Who holds power in decision making for young people's future?

Public health policy decision making involves multiple actors, including government officials, health professionals, academics, advocacy groups, industry and the public. Questions of power lie at the heart of this process: who has the power to meaningfully participate in and shape public health policy, what factors influence decision making, and who is sidelined? To address the health and wellbeing of current and future generations — including the impacts of climate events, the promotion of harmful products, the predictors for mental ill‐health, food insecurity etc — the inequitable distribution of power and resources, and how these limit youth participation in decision‐making processes, should be considered. Specifically, the voices and experiences of Aboriginal and Torres Strait Islander, culturally diverse, low income, LGBTQIA+ and disabled children and young people (among other groups experiencing marginalisation) are seldom included in meaningful ways in public health decisions.1

“Participation” is one of seven domains considered in the supplement on the Future Healthy Countdown 2030 as essential to children and young people's health and wellbeing. Eight of the 16 national and international youth health and wellbeing frameworks outlined in this supplement's framing article2 recognise the benefits of youth participation in some form. The Nest framework developed in 2021 by the Australian Research Alliance for Children and Youth (ARACY) describes “Participation” through child and youth voices as children and young people having a say (ie, civic participation) in decisions that affect them.3 The United Nations (UN) Convention on the Rights of the Child further emphasises children's and young people's rights to express views that are taken seriously by decision makers.4 Critically, when viewed through a power lens, participation necessitates building the conditions that allow children and young people to have economic, social, institutional and political power to be influential members in society.5 Evidence suggests that children and young people should be supported to be architects of their futures because they have many strengths, including being more future‐oriented and affected by policy decisions for longer than adults, and often being highly engaged in social and political issues as mobilisers and advocates (eg, through social media and digital tools).6

Critically, youth participation can vary from manipulative and tokenistic forms of consultation where power is maintained by adults and institutions to youth‐led processes that support children and young people to influence or change systems through genuine partnerships and delegated forms of power and control.7 With children and young people often being under voting age and/or rarely having the same level of access to decision makers as older groups with more resources and power (eg, corporations), their policy participation can often be limited.6 Unfair biases that young people from certain demographic groups lack knowledge and expertise create additional barriers for their voices to be heard by decision makers. These examples and existing evidence suggest that youth participation is often poorly conceived and heavily constrained by the institutional status quo.5

With multiple public health issues (some at crisis levels) threatening the health and wellbeing of children and young people, diverse groups of young people and the UN are increasingly calling for governments and institutions to be held accountable for bettering youth participatory practices. These efforts aim for young people's power to be elevated to transform traditional adult‐centric institutional and policy decision making.8,9

Our team of young codesigners is comprised of 14 authors aged less than 30 years with diverse lived experiences. We set out to explore how to strengthen and measure young people's power in public health decision making through various forms of participation. The topic was explored through three one‐hour open group discussions and by inviting each co‐author to freely contribute their ideas verbally and/or in writing. All authors approved the ideas expressed here, which illustrate ways to transform youth participation across levels of impact on public health. We map Australian examples using a three‐tier framework for advancing youth participation as per The SAGE handbook of youth work practice.5

Transforming institutional dialogue and perceptions of young people

Developing youth‐affirming platforms

The UN has institutionalised two major developments for young people in decision making: the UN Youth 2030 Strategy (2018)10 and the UN Youth Office (2022).11 The UN Youth Office aims to coordinate leadership, participation and advocacy for the advancement of youth issues (including advancing the Sustainable Development Goals) across the UN and member states.11 In 2021, the Youth 2030 global progress report indicated that not all UN entities were working to advance youth participation in health.12 In the Asia–Pacific region, it remains unclear whether opportunities for youth input into strategic UN developments will occur. However, young people in Australia have already demonstrated their capacity to advance the objectives of the UN Youth Office through strategies for social connection and partnership development globally. In the 2022 Australian Youth Representative to the UN report, Australian youth advocated for youth‐affirming structures that harness youth power and rights to contribute to effective health and social policy decisions.13 Recommendations include mentoring and affirming diverse youth perspectives in international diplomacy, providing networking opportunities across UN entities, providing resources that are free, evaluating youth contributions to knowledge‐building, and embracing future thinking and the acceleration of local action.13

