Prevalence of adolescent mental disorders in Kenya, Indonesia, and Viet Nam measured by the National Adolescent Mental Health Surveys (NAMHS): a multi-national cross-sectional study.

BACKGROUND: Mental disorders are the leading global cause of health burden among adolescents. However, prevalence data for mental disorders among adolescents in low-income and middle-income countries are scarce with often limited generalisability. This study aimed to generate nationally representative prevalence estimates for mental disorders in adolescents in Kenya, Indonesia, and Viet Nam. METHODS: As part of the National Adolescent Mental Health Surveys (NAMHS), a multinational cross-sectional study, nationally representative household surveys were conducted in Kenya, Indonesia, and Viet Nam between March and December, 2021. Adolescents aged 10-17 years and their primary caregiver were interviewed from households selected randomly according to sampling frames specifically designed to elicit nationally representative results. Six mental disorders (social phobia, generalised anxiety disorder, major depressive disorder, post-traumatic stress disorder, conduct disorder, and attention-deficit hyperactivity disorder) were assessed with the Diagnostic Interview Schedule for Children, Version 5. Suicidal behaviours and self-harm in the past 12 months were also assessed. Prevalence in the past 12 months and past 4 weeks was calculated for each mental disorder and collectively for any mental disorder (ie, of the six mental disorders assessed). Prevalence of suicidal behaviours (ie, ideation, planning, and attempt) and self-harm in the past 12 months was calculated, along with adjusted odds ratios (aORs) to show the association with prevalence of any mental disorder in the past 12 months. Inverse probability weighting was applied to generate national estimates with corresponding 95% CIs. FINDINGS: Final samples consisted of 5155 households (ie, adolescent and primary caregiver pairs) from Kenya, 5664 households from Indonesia, and 5996 households from Viet Nam. In Kenya, 2416 (46·9%) adolescents were male and 2739 (53·1%) were female; in Indonesia, 2803 (49·5%) adolescents were male and 2861 (50·5%) were female; and in Viet Nam, 3151 (52·5%) were male and 2845 (47·4%) were female. Prevalence of any mental disorder in the past 12 months was 12·1% (95% CI 10·9-13·5) in Kenya, 5·5% (4·3-6·9) in Indonesia, and 3·3% (2·7-4·1) in Viet Nam. Prevalence in the past 4 weeks was 9·4% (8·3-10·6) in Kenya, 4·4% (3·4-5·6) in Indonesia, and 2·7% (2·2-3·3) in Viet Nam. The prevalence of suicidal behaviours in the past 12 months was low in all three countries, with suicide ideation ranging from 1·4% in Indonesia (1·0-2·0) and Viet Nam (1·0-1·9) to 4·6% (3·9-5·3) in Kenya, suicide planning ranging from 0·4% in Indonesia (0·3-0·8) and Viet Nam (0·2-0·6) to 2·4% (1·9-2·9) in Kenya, and suicide attempts ranging from 0·2% in Indonesia (0·1-0·4) and Viet Nam (0·1-0·3) to 1·0% (0·7-1·4) in Kenya. The prevalence of self-harm in the past 12 months was also low in all three countries, ranging from 0·9% (0·6-1·3) in Indonesia to 1·2% (0·9-1·7) in Kenya. However, the prevalence of suicidal behaviours and self-harm in the past 12 months was significantly higher among those with any mental disorder in the past 12 months than those without (eg, aORs for suicidal ideation ranged from 7·1 [3·1-15·9] in Indonesia to 14·7 [7·5-28·6] in Viet Nam). INTERPRETATION: NAMHS provides the first national adolescent mental disorders prevalence estimates for Kenya, Indonesia, and Viet Nam. These data can inform mental health and broader health policies in low-income and middle-income countries. FUNDING: The University of Queensland in America (TUQIA) through support from Pivotal Ventures, a Melinda French Gates company.

A latent class approach to understanding patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries.

