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The Health and Well-Being of Adolescents in China: The Past, Present, and Future

      With this issue of the Journal of Adolescent Health, we bring you a landmark supplement highlighting the progress that has been made to improve the health and well-being of adolescents in China, where there are some unique opportunities to focus on young people in novel ways [
      • Liu L.
      Improving adolescent survival, health & well-being in China.
      ]. Six original articles in this supplement review the historical mortality of young people in China [
      • Dong Y.
      • Hu P.
      • Song Y.
      • et al.
      National and subnational trends in mortality and causes of death in Chinese children and adolescents aged 5–19 years from 1953 to 2016.
      ]; highlight the current status of adolescent health, including those young people who are most marginalized [
      • Luo X.
      • et al.
      Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.
      ,
      • Zhang
      • et al.
      Financing adolescent health in China: how much, who pays, and where it goes.
      ,
      • Zhou Y.
      • et al.
      Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.
      ]; and point to the future, as systems are being developed now that will monitor health status and improve healthcare delivery systems [
      • Dong B.
      • et al.
      Adolescent health and healthy China 2030: a review.
      ,
      • Xu R.
      • et al.
      Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.
      ].
      In 2016, the Chinese government set out to develop the Healthy China 2030 Planning Outline, a strategic plan for the entire Chinese health sector that incorporated the UN 2030 Agenda for Sustainable Development Goals. In 2018, Beijing reaffirmed its commitment to working toward achieving these goals for the entire population. Embedded in these goals was a specific focus on improving the health and well-being of young people. Some of the areas that were included in the goals for young people include nutrition, substance abuse, road traffic injuries, and other noncommunicable diseases (NCD) [
      • Xu R.
      • et al.
      Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.
      ].
      The supplement’s lead editorial by Dr. Li Liu highlights many of the changes that have been made to improve the survival, health, and well-being of adolescents [
      • Liu L.
      Improving adolescent survival, health & well-being in China.
      ]. She challenges China to use this opportunity to develop a broader system of measures that may be better able to identify the progress that has been made and provide opportunities for the government to make greater strides in improving the health of adolescents.
      In reviewing the past, Dong et al. [
      • Dong Y.
      • Hu P.
      • Song Y.
      • et al.
      National and subnational trends in mortality and causes of death in Chinese children and adolescents aged 5–19 years from 1953 to 2016.
      ] document the trends in mortality from 1953 to 2016. This period has seen monumental decrements in mortality for children and adolescents (5–19 years), from 366/100,000 to 27.2/100,000—a 90% reduction in mortality—with the largest reduction among adolescents 15–19 years. Even with these remarkable declines in mortality, however, the authors acknowledge the need to refocus on road traffic injury, drowning, self-harm, and NCD, including cancer identification and treatment.
      In reviewing the present state of adolescent health in China, 3 articles outline different parameters for the growing focus on the second decade: the current delivery system [
      • Luo X.
      • et al.
      Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.
      ], the financing system [
      • Zhang
      • et al.
      Financing adolescent health in China: how much, who pays, and where it goes.
      ], and the plight of children left behind by migrant worker parents [
      • Zhou Y.
      • et al.
      Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.
      ]. Luo et al. [
      • Luo X.
      • et al.
      Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.
      ] review the distribution of the adolescent–healthcare system, which is primarily embedded within the Maternal and Children’s Healthcare Hospitals (MCH), with a minority of these having identified adolescent clinics. In interviews with providers and healthcare administrators, there were major differences in the perspectives of the providers and the administrators of the MCH systems. Clinicians focused on the demands of providing high-quality care to young people and administrators on costs of operation for adolescent clinics in the MCH system. The most valuable component of this exploratory work was the development of strategic priorities to guide the development of the adolescent–healthcare system in China, with strong linkages among health, education, and community systems to develop comprehensive approaches beyond sexual and reproductive health. A key component of these recommendations is an emphasis on workforce development. Zhang et al. [
      • Zhang
      • et al.
      Financing adolescent health in China: how much, who pays, and where it goes.