Elevating diverse voices and experiences in policy dialogue

Children and young people actively advocate for policies related to mental health, gun control, reproductive rights, climate change, and the right to healthy food, among other topics. The global Fridays for Future (www.fridaysforfuture.org) movement comprises decentralised organisations tackling climate change by elevating the voices of school students. Since 2018, Fridays for Future has also elevated the profile of health outcomes linked to climate change (eg, climate anxiety), centring these concerns in public policy discussions.14 Climate change experiences raised by young advocates in the hardest‐hit parts of the world, notably the Pacific Islands, are increasingly being integrated into public advocacy, demonstrating young people's responsiveness to greater inclusion and representation in policy.15 Bite Back 2030 (www.biteback2030.com) is another youth‐led movement in the United Kingdom focused on identifying and addressing the underlying inequities that contribute to child obesity. To challenge systems of under‐representation, young people involved in Bite Back 2030 are governed by a diverse, multicultural and representative National Youth Board consisting of 16 change makers. These youth advocates sit across different local governments and champion social equity by creating campaigns and leading policy conversations that elevate their lived experiences and stories.16

Maximising youth agency: supporting young people's leadership and creativity

The UN Youth, Fridays for Future and Bite Back 2023 movements show us that children and young people everywhere want institutions to support their agency by fostering opportunities for youth leadership and creativity. Global Health Youth Connect (www.ghyc.org.au) is another example of this. It was established by Australian young people who are committed to engaging youth in understanding and addressing health inequities through a social determinants of health approach. Fundamental principles of Global Health Youth Connect include trusting young people to lead, innovate and have ownership over projects that align with causes they are passionate about, thereby showcasing their expertise and talents, which may otherwise be overlooked by decision makers. Two projects that exemplify this are the “Your Mind in Colour” (a mental health art and photography competition) and “My Body Is My Own” (a sexual health and body autonomy art call). Photovoice, an arts‐based visual approach that arms participants with cameras to foster social change, is an example of an evidence‐based participatory approach that can build bridges across communities (including with youth and decision makers), promote empathy, and inspire collective action towards creating more equitable health policies and programs.17

Generating new policy processes

Codesigning equitable policy

In Australia, the Centre for Multicultural Sport is a new initiative born out of the Centre for Multicultural Youth (CMY; www.cmy.net.au/victorian‐election) after the coronavirus disease 2019 (COVID‐19) pandemic lockdowns. Sport was identified as one way for traditionally excluded multicultural communities to have power in community decisions and achieve improved health and wellbeing.18 The Centre for Multicultural Sport uses a codesign model to inform its practices, giving youth a meaningful and powerful platform to identify equitable physical activity policy and practice recommendations. By integrating the collective voices of young people into the organisational practices of a well known not‐for‐profit organisation, the opinions of multicultural young people can overcome the power imbalances that traditionally exist and create a ripple effect across sports settings. If other youth‐facing organisations such as schools and universities used similar processes, young people with a range of experiences could inform health‐promoting policy that is culturally sensitive and builds their capacity for effective advocacy into the future.

Investing in including youth voices in democracy

Youth Affairs Council Victoria (YACVic) works to uphold the rights of young Victorians. The YACVic 2019 submission to the Royal Commission into Victoria's Mental Health System provides an example of how youth voice and power can inform policy decision making.19 The submission process was led by a diverse working group of 18 rural and regional children and young people aged 12–25 years and was strengthened by input from over 200 young people and sector workers across rural and regional Victoria. Members of the working group codesigned and cofacilitated the consultations across Victoria. Youth were upskilled in facilitation techniques, remunerated for their time and expertise, contributed to editing the submission, and codesigned resources and advocacy materials. The Commission's final report was well received by YACVic, which noted that it considered young people's calls to action, including a focus on codesigning mental health systems with young people who have lived experience.20 A similarly robust process was followed by the Youth Disability Advocacy Service's recent submission to the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.21 This policy submission is the first of its kind to be peer‐led by a working group of five disabled young people, rendering investment in amplifying their lived experience invaluable to the process.

