Publisher Correction: Adolescence and the next generation.

In Fig. 4a of this Analysis, owing to an error during the production process, the year in the header of the right column was '2016' rather than '2010'. In addition, in the HTML version of the Analysis, Table 1 was formatted incorrectly. These errors have been corrected online.

Adolescence and the next generation.

Adolescent growth and social development shape the early development of offspring from preconception through to the post-partum period through distinct processes in males and females. At a time of great change in the forces shaping adolescence, including the timing of parenthood, investments in today's adolescents, the largest cohort in human history, will yield great dividends for future generations.

Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990-2016.

BACKGROUND: Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016. METHODS: Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset. FINDINGS: From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings. INTERPRETATION: Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries. FUNDING: Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation.

Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data.

BACKGROUND: Indigenous populations have high rates of disease and premature mortality. Most Indigenous communities are young, and adolescence (age 10-24 years) provides great opportunities for population health gain. However, the absence of a comprehensive account of Indigenous adolescents' health has been a barrier to effective policy. We aimed to report a national health profile for Indigenous adolescents in Australia. METHODS: We undertook a systematic synthesis of population data to report the health and wellbeing of Indigenous adolescents in Australia. A reporting framework for Indigenous adolescent health in Australia was defined to measure health outcomes, health risks, and sociocultural determinants. Available data (primary data from national surveys and administrative datasets, and available published data) were mapped against the defined reporting framework, and the quality graded, with the highest quality data selected to report a health profile for Indigenous adolescents. Comparison with non-Indigenous adolescents was made where possible, and estimates (disaggregated by age, sex, and remoteness) were reported as relative risks. A national advisory group (six Indigenous young people, three Indigenous adult community members, three researchers, three policy makers, and two service providers, all aged ≥16 years) provided input about the reporting framework, interpretation of findings, and policy recommendations. FINDINGS: Data were available for 184 (79%) of 234 elements of the reporting framework. All-cause mortality for Indigenous adolescents (70 per 100 000) was more than twice that of non-Indigenous adolescents, with about 60% of deaths due to intentional self-harm and road traffic injury. 80% of all deaths among Indigenous adolescents were considered as potentially avoidable in the current health system. Communicable diseases (particularly sexually transmitted infections) were leading contributors to morbidity. Almost a third of Indigenous adolescents aged 18-24 years reported high levels of psychological distress (twice the non-Indigenous rate). There was an excess burden of mental disorders and substance use, alongside emerging type 2 diabetes and ischaemic heart disease. Additionally, there were excess intentional and unintentional injuries. Many aspects of this health profile differed markedly from that of non-Indigenous adolescents: rates of acute rheumatic fever, pneumococcal infection, gonorrhoea, and type 2 diabetes resulting in admission to hospital were ten times higher; rates of assault and childbirth in those aged 15-19 years were five times higher; whereas rates of eating disorders, melanoma and other skin cancers, and anaphylaxis were significantly lower. Risks for future ill-health were common; 43% of 15-24 year olds were current tobacco smokers and about 45% had high body mass (overweight or obese). Disadvantage across sociocultural health determinants also emerged, particularly around education. INTERPRETATION: Despite Australia's adolescents having one of the best health profiles globally, Indigenous adolescents have largely been left behind. Adequate responses will require intersectoral actions, including a health system responsive to the needs of Indigenous adolescents. Without a specific focus on adolescents, Australia will not redress Indigenous health inequalities. FUNDING: Australia's National Health and Medical Research Council, Sidney Myer Foundation, and the Murdoch Children's Research Institute.

Prevalence of Eating Disorder Symptoms in Transgender and Gender Diverse Adolescents Presenting for Gender-Affirming Care.

PURPOSE: To describe the prevalence of eating disorder symptoms among adolescents seeking gender-affirming care. METHODS: Cross-sectional study of 660 gender-diverse adolescents who completed the Branched Eating Disorder Test to measure anorexia and bulimia symptoms. RESULTS: 23.9% (95% CI 20.7-27.4) reported both anorexia symptoms, namely overvaluation of weight and fear of (or recurrent interference with) weight gain. 0.9% (95% CI 0.3-2.0) reported all bulimia symptoms, namely overvaluation of weight, recurrent binge eating, and recurrent compensatory behaviors (e.g., weekly purging). For all symptoms, prevalence was higher among i) adolescents assigned female at birth compared to those assigned male at birth, and ii) adolescents who felt unsure about their gender identity compared to those who identified as trans or nonbinary. DISCUSSION: Clinicians should monitor eating disorder symptoms among adolescents presenting for gender-affirming care, especially among those assigned female at birth or who are unsure about their gender identity.