Early adolescents (ages 10-14) living in low- and middle-income countries have heightened vulnerability to psychosocial risks, but available evidence from these settings is limited. This study used data from the Global Early Adolescent Study to characterize prototypical patterns of emotional and behavioral problems among 10,437 early adolescents (51% female) living in the Democratic Republic of Congo (DRC), Malawi, Indonesia, and China, and explore the extent to which these patterns varied by country and sex. LCA was used to identify and classify patterns of emotional and behavioral problems separately by country. Within each country, measurement invariance by sex was evaluated. LCA supported a four-class solution in DRC, Malawi, and Indonesia, and a three-class solution in China. Across countries, early adolescents fell into the following subgroups: Well-Adjusted (40-62%), Emotional Problems (14-29%), Behavioral Problems (15-22%; not present in China), and Maladjusted (4-15%). Despite the consistency of these patterns, there were notable contextual differences. Further, tests of measurement invariance indicated that the prevalence and nature of these classes differed by sex. Findings can be used to support the tailoring of interventions targeting psychosocial adjustment, and suggest that such programs may have utility across diverse cross-national settings.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review.

BACKGROUND: Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry. METHODS: A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies. RESULTS: Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women's identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women's daily activities. CONCLUSION: QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women's quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Sexual wellbeing in early adolescence: a cross-sectional assessment among girls and boys in urban Indonesia.

BACKGROUND: Early adolescence (ages 10-14) is a critical period of physical, cognitive, social and emotional development, which affect sexual and reproductive health and rights (SRHR). Yet, little is known about positive or healthy aspects of sexuality development during this period of life, especially in South East Asia where sexual norms remain restrictive. The objective of this study is to assess the prevalence and correlates of sexual wellbeing among early adolescent girls and boys ages 10-14 years in Indonesia. METHODS: Data for this cross-sectional study were collected as part of the Global Early Adolescent Study via a school-based survey in three Indonesian urban sites in 2018 (N = 4309). We assessed the prevalence of multiple indicators of sexual wellbeing (e.g. SRHR knowledge and communication, gender attitudes, body satisfaction, self-efficacy, freedom from violence) and tested for differences by sex using Chi-square, Student t-test, and Wilcoxon rank-sum test. Multivariable logistic regression models were used to assess the adjusted odds ratio of selected indicators in relation to sociodemographic factors, romantic relationship status, and sexual activities. RESULTS: The mean age of students was 12 years (53% girls); 90% had started puberty. SRHR knowledge and communication was low overall, but higher among boys than girls. Boys were more likely than girls to report high body satisfaction, less feelings of guilt in relation to sexuality, but also to have experienced physical peer violence. In contrast, girls were more likely to hold gender equal attitudes, greater perceived self-efficacy to say 'no', and to report being bullied by boys. In multivariable models, romantic relationship experiences, perceived voice (boys and girls) and decision-making (girls) were associated with three or more indicators of sexual wellbeing. CONCLUSIONS: While young adolescents in Indonesia score high on some aspects of sexual wellbeing, misconceptions, feelings of guilt and uncertainties related to sexuality are common, with clear gender differences. These findings confirm the need for comprehensive sexuality education that begins early in adolescence.

Progress towards reducing sociodemographic disparities in breastfeeding outcomes in Indonesia: a trend analysis from 2002 to 2017.

BACKGROUND: Improving breastfeeding practice is important for reducing child health inequalities and achieving several Sustainable Development Goals. Indonesia has enacted legislation to promote optimal breastfeeding practices in recent years. We examined breastfeeding practices among Indonesian women from 2002 to 2017, comparing trends within and across sociodemographic subgroups. METHODS: Data from four waves of the Indonesia Demographic and Health Surveys were used to estimate changes in breastfeeding practices among women from selected sociodemographic groups over time. We examined three breastfeeding outcomes: (1) early initiation of breastfeeding; (2) exclusive breastfeeding; and (3) continued breastfeeding at 1 year. Multivariate logistic regression was used to assess changes in time trends of each outcome across population groups. RESULTS: The proportion of women reporting early initiation of breastfeeding and exclusive breastfeeding increased significantly between 2002 to 2017 (p < 0.05), with larger increases among women who: were from higher wealth quintiles; worked in professional sectors; and lived in Java and Bali. However, 42.7% of women reported not undertaking early initiation of breastfeeding, and 48.9% of women reported not undertaking exclusive breastfeeding in 2017. Women who were employees had lower exclusive breastfeeding prevalence, compared to unemployed or self-employed women. Women in Java and Bali had higher increase in early initiation of breastfeeding and exclusive breastfeeding compared to women in Sumatra. We did not find statistically significant decline in continued breastfeeding at 1 year over time for the overall population, except among women who: were from the second poorest wealth quintile; lived in rural areas; did not have a health facility birth; and lived in Kalimantan and Sulawesi (p < 0.05). CONCLUSIONS: There were considerable improvements in breastfeeding practices in Indonesia during a period of sustained policy reform to regulate breastfeeding and community support of breastfeeding, but these were not distributed uniformly across socioeconomic, occupation and geographic subgroups. Concerted efforts are needed to further reduce inequities in breastfeeding practice through both targeted and population-based strategies.

