of humanity to make the world a better place by 2030 (Fig. 2). • The SDGs will highly affect the way our life will look like, that is why they are important to us. • The SDGs are universal and interlinked, meaning that progress in one goal can positively influence other goals as well. • The SDGs do not simply set the scene for a sustainable future, the process of achieving them will also shape our current realities. • We currently have the largest generation of youth the world has ever known, and we also want this to be the healthiest generation of youth ever. • Investments in our health will yield a triple dividend: for us now, for decades to come and for the next generation! We co-created this 2030 Agenda for Sustainable Development! From the inception onwards, we were included in the design of the Agenda in three ways (4). 4 1. We were formally included in United Nations negotiations about sustainable development. 2. National governments consulted us to inform them about their national positions. 3. We were consulted through the My World Survey, which is the largest global consultation programme in the history of the United Nations. The My World Survey allowed participants from all around the world to vote on the issues that are the most important to them. To date, it received more than 9.7 million answers from around the world, with most respondents being under 30 years of age. The top three issues identified by people under 30 years of age as a priority are a good education, better health care and better job opportunities. And we have the greatest stake in seeing these goals realized by 2030, as it is about our life today and also our future! We will also be in the best position to sustain the results after 2030. We are at the centre of the SDGs. The words “children”, “young” and “youth” are mentioned 33 times in the SDGs and at least 10 of the 17 SDGs relate directly to us and our development (5). Over a third of the SDG targets highlight our role as a key population group and the importance of our empowerment, participation and well-being (6). Fig. 2. The SDGs GOAL 1 End poverty in all its forms everywhere GOAL 2 End hunger, achieve food security and improved nutrition, and promote sustainable agriculture GOAL 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all GOAL 5 Achieve gender equality and empower all women and girls GOAL 3 Ensure healthy lives and promote wellbeing for all at all ages GOAL 6 Ensure availability and sustainable management of water and sanitation for all GOAL 7 Ensure access to affordable, reliable, sustainable, and modern energy for all GOAL 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for all GOAL 9 Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation The SDGs at a glance (click on each goal to learn more!) The 17 SDGs are supported by targets that define them in clearer terms and by indicators that focus on measurable outcomes. When these 17 SDGs were created, one simple thing became clear: these goals should concern everyone! And by everyone, it really means e-v-e-r-y-o-n-e. No matter the age, sex, gender or sexual preference, the place one lives in, the ethnic background, the health or financial status, these 17 SDGs do count us all in. That is what “no one must be left behind” means. In such a society, every person will have the opportunity to reach their full potential. GOAL 11 Make cities and human settlements inclusive, safe, resilient and sustainable GOAL 12 Ensure sustainable consumption and production patterns GOAL 13 Take urgent action to combat climate change and its impacts GOAL 14 Conserve and sustainably use the oceans, seas and marine resources for sustainable development GOAL 15 Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss GOAL 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels GOAL 17 Strengthen the means of implementation and revitalize the global partnership for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels GOAL 10 Reduce inequality within and among countries 6 If we look closely at these 17 SDGs, it is clear how they all influence each other. For example, by moving into cleaner energy and transportation (Goal 7), we will make our cities more sustainable (Goal 11), fight climate change (Goal 13) and our health will greatly benefit from less air pollution (Goal 3). If we achieve Goal 8 on decent work and economic growth, then this will improve Goal 1 on eliminating poverty and Goal 10 on reducing inequalities and then positively benefit our health again (Goal 3). This is what we mean by interconnections, the interlinked nature of the SDGs. If we don’t achieve one goal, this might put the other goals at risk. Therefore, it is important we acknowledge the links between all the 17 SDGs: when we work on one goal, we need to keep all the other goals in mind (Fig. 3)! The 17 SDGs are all interlinked! Can you spot Goal 3? The green one which says: “good health and well-being” SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. All ages… including you(th)! Health and well-being play an essential part in achieving all the goals, as our health is inseparable from the health of our society and our planet. The determinants of health (e.g. clean air) are included in other goals (e.g. Goal  11, sustainable cities and communities). Good health can’t be achieved if we focus on Goal 3 alone, as determinants of health span across other goals too: health is in all goals. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity! The enjoyment of the highest attainable standard of health is one of our fundamental human rights and should be without distinction of race, religion, political belief, economic or social condition. The SDGs recognize that everyone can and should achieve the highest standards of health and health care – not only the wealthiest. For example, no one should be pushed into poverty through paying for the health services they need. Fig. 3. All the SDGs interact with one another 7 HEALTH AND WELL-BEING IN THE SDGS Our health and well-being are shaped by rapidly changing environments and global uncertainty, and the future will bring a completely different list of unprecedented challenges. Because of our better childhood health and living conditions compared with previous generations, our generation has the potential of being the healthiest ever. However, there are many challenges threatening our health and well- being, such as the crisis of youth unemployment, unhealthy lifestyles and environmental degradation (7). Youth years are mostly seen as a healthy period of life, and most of us are indeed healthy. However, it is estimated that more than 1.3  million people aged between 15 and 24  years die each year from preventable causes (8,9). Not to mention the even larger number of us suffering from injuries or illnesses that limit our daily lives. Factors such as overweight and obesity, not enough physical activity, tobacco use and alcohol consumption can have long-term effects seen in later life. Indeed, two thirds of premature deaths and one third of the total disease burden in adults are associated with conditions or behaviours that began in our youth (10)! For example, many risk factors for noncommunicable diseases (diabetes, cardiovascular diseases, cancer, chronic respiratory diseases and mental disorders) occur for the first time during adolescence. Unhealthy behaviours may have a huge impact and a negative snowball effect on health systems. The good news is that healthy behaviour has the same ripple effect, so investments in our health will yield a triple dividend. We can also play a big role to protect our own health and the health of others by engaging in our own communities, sharing information about risk factors, supporting peer-education programmes to promote healthy behaviour and advocating for high-level policy changes (10). YOUTH TALK ABOUT HEALTH WHAT DOES YOUR HEALTH MEAN TO YOU? PLAY VIDEO PLAY VIDEO What areas affect our health and well-being? Here are some examples of issues covered by the SDGs that affect our health. Road safety Substance abuse Mental healthYouth violence Youth-friendly health services Sexual and reproductive health and rights Climate change and air pollution Digital technologies and health Education and employment Nutrition and physical activity Waste and chemicals These are looked at in the following sections. 9 2030 10 ROAD SAFETY What are the facts? Without action, road traffic crashes globally are predicted to result in the deaths of around 1.9 million people annually by 2020 (11) 11 Road traffic injuries are the leading cause of death of youth aged under 30 in the WHO European Region (12) More young men than women die in road traffic crashes (3.6 times more) (12) Young people are more prone to take risks, such as speeding and driving under the influence of alcohol (14) In 2016, over 40% of people who died as a result of road crashes in the WHO European Region were vulnerable road users such as pedestrians, cyclists or motorcyclists (13) Lowering average speeds by 5 km/h can reduce the number of fatalities by 30% (14) Seat-belts reduce the risk of death among drivers by 45–50% (14) Over 21 666 young adults under 30 years die from road traffic crashes annually in the WHO European Region (12) 85 629 PEOPLE die annually from road traffic injuries in the WHO European Region (13) BOX 1. TWENTY IS PLENTY: THE EXAMPLE OF THE UNITED KINGDOM Zones where the speed limit should not exceed 20 miles/hour (30 km/hour) are becoming more and more common around schools and residential areas all around the United Kingdom. This speed limit, associated with other measures like speed humps, have helped to make the roads safer for youth, especially young people aged up to 15 years of age. There has been a reduction of 46% in deaths among pedestrians and a reduction of 28% in deaths among cyclists during the period 1987–2006 (15). These speed limit zones are also found in other cities across Europe and are continuing to be adopted by more and more cities. By 2030, provide access to safe, affordable, accessible and sustainable transport systems for all, improving road safety, notably by expanding public transport, with special attention to the needs of those in vulnerable situations, women, children, people with disabilities and older people RELATED SDG TARGETS By 2020, halve the number of global deaths and injuries from road traffic accidents Related SDG targets 13 The 2030 Agenda recognizes road safety as essential to ensuring healthy lives, promoting well-being and making our cities inclusive and safe. That is why the United Nations General Assembly proclaimed in March 2010 the Decade of Action for Road Safety 2011–2020 (11). The Decade for Action seeks to save millions of lives by making our roads and vehicles safer, improving the behaviour of road users and improving responses when there is a road traffic accident. The 10 strategies described below are those which are best known to keep us safe on the roads (15): 1. Control speed (Box 1) 2. Reduce drinking and driving 3. Use helmets for bicyclists and motorcyclists 4. Restrain children in vehicles 5. Improve young people’s ability to see and be seen 6. Enhance road infrastructure 7. Adapt vehicle design 8. Implement graduated driver licensing 9. Provide appropriate care for injured children 10. Supervise children around roads. We all have an interest in ensuring the vision of the Decade of Action becomes a reality. We can serve as the ambassadors for road safety and ensure the safety of roads around schools. We can use our networks to raise awareness and encourage good behaviour. As with all health issues, prevention is better than