Despite these case studies demonstrating movements towards better inclusion of diverse youth voices in institutions, leadership positions and high level policy processes, we must recognise case studies and evidence that have shown how governments and other institutions often mismanage the advice they receive from children and young people.22,23 To prevent this, youth participation efforts should be monitored with a view to reduce external barriers that prevent young people from having power in decision making and cocreate impactful pathways that shift power to children and young people.22

Tracking progress

To date, measures of youth participation in civil society are limited in several ways, including a lack of explicit focus on health and power, a focus on individual rather than structural‐level participation (eg, volunteering), infrequent monitoring, and inadequate disaggregated data.24 Australia's First Wellbeing Framework, which was released in July 2023, is an example of how youth power is overlooked by governments and institutions in these ways.25 In the absence of established measures of youth participation in policy, we have worked with the Victorian Government's Department of Health to propose a Youth Engagement and Evaluation Framework.26 Such framework should inform the development of new indicators in future wellbeing frameworks that reflect government accountability for strengthening social cohesion through strengths‐based and structurally focused measures of youth participation across different cohorts of young Australians. Adequate resourcing, investment and political and institutional power sharing from adult stakeholders will be critical.

Based on the available sources, we can begin to routinely track progress using the following five available indicators and reporting them by key sociodemographic characteristics (Box). These include two individual‐level indicators:

• The proportion of youth enrolled in voting (eg, the proportion of youth enrolled on the electoral roll, Australian Electoral Commission). In 2023, 90% of eligible young people aged 18–24 years were enrolled to vote.27
• The proportion of youth participating in political groups and activities. This is measured annually for young people aged 15–19 years by the national Mission Australia Annual Youth Survey. In 2022, Mission Australia reported that participation in political groups and activities was less common than all other activities assessed, but higher among Aboriginal and Torres Strait Islander respondents (15%) compared with non‐Indigenous respondents (8%).28

• The percentage of youth experiencing discrimination in decision making. This indicator measures the significant consequences for youth when there is a lack of opportunity for meaningful participation in policy. Although the Longitudinal Studies of Australian and Indigenous Children measure discrimination experienced by Aboriginal and Torres Strait Islander parents (87–93% experience discrimination daily) and racism experienced daily by Aboriginal and Torres Strait Islander children (46–59%), robust national estimates of the prevalence of discrimination and racism experienced by diverse groups of children and young people are lacking.29
• The number of established federal‐ and state‐based Youth Commissioners, Offices for Youth participation, and youth‐focused activities across all government levels and sociodemographic characteristics.30 The Victorian Office for Youth (www.youthcentral.vic.gov.au) and the Youth Strategy 2022–202731 provide initial examples of these types of platforms.
• The number of government‐led training and mentoring opportunities for young people to participate in all aspects of public policy making relevant to their future health and wellbeing. The numbers, diversity and proportions of young people participating annually, should be routinely reported at all levels of government.30

Conclusion

Power imbalances and structural factors currently prevent young people, especially those from under‐represented communities, from participating in public policy decisions that affect their health and wellbeing and that of future generations. Tangible opportunities for adult‐centred institutions to share power with children and young people by enabling inclusive dialogue and policy processes and investing in youth leadership, as we describe here, are required. Such opportunities allow decision makers to tap into the insights and creativity of young people to sustainably mobilise and measure policy responses that support wellbeing for all. A shift towards focusing on institutional barriers to the equitable participation of children and young people (rather than individually focused activities) and adequate resourcing of participatory activities will be central to realising this vision.