The role of decision-making pattern on the use of long-acting and permanent contraceptive methods among married women in Indonesia.

Objectives: This study aimed to analyse the association between the decision-making pattern and the use of long-acting and permanent methods of contraception (LAPMs) among married and cohabiting women in Indonesia, by controlling for variables at the individual and community or regional level, and geographical area (province).Methods: A cross-sectional survey was conducted using secondary data from Performance Monitoring and Accountability 2020 (PMA2020) which involved 4724 married or cohabitating women aged 15-49 years. Data were analysed using bivariate and multivariate analysis. Multilevel logistic regression was performed to investigate the determinants by taking geographical area into account.Results: The majority of women (63.8%) had made their own decision on current contraceptive use, 30.1% had made a joint decision with their partner or health care provider, and 6.1% had not been involved in the decision-making process. Multilevel analysis showed that the decision-making pattern and individual level factors were significantly associated with LAPM use, and variables at community or regional level were not significant predictors. Compared with women who had made their own decision on contraceptive use, LAPM use was 2.3 times higher in women who had made a joint decision with their partner or health care provider (odds ratio [OR] 2.3; 95% confidence interval [CI] 2.0, 2.7; p < .001) and more than three times higher in women not involved in the decision-making process (OR 3.1; 95% CI 2.3, 4.1; p < .001).Conclusion: Coercion potentially occurs in the contraceptive decision-making process. Our findings suggest that LAPM use may be increased by encouraging joint contraceptive decision making. Increasing women's participation in the decision-making process is an integral part of respecting women's reproductive autonomy.

'I wanted to enjoy our marriage first but I got pregnant right away': a qualitative study of family planning understandings and decisions of women in urban Yogyakarta, Indonesia.

BACKGROUND: Despite several decades of investment into family planning and maternal health systems strengthening, Indonesia's maternal mortality ratio remains among the highest in Southeast Asia. Among postpartum women unmet need for family planning is greater than at any other time, thus there is great potential to improve the reproductive health outcomes of Indonesian women through enhanced postpartum family planning access. This article explores the socially embedded nature of family planning choices in the Indonesian context, drawing on the experiences of a sample of urban dwelling and predominantly middle class women. METHODS: This was an ethnographic study which explored the reproductive experiences of women residing in Yogyakarta City, and Sleman and Bantul regencies. Fieldwork was undertaken over 18 months from September 2014 to March 2016. This article draws on 31 in-depth interviews (IDIs) conducted with 20 women aged 21 to 38 years who had given birth less than two years prior. RESULTS: Though there was great variance across women's reproductive trajectories, the majority had limited understandings of family planning, especially in relation to contraception. Societal norms pertaining to women's fertility and reproduction underpinned women's desires to become pregnant soon after marriage. Normative ideals concerning family size and the composition of families underpinned women's desires for a maximum of two to three children, with at least one child of each sex. Negotiations concerning timing of pregnancies and family size occurred within spousal relationships. The majority of women were using some form of fertility control to prevent or space pregnancies, with method choice decisions often informed by family members, friends and family planning providers. Quality of care among family planning providers was often lacking, perpetuating misinformation, and women's choices were not always respected. CONCLUSIONS: Our analysis reveals the socially embedded nature of women's postpartum family planning understandings and choices, and the ways in which social and relational factors sometimes constrain and at other times support women's reproductive agency. We identify key areas for health sector reform to enhance women's understandings of postpartum family planning and improve family planning quality of care.