cure! Road safety WANT TO KNOW MORE? Follow the Decade of Action for Road Safety 2011–2020 on Facebook on Twitter WHAT CAN BE DONE ABOUT IT? 14 YOUTH VIOLENCE What are the facts? Youth violence is preventable. Together, we can save lives and ensure a safer future for young people in Europe (16) 15 9/10 MURDERS could be avoided and Europe could potentially save over 13 000 young lives per year (17) Poorer young males are much more at risk of violence than those better off (17) Over 15 000 youth are murdered each year in the WHO European Region, 4 out of 10 by a knife (17) Deaths are just the tip of the iceberg and it is estimated that for every death, 20 young people are admitted to hospital (17) Interpersonal violence is the fourth leading cause of death among youth aged 15–29 years (12) Youth violence has a lasting impact leading to mental health problems; poor performance in school; harmful use of tobacco, drugs and alcohol; and being a victim or perpetrator of violence in later life (19) 1 in 8 girls under 18 years of age in the WHO European Region experience sexual violence at some point in their life and up to 55 million young people experienced some form of violence before reaching the age of 18 years (19) Bullying (including cyberbullying) involves repeated physical, psychological or social harm, and often takes place in schools and other settings where youth gather and online (18) 55 MILLION PLAY VIDEO PREVENT CHILD ABUSE AND NEGLECT PLAY VIDEO INJURIES AND VIOLENCE: THE FACTS 17 Significantly reduce all forms of violence and related death rates everywhere End abuse, exploitation, trafficking and all forms of violence against children RELATED SDG TARGETS Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation Related SDG targets European report on preventing violence and knife crime among young people The Violence Prevention Alliance Evidence for gender responsive actions to prevent violence: young people’s health as a whole-of-society approach INSPIRE: seven strategies for ending violence against children WANT TO KNOW MORE? Youth violence takes many forms and affects those most vulnerable, leading to increases in ill health. Reducing all forms of crime and violence has positive impacts on our health and well-being and that of our communities. Under the leadership of WHO, a group of 10 international agencies have developed and endorsed an evidence-informed technical package called INSPIRE: seven strategies for ending violence against children. The package aims to help countries and communities to achieve SDG target 16.2 on ending violence against children. Each letter of the word INSPIRE stands for one of the strategies, and most have been shown to have preventive effects across several different types of violence, as well as benefits in areas such as mental health, education and crime reduction (18). Youth violence Factors that can protect against violence developing among us include good social skills, self-esteem, academic achievement, strong bonds with parents, positive peer groups, good attachment to school, community involvement and access to social support. Quite the list, right? But there is more: you could challenge the social norms you see around you that promote male authority over women, and you could train yourself to act when you spot gender inequalities instead of being a bystander (16,20). WHAT CAN BE DONE ABOUT IT? I N S P I R E mplementation and enforcement of laws (e.g. banning violent discipline and restricting access to alcohol and firearms); orms and values change (e.g. altering norms that condone the sexual abuse of girls or aggressive behaviour among boys); afe environments (e.g. identifying neighbourhood hot spots for violence such as clubs and bars and then addressing the local causes); arental and caregiver support (e.g. providing parent training to young, first-time parents); ncome and economic strengthening (e.g. improving families’ economic stability); esponse services provision (e.g. ensuring that those of us who are exposed to violence can access effective emergency care and receive appropriate psychosocial support); 18 ducation and life skills (e.g. ensuring that we attend school and are provided with life and social skills training). MENTAL HEALTH Good mental health is a prerequisite for participation in the local community, economic productivity, independence and many other factors that influence well-being (21) 19 What are the facts? EVERY 40 SECONDS someone dies by suicide (22) Suicide is the second leading cause of death among those aged 15–29 years (22) Depression and anxiety are the most common mental disorders in the WHO European Region (23) Discrimination against people with severe mental disorders can prevent them from accessing services and increases their risk for premature death and disability (25) Risk for depression increases with experiences such as bullying, harsh parenting, child abuse and neglect or stressful life events such as the loss of a parent (26) Rates of depression and anxiety disorders are 50% higher in women than in men (28) People with mental disorders die 20 years younger than the general population (24) Men are almost five times more likely to commit suicide than women (27) PLAY VIDEO I HAD A BLACK DOG, HIS NAME WAS DEPRESSION PLAY VIDEO PLAY VIDEO YOUTH VOICES: KYLIE VERZOSA ON DEPRESSION LIVING WITH A BLACK DOG PLAY VIDEO DEPRESSION – LET’S TALK 21 Depression: what you should know Living with someone with depression? Worried about the future? Preventing depression during your teens and twenties Wondering why your new baby is not making you happy? Do you know someone who may be considering suicide? Do you feel like life is not worth living? WANT TO KNOW MORE? PL Y I E PLAY VIDEO • online psychological interventions; • family-focused interventions (e.g. caregiver skills training); • school-based interventions (e.g. teaching on mental health and life skills or making sure that schools offer a safe, secure and positive psychological environment); • community-based interventions (e.g. peer leadership or mentoring programmes); • prevention programmes targeting vulnerable adolescents (e.g. those affected by humanitarian and fragile settings, and minority or discriminated groups); • violence prevention; • programmes to prevent and manage the effects of sexual violence on adolescents; • suicide prevention; • alcohol and substance abuse prevention; and • comprehensive sex education to help to prevent risky sexual behaviours. Prevention begins with being aware of and understanding the early warning signs and symptoms of mental illness. Much can be done to help to build mental resilience from an early age to help in preventing mental distress and illness among us, and to manage and recover from mental illness. Examples of mental health promotion and prevention activities include (29): Mental health WHAT CAN BE DONE ABOUT IT? By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being Related SDG target 22 Young people are more likely to adopt behaviours (such as drug use) when they consider them normal or socially accepted among peers, even when they are aware of social or health consequences of such behaviour (30,31) 23 SUBSTANCE ABUSE What are the facts? 45 000 DEATHS In 2004, 45 000 deaths caused by illicit drugs were recorded in the WHO European Region (37) There is no threshold for safe drinking and all levels bring some added risk of cancer: less is better (34) 16.4% of boys and 9.4% of girls aged 15 years report drinking alcohol at least once a week in the WHO European Region (36) 3 in 4 young people who smoke in adolescence go on to smoke daily in adulthood (32) 1 in 5 people aged 15 years or more report heavy episodic drinking (five or more drinks on an occasion) at least once a week (35) An estimated 1 in 4 people who inject drugs is under 20 years of age in central and eastern Europe (38) 22% of boys and 13% of girls had initiated smoking by age 13 in the WHO European Region (32) The WHO European Region has the highest level of alcohol consumption in the world (33) PLAY VIDEO WORLD NO TOBACCO DAY 2017 – TOBACCO: A THREAT TO DEVELOPMENT PLAY VIDEO TOBACCO BREAKS HEARTS – WORLD NO TOBACCO DAY 2018 BOX 2. GAMING DISORDER: A SIMILAR ADDICTION TO SUBSTANCE ABUSE A gaming disorder is a certain pattern of gaming behaviour where the person engaging in video-gaming has an impaired control over the gaming. Gaming is given priority over other activities and other interests and daily activities are neglected, even when negative consequences occur (39,40). For it to be gaming disorder, this pattern of behaviour should be of sufficient severity for at least 12 months, resulting in a significant impairment of personal, family, social, educational, occupational and other crucial areas of functioning. The health concerns that come with gaming disorder often include problems with psychosocial functioning, physical inactivity, an unhealthy diet, musculoskeletal problems, sleep deprivation, aggressive behaviour, depression and problems with eyesight or hearing. Luckily, only a small proportion of people who engage in gaming have a gaming disorder (39). Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate Related SDG targets 25 Individual and environmental intervention strategies are two approaches to preventing substance use disorders. Individual prevention approaches focus on helping us to develop the knowledge, attitudes and skills we need to change our behaviour (Box 2). Environmental strategies take a broader approach. Examples of such interventions to reduce substance abuse include: • for alcohol: setting a minimum age for buying and consuming alcohol, reducing hours of sale, increasing prices and regulating exposure to alcohol advertising (across multiple types of media) (41); and • for tobacco: prohibiting the sale of tobacco products to minors; increasing the price of tobacco products; banning tobacco promotion, advertising and sponsorship; adding large pictorial warning labels and using plain packaging; regulating the content of tobacco products; and ensuring smoke-free environments. Other prevention approaches include: • public awareness and mass media campaigns; • prevention in schools (e.g. life skills training); and • prevention in families (e.g. focusing on parental skill building and parent–child relationships). Marketing represents an important factor contributing to substance use among us, including alcohol and tobacco use. Multiple media exposures appear to have an effect on consumption (e.g. the depiction of substance use on television, in movies, music videos; advertisements in magazines; and advertising on radio and stands at promotional events) (7). Substance abuse WHAT CAN BE DONE ABOUT IT? Alcohol and young women How can I drink alcohol safely? European action plan to reduce the harmful use of alcohol 2012–2020 A guide for tobacco users to quit Tobacco-free generations: protecting children from tobacco in the WHO European Region WANT TO KNOW MORE? SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS Many people in the WHO European Region still lack information on sexuality, family planning, pregnancy and childbirth, sexually transmitted infections, infertility, cervical cancer prevention and menopause (42) 27 What are the facts? 