From 'Pen Sao' to 'Tue Pa': Understanding diverse pathways to adolescent pregnancy in Lao People's Democratic Republic through qualitative investigation with girls in Vientiane Capital, Vientiane Province, and Luang Namtha.

Adolescent birth rates in Lao People's Democratic Republic (PDR) remain the highest in Southeast Asia. There is growing recognition that adolescent pregnancy in Lao PDR is occurring within and outside marriage, but there is a lack of robust qualitative evidence to understand girls' pathways to adolescent pregnancy and contributing factors, especially outside of union (cohabitation or marriage). This study aimed to improve understanding of pathways to adolescent pregnancy in Lao PDR among girls who experienced pregnancy at age 18 or below. We conducted participatory timeline interviews with 57 girls from urban, peri-urban, and rural communities in Vientiane Capital, Vientiane Province, and Luang Namtha, and follow-up interviews with a subset of 20 girls. We identified six pathways to pregnancy, including pathways outside (n = 23) and within union (n = 34). Outside-union pathways diverged according to the nature of sex preceding pregnancy (consensual/pressured, or forced), and pregnancy intention (unplanned, partner-led, or planned). Within-union pathways diverged according to the nature of the relationship before union (romantic or no romantic relationship/arranged union), who initiated the union (couple/girl, parent/partner, or pressured), and pregnancy intention. Factors contributing to girls' pregnancy included barriers to sexual and reproductive health (SRH) information and services; partner's control over reproductive decision-making; male sexual entitlement and alcohol use driving pressured/forced sex; cultural acceptance of child marriage and early union; and attitudes and norms regarding sex and pregnancy outside of union. Our findings support strengthening comprehensive sexuality education, including a focus on addressing myths about contraception, building girls' and boys' communication skills, engaging in respectful relationships, and addressing harmful gender norms. Our findings also highlight the need to improve girls' access to adolescent-responsive SRH services, address harmful substance use, challenge sociocultural barriers to young people accessing SRH information and services, and respond to sociocultural and financial drivers of child marriage/early union that contribute to adolescent pregnancy.

Menstrual Practice Needs Scale short form (MPNS-SF) and rapid (MPNS-R): development in Khulna, Bangladesh, and validation in cross-sectional surveys from Bangladesh and Uganda.

OBJECTIVES: Develop and validate short and rapid forms of the 36-item Menstrual Practice Needs Scale (MPNS-36). DESIGN: Item reduction prioritised content validity and was informed by cognitive interviews with schoolgirls in Bangladesh, performance of scale items in past research and stakeholder feedback. The original MPNS-36 was revalidated, and short and rapid forms tested in a cross-sectional survey. This was followed by further tests of dimensionality, internal consistency and validity in multiple cross-sectional surveys. SETTING AND PARTICIPANTS: Short form (MPNS-SF) and rapid form (MPNS-R) measures were developed in a survey of 313 menstruating girls (mean age=13.51) in Khulna, Bangladesh. They were further tested in the baseline survey of the Adolescent Menstrual Experiences and Health Cohort, in Khulna, Bangladesh (891 menstruating girls, mean age=12.40); and the dataset from the MPNS-36 development in Soroti, Uganda (538 menstruating girls, mean age=14.49). RESULTS: The 18-item short form reflects the six original subscales, with the four core subscales demonstrating good fit in all three samples (Khulna pilot: root mean square error of approximation (RMSEA)=0.064, 90% CI 0.043 to 0.084, Comparative Fit Index (CFI)=0.94, Tucker-Lewis Index (TLI)=0.92. Cohort baseline: RMSEA=0.050, 90% CI 0.039 to 0.062, CFI=0.96, TLI=0.95. Uganda: RMSEA=0.039, 90% CI 0.028 to 0.050, CFI=0.95, TLI=0.94). The 9-item rapid form captures diverse needs. A two-factor structure was the most appropriate but fell short of adequate fit (Khulna pilot: RMSEA=0.092, 90% CI 0.000 to 0.158, CFI=0.93, TLI=0.89). Hypothesised associations between the MPNS scores and other constructs were comparable between the MPNS-36 and MPNS-SF in all populations, and replicated, with attenuation, in the MPNS-R. Internal consistency remained acceptable. CONCLUSIONS: The MPNS-SF offers a reliable and valid measure of adolescent girls' menstrual hygiene experience while reducing participant burden, to support implementation and improve measurement in menstrual health research. The MPNS-R provides a brief measure with poorer structural validity, suited to short surveys and including menstrual health within broader research topics.