Levels, trends and correlates of unmet need for family planning among postpartum women in Indonesia: 2007-2015.

BACKGROUND: Although Indonesia has relatively high contraceptive prevalence, postpartum family planning (PP-FP) has not been a particular point of emphasis. This article reports the results of analyses undertaken in order to (1) better understand levels and trends in unmet need for family planning among postpartum women, (2) assess the extent to which unmet need is concentrated among particular population sub-groups, and (3) assess the policy priority that PP-FP should have in relation to other interventions. METHODS: The analyses were based on data from the 2007 and 2012 Indonesia Demographic and Health Surveys (IDHS) and the 2015 PMA2020 survey. Postpartum contraceptive use and unmet need were analyzed for fecund women who had given birth in the 3-5 years of preceding the respective surveys who were in the extended postpartum period at the time of the respective surveys. Factors associated with contraceptive use and unmet were assessed via multivariable logistic regressions using merged data from all three surveys. A wide range of biologic, demographic, socio-economic, geographic and programmatic factors were considered. RESULTS: Contraceptive use during the extended postpartum period is high in Indonesia, with more than 74% of post-partum women reporting currently using a family planning method in the 2015 PMA2020 survey. This is up from 68% in 2007 and 70% in 2012. Total unmet need was 28% in 2007, falling slightly to 23% in 2012 and 24% in 2015. However, the timing of contraceptive initiation is less than optimal. By six months postpartum, only 50% of mothers had begun contraceptive use. Unmet need was highest among older women, women with 4+ children, with limited knowledge of contraceptive methods, making fewer ANC visits, from poor families and residents of islands other than Java and Bali. CONCLUSION: Unmet need for family planning among postpartum women in Indonesia is low in comparison with other low- and middle-income countries. However, because of limited durations of exclusive breastfeeding, many Indonesian women do not initiate contraception early enough after delivering children. Given already high contraceptive prevalence, targeting postpartum women for increased programmatic attention would seem strategically prudent.

What works to improve duration of exclusive breastfeeding: lessons from the exclusive breastfeeding promotion program in rural Indonesia.

The aim of the study was to identify determinants of exclusive breastfeeding (EBF) at the individual, family, community, and organizational level. This study was a secondary analysis of data from a multilevel promotion of EBF program in two rural public health centers (PHCs) in the Demak district, Central Java, Indonesia. The program was a quasi-experimental study with a pretest-posttest control group. A total of 599 participants were enrolled, consisting of 163 mother infant pairs, 163 fathers, 163 grandmothers, 82 community leaders, and 28 midwives. EBF duration and its determinants were measured and analyzed using Cox proportional-hazard model. Mothers with a high level of breastfeeding knowledge had the greatest EBF duration. Mothers who had a knowledge score >80 had a 73 % (HR 0.27, 95 % CI 0.15, 0.48) greater chance of EBF compared to mothers who had a knowledge score of <60. Factors which shortened EBF duration were grandmother's lack of support for EBF (HR 2.04, 95 % CI 1.33, 3.14), received formula samples at discharge (HR 1.99, 95 % CI 1.25, 3.16), and maternal experience of breast engorgement (HR 1.97, 95 % CI 1.32, 2.94). High maternal breastfeeding knowledge was the only factor associated with longer duration of EBF. Barriers to EBF were breast engorgement, receiving formula samples at discharge, and a grandmother's lack of support for EBF.

Indonesian Mothers' Experience of Their Daughter's HPV Vaccination, and Factors Associated with Their Willingness to Recommend HPV Vaccination for Girls.