3.9 MILLION Adolescent pregnancy rate is 17.1 per 1000 girls aged 15–19 years in the WHO European Region (42) and some 3.9 million girls aged 15–19 years undergo unsafe abortions every year (50) Among 15-year-old adolescents, 25% have had sexual intercourse, but more than 35% have unprotected sex (44,45) Unmet family planning needs range from 5% to nearly 23% across the WHO European Region (47) Only 55% of countries in WHO European Region have a policy of having sexual education in primary and secondary schools and only 58% of countries provide adolescents access to all health services without paying (45) Only two thirds of countries in WHO European region provide legal access to contraception without parental consent for adolescents under 18 years of age and only half of countries provide access to abortions without parental consent (45) More than half of all sexually transmitted infections, excluding HIV, occur among young people aged 15–24 years (43) HIV incidence in the WHO European Region nearly doubled between 2000 and 2013 (46) The contraceptive prevalence rate, using modern methods, increased slightly from 55.6% in 2000 to 61.2% in 2015 (46) Laws criminalizing young people because of sexual orientation (lesbian, gay, bisexual, transgender and intersex) limit or deny access to sexual health-care services and information, thus preventing them from enjoying their sexual and reproductive health and rights (49) In adolescents, negative body image (e.g. being overweight) has been associated with riskier sexual behaviours (48) BOX 3. SCHOOL-BASED SEXUALITY EDUCATION: THE EXAMPLE OF ESTONIA Between 1992 and 2009, Estonia introduced school-based sexuality education and youth counselling centres addressing sexual health matters. The results of two research studies show positive associations between the implementation of the programmes and improvements in sexual health indicators among young people (51,52): • increased usage of condoms and reliable contraceptive methods; • decline of abortion rate among those aged 15–19 by 61% and the fertility rate by 59%; • decline of annual registration of new HIV cases among those aged 15–19 years from 560 in 2001 to 25 in 2009; • decline of new syphilis cases from 116 in 1998 to 2 in 2009; and • decline of gonorrhoea cases from 263 in 1998 to 20 in 2009. 29 BOX 4. INTRODUCING SEXUALITY EDUCATION IN ALBANIA Mandatory sexuality and life skills education for students aged 10–18 years was introduced in 2015 in Albania despite strong opposition from certain segments of the population of this south-eastern European country (53). A key position paper adopted by the Ministry of Health in 2012 called for sexuality education to be comprehensive, based on human rights and multisectoral. Piloting of the sexuality education in schools showed encouraging results among students and teachers: • misinformation among pupils was reduced by 80% and correct knowledge was similarly increased; • positive values and attitudes were strengthened; • after receiving the sexuality education course, pupils declared being aware that sexuality is not just about sex but is about communication, power and informed choices; and • trained teachers felt prepared to teach the sexuality education modules in line with standards. Currently, the programme is implemented in public schools. As young people, we have a need and right for a healthy, safe and pleasurable life, including in the aspects of reproduction and sexuality. It is, therefore, important to know our rights, the evidence and how to act. Our sexuality is often a subject that is unjustly stigmatized, but to reach the SDGs and fully use our human rights we need to empower all of us, in all our diversity, to gain access to comprehensive sexuality education (Boxes 3 and 4), evidence-informed family planning and youth-friendly services, including safe abortion. By realizing our need for comprehensive sexuality education, we are empowered to make informed decisions about our sexual and reproductive lives. This enables us to be autonomous and healthy. Addressing and eliminating obstacles (e.g. financial barriers or the third-party consent requirements) and expanding the scope and reach of sexual and reproductive health services for all of us will improve universal access and eliminate inequities in sexual and reproductive health. Sexual and reproductive health and rights WHAT CAN BE DONE ABOUT IT? 30 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and of culture’s contribution to sustainable development Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences 31 Related SDG targets WANT TO KNOW MORE? Sexuality education: what is it? Sexuality education: what is its impact? Introducing sexuality education: key steps for advocates in Europe and Central Asia Why should sexuality education be delivered in school-based settings? International technical guidance on sexuality education: an evidence- informed approach for schools, teachers and health educators. Volume 2: topics and learning objectives Check out these briefs and technical guidance documents: Unhealthy diet and lack of physical activity are leading global risks to health (54) NUTRITION AND PHYSICAL ACTIVITY 33 What are the facts? 1.7 MILLION DEATHS could be prevented each year if people’s salt consumption was reduced to the recommended level of less than five grams per day (56) 60% of young people who are overweight before puberty stay overweight (55) The excessive consumption of sugars increases the risk of dental caries and contributes to unhealthy weight gain and heart disease (57) The worldwide prevalence of obesity nearly tripled between 1975 and 2016 (54) Insufficient physical activity is estimated to be associated with nearly 1 million deaths per year in the WHO European Region (58) Breastfeeding has long-term health benefits: it reduces a baby’s risk of becoming overweight or obese and developing diseases later in life (54) Of the WHO regions, the WHO European Region has some of the lowest levels of children exclusively breastfed for the first 6 months of life (60) Eating at least 400 grams or five fist-sized portions of fruits and vegetables per day reduces the risk of disease (59) PLAY VIDEO LET’S BE ACTIVE FOR HEALTH FOR ALL PLAY VIDEO FIVE KEYS TO SAFER FOOD By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being 35 Related SDG targets Five keys information: Five keys to safer food, Five keys to a healthy diet, Five keys to appropriate physical activity Global recommendations on physical activity for health: 5–17 years old Global recommendations on physical activity for health: 18–64 years old WANT TO KNOW MORE? Unhealthy diets are one of the major risk factors for chronic diseases such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. In past decades, there has been an increase in consumption of processed foods high in energy, fats, sugars and salt and a decrease in consumption of fresh fruits and vegetables and fibre such as whole grains. But you can act now to reverse this trend! There are five keys to a healthy diet. Breastfeed babies and young children. Healthy diets start early in life! Breast milk is safe and gives newborns and infants all the nutrients they need for their healthy development, while helping to protect them from common childhood illnesses. Babies should be exclusively breastfed for the first 6 months of life. Eat a variety of foods. Eat a combination of unprocessed and fresh foods from many sources such as cereals, legumes (lentils and beans), vegetables, fruit and food from animal sources (e.g. meat, fish, eggs and milk). Eat plenty of vegetables and fruit. Make sure you always include fresh fruit and/or vegetables in meals and snacks. Ideally, the fruit and vegetables should be in season. When using canned or dried vegetables and fruit, choose varieties that do not have added salt or sugars. Eat moderate amounts of fats and oils. This can be done by limiting the consumption of baked and fried foods or snacks that contain industrially produced trans-fats (partially hydrogenated oils) and eating reduced-fat dairy foods and lean meats. It is also important to change the way we cook by steaming or boiling food instead of frying it and replacing butter, lard and ghee with soybean, canola (rapeseed), corn, safflower or sunflower oils. Eat less salt and sugars. Salt consumption can be reduced by avoiding highly processed foods, not adding salt, soy sauce or fish sauce during the preparation of food, not having salt on the table, limiting the consumption of salty snacks or choosing products with less salt. Sugar intake can be reduced by limiting the consumption of sugary snacks, candies and sugar-sweetened beverages and eating fresh fruit and raw vegetables as snacks instead of sugary snacks. Physical activity as part of everyday life: a pathway to much more! Regular physical activity such as walking, cycling or dancing not only makes us feel good, but it has significant benefits for health. It reduces the risk of cardiovascular disease, diabetes and some cancers, helps to control weight, and contributes to mental well- being. It only takes 30 minutes of moderate–intensity physical activity five days a week to improve and maintain our health. Each day, we should accumulate at least 60 minutes of moderate to vigorous intensity physical activity to ensure healthy development. Nutrition and physical activity WHAT CAN BE DONE ABOUT IT? 36 1 2 3 4 5 Young people need friendly health services: services that they can reach and that reach them when needed (61) YOUTH- FRIENDLY HEALTH SERVICES 37 What are the facts? Youth is a phase of life with increased need of mental and sexual health services (63) Young people may not appreciate the importance of seeking treatment when unwell and often underestimate the severity of their condition (62) Youth fear that health workers will scold them, ask difficult questions or carry out unpleasant procedures (64) Young people might also not access services because of lack of knowledge of which services are provided (64) In the WHO European Region, 28 countries provide adolescents with free access to all health services (45) Youth seek help from friends and family members when facing mental-health problems (64) Fear about lack of confidentiality, especially from parents, is a major reason that prevents young people seeking help (64) 70–90% of young people use primary care services at least once a year (64) ? PRIMARY HEALTH CARE THROUGHOUT OUR LIFE BOX 5. FRIENDLY YOUTH SERVICES: THE EXAMPLE OF SWITZERLAND In Switzerland, young people under 20 years have medical insurance, including young immigrants, some of whom are minors with no parents and/or are in the country illegally (68). They have rights to health care regardless of status. Competent minors are enabled through an article in the Civil Code to make decisions on their own health, including the right to make a decision that goes against their parents’ wishes. There is no age limit for the acquisition of competency; health professionals must make judgements on a case-by-case basis, considering the complexities of each situation. Also, there are family planning centres that are well known to young people and efforts are being made to spread information about the centres to those who are most at risk. WHO: WHAT IS PEOPLE-CENTRED CARE? 39 Adolescents are unique What adolescents can do What health workers can do What governments can do WANT TO KNOW MORE? Check out these briefs and technical guidance documents: Be aware! Health services oriented to respond to our needs have a positive impact through enhancing trust and access to health-care services and, to a certain extent, through promoting healthy behaviours (e.g. safer sex practices) (65). According to WHO standards, our services should be equitable, accessible, acceptable, appropriate and effective (66). Equitable. Health providers should treat us all with equal care and respect, regardless of status and policies and procedures should be in place that consider factors that might be an obstacle for