Towards Harmonized Adolescent Health Measurement: Assessing Alignment Between Current Recommendations and the Global Action for Measurement of Adolescent Health-Recommended Indicators.

PURPOSE: This study identified alignment of indicators across different initiatives and data collection instruments as a foundation for future harmonization of adolescent health measurement. METHODS: Using the Global Action for Measurement of Adolescent health (GAMA) recommended indicators as the basis for comparison, we conducted a desk review of 14 global-level initiatives, such as the Sustainable Development Goals and the Global Strategy for Women's, Children's and Adolescents' Health, and five multicountry survey programs, such as the Multiple Indicator Cluster Surveys and the Global school-based Student Health Survey. We identified initiative and survey indicators similar to a GAMA indicator, deconstructed indicators into standard elements to facilitate comparison, and assessed alignment to the corresponding GAMA indicator across each of the elements. RESULTS: A total of 144 initiative indicators and 90 survey indicators were identified. Twenty-four initiative indicators (17%) and 14 survey indicators (16%) matched the corresponding GAMA indicators across all elements. Population of interest was the most commonly discrepant element; whereas GAMA indicators mostly refer to ages 10-19, many survey and initiative indicators encompass only part of this age range, for example, 15-19-year-olds as a subset of adults ages 15-49 years. An additional 53 initiative indicators (39%) and 44 survey indicators (49%) matched on all elements except the population of interest. DISCUSSION: The current adolescent measurement landscape is inconsistent, with differing recommendations on what and how to measure. Findings from this study support efforts to promote indicator alignment and harmonization across adolescent health measurement stakeholders at the global, regional, and country levels.

Indicators to Measure Adolescent Health at the Country, Regional, and Global Levels: Results of a Five-Year Selection Process by the Global Action for the Measurement of Adolescent Health.

PURPOSE: To improve adolescent health measurement, the Global Action for the Measurement of Adolescent health (GAMA) Advisory Group was formed in 2018 and published a draft list of 52 indicators across six adolescent health domains in 2022. We describe the process and results of selecting the adolescent health indicators recommended by GAMA (hereafter, "GAMA-recommended indicators"). METHODS: Each indicator in the draft list was assessed using the following inputs: (1) availability of data and stakeholders' perceptions on their relevance, acceptability, and feasibility across selected countries; (2) alignment with current measurement recommendations and practices; and (3) data in global databases. Topic-specific working groups comprised of GAMA experts and representatives of United Nations partner agencies reviewed results and provided preliminary recommendations, which were appraised by all GAMA members and finalized. RESULTS: There are 47 GAMA-recommended indicators (36 core and 11 additional) for adolescent health measurement across six domains: policies, programs, and laws (4 indicators); systems performance and interventions (4); health determinants (7); health behaviors and risks (20); subjective well-being (2); and health outcomes and conditions (10). DISCUSSION: These indicators are the result of a robust and structured five-year process to identify a priority set of indicators with relevance to adolescent health globally. This inclusive and participatory approach incorporated inputs from a broad range of stakeholders, including adolescents and young people themselves. The GAMA-recommended indicators are now ready to be used to measure adolescent health at the country, regional, and global levels.

Exploring a Preliminary Set of Indicators to Measure Adolescent Health: Results From a 12-Country Feasibility Study.

PURPOSE: To explore data availability, perceived relevance, acceptability and feasibility of implementing 52 draft indicators for adolescent health measurement in different countries globally. METHODS: A mixed-methods, sequential explanatory study was conducted in 12 countries. An online spreadsheet was used to assess data availability and a stakeholder survey to assess perceived relevance, acceptability, and feasibility of implementing each draft indicator proposed by the Global Action for Measurement of Adolescent health (GAMA). The assessments were discussed in virtual meetings with all countries and in deep dives with three countries. Findings were synthesized using descriptive statistics and qualitative thematic analysis. RESULTS: Data availability varied across the 52 draft GAMA indicators and across countries. Nine countries reported measuring over half of the indicators. Most indicators were rated relevant by stakeholders, while some were considered less acceptable and feasible. The ten lowest-ranking indicators were related to mental health, sexual health and substance use; the highest-ranking indicators centered on broader adolescent health issues, like use of health services. Indicators with higher data availability and alignment with national priorities were generally considered most relevant, acceptable and feasible. Barriers to measurement included legal, ethical and sensitivity issues, challenges with multi-sectoral coordination and data systems flexibility. DISCUSSION: Most of the draft GAMA indicators were deemed relevant and feasible, but contextual priorities and perceived acceptability influenced their implementation in countries. To increase their use for a more comprehensive understanding of adolescent health, better multi-sectoral coordination and tailored capacity building to accommodate the diverse data systems in countries will be required.

The quality of health research for young Indigenous Australians: systematic review.

OBJECTIVE: To assess the extent and quality of the evidence base related to the health and wellbeing of young Indigenous Australians. STUDY DESIGN: Systematic review of peer-reviewed literature; grading of quality of literature; mapping of sample characteristics and study foci. DATA SOURCES: English language publications, 1 Jan 1994 - 1 Jan 2011 in MEDLINE, ERIC, CINAHL, EMBASE, ATSIhealth, PsycINFO, the Cochrane Library and the Australian Indigenous HealthInfoNet. STUDY SELECTION: Inclusion criteria were: published 1 Jan 1994 - 1 Jan 2011; original peer-reviewed research; reported data for Australian Aboriginal and Torres Strait Islanders aged 10-24 2013s; focused on health and wellbeing. Grading for quality included ascertainment of Indigenous status, representativeness of the sample for the target population, and quality of measures of exposure and outcome. DATA SYNTHESIS: 360 peer-reviewed publications met inclusion criteria; 90 (25%) exclusively sampled Indigenous young people. 250 studies (69%) were of good-quality design; 124 of these focused on health outcomes (15 of these evaluated an intervention) and 116 focused on health-risk exposure (26 evaluative). The methodological quality of data improved during 1994-2010; however, only 17% of studies focused on urban populations. A third of good-quality studies of health outcome focused on communicable diseases such as sexually transmitted infections and tuberculosis. There was good-quality data for oral health and substance use, and some data for adolescent pregnancy. Data on mental disorders, injury and cause-specific mortality were limited. CONCLUSIONS: Despite improvements, there are important gaps in the evidence base for the health of young Indigenous Australians. Our study points to the need for greater research investment in urban settings and with regard to mental disorders and injury, with a further emphasis on trials of preventive and clinical intervention.

Cardiometabolic Risk Markers for Aboriginal and Torres Strait Islander Children and Youths: A Systematic Review of Data Quality and Population Prevalence.

Cardiovascular disease and type 2 diabetes mellitus are leading contributors to the health inequity experienced by Aboriginal and Torres Strait Islander peoples, and their antecedents can be identified from early childhood. We aimed to establish the quality of available data and the prevalence of cardiometabolic risk markers among Aboriginal and Torres Strait Islander children and youths (0-24-year-olds) to inform public health approaches. A systematic review of the peer-reviewed and grey literature was conducted between 1 January 2000-28 February 2021. Included studies reported population prevalence of cardiometabolic risks, including elevated blood pressure, obesity, central adiposity, dyslipidaemia, hyperglycaemia, and 'metabolic syndrome' for Aboriginal and Torres Strait Islander people aged 0-24 years. Fifteen studies provided population estimates. Data quality was limited by low response rates (10/15 studies) and suboptimal outcome measurements. Obesity is the most reported risk (13/15 studies). Aboriginal and Torres Strait Islander children have an excess risk of obesity from early childhood and prevalence increases with age: 32.1% of Aboriginal and Torres Strait Islander 18-24-year-olds had obesity and 50.8% had central adiposity. In a cohort of 486 9-14-year-olds in Darwin, 70% had ≥1 component of metabolic syndrome; 14% met the full criteria for the syndrome. The prevalence of cardiometabolic risk in Aboriginal and Torres Strait Islander young people is difficult to estimate due to limitations in measurement quality and sampling representativeness. Available data suggest that cardiometabolic risk markers are evident from early childhood. The establishment of national and state-level datasets and a core outcome set for cardiometabolic screening would provide opportunities for preventative action.

Contemporary pathways to adolescent pregnancy in Indonesia: A qualitative investigation with adolescent girls in West Java and Central Sulawesi.

In the last decade, reduction in adolescent fertility rates in Indonesia has slowed despite national programmes and policies focused on addressing child marriage. Indonesia currently has the highest number of births to adolescent girls aged 15-19 years in Southeast Asia. There is a need to develop a more nuanced understanding of the drivers of adolescent pregnancy in Indonesia to inform programmes and policies tailored to young people's needs and priorities. This study explored adolescent girls' pathways to pregnancy across two provinces (Central Sulawesi and West Java) in Indonesia. We conducted participatory timeline interviews with 79 girls aged 15-21 years from urban, peri-urban, and rural communities and inquired about their relationships and life experiences leading up to pregnancy. We conducted follow-up interviews with 19 selected participants to validate and clarify preliminary findings. We identified six pathways to adolescent pregnancy which were broadly differentiated by the timing of pregnancy relative to marriage. Three pregnancy pathways within marriage were further differentiated by the main motivation for marriage-financial reasons, protecting the girl and family's reputation, or to progress a romantic relationship. Three pregnancy pathways outside marriage were distinguished by the nature of the sexual relationship preceding pregnancy-consensual sex, unwanted or pressured sex, and forced sex. Drivers of adolescent pregnancy include the acceptability of child marriage and stigma surrounding premarital pregnancy, family and social expectations of pregnancy following marriage, harmful gender-based norms and violence, and lack of sexual and reproductive health information and access to services. Adolescents follow varied pathways to pregnancy in Indonesia. The idealisation and acceptance of child marriage is both a catalyst and outcome of adolescent pregnancy, which is occurring amid stigma surrounding premarital sex and pregnancy, harmful gender-based norms and violence, and barriers to contraceptive access and use. Our findings emphasise that there are many drivers of adolescent pregnancy and different pathways will require intervention approaches that address child marriage alongside other key contributors.

Towards responsive policy and actions to address non-communicable disease risks amongst adolescents in Indonesia: insights from key stakeholders.

Background: Non-communicable diseases (NCDs) such as cancer, diabetes, heart disease, mental disorder and chronic lung conditions are the leading cause of death and disability in Indonesia. Adolescence is when risks for NCDs emerge and it is also an important life stage for intervention, yet young people are often at the margins of NCD policy and actions. This study aimed to understand how policies and actions should address NCD risks (tobacco smoking, inadequate physical activity, and diet) for adolescents in Indonesia, and how young people can be meaningfully involved. Methods: Qualitative in-depth interviews over videoconference (n = 21) were conducted in English or Bahasa with stakeholders in Indonesia. Participants included policymakers, implementation partners, and advocates who were focused on adolescent health or NCDs. Interviews were recorded, transcribed, translated, and thematically analysed using NVivo12. Findings were disseminated to participants for validation and feedback. Youth participants (n = 7) attended an additional workshop and considered recommendations and actions arising from this research. Findings: Participants identified that government and non-government organisations are acting on NCDs in Indonesia, but few of the existing initiatives target adolescents, and adolescent services rarely addressed NCD risks. Participants also felt that policies to protect adolescents from NCD risks (i.e., smoke-free areas in public) were not always enforced. For programs or initiatives focused on adolescent health, those that had engaged adolescents as co-creators and leaders were perceived to be more successful. As such, participants recommended more meaningful engagement of young people, including young people's leadership of initiatives. Additional recommendations included the need for intersectoral engagement and a 'whole-of-government' approach to prevention given the complex determinants of NCD risks, and the need for evidence-based actions that are underpinned by quality data to enable monitoring of progress. Interpretation: There is a recognised need to strengthen policies and actions to address NCD risks amongst adolescents in Indonesia. Meaningful youth engagement that allows young people to take the lead, intersectoral actions, and evidence-based data driven responses were key strategies identified. Funding: UNICEF East Asia and Pacific Regional Office.

Foregone health care in adolescents from school and community settings in Indonesia: a cross-sectional study.

Background: Adolescence is a development period marked by the onset of a new set of health needs. The present study sought to quantify the prevalence of foregone care (not seeking medical care when needed) and identify which adolescents are at greater risk of having unmet healthcare needs. Methods: A multi-stage random sampling strategy was used to recruit school participants (grade 10-12) in two provinces in Indonesia. Respondent driven sampling was used to recruit out-of-school adolescents in the community. All participants completed a self-reported questionnaire which measured healthcare seeking behaviours, psychosocial wellbeing, use of healthcare services, and perceived barriers to accessing healthcare. Multivariable regression analysis was performed to examine factors associated with foregone care. Findings: A total of 2161 adolescents participated in the present study and nearly one in four adolescents reported foregone care in the past year. Experiences of poly-victimisation and seeking care for mental health needs increased the risk of foregone care. In-school adolescents who reported psychological distress [adjusted risk ratio (aRR) = 1.88, 95%CI = 1.48-2.38] or had high body mass index (aRR = 1.25, 95%CI = 1.00-1.57) were at greater risk of foregone care. The leading reason for foregone care was lack of knowledge of available services. In-school adolescents predominantly reported non-access barriers to care (e.g., perception of the health concern or anxiety about accessing care) whereas most out-of-school adolescents reported access barriers (e.g., did not know where to get care or could not pay). Interpretation: Foregone care is common among Indonesian adolescents, especially in adolescents with mental and physical health risks. Differences between in-school and out-of-school adolescents suggest that interventions to promote appropriate healthcare use will need tailoring. Further research is needed to determine causal relationships around barriers in access to healthcare. Funding: Australia-Indonesia Centre.

Adolescent girls' experiences of menstruation and schooling in monastic schools in Magway Region, Myanmar: A mixed-methods exploration.

Background: Despite increasing recognition that menstruation matters for adolescent girls' health and education, few studies have investigated menstrual health challenges and impacts in Myanmar. In this study we aimed to (1) understand the menstrual experiences of girls attending monastic schools in Magway Region, Myanmar and (2) explore the associations between their reported unmet menstrual health needs and school absenteeism. Methods: We undertook a mixed-methods exploration across 16 Monastic schools in rural and semi-rural areas. In-depth interviews with 10 adolescent girls, 10 Focus-Group Discussions (FGDs) with girls, 10 FGDs with boys, 5 FGDs with mothers, along with 24 key-informant interviews were analyzed using a framework approach to explore girls' menstrual experiences and challenges in school settings. A cross-sectional survey of 421 post menarche girls (mean-age-14 years) was used to describe the prevalence of menstrual health challenges and test associations with self-reported school absenteeism. Results: Girls described a range of menstrual health challenges including access to information and social support, behavioral restrictions, stigma surrounding menstruation, difficulties managing menstrual bleeding and pain. Girls also described fear and distress associated with menstruation and impacts on school attendance and participation. Of girls surveyed, 12.8% had missed school due to their last period. In multivariable analysis, grade level (aOR = 0.76 95%CI 0.60-0.97), menstrual pain (aOR = 2.10 95%CI 1.10-4.00), and heavy bleeding (aOR = 3.33 95%CI 1.51-7.34) were associated with absenteeism. Knowledge about menstrual biology was not related to absenteeism, but a more negative attitude toward menstruation may have predicted greater absences (aOR 1.34 95%CI 0.99-1.80). Confidence to talk to friends or teachers about menstruation was not associated with absenteeism, nor was using a disposable-pad or feeling confident to manage menses at school. However, feeling confident to ask a teacher for a pad was associated with greater absenteeism and may have indicated that girls more regularly needing to request products had lower attendance (aOR = 1.93 95%CI 1.06-3.54). Conclusions: Adolescent girls in Magway face substantial challenges during menstruation, adversely impacting on their education and wellbeing. Providing age-appropriate education and addressing shame and taboos are important components of a comprehensive menstrual health response. In addition, our study highlights the need to ensure access to menstrual resources and WASH facilities, along with access to adequate menstrual pain relief.

Strengthening assessment and response to mental health needs for Aboriginal and Torres Strait Islander children and adolescents in primary care settings: study protocol for the Ngalaiya Boorai Gabara Budbut implementation project.

INTRODUCTION: Opportunities for improved mental health and wellbeing of Aboriginal and Torres Strait Islander children and young people lie in improving the capability of primary healthcare services to identify mental healthcare needs and respond in timely and appropriate ways. The development of culturally appropriate mental health assessment tools and clinical pathways have been identified as opportunities for strengthening workforce capacity in this area. The Ngalaiya Boorai Gabara Budbut implementation project seeks to pursue these opportunities by developing and validating a psychosocial assessment tool, understanding what services need to better care for your people and developing resources that address those needs. METHODS AND ANALYSIS: The project will be governed by a research governance group comprising Aboriginal service providers, young people, and researchers. It will be implemented in an urban health service in Canberra, and regional services in Moree, Wollongong, and the Illawarra regions of New South Wales Australia. The validation study will follow an argument-based approach, assessing cultural appropriateness and ease of use; test-retest validity; internal consistency, construct validity and the quality of decisions made based on the assessment. Following piloting with a small group of young people and their caregivers (n=10), participants (n=200) will be young people and/or their caregivers, attending one of the partner services. The needs assessment will involve an in-depth exploration of service via an online survey (n=60) and in-depth interviews with service providers (n=16) and young people (n=16). These activities will run concurrently. Service providers, researchers and the governance group will codesign resources that respond to the needs identified and pilot them through the participating services. ETHICS AND DISSEMINATION: The Aboriginal Health and Medical Research Council of NSW Human Research Ethics committee (#1769/21) has approved this project. Informed consent will be obtained from all participants and/or their caregivers (with assent from those aged <16 years) prior to participating in all aspects of the study. Research dissemination will occur through participating health services, academic journal articles and conference presentations.

Monitoring Menstrual Health Knowledge: Awareness of Menstruation at Menarche as an Indicator.

As initiatives to support menstrual health are implemented globally, monitoring progress through a set of comprehensive indicators provides important feedback to direct policies and programs. One proposed core indicator is awareness of menstruation at menarche. That is, at the time of menarche an adolescent girl knowing that menstrual bleeding is something she will experience. In this investigation, we undertook secondary analysis of data collected across four studies to support interpretation of this indicator. We (1) describe the proportion of each sample aware of menstruation at menarche, (2) test variations in awareness according to sociodemographic characteristics, and (3) describe the associations between this indicator and self-reported experience at menarche, social support, and confidence to manage menstruation. Studies included cross-sectional survey data from 421 schoolgirls in Magway, Myanmar, 537 schoolgirls in Soroti, Uganda, 1,359 schoolgirls in Netrokona, Bangladesh, and 599 adult women working in Mukono, Uganda. Awareness of menstruation at menarche varied from 84% in Myanmar to 34% in Bangladesh. Older age at menarche was associated with awareness. Awareness at menarche was not associated with household poverty in the adolescent samples, but greater poverty was associated with lower levels of awareness among adult women. In Myanmar, girls aware of menstruation had significantly higher odds of reporting that they felt prepared (2.85 95% CI 1.34-6.08), happy (OR = 3.81 95% CI 1.74-8.37) and knew what was happening at menarche (OR = 2.37 95% CI 1.34-4.19). However, they also reported higher levels of embarrassment (OR = 1.76 95% CI 1.04-2.97) and did not report significantly less fear (OR = 1.24 95% CI 0.82-1.85). Awareness of menstruation at menarche was associated with higher scores on a menstrual knowledge quiz in both Myanmar (b = 9.51 95% CI 3.99-15.04) and Bangladesh (b = 4.78 95% CI 1.70-7.87). In these studies girls aware of menstruation at menarche also had higher odds of reporting they felt confident discussing menstruation with support sources and managing menstruation at school, while these differences were not significant among schoolgirls in Uganda. Findings support the usefulness of awareness of menstruation at menarche as an indicator to describe minimal knowledge of menstruation and suggest that awareness may signal greater knowledge, social support, and confidence in some settings.