In Indonesia, knowledge of parents' experiences of their daughters' HPV vaccination in school settings is limited. As Indonesia seeks to scale up its HPV vaccination program nationwide, parents' perspectives hold important insights into how elements of the vaccination model can be sustained and improved. This study explored mothers' experiences of their daughters' HPV vaccination experiences, their knowledge of HPV risks and prevention, and factors associated with willingness to recommend HPV vaccination for girls. A cross-sectional online survey was conducted with 143 mothers of schoolgirls who had received HPV vaccination at schools in Yogyakarta and Jakarta. Multivariate logistic regression was used to assess factors associated with willingness to recommend HPV vaccination. Chi-square and independent t-tests were performed to assess relationships between variables. One-way ANOVA was used to test mean differences in knowledge scores among mothers with different education levels. Many respondents (62.4%) received key health information before their daughters' HPV vaccination. Mothers' average knowledge score was 6.07/10 (SD 2.35). Receiving satisfactory information was significantly associated with willingness to recommend HPV vaccination for girls to others. A significant association was found between mothers' willingness to recommend HPV vaccination and having ever participated in cervical cancer screening themselves. Providing consistent health information that addresses the knowledge gaps and affirms the benefits and safety of HPV vaccines can improve the likelihood of mothers recommending HPV vaccination to others. The benefit of a synchronized approach to promoting primary and secondary prevention was supported by the findings.

Short-Term Effects of a School-Based Comprehensive Sexuality Education Intervention Among Very Young Adolescents in Three Urban Indonesian Settings: A Quasi-Experimental Study.

PURPOSE: To evaluate the effects of a comprehensive sexuality education (CSE) intervention on short-term psychosocial outcomes related to healthy sexuality among very young adolescents in urban Indonesia. METHODS: A quasi-experimental study was conducted between 2018 and 2021 with students aged 10-14 years at 18 schools in Indonesia (Lampung, Denpasar, Semarang). Three schools per site were purposefully selected to receive the SEmangaT duniA RemajA intervention, a two-year, rights-based teacher-led CSE intervention delivered in classrooms (or online after the 2020 COVID-19 outbreak); and matched with three control schools. Surveys were completed by 3,825 students at pre- and posttest (82% retention). The final analytical sample included 1852 intervention and 1483 control students (N = 3,335). Difference-in-difference analysis was conducted to examine the intervention effect on healthy sexuality competencies (knowledge, skills, and attitudes) and personal sexual well-being. RESULTS: Baseline characteristics for intervention and control groups were similar in terms of sex (57% female) and age (mean 12 years). Students receiving SEmangaT duniA RemajA demonstrated significantly greater increase in competencies, including greater pregnancy knowledge, more gender equal attitudes, and communication about sexual and reproductive health and rights, compared to controls. There was no intervention effect on personal sexual well-being, except for self-efficacy to prevent pregnancy. Subgroup analysis indicated more significant effects among females and students in Semarang and Denpasar, than males or students in Lampung. DISCUSSION: While findings demonstrate the potential for CSE programs to improve healthy sexuality competencies in early adolescence, the effect appears to be highly contextualized which may be due to varying levels of implementation quality, especially since the COVID-19 outbreak.

The Impacts of Two Gender-Transformative Interventions on Early Adolescent Gender Norms Perceptions: A Difference-in-Difference Analysis.

PURPOSE: Inequitable gender norms are widespread and can be harmful to the wellbeing of adolescents. This study estimates the effects of two gender-transformative interventions, Semangat Dunia Remaja or Teen Aspirations (SETARA) and Growing Up Great! (GUG!), on gender norms perceptions and attitudes among very young adolescents in poor urban settings in Bandar Lampung, Semarang, Denpasar (Indonesia), and Kinshasa (Democratic Republic of the Congo). METHODS: The study draws from the longitudinal Global Early Adolescent Study, using a quasi-experimental design to evaluate the interventions. Data collection took place between 2017 and 2020. Our analytical samples included 2,159 adolescents in Kinshasa and 3,335 in Indonesia. We conducted a difference-in-difference analysis using generalized estimation equations and generalized linear models, after stratification by site and sex. RESULTS: The interventions shifted a range of gender perceptions, although effects varied by program, city, and sex. SETARA shifted gender-normative perceptions related to traits, roles, and relations, while GUG! effects were more concentrated on attitudes toward chore sharing. SETARA was most effective in Semarang and Denpasar, but not in Bandar Lampung. In addition, both interventions were more consistently effective for girls than boys. DISCUSSION: Gender-transformative interventions can effectively promote gender equality in early adolescence, but effects are program-specific and context-specific. Our findings emphasize the importance of defined theories of change and consistent implementation in gender-transformative intervention.