      ] conducted a critical analysis of the health financing system by focusing on 3 questions: How much does adolescent healthcare cost? Who pays for the services? and Where does the money go? In 2014, adolescent health expenditures accounted for 2.6% of healthcare expenditures in China, with over 70% focusing on curative care and 10% on preventive care. Out-of-pocket spending was a major source of funding for adolescent health, accounting for more than half of total spending. These data offer some opportunities for reframing how we develop adolescent–healthcare systems and for what and where we allocate resources. The distribution and burden of these costs weigh heavily on young people and their families’ ability to pay for the needed services. Zhang et al. emphasize the critical importance of looking at the total costs for healthcare, with an emphasis on investing in sexual and reproductive health and prevention of NCD, in an effort to reduce the costs of curative care. The third paper on the current state of adolescent health in China focuses on the persistent impact of disparities among left-behind children, who have been left to fend for themselves as their parents pursue work [
      • Zhou Y.
      • et al.
      Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.
      ]. Zhou et al. [
      • Zhou Y.
      • et al.
      Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.
      ] report on a cross-sectional study of children who are under 16 years old and who no longer have parents in their lives. They compared them with children who had at least one parent at home, finding that the left-behind children group had higher prevalence of insomnia, loneliness, sadness, self-harm behavior, and academic stress.
      The supplement’s final 2 papers build on the previous 4 and pave the way for future of improvements in adolescent healthcare in China [
      • Dong B.
      • et al.
      Adolescent health and healthy China 2030: a review.
      ,
      • Xu R.
      • et al.
      Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.
      ]. Dong et al. [
      • Dong B.
      • et al.
      Adolescent health and healthy China 2030: a review.
      ] explore the differences between the current health status of adolescents and the targets that have been set by the China 2030 initiative. Two data sources—the Global Burden of Disease Study (1990–2016) and the Chinese National Survey on Students’ Constitution and Health (1985–2014)—were used to analyze time trends of health indicators for adolescents (10–19 years) in China. In looking toward 2030, Dong et al. highlight the fact that even though mortality among adolescents has been halved over the past 25 years, new emergent problems such as road injuries, drowning, obesity, decrements in physical fitness, and self-harm must be part of the strategy for 2030. Taking on these new problems while maintaining a focus on traditional problems such as poor vision, stunting, and sexual/reproductive health will require targeted prevention and intervention programs that recognize the unique needs of those in their second decade of life. The final paper in this supplement, by Xu et al. [
      • Xu R.
      • et al.
      Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.
      ], underlines the need for a system of adolescent health indicators. This critically important paper supports the old adage, “What gets measured gets done.” Close monitoring of Xu et al.’s proposed indicators will enable continuous opportunities for shifting efforts to meet the defined goals of China 2030. This paper raises the bar for developing an indicator system by using the Global Burden of Diseases 2015, policy documents from the State Council of China, and published literature reviews to identify 100 indicators (72 of them are available in national data systems). These were then categorized around 5 dimensions: health outcomes, health knowledge, skills and risk behaviors, demographics, responsiveness of health systems, and the physical and social environments. This comprehensive review with clearly identified indicators and data systems in place bodes well for opportunities to improve the health and well-being of adolescents in China.

      References

        • Liu L.
        Improving adolescent survival, health & well-being in China.
        J Adolesc Health. 2020; 67: S1-S2
        • Dong Y.
        • Hu P.
        • Song Y.
        • et al.
        National and subnational trends in mortality and causes of death in Chinese children and adolescents aged 5–19 years from 1953 to 2016.
        J Adolesc Health. 2020; 67: S3-S13
        • Luo X.
        • et al.
        Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.
        J Adolesc Health. 2020; 67: S32-S37
        • Zhang
        • et al.
        Financing adolescent health in China: how much, who pays, and where it goes.
        J Adolesc Health. 2020; 67: S38-S47
        • Zhou Y.
        • et al.
        Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.
        J Adolesc Health. 2020; 67: S48-S54
        • Dong B.
        • et al.
        Adolescent health and healthy China 2030: a review.
        J Adolesc Health. 2020; 67: S24-S31
        • Xu R.
        • et al.
        Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.
        J Adolesc Health. 2020; 67: S14-S23