equitable care. We will not attend a point of service delivery if we feel excluded or discriminated against in any way. Being treated equally will have a positive effect, encouraging us to attend further appointments and recommend the service to our peers. Accessible. Services should be free or affordable, with convenient opening hours and locations, and we should be well informed about the services and how to get them. Those of us who are dependent on our families may not want to “add to the burden” by asking for money to pay for services. We may also be reluctant to disclose why we need to obtain health services. In addition, we may find it difficult to obtain health services if the working hours coincide with times when we are busy with study, work or other activities. Acceptable. Confidentiality and privacy should be ensured; the health service environment should be clean and welcoming; and health-care providers should not be judgemental. We should be actively involved in designing, assessing and providing health services. We are very sensitive to privacy and confidentiality and concerns about lack of privacy and confidentiality discourage our use of health services. Appropriate. The services offered should fulfil the needs of all of us adequately. Effective. Health-care providers should have the competences to work with us and provide us with required health services, using evidence-based protocols and guidelines and dedicating sufficient time to deal effectively with our needs. These five requirements for services overlap with the eight domains that are central to a positive experience of care from our perspective: accessibility of health care, staff attitude, communication, medical competence, guideline-driven care, age-appropriate environments, youth involvement in health care and health outcomes (67). The main means for influencing us is to have youth-led national advocacy towards health policy and procedures that are more youth friendly, and that follow all dimensions of quality health services. National ministries of health are fundamental in the improvement towards better health-care systems, so reaching out to them is a possible way to influence change. Many countries are taking initiatives to make it easier for us to obtain the health services we need (Box 5). Youth-friendly health services WHAT CAN BE DONE ABOUT IT? Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Related SDG target wCLIMATE CHANGE AND AIR POLLUTION Limiting global warming to safe levels is feasible, but urgent action is needed by all countries (69) 41 What are the facts? w70 000 DEATHS More than 70 000 excess deaths were recorded in 12 European countries as a result of heatwaves in 2003 (71) Climate change is expected to cause over 250 000 additional deaths per year globally between 2030 and 2050 (70) Outdoor and household air pollution cause about 556 000 premature deaths every year in the WHO European Region (72) Reducing air/climate pollutants would prevent around 74 000 premature deaths annually in the WHO European Region by 2030 (73) Floods in the WHO European Region affected 3.4 million people from 2000 to 2011 (76) Climate change is projected to increase the occurrence and frequency of floods and droughts in large areas of Europe (76,77) Over 80% of Europeans are exposed to air pollution exceeding the WHO Air Quality Guidelines (74) Global warming has extended the pollen season in Europe, leading to more allergies and asthma (75) By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination By 2030, build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social and environmental shocks and disasters Strengthen resilience and adaptive capacity to climate- related hazards and natural disasters in all countries Improve education, awareness raising and human and institutional capacity on climate change mitigation, adaptation, impact reduction and early warning 43 Related SDG targets Tackling climate change could be the greatest global health opportunity of the 21st century! Indeed, measures to reduce emissions of health-damaging pollutants through changes in energy production, energy efficiency and sustainable transportation can address climate change while providing health benefits to all of us, which we call co-benefits (Box 6). Climate change seen from a health perspective, rather than from an environmental, economic or technological challenge perspective, makes it clear that we are facing a threat that strikes at the heart of humanity. Health puts a human face on climate change, which sometimes seems to be a distant threat. There is a strong need for innovation along with fresh and new approaches from our generation to address the biggest global challenge threatening human civilization. Luckily, one does not need to be a government or a corporate superpower to be part of the solution. Organized and innovative approaches by youth-led groups to raise awareness among civil society have been shown to be important in addressing the climate challenge. Through lobbying and advocacy as part of youth-led organizations, it is possible for us to put pressure on governments to increase climate action (Box 7). Umbrella organizations and youth constituencies, such as the Climate Action Network Europe and YOUNGO (Children and Youth constituency to the United Nations Framework Convention on Climate Change), allow us to be part of the decision-making table where our futures are being discussed without us having to be climate experts. Climate change and air pollution WHAT CAN BE DONE ABOUT IT? BOX 6. THE PARIS AGREEMENT The Paris Agreement in 2016 set out a global action plan to put the world on track to avoid dangerous climate change by limiting global warming to well below 2 °C and to pursue efforts to limit the temperature increase even further to 1.5 °C by the end of the century. It took the Member States over 20 years to negotiate this global climate agreement, which is basically our lifetime for those of us in the climate generation (78). Given the Paris Agreement timeline of 2100, our generation is the last one to be able to tackle the climate challenge and implement this climate agreement before the window of opportunity will close and further global warming becomes irreversible! 44 BOX 7. EMPOWERMENT THROUGH INNOVATIVE TOOLS FOR INTRODUCING NEW MINDSETS: CliMates CliMates is a youth-led think-and-do-tank creating innovative tools to tackle climate change, such as COP in MyCity, Heat Wave in MyCity or Innov’City. Through interactive and participatory events, these projects aim to inform and mobilize young agents of change on diversified topics, such as solidarity, gender or even diplomacy; to raise awareness on climate change issues; and to be a catalyst for young people to commit and take actions at their own level. To be empowered, see what tools CliMates provides you (https://www.weareclimates.org) 45 Protect health from climate change: act now! How to reduce your carbon footprint Health advice: how to keep cool in the heat YOUNGO WANT TO KNOW MORE? CHEMICALS AND WASTE Chemicals such as heavy metals, pesticides, solvents, paints, detergents, kerosene, carbon monoxide and drugs lead to unintentional poisonings at home and in the workplace (79) 47 What are the facts? 100 million tonnes of waste generated each year is hazardous, containing heavy metals and other toxins (82) Polluted environments result in the premature deaths of at least 1.4 million Europeans every year (80) Worldwide, unintentional poisonings are estimated to cause 193 000 deaths annually, the majority of which are children (81) Children are more vulnerable to the effects of exposure to chemicals and cannot protect their rights to live in a safe environment (81) Each year, an estimated one third of all food produced ends up being wasted (84) About one third of Member States in the WHO European Region lack policies aiming to protect vulnerable population groups from the negative impact of chemicals (83) Every year, 25 million tonnes of plastic waste, is generated in the countries of the European Union, and less than 30% is recycled (80) Children are exposed to chemicals every day and throughout their lives (81) Think before you buy: is the product recycled or recyclable? Check labels and avoid buying products containing hazardous chemicals (no consumption – no production). Avoid packaged waste: food packaged into separate compartments or presented as a mini-kit is not only more expensive but also produces more waste. Composting: composting is an easy and natural process that takes remains of plants and kitchen waste and turns it into nutrient-rich material to help plants to grow. Build a compost bin in your garden – or even a small one in your house. Reduce food waste: buy the amount of fresh food you will use and enjoy your leftovers by turning them into exciting new dishes. Use rechargeable and high-quality batteries: they will last longer and produce less waste. Spent batteries in the household rubbish contain harmful chemicals that can leak into the earth and water. Collect them separately! Your local authorities, supermarkets or electronic retailers can dispose of them safely. Use fewer single use products: Reusable products are better than disposable products (e.g. paper napkins, plastic razors or plastic cups), which use more resources and energy than their reusable counterparts and quickly end up in landfill. Recycle: don’t just throw away old glass bottles or aluminium cans. Instead, recycle them. Donate old clothes: as well as raising money for charity, clothing can also be shredded and turned into packaging, insulation or raw material for textiles. Reuse: take an old shopping bag with you while going out for shopping. An old shopping bag can replace hundreds of plastic bags that will end up in landfills. Get actively involved: talk to others in your community about the benefits of reducing waste – family, friends, neighbours, anyone. If you start to make a difference, others will follow your example! BOX 8. ELEVEN EASY WAYS TO REDUCE WASTE! LOOK UP FOR SOME INSPIRATION 1 2 3 4 5 6 7 8 9 10 11 49 Chemicals and waste WHAT CAN BE DONE ABOUT IT? PLAY VIDEO WHO: PREVENTING DISEASE THROUGH HEALTHY ENVIRONMENTS By 2030, build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social and environmental shocks and disaster By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries Related SDG targets 50 • Try and adopt the 3Rs in everything. Sustainable consumption and production (Goal 12) aims at “doing more and better with less”. Before buying something, we can make sure it is really needed. Instead of sending old electronics to recycling, we can see whether they can be given a new lease of life elsewhere in the friend and family circles (82,85). And always leave the bin as the last resort (Box 8)! Reduce, Reuse, Recycle: the 3Rs EDUCATION AND EMPLOYMENT Youth unemployment increases the vulnerability of youth – especially those from families with low levels of education or low incomes. This stalls social mobility and further marginalizes disadvantaged youth, which can fuel social instability and undermine their potential (86) 51 What are the facts? 6.3 MILLION More than 6.3 million young people aged 15–24 years were neither in employment nor in education or training (NEETs) in the European Union in 2016 (87) NEETs have higher rates of depression and mental health problems and increased risk of suicide and substance abuse (7) Only 15% of workers worldwide have access to specialized occupational health services (88) Stress at work is associated with a 50% excess risk of heart disease (89) Poor working conditions result in a total of 300 000 work-related deaths every year (88) Poor working conditions are concentrated among those with low skills and low education, which perpetuates health inequities (92) Young workers run a higher risk of work injuries arising from lack of experience or a limited awareness of existing or potential risks (90) Child labour in all its forms can result in injuries and premature death as well as in loss of opportunities for education and social development (91) By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non- violent, inclusive and effective learning environments for all By 2020, substantially reduce the proportion of youth not in employment, education or training Related SDG targets 53 Having a job, being financially independent and getting enough income to lead a decent life are important aspects of adult life and becoming a contributing member of society. A good livelihood is important for our well-being, as it influences self-esteem, a sense of connectedness, social relations and improves social mobility for those of us in low- income families (21). Seeing how urgent this social problem is, the 2030 Agenda states that we need to substantially reduce the proportion of those of us not in employment, education or training by 2020 – not just by 2030! We should also address the rise in precarious employment, which particularly affects us and has negative consequences for both physical and mental health. We as young people are twice as likely to be employed in temporary, part time and insecure work, thus limiting our opportunity for in-work training and skills development (93). Without investing in creating more economic opportunities for us, other investments made in our health, education, civic participation and technology access cannot be sustainable (21). The Global Initiative on Decent Jobs for Youth is a one-stop shop for everything you want to know about youth employment. It was launched in 2016 and brings together 22 entities of the United Nations to improve the promotion of effective youth employment strategies. The Youth Hub is an interprofessional community hosted by the Global Health Workforce Network and the Health Workforce Department at WHO. The Hub is concerned with youth employment in health and social care and aims at engaging and working for youth, working to promote the human resource for health agenda at national, regional and global levels. Close that skills gap The period in which we transition from schools and training institutions to the labour market is a critical phase. However, schools and training institutions today have a hard time keeping up with all the technological innovations and changing labour market. They struggle to know which skills will be in demand for what jobs. Skill development is an important issue, because if we are to be future-proof, it is crucial that we have access to quality training in the right skills that will serve us in any field and throughout our careers (21). Education and employment WHAT CAN BE DONE ABOUT IT? The Global Initiative on Decent Jobs for Youth Youth Skills Day, celebrated on 15 July! The Youth Hub WANT TO KNOW MORE? DIGITAL TECHNOLOGIES AND HEALTH 71% of those aged 15–24 years are online, making them the most connected age group worldwide (94) 55 What are the facts? Telemedicine serves people in isolated areas by providing access to medical services that may not otherwise be available or affordable (99) Digital health has been shown to improve the quality and coverage of care, increase access to health information, services and skills, as well as promote positive changes in health behaviours (95,96) Telepsychiatry, also known as eMental health, is being used increasingly widely, especially in the form of internet-based therapy (100) Online communities and social media are used by adolescents with short-term or long-term illnesses to access valuable support networks and facilitate peer-to-peer connections (98) The internet is a major resource in supporting self-care and health-related activities and services for youth and offers potential benefits for youth health promotion (98) Digital technologies can enable people and communities to take control of their own health (97) BOX 9. DIGITAL TECHNOLOGIES FOR THE HEALTH OF YOUTH: THE EXAMPLE OF DENMARK The general hospital in Copenhagen has been piloting a project using a virtual reality game designed specifically for hospital situations to distract children from procedural pain so they can lie calmly while a physician or nurse takes a blood sample or administers an intravenous injection. Virtual reality is also being used in psychology as a therapeutic tool for social anxiety, for example treating children suffering from dog phobia using exposure therapy. This is being done by gradually exposing them to dogs in a controlled virtual environment. BOX 10. ONLINE RESOURCES FOR HEALTH OF YOUNG MEN AND WOMEN Young Men’s Health is a useful resource for boys and young men to explore health information in depth. The website is divided into sections including featured articles, an “Ask Us” page, health guides and a blog. The health guides provide research-based, easy-to-understand answers about topics ranging from nutrition and fitness to sexuality and health. Many of the pages also include a section on how to talk to your health-care provider about health concerns. The site links to the corresponding site for girls, Center for Young Women’s Health, and a teen health blog, Teen Speak. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Related SDG target 57 Digital technologies and health Digital health technologies can improve geographical access to health services, reduce costs, improve quality of care and enhance the efficiency of health systems. Digital health offers us the ability to actively engage in health care in ways that have previously not been possible, and participation extends beyond “just” consumption of health-care services! The 2030 Agenda recognizes that there is a need to significantly increase access to information and communication technologies, and that digital health can also help to collect, analyse and share the data that will be required to monitor progress towards the achievement of the SDGs. Much of our behaviour nowadays is in the digital world, since our education, social networking and entertainment pursuits are accessed more and more often through electronic means. It is equally important to adapt health promotion, health information and communication about health to this new reality. Internet-enabled technologies provide innovative opportunities to reach us with public health messages and quality health information (Boxes 9–11) (55). BOX 11. RareConnect: ONLINE SUPPORT FOR PATIENTS WITH RARE CONDITIONS RareConnect is an online patient community that connects patients with rare conditions, their families and those involved in their care. It is also a peer support platform, allowing professionals who treat rare diseases to exchange information and experience on treatment, prognosis, symptoms and coping strategies. In this way it promotes research and builds relationships among health-care professionals in different countries. A survey of members of the forum showed that 76% of patients considered that they understood their condition better, 72% felt that were better able to cope with their problems, 41% of members with HIV infection reported that they had reduced risky behaviour, and 22% with mood disorders found that they needed less inpatient care after using the site. WHAT CAN BE DONE ABOUT IT? 58 Digital health technologies also offer us ways to self-manage our health and increase the focus on preventing disease and illness rather than simply treating them after they occur (99). Providing us with access to quality health information and appropriate services via digital means, where we already access much of our daily information, aids in the shift to preventative and proactive approaches to health. However, there are still challenges faced by digital health technologies, including the need for a health workforce skilled in using digital health solutions; the need for proper governance and sustainable funding; gaps in research; and issues around trust, privacy and security; among others. The 5Rights Foundation has developed a list of five rights that serves as a minimum requirement to enjoy a respectful and supportive relationship with digital technologies (including digital health technologies) (101). 1. The right to remove: every one of us should have the right to easily edit or delete all content we have created. 2. The right to know: we have the right to know who is holding and profiting from our information, what our information is being used for and whether it is being copied, sold or traded. 3. The right to safety and support: we should be confident we would be protected from illegal practices such as exploitation or abuse and supported if confronted by such. 4. The right to informed and conscious use: we should be empowered to reach into creative places online, but at the same time have the capacity and support to easily disengage. 5. The right to digital literacy: to access the knowledge that the Internet can deliver we need to be taught the skills to use and critique digital technologies effectively. An interdisciplinary and intersectoral approach is needed to achieve these rights, bringing together all the main actors using and benefiting from digital health, including youth (102). 59 60 Fig. 1. The 5Ps of sustainable development MOVING FORWARD Raise awareness! Over half of youth (55%) are still not aware of the SDGs, according to the YouthSpeak Survey (2). A very simple action that can already be taken today is to talk about these 17 SDGs to everyone! Everyone needs to be aware of them, understand what they are for and everyone should do their part. Build your capacity! Learn to understand what is our unique role and contribution in creating solutions to the world’s most pressing challenges. Act! Make sure to engage in volunteering activities and adopt personal behaviours that contribute to the SDGs. No contribution is too small! Youth in action Helping others by being involved in the community can bring satisfaction and contribute to happiness and a higher self-esteem. Taking on some form of responsibility or action through volunteering improves our social cohesion. It helps to shift the focus from our own problems to other people’s needs, forms social networks and creates new opportunities. This all greatly improves mental health and well-being (103). When given the opportunity, we as young people can be powerful agents for the promotion of our own health and well-being (6). Our participation in the process of promoting healthy behaviour is an effective way of building our knowledge and changing our behaviour for the better. Indeed, peer education is frequently used as a way to inform us and build our skills in areas such as HIV/AIDS, drug use and conflict resolution (104). Therefore, youth-led organizations can play a strong role in reaching the SDGs by 2030, through training, awareness-raising and volunteering (Boxes 12 and 13) (4). BOX 12. GET INVOLVED! The United Nations Major Group for Children and Youth is the United Nations General Assembly- mandated, official, formal and self-organized space for young people (under 30) to contribute to and engage in certain intergovernmental and allied policy processes at the United Nations. Its work includes providing platforms for dialogue, building our capacity and coordinating youth-led participation. Find out more at https://www.unmgcy.org/ 61 Is this SDG story old news? Maybe you’ve already taken it a step further and you are currently a youth leader, representing youth and youth’s voice in a youth-led organization? In that case, we invite you to go over the following recommendations on what needs to be done and on how to get more involved in the Sustainable Development Agenda. Young people from Croatia, Georgia, Lithuania, Malta, the Netherlands, Poland, Portugal, the Republic of Moldova, the Russian Federation, Serbia, the United Kingdom and Ukraine took and sent photos for the youth photo competition “Ready. Set. Wow!” organized by the European Environment and Health Youth Coalition (106). The photo “Despair” won the first place. This was in the thematic area of climate change. The competition coincided with the Sixth Ministerial Conference on Environment and Health (explore on social media: #6MCEH2017; #EuropeEnvHealth; #EEHYC), which took place in Ostrava, the Czech Republic, 13–15 June 2017. The competition was aimed to draw the attention of the public, policy-makers, and relevant stakeholders to our views on issues related to environment, health and sustainability in Europe in the following categories: • air quality • chemical safety • climate change adaptation, resilience and mitigation • environmentally sustainable health systems • healthy and sustainable cities and regions • waste and contaminated sites • water, sanitation and hygiene. Youth strongly proved that we are more cohesive than ever, not just in listing the challenges but in defying them with real action, in making a difference by presenting and adopting the Ostrava Youth Declaration (106), which represents direct input from more than 70 international youth delegates from across the European Region. Time to continue acting now! BOX 13. ACTIVE AND MEANINGFUL YOUTH PARTICIPATION IN POLICY DECISION-MAKING STRIKES AGAIN! 62 The United Nations Office at Geneva published a booklet with 170 daily actions to transform our world! You can find it in the following languages by clicking on the corresponding flags: Simple actions that can be taken every day to make the SDGs a reality! Simple actions that can be taken every day to make the SDGs a reality! The SDGs contains the pledge to leave no one behind and to reach first those who are the furthest behind. At the core, they are about social inclusion. Social inclusion is about making sure all of us have the opportunity to enjoy an adequate standard of living and well-being. It is about making sure we are all granted full access to our economic, social and human rights, including the rights to health, to education, to employment, to social protection, to participation and to live in dignity (107). Goal 17 aims to revitalize a global partnership for sustainable development by ensuring that no one is left behind in the collective endeavour towards achieving SDGs. We should all join this multistakeholder effort! Meaningful participation for youth in governance The United Nations defines youth participation as “the active and meaningful involvement of young people in all aspects of their own, and their communities’ development, including their empowerment to contribute to decisions about their personal, family, social, economic and political development” (7,108). Participation is our fundamental right and a guiding principle of the Universal Declaration of Human Rights. Active participation empowers us to promote positive civic action and take up a vital role in our own development and that of our communities (109). Today, we are still not enough involved in decision- making processes at the local or national levels. Current models of involvement do not give us positions in which we are able to affect real change. Many political, social and economic decisions are still made with limited youth participation (Table 1). However, we are increasingly demanding to be involved in the decisions shaping our communities and futures. In response, several countries have established youth structures and programmes to bring our voices to government representatives. ENGLISH GERMAN SPANISH RUSSIAN FRENCH Table 1. Activities for each aspired level of the participation sequence Aspired level of participation Direction of communication Forms of participation Advantages Disadvantages Interactive Co-decide • Not very common in practice • Participation in working groups • Optimal use of participants’ resources • Fulfils democratic motives • In extreme cases, stakeholders determine the content of PM reports • PM risk losing control Co-produce • Interactive scenario development • Alternation of research and participation • Use of participatory methods • Increases commitment of participants • Reflective approach to co-production can make a major contribution to producing knowledge • Ideally, generates support and produces knowledge • Demands open-mindedness from the PM • PM have to commit to obtained results to some extent, which is only possible if everyone is open to this • Intensive process • Participants’ choice and quality of the facilitator are key factors for success Take advice/ consult • Interactive workshops for defining the problem, research design and conclusions • Bilateral sessions • Review of project design and conclusions: written reports, workshops • Themed workshops for knowledge production • Can result in new perspectives • Highly goal-oriented approach; can be put into action at key stages in a project • Less easy for the PM to steer the process; can produce unintended results • Stakeholders may disagree with the framing • Difficult to guarantee transparency Non-interactive Listen • Set up feedback channels • Keep an eye on the media • Receive complaints, protest and criticism • PM get answers to questions they did not ask; prevents tunnel vision • PM are able to draw attention to problems at an early stage • Difficult to draw a line between where listening brings benefits and where it does not • Can be very time consuming Study • Surveys • Interviews • Focus groups • Many stakeholders can be reached with relatively little effort • Information can be collected in a highly targeted way • A strong framing effect may occur; other factors which were not asked about may be relevant Inform • Presentations • Takes relatively little time and effort • Can cause dissatisfaction among stakeholders • No opportunity to make a contribution, no real participation No participation • None • Project receives little attention; under certain circumstances, this may be desirable • No feedback • No utilization of external sources of information • No legitimization PM: policy-makers. Adapted from the Stakeholder participation guidance for the Netherlands Environmental Assessment Agency (110) and Hage et al., 2010 (111). PM Youth PM Youth PM Youth PM Youth PM Youth PM Youth 64 PM Youth Table 1 shows each aspired level of participation on the participation ladder, based on Arnstein’s original model published in 1969 (112). In this, the direction of communication (one-way or two-way, as indicated by arrows), the forms of participation to be considered, and the associated advantages and pitfalls are shown for each rung of the participation ladder (110). High-quality and meaningful participation in all aspects of society means our voice should be heard not only when it comes to youth policy but for all policies. All policies affect society and we are full members of society (4). Meaningful youth participation and leadership require that we and youth-led organizations have opportunities and capacities to participate and benefit from an enabling environment, relevant evidence-informed programmes to help and support us and youth- friendly policies at all levels (113). Efforts should be made to combine both in- person and online consultation channels to ensure that we are genuinely engaged at the higher levels of participation, with an adequate level of empowerment, responsibility and decision-making power to participate actively (4). For example, encouraging our full participation in the development and promotion of health-related programmes and policies would enable us to become agents of positive change in our communities and positively affect our lives and well-being and those of our peers (Box 14)! BOX 14. NATIONAL YOUTH COUNCILS: THE EXAMPLE OF THE REPUBLIC OF MOLDOVA National youth councils are organizations that represent and coordinate youth organizations (e.g. youth nongovernmental organizations, student organizations or youth wing political parties) across a country. In the Republic of Moldova, the National Youth Council represents youth civil society, promotes exchanges among youth organizations and acts as a bridge between national and international youth organizations (114). Its main areas of intervention are youth policy, formal and informal education, youth employment and youth rights, as well as youth capacity-building. Based on the Moldovan National Youth Strategy, and as a representative of Moldovan youth, the National Youth Council takes positions on every major policy impacting young people. It is part of an interministerial commission on youth, which is chaired by the Prime Minister and consists of three civil society representatives and three government representatives. In biannual meetings, the commission discusses youth policies and issues recommendations. The National Youth Council is regularly consulted by different ministries on youth-related issues and frequently participates in ministerial working groups. For example, it contributed to: • the drafting of the Ministry of Health’s Health Code; and • the extension of public transportation hours with the Agency of Transportation. WHO WHO is a specialized agency of the United Nations and is devoted to international public health. It was established on 7 April 1948, and its headquarters are in Geneva, Switzerland. The objective of WHO is the attainment by all people of the highest possible level of health. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO provides leadership on health issues, shapes the health research agenda, sets norms and standards, monitors health trends and provides support to countries. To do all of this, it engages with partners, including youth-led organizations, to stimulate us to survive, thrive and transform. The WHO Regional Office for Europe is one of six regional offices around the world. There are 53 countries in the WHO European Region, covering a vast geographical area from the Atlantic to the Pacific Ocean. WHO – PROTECTING HEALTH EVERY DAY, EVERYWHERE WHO: GUARDIAN OF HEALTH 66 Countries in the WHO European Region (click on a flag to learn more about the country) 67 We would love to hear from you! Did you enjoy reading this brochure? Do you have any ideas, feedback or recommendation for us? Let us know, we care about your opinion! Contact us through any of the following channels. whosdgeurope@who.int @WHO_Europe @WHOEurope or ‘WHO Regional Office for Europe’ 68 The information contained in this brochure is not intended to be, nor implied to be, a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information. Always seek the advice of your doctor or other qualified health-care provider before starting any new treatment or discontinuing an existing treatment. Talk with your health-care provider about any questions you may have regarding a medical condition. Nothing in this brochure is intended to be used for medical diagnosis or treatment. 1. Youth. In: Shaping our future together [website]. New York: United Nations; 2019 (https://www.un.org/en/sections/ issues-depth/youth-0/, accessed 2 November 2019). 2. YouthSpeak Global Report 2016. Montreal: AIESEC; 2017 (https://s3-eu-west-1.amazonaws.com/cdn.expa.aiesec.org/ assets/images/aiesec_org/pdf/YouthSpeak_Report_2016.pdf). 3. Report of the World Commission on Environment and Development: our common future. Oxford: Oxford University Press; 1987 (http://www.un-documents.net/our-common-future. pdf). 4. Youth development links to sustainable development. Report of the Secretary-General to the United Nations General Assembly. New York: United Nations; 2017 (A/72/190; (https:// www.un.org/development/desa/youth/news/2017/10/youth- development-links-to-sustainable-development/). 5. Ekram A. What are the SDGs and how do they relate to the youth giving movement [website]? YouthGiving.org; 2016 (http://youthgiving.org/blog/what-are-the-sdgs-and-how-do-they- relate-to-the-youth-giving-movement/, accessed 23 July 2018). 6. Youth as partners for the implementation of the SDGs. New York: United Nations Development Programme; 2017 (http:// www.undorg/content/dam/undp/library/Democratic Governance/ Youth/Fast Facts - Youth & SDGs_2017-January_final.pdf). 7. Patton GC, Sawyer SM, Santelli JS et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423–2478. doi: 10.1016/S0140-6736(16)00579-1. 8. Dick B, Ferguson BJ. Health for the world’s adolescents: a second chance in the second decade. J Adolesc Health; 2015;56(1):3–6. doi: 10.1016/j.jadohealth.2014.10.260. 9. Mabaso Z, Erogbogbo T, Toure K. Young people’s contribution to the global strategy for women’s, children’s and adolescents’ health (2016–2030). Bull World Health Organ. 2016; 94(5):312. doi: 10.2471/BLT.16.174714. 10. WHO highlights obesity as a threat to health and the environment at the World Festival of Youth and Students [website]. Copenhagen: WHO Regional Office for Europe; 2017 (http://www. euro.who.int/en/health-topics/noncommunicable-diseases/pages/ news/news/2017/10/who-highlights-obesity-as-a-threat-to-health- and-the-environment-at-the-world-festival-of-youth-and-students). 11. Decade of action for road safety 2011–2020: saving millions of lives. Geneva: World Health Organization; 2011 (http://www.who.int/violence_injury_prevention/publications/ road_traffic/saving_millions_lives_en.pdf?ua=1). 12. Disease burden and mortality estimates.Cause-specific mortality 2000–2016 [online database]. Geneva: World Health Organization; 2019 (https://www.who.int/healthinfo/global_ burden_disease/estimates/en/). 13. Sethi D, Racioppi F, Mitis F. Youth and road safety in Europe. Copenhagen: WHO Regional Office for Europe; 2007 (Policy briefing; http://www.euro.who.int/__data/assets/pdf_ file/0003/98454/E90142.pdf?ua=1). 14. Global status report on road safety 2018. Geneva: World Health Organization; 2018 (https://www.who.int/violence_injury_ prevention/road_safety_status/2018/en/). 15. Ten strategies for keeping children safe on the road. Geneva: World Health Organization; 2015 (http://www.who.int/ roadsafety/week/2015/Ten_Strategies_For_Keeping_Children_ Safe_on_the_Road.pdf). 16. Youth violence: the health sector role in prevention and response. Geneva: World Health Organization; 2015 (https:// www.who.int/violence_injury_prevention/violence/youth-violence- infographic-2015.pdf?ua=1). 17. Youth violence [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/health-topics/ disease-prevention/violence-and-injuries/areas-of-work/violence/ youth-violence). 18. Violence against children [website]. Geneva: World Health Organization; 2019 (https://www.who.int/news-room/fact-sheets/ detail/violence-against-children). 19. European report on preventing child maltreatment. Copenhagen: WHO Regional Office for Europe; 2013 (http:// www.euro.who.int/__data/assets/pdf_file/0019/217018/European- Report-on-Preventing-Child-Maltreatment.pdf?ua=1) 20. Evidence for gender responsive actions to prevent violence: young people’s health as a whole-of-society response. Copenhagen: WHO Regional Office for Europe; 2011 (http://www. euro.who.int/__data/assets/pdf_file/0015/158100/316637_WHO_ brochure_226x226_3-violece.pdf?ua=1). 21. Global youth wellbeing index. Baltimore (MD): International Youth Foundation; 2017 (www.youthindex.org). 22. Suicide data [online database]. Geneva: World Health Organization; 2019 (https://www.who.int/mental_health/ prevention/suicide/suicideprevent/en/). 23. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017 (http:// apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD- MER-2017.2-eng.pdf?sequence=1). 24. Excess mortality in persons with severe mental disorders. Geneva: World Health Organization; 2015 (Meeting report; https:// www.who.int/mental_health/evidence/excess_mortality_meeting_ report.pdf). 25. Cohen A. Addressing comorbidity between mental disorders and major noncommunicable diseases. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who. int/__data/assets/pdf_file/0009/342297/Comorbidity-report_E- web.pdf?ua=1). 26. Global accelerated action for the health of adolescents (AA-HA!). Guidance to support country implementation. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstre am/10665/255415/1/9789241512343-eng.pdf?ua=1%0Ahttp:// www.who.int/zh/news-room/detail/16-05-2017-more-than-1-2- million-adolescents-die-every-year-nearly-all-preventable). 27. European health for all family of databases [online database]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/data-and-evidence/ databases/european-health-for-all-family-of-databases-hfa-db). REFERENCES All URLs were accessed on 24 July 2019 unless indicated otherwise. 69 28. Global Burden of Disease Study. Global health data exchange [online database]. Seattle (WA): Institute for Health Metrics and Evaluation; 2019 (http://ghdx.healthdata.org/gbd- results-tool). 29. Adolescent mental health [website]. Geneva: World Health Organization; 2019 (https://www.who.int/news-room/fact- sheets/detail/adolescent-mental-health). 30. Perkins HW, Berkowitz AD. Perceiving the community norms of alcohol use among students: some research implications for campus alcohol education programming. Int J Addict. 1986;21(9–10):961–976. 31. Stacy AW, Wiers RW. Implicit cognition and addiction: a tool for explaining paradoxical behavior. Annu Rev Clin Psychol. 2010;6:551–575. doi: 10.1146/annurev.clinpsy.121208.131444. 32. Tobacco-free generations. Protecting children from tobacco in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who. int/__data/assets/pdf_file/0008/343376/20170428_WHO- TobaccoFreeGeneration-DRAFT09.pdf?ua=1). 33. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/ bitstream/handle/10665/274603/9789241565639-eng.pdf?ua=1). 34. GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10152):1015–1035. doi: https://doi.org/10.1016/S0140- 6736(18)31310-2. 35. Alcohol use [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/health-topics/ disease-prevention/alcohol-use). 36. Adolescent alcohol-related behaviours: trends and inequalities in the WHO European Region, 2002–2014. Copenhagen: WHO Regional Office for Europe; 2018 (http://www. euro.who.int/__data/assets/pdf_file/0007/382840/WH15-alcohol- report-eng.pdf?ua=1). 37. Illicit drugs: data and statistics [website]. Copenhagen: WHO Regional Office for Europe;2019 (http://www.euro.who. int/en/health-topics/disease-prevention/illicit-drugs/data-and- statistics) 38. HIV and young people who inject drugs. Geneva: World Health Organization; 2015 (Technical brief; https://www.unfpa.org/ sites/default/files/pub-pdf/WHO_HIV_2015.10_eng.pdf). 39. Gaming disorder: Q&A [website]. Geneva: World Health Organization; 2018 (https://www.youtube.com/ watch?v=lJ71KAO0mtc). 40. Starcevic V, Aboujaoude E. Cyberchondria, cyberbullying, cybersuicide, cybersex: “new” psychopathologies for the 21st century? World Psychiatry, 2015;14(1):97–100. doi: 10.1002/ wps.20195. 41. Adolescents: health risks and solutions [website]. Geneva: World Health Organization; 2018 (http://www.who.int/en/news-room/ fact-sheets/detail/adolescents-health-risks-and-solutions). 42. Sexual and reproductive health [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/health-topics/Life-stages/ sexual-and-reproductive-health/sexual-and- reproductive-health). 43. Young people are leading the HIV prevention revolution. Geneva: Joint United Nations Programme on HIV and AIDS; 2010 (http://files.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2010/20100713_outlook_ youngpeople_en.pdf). 44. Growing up unequal: gender and socioeconomic differences in young people’s health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report from the 2013–2014 survey. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/ pdf_file/0003/303438/HSBC-No.7-Growing-up-unequal-Full- Report.pdf?ua=1). 45. Situation of child and adolescent health in Europe. Copenhagen: WHO Regional Office for Europe; 2018 (http://www. euro.who.int/__data/assets/pdf_file/0007/381139/situation-child- adolescent-health-eng.pdf?ua=1). 46. Action plan for sexual and reproductive health: towards achieving the 2030 Agenda for Sustainable Development in Europe: leaving no one behind. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who.int/__data/assets/ pdf_file/0003/322275/Action-plan-sexual-reproductive-health. pdf?ua=1). 47. Contraception [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/health- topics/Life-stages/sexual-and-reproductive-health/areas-of-work/ contraception). 48. Noncommunicable diseases and sexual and reproductive health. Entre Nous. 2012;75:3–31 (http://www.euro.who.int/__data/ assets/pdf_file/0005/176126/Entre-Nous-75-Eng.pdf?ua=1). 49. Information series on sexual and reproductive health and rights. Lesbian, gay, bisexual and transgender and intersex people. Geneva: Office of the United Nations High Commissioner for Human Rights; 2015 (https://www.ohchr.org/Documents/Issues/ Women/WRGS/SexualHealth/INFO_LGTG_WEB.pdf). 50. Darroch J, Woog V, Bankole A et al. Adding it up: costs and benefits of meeting the contraceptive needs of adolescents. New York: Guttmacher Institute; 2016 (https://www.guttmacher. org/sites/default/files/report_pdf/adding-it-up-adolescents-report. pdf). 51. Haldre K, Part K, Ketting E. Youth sexual health improvement in Estonia, 1990–2009: the role of sexuality education and youth-friendly services. Eur J Contracept Reprod Health Care. 2012;17(5):351–362. doi: 10.3109/13625187.2012.696751. 52. Part K, Rahu K, Rahu M et al. Factors associated with Estonian adolescents’ sexuality-related knowledge: Findings from the 1994 and 1999 KISS studies. Eur J Contracept Reprod Health Care. 2008;13(2):173–181. doi: 10.1080/13625180701800631. 53. Ketting E, Ivanova O. Sexuality education in Europe and central Asia: state of the art and recent developments. An overview of 25 countries. Cologne: Federal Centre for Health Education; 2018 (https://www.bzga-whocc.de/fileadmin/user_ upload/Dokumente/BZgA_Comprehensive Country Report_online_ EN.pdf). 54. Healthy diet [website]. Geneva: World Health Organization; 2018 (http://www.who.int/news-room/fact-sheets/ detail/healthy-diet). 55. Investing in children : the European child and adolescent health strategy. Copenhagen: WHO Regional Office for Europe; 2014. (http://www.euro.who.int/__data/assets/pdf_ file/0010/253729/64wd12e_InvestCAHstrategy_140440.pdf). 70 56. Mozaffarian D, Fahimi S, Singh GM et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371(7):624–634. doi: 10.1056/NEJMoa1304127. 57. Te Morenga LA, Howatson AJ, Jones RM et al. Dietary sugars and cardiometabolic risk: systematic review and meta- analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014;100(1):65–79. doi: 10.3945/ajcn.113.081521. 58. Cities, transport, health and environment. Copenhagen: WHO Regional Office for Europe; 2017 (Fact sheet 1; http://www. euro.who.int/__data/assets/pdf_file/0019/341128/Fact-Sheet-1- City-Transport-health-and-environment.pdf?ua=1). 59. Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. Geneva: World Health Organization; 2003 (http://apps.who.int/iris/bitstream/ handle/10665/42665/WHO_TRS_916. 60. Breastfeeding mothers need peer counselling [website]. Copenhagen: WHO Regional Office for Europe; 2013 (http://www. euro.who.int/en/health-topics/Life-stages/maternal-and-newborn- health/news/news/2013/08/breastfeeding-mothers-need-peer- counselling). 61. Child and adolescent health [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/ en/health-topics/Life-stages/child-and-adolescent-health/child- and-adolescent-health). 62. Adolescent friendly health services: an agenda for change. Geneva: World Health Organization; 2003 (http:// apps.who.int/iris/bitstream/handle/10665/67923/WHO_FCH_ CAH_02.14.p?sequence=1). 63. Patton GC, Viner R. Pubertal transitions in health. Lancet. 2007;369(9567):1130–1139. doi: 10.1016/S0140-6736(07)60366-3. 64. Tylee A, Haller DM, Graham T et al. Youth-friendly primary- care services: how are we doing and what more needs to be done? Lancet. 2007;369(9572):1565–1573. doi: 10.1016/S0140- 6736(07)60371-7. 65. Thomée S, Malm D, Christianson M et al. Challenges and strategies for sustaining youth-friendly health services: a qualitative study from the perspective of professionals at youth clinics in northern Sweden. Reprod Health. 2016;13(1):147. doi: 10.1186/ s12978-016-0261-6. 66. Making health services adolescent friendly: developing national quality standards for adolescent-friendly health services. Geneva: World Health Organization; 2012 (http://apps.who. int/iris/bitstream/handle/10665/75217/9789241503594_eng. pdf?sequence=1). 67. Ambresin AE, Bennett K, Patton GC et al. Assessment of youth-friendly health care: a systematic review of indicators drawn from young people’s perspectives. J Adolesc Health. 2013;52(6):670–681. doi: 10.1016/j.jadohealth.2012.12.014. 68. Youth-friendly health policies and services in the European Region: sharing experiences. Copenhagen: WHO Regional Office for Europe; 2010 (http://www.euro.who.int/__data/assets/pdf_ file/0017/123128/E94322.pdf). 69. The emissions gap report 2018. New York: United Nations Development Programme; 2018 (http://wedocs.uneorg/ bitstream/handle/20.500.11822/26895/EGR2018_FullReport_ EN.pdf?sequence=1&isAllowed=y). 70. Climate change and health [website]. Geneva: World Health Organization; 2018 (http://www.who.int/news-room/fact- sheets/detail/climate-change-and-health). 71. Robine JM, Cheung SL, Le Roy S et al. Death toll exceeded 70  000 in Europe during the summer of 2003. C R Biol.2008;331(2):171–178. doi: 10.1016/j.crvi.2007.12.001. 72. Burden of disease from the joint effects of household and ambient air pollution for 2016. Geneva: World Health Organization; 2018 (https://www.who.int/airpollution/data/AP_joint_effect_BoD_ results_May2018.pdf?ua=1). 73. Policy brief: healthy mitigation in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/__data/assets/pdf_file/0005/341744/ POLICY-BRIEF-9-June-2017-edited-v2-added- paragraph_APPROVED-PCR.pdf?ua=1). 74. Air quality in Europe: 2018 report. Copenhagen: European Environment Agency; 2018 (https://www.eea.europa. eu//publications/air-quality-in-europe-2018). 75. Ziello C, Sparks TH, Estrella N et al. Changes to airborne pollen counts across Europe. PLoS One. 2012;7(4):e34076. doi: https://doi.org/10.1371/journal.pone.0034076. 76. Jakubicka T, Vos F, Phalkey R et al. Health impacts of floods in Europe: data gaps and information needs from a spatial perspective. Brussels: Centre for Research on the Epidemiology of Disasters, Catholic University of Louvain; 2010 (www.cred.be/sites/default/files/Health_impacts_of_floods_ in_Europe.pdf). 77. Lehner B, Döll P, Alcamo J et al. Estimating the impact of global change on flood and drought risks in Europe: a continental, integrated analysis. Clim Change. 2006;75(3):273–299. doi: https:// doi.org/10.1007/s10584-006-6338-4. 78. The Paris Agreement [website]. Bonn: United Nations Framework Convention on Climate Change Secretariat; 2019 (https://unfccc.int/process-and-meetings/the-paris-agreement/ the-paris-agreement, 2 November 2019). 79. The public health impact of chemicals: knowns and unknowns. Geneva: World Health Organization; 2016 (https:// apps.who.int/iris/bitstream/handle/10665/206553/WHO_FWC_ PHE_EPE_16.01_eng.pdf?sequence=1). 80. Protect our environment, protect our health: World Environment Day 2018 [website]. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/en/health-topics/ environment-and-health/chemical-safety/news/news/2018/6/ protect-our-environment,-protect-our-health-world-environment- day-2018). 81. Healthy environments for healthier people. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who. int/__data/assets/pdf_file/0006/367188/eceh-eng.pdf?ua=1). 82. Being wise with waste: the EU’s approach to waste management. Luxembourg: Publications Office of the European Union; 2010 (http://ec.europa.eu/environment/waste/pdf/WASTE BROCHURE.pdf). 83. The Minsk declaration: the life-course approach in the context of Health 2020. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_ file/0009/289962/The-Minsk-Declaration-EN-rev1.pdf?ua=1). 84. Goal 12: Ensure sustainable consumption and production patterns [website]. New York: United Nations; 2019 (https:// www.un.org/sustainabledevelopment/sustainable-consumption- production/). 85. 15 easy ways to reduce landfill waste [website]. Conserve Energy Future; 2019 (https://www.conserve-energy-future.com/15- easy-ways-to-reduce-landfill-waste.php). 71 86. Call for submissions: youth in health and social care – Global Health Workforce Network Youth Hub [website]. Geneva: World Health Organization; 2018 (http://www.who.int/hrh/ news/2018/call-youth-health-social-care-ghwnyh/en/). 87. Youth employment [website]. Brussels: European Commission; 2019 (https://ec.europa.eu/social/main. jsp?catId=1036). 88. Occupational health [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/ en/health-topics/environment-and-health/occupational-health/ occupational-health). 89. Marmot M. The status syndrome: how social standing affects our health and life expectancy. London: Bloomsbury Publishing; 2004. 90. Runyan CW, Zakocs RC. Epidemiology and prevention of injuries among adolescent workers in the United States. Annu Rev Public Health. 2000;21:247–269. doi: 10.1146/annurev. publhealth.21.1.247. 91. Work injuries in children and young people. Copenhagen: WHO Regional Office for Europe; 2009 (Fact sheet 4.7; http:// www.euro.who.int/__data/assets/pdf_file/0009/97065/4.7.-Work- injuries-EDITED_layouted.pdf?ua=1). 92. Siegrist J, Montano D, Hoven H. Final scientific report: working conditions and health inequalities, evidence and policy implications. Report produced as part of the DRIVERS for Health Equity project. Düsseldorf: Centre for Health and Society, Faculty of Medicine, Heinrich Heine-Universität; 2014 (https://www.siis. net/documentos/ficha/499738.pdf). 93. Gross SA, Musgrave G, Janciute L et al. Well-being and mental health in the gig economy: policy perspectives on precarity. London: University of Westminster Press; 2018 (http://www.jstor. org/stable/j.ctv5vdf26). 94. Editorial. Growing up in a digital world: benefits and risks. Lancet Child Adolesc Health. 2018;2(2):79 (https://www.thelancet. com/pdfs/journals/lanchi/PIIS2352-4642(18)30002-6.pdf). 95. Quinn CC, Shardell MD, Terrin ML et al. Cluster- randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care. 2011;34(9):1934–1942. doi: 10.2337/dc11-0366. 96. Free C, Phillips G, Galli L et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10(1):e1001362. doi: 10.1371/ journal.pmed.1001362. 97. Astana declaration on primary health care: from Alma- Ata towards universal health coverage and the sustainable development goals. Geneva: World Health Organization; 2018 (https://www.who.int/primary-health/conference-phc/DRAFT_ Declaration_on_Primary_Health_Care_28_June_2018.pdf). 98. Park E, Kwon M. Health-related internet use by children and adolescents: systematic review. J Med Internet Res. 2018;20(4):e120. doi: 10.2196/jmir.7731. 99. What you need to know about digital health systems [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/health-topics/Health-systems/pages/ news/news/2019/2/what-you-need-to-know-about-digital-health- systems). 100. Tackling mild depression: “iCBT was perfect for me” [website]. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/Health-systems/e-health/ news/news/2017/04/tackling-mild-depression-icbt-was-perfect-for-me.). 101. Fulfilling the 5Rights [website]. London: 5Rights Foundation; 2019 (https://5rightsfoundation.com/in-action/ fulfilling-the-5rights.html). 102. Novillo-Ortiz D, De Fátima Marin H, Saigí-Rubió F. The role of digital health in supporting the achievement of the Sustainable Development Goals (SDGs). Int J Med Inform. 2018;114:106–107. doi: 10.1016/j.ijmedinf.2018.03.011. 103. World youth report 2015: youth civic engagement. New York: United Nations Department of Economic and Social Affairs; 2017 (https://www.un.org/development/desa/youth/wp-content/ uploads/sites/21/2018/12/un_world_youth_report_youth_civic_ engagement.pdf). 104. Does peer education work in Europe? Entre Nous. 2003;56:3–27 (http://www.euro.who.int/__data/assets/pdf_ file/0016/74050/EN56.pdf?ua=1). 105. Ready. Set. Wow! Youth photo competition for better health and environment [website]. Vilnius: European Environment and Health Youth Coalition; 2017 (http://www.eehyc.org/wp- content/uploads/2017/09/EEHYC_2017_Competition_Information_ Sheet-2.pdf). 106. Ostrava Youth Declaration. Vilnius: European Environment and Health Youth Coalition; 2017 (http://www.euro.who.int/__data/ assets/pdf_file/0007/342376/Ostrava-Youth-Declaration-2017. pdf?ua=1). 107. Social inclusion and young people. Excluding youth: a threat to our future. Brussels: European Youth Forum; 2016. (https://www.youthforum.org/sites/default/files/publication-pdfs/ Excluding-youth-a-threat-to-our-future.pdf). 108. World youth report 2007: young people’s transition to adulthood – progress and challenges. New York: United Nations Department of Economic and Social Affairs; 2007 (https://www. un.org/esa/socdev/unyin/documents/wyr07_complete.pdf). 109. Issue brief: youth participation. New York: United Nations Department of Economic and Social Affairs; 2013 (https:// www.un.org/esa/socdev/documents/youth/fact-sheets/youth- participation.pdf). 110. Stakeholder participation guidance for the Netherlands Environmental Assessment Agency: main document. Nijmegen: Netherlands Environmental Assessment Agency; 2008 (https:// www.pbl.nl/sites/default/files/cms/publicaties/550032007.pdf). 111. Hage M, Leroy P, Petersen AC. Stakeholder participation in environmental knowledge production. Futures. 2010;42(3):254– 264. doi: https://doi.org/10.1016/j.futures.2009.11.011. 112. Arnstein SR. A ladder of citizen participation. J Am Inst Plann. 1969;35(4):216–224. 113. Dovile A, Ilse L. Searching for best and new emerging practices for involving youth in environmental health risk communication and risk governance. Public Health Panorama. 2017, 3(2):337–345 (http://www.euro.who.int/__data/assets/pdf_ file/0005/341564/13_Review_HealthRisks_youth_ENG.pdf?ua=1). 114. Evidence-based policy making for youth well-being : a toolkit. Paris: Organisation for Economic Co-operation and Development; 2017 (http://www.oecd-ilibrary.org/ development/evidence-based-policy-making-for-youth-well- being_9789264283923-en). 72 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg North Macedonia Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Original: English WHO/EURO:2020-5566-45331-64875