National health insurance contribution to family planning program funding in Indonesia: A fund flow analysis.

Background: Launched in 2014, Indonesia's national health insurance system (JKN) aimed to provide universal health coverage, including contraceptive services, to its population. We aim to evaluate the contribution of JKN to the overall spending for the family planning program in Indonesia. Methods: Data from the Indonesian Demographic Health Survey, Survey on Financial Flows for Family Planning, Indonesia Motion Tracker Matrix, World Population Prospect, and Indonesian ministries' budget accountability reports were entered into the CastCost Contraceptive Projection Tool to define budgetary allocation and spending for the family planning program at the national level in 2019. Results: Indonesia's family planning program in 2019 was financed mostly by the national budget (64.0%) and out-of-pocket payments (34.6%). There were three main ministries responsible for family planning financing: the National Population and Family Planning Board (BKKBN) (35.8%), the Ministry of Finance (26.2%), and the Ministry of Health (2.0%). Overall, JKN contributed less than 0.4% of the funding for family planning services in Indonesia in 2019. The majority of family planning spending was by public facilities (57.3%) as opposed to private facilities (28.6%). Conclusion: JKN's contribution to funding Indonesia's family planning programs in 2019 was low and highlights a huge opportunity to expand these contributions. A coordinated effort should be conducted to identify possible opportunities to realign BKKBN and JKN roles in the family planning programs and lift barriers to accessing family planning services in public and private facilities. This includes a concerted effort to improve integration of private family planning providers into the JKN program.

"If it's really excessive, it can enter your heart": A Mixed Methods Investigation of Bullying Among Early Adolescents in Semarang, Indonesia.

Bullying is a major public health concern for Indonesian adolescents, with well-documented links to a range of emotional and behavioral problems. Despite such evidence, few investigations have employed qualitative methods to illuminate youth's own perceptions of bullying and its psychosocial correlates in this context. The current study aimed to address this gap through an exploration of Indonesian adolescents' motivations, perceptions, and beliefs regarding bullying. Building on prior quantitative findings, an explanatory sequential mixed methods approach was used to better understand the myriad ways in which bullying ties into other psychosocial challenges. Qualitative interviews were conducted with a total of 45 adolescents ages 13 to 14 (25 girls and 20 boys) in two junior high schools in Semarang between October and December 2019. Interviews were audio-recorded, transcribed verbatim, and translated into English for analysis. Qualitative data were then coded using an inductive thematic analysis approach. Interviews yielded contextual insights into adolescents' definitions of bullying including the distinction between "normal" and "serious" bullying; related risk behaviors; key drivers; social and emotional consequences; and coping strategies. Across these thematic categories, a number of noteworthy gender differences emerged, highlighting the role that underlying gender norms can play in driving bullying involvement. Further, findings emphasize the need to develop a locally valid definition of bullying which takes into account the ways in which emotional distress may be both a criterion and a consequence of bullying. Findings can be used to inform bullying prevention programs targeting Indonesian youth.

Measuring the Prevalence of Mental Disorders in Adolescents in Kenya, Indonesia, and Vietnam: Study Protocol for the National Adolescent Mental Health Surveys.

PURPOSE: In low- and middle-income countries, there are limited data on mental disorders among adolescents. To address this gap, the National Adolescent Mental Health Surveys (NAMHS) will provide nationally representative prevalence data of mental disorders among adolescents in Kenya, Indonesia, and Vietnam. This paper details the NAMHS study protocol. METHODS: In each country, a multistage stratified cluster sampling design will be used. Participants will be eligible pairs of adolescents aged 10-17 years and their primary caregiver. Adolescents will be assessed for social phobia, generalized anxiety disorder, major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and post-traumatic stress disorder using the Diagnostic Interview Schedule for Children, version 5. Demographics, risk and protective factors, and service use information will also be collected. In the parallel clinical calibration study, diagnoses of major depressive disorder, social phobia, and generalized anxiety disorder made using the Diagnostic Interview Schedule for Children, version 5 will be calibrated against a diagnostic assessment by in-country clinicians in a separate sample. RESULTS: Data collection for the national survey and clinical calibration study will commence in 2021, with dissemination of findings and methodology due to occur in 2022. CