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Despite the high number of humanitarian and fragile settings globally, evidence documenting the effects of such crises on adolescent wellbeing is limited.3 7 This lack of data cuts across all five domains in the 2020 framework conceptualising adolescent wellbeing8: good health and optimum nutrition; connectedness, positive values, and contribution to society; safety and a supportive environment; learning, competence, education, skills, and employability; and agency and resilience. Current indicators focus on physical health, education, fertility, and employment and overlook critical but difficult to measure aspects of wellbeing such as self-esteem, relationships and connectedness, resilience, stress, depression, and anxiety.3 In addition, most studies are cross sectional because the high mobility of these populations makes collecting longitudinal data difficult, and they therefore cannot assess causality.3 Even conducting cross sectional studies among representative samples is challenging in these contexts, as sampling frames usually do not exist, and refugees and displaced populations tend to be very mobile and may be living among local host communities. Data are often lacking on the situation before the crisis, making comparisons difficult. In the case of refugees, there are relatively few studies comparing their status with that of host population adolescents, although there have been promising moves in that direction.9 10

may be living among local host communities. Data are often lacking on the situation before the crisis, making comparisons difficult. In the case of refugees, there are relatively few studies comparing their status with that of host population adolescents, although there have been promising moves in that direction.9 10 A World Health Organization report describes special ethical considerations that pose challenges when including young people in research on topics such as sexual and reproductive health and rights.11 Parental consent is recommended for participation of younger adolescents but can be difficult to obtain in humanitarian and fragile settings as families become separated. Although guidelines from the Council for International Organizations of Medical Sciences and WHO allow parental consent to be waived in certain circumstances, this recommendation is not evenly applied or followed globally.12 Other ethical challenges when collecting data from adolescents include the sensitivity around asking about traumatic events such as abuse, difficulties ensuring privacy and confidentiality, and concerns around the power relations between researchers and adolescents.3

The effectiveness of current interventions that promote adolescent wellbeing in humanitarian and fragile settings is largely unknown because of a lack of evaluation. The quality of the evidence from the studies that have been done is often low, and they do not always sufficiently analyse the respective contributions of different components of the interventions. For example, a review of mechanisms of change for psychosocial interventions for children and adolescents in conflict settings found gaps in the testing of intervention mechanisms; nine of the 13 mechanisms had only moderate or poor quality evidence to support their use.13 Likewise, large evidence gaps still exist despite increasing research attention on the effectiveness of mental health interventions for young people affected by war. These gaps include evidence on prevention and maintenance, multilevel interventions, comorbidities, differential effects, measurement tools, and strengthening mental health services.14 Similarly, a stronger evidence base is needed to examine how sexual and reproductive health interventions with effectiveness data from stable settings work (or not) for different young people across varying humanitarian and fragile settings.15 For example, there is a lack of implementation and documentation of evidence based strategies that address the specific sexual and reproductive health needs of adolescents of varying age (eg, younger versus older), religion, gender, race, ethnicity, disability status, and sexual orientation in humanitarian and fragile settings.16

, there is a lack of implementation and documentation of evidence based strategies that address the specific sexual and reproductive health needs of adolescents of varying age (eg, younger versus older), religion, gender, race, ethnicity, disability status, and sexual orientation in humanitarian and fragile settings.16 Although reaching adolescents is often challenging in any setting, many commonly used points of access may be inappropriate in humanitarian and fragile settings. For example, school based interventions, while cost effective, do not reach the high proportions of adolescents who are out of school or mobile in such settings; similarly, community based interventions such as safe spaces17 may fail to reach female adolescents, who often have restricted mobility in public spheres; finally, family based interventions, though promising,18 may face resistance or time constraints among families affected by conflict, disaster, or forced displacement.

Adolescent wellbeing in humanitarian and fragile settings will continue to be largely neglected unless all relevant actors identify and prioritise the specific needs of this age group by calling for appropriate investments. Efforts to monitor and evaluate and improve this important population’s wellbeing require urgent attention. Financial commitment to developing health services and programmes that are designed to be receptive to adolescents is essential, and ensuring engagement requires involving adolescents in the design and evaluation of interventions.7 We outline four key policy and programmatic recommendations below. Data are critically needed both to evaluate existing programmes and to promote the routine collection and use of age and sex disaggregated data. Such data collection should include rigorous evaluations of existing programmes to examine both process and the short, medium, and long-term effects on adolescents, and to establish any causal links between humanitarian interventions (eg, the transition to cash-based assistance) and adolescent outcomes. With donors’ support, programme implementers must prioritise and allocate resources for working with evaluators and researchers either within or external to their organisation, to include systematic evaluations of the effectiveness and cost effectiveness of their programmes

sh-based assistance) and adolescent outcomes. With donors’ support, programme implementers must prioritise and allocate resources for working with evaluators and researchers either within or external to their organisation, to include systematic evaluations of the effectiveness and cost effectiveness of their programmes Adolescent specific modules must also be added to routine data collection systems (eg, Health Management Information System) and ad hoc surveys such as those assessing demographic and health characteristics, living standards, and violence against children. Such modules are being piloted within Unicef’s multi-indicator cluster surveys.3 This type of research, focusing on context specific interventions, should be conducted at all stages of humanitarian response, from preparation to evaluation. Implementation research and preparations before interventions are particularly important to prevent resistance from the community, especially for those concerning girls’ and women’s rights and the sexual and reproductive health of adolescents. Interventions should also be focused on increasing adolescents’ resilience. Greater resilience developed during traumatic experiences within humanitarian and fragile settings can be of lifelong benefit.

ity, especially for those concerning girls’ and women’s rights and the sexual and reproductive health of adolescents. Interventions should also be focused on increasing adolescents’ resilience. Greater resilience developed during traumatic experiences within humanitarian and fragile settings can be of lifelong benefit. Given the protracted and cyclical nature of many conflicts, it is important to ensure care for affected adolescents continues throughout their lifespan and meets their diverse needs. To deliver this, humanitarian and development sectors must work together in a timely manner. This requires strengthening the links between sectors, including health, protection, education, and livelihoods, to create a holistic, multisectoral response (including monitoring and evaluation) for adolescents using existing structures in humanitarian and fragile settings.

ctors must work together in a timely manner. This requires strengthening the links between sectors, including health, protection, education, and livelihoods, to create a holistic, multisectoral response (including monitoring and evaluation) for adolescents using existing structures in humanitarian and fragile settings. Delivering meaningful engagement entails including adolescents in design, implementation, and evaluation of interventions and considering them as full actors with diverse needs. This requires prioritising the support of local adolescent led initiatives and organisations. Additionally, there is a need to build sustainable systems for adolescent participation in decision-making (especially for girls) and to invest in gender-transformative approaches to improve adolescent girls’ agency and leadership at community, provincial, national, and global levels. Investing in systems where adolescents work on current and future challenges faced by humanitarian and fragile settings will result in positive outcomes for them, their families, and communities in the short, medium, and long term. ● Adolescents are particularly vulnerable in humanitarian and fragile settings, where they often face high risk situations and may be forced to take on adult roles ● Data are lacking on the specific needs of adolescents in these settings and how to improve their wellbeing ● Greater investment is needed in adolescent specific strategies and in collecting disaggregated data by age, gender, sexual orientation, and disability status

● Adolescents are particularly vulnerable in humanitarian and fragile settings, where they often face high risk situations and may be forced to take on adult roles ● Data are lacking on the specific needs of adolescents in these settings and how to improve their wellbeing ● Greater investment is needed in adolescent specific strategies and in collecting disaggregated data by age, gender, sexual orientation, and disability status ● Humanitarian and development sectors must work together to support the diverse needs of adolescents throughout their lives ●Adolescents must be involved in the design, implementation, and evaluation of interventions to ensure meaningful engagement

Data are critically needed both to evaluate existing programmes and to promote the routine collection and use of age and sex disaggregated data. Such data collection should include rigorous evaluations of existing programmes to examine both process and the short, medium, and long-term effects on adolescents, and to establish any causal links between humanitarian interventions (eg, the transition to cash-based assistance) and adolescent outcomes. With donors’ support, programme implementers must prioritise and allocate resources for working with evaluators and researchers either within or external to their organisation, to include systematic evaluations of the effectiveness and cost effectiveness of their programmes Adolescent specific modules must also be added to routine data collection systems (eg, Health Management Information System) and ad hoc surveys such as those assessing demographic and health characteristics, living standards, and violence against children. Such modules are being piloted within Unicef’s multi-indicator cluster surveys.3

This type of research, focusing on context specific interventions, should be conducted at all stages of humanitarian response, from preparation to evaluation. Implementation research and preparations before interventions are particularly important to prevent resistance from the community, especially for those concerning girls’ and women’s rights and the sexual and reproductive health of adolescents. Interventions should also be focused on increasing adolescents’ resilience. Greater resilience developed during traumatic experiences within humanitarian and fragile settings can be of lifelong benefit.

Given the protracted and cyclical nature of many conflicts, it is important to ensure care for affected adolescents continues throughout their lifespan and meets their diverse needs. To deliver this, humanitarian and development sectors must work together in a timely manner. This requires strengthening the links between sectors, including health, protection, education, and livelihoods, to create a holistic, multisectoral response (including monitoring and evaluation) for adolescents using existing structures in humanitarian and fragile settings.

Delivering meaningful engagement entails including adolescents in design, implementation, and evaluation of interventions and considering them as full actors with diverse needs. This requires prioritising the support of local adolescent led initiatives and organisations. Additionally, there is a need to build sustainable systems for adolescent participation in decision-making (especially for girls) and to invest in gender-transformative approaches to improve adolescent girls’ agency and leadership at community, provincial, national, and global levels. Investing in systems where adolescents work on current and future challenges faced by humanitarian and fragile settings will result in positive outcomes for them, their families, and communities in the short, medium, and long term. ● Adolescents are particularly vulnerable in humanitarian and fragile settings, where they often face high risk situations and may be forced to take on adult roles ● Data are lacking on the specific needs of adolescents in these settings and how to improve their wellbeing ● Greater investment is needed in adolescent specific strategies and in collecting disaggregated data by age, gender, sexual orientation, and disability status ● Humanitarian and development sectors must work together to support the diverse needs of adolescents throughout their lives ●Adolescents must be involved in the design, implementation, and evaluation of interventions to ensure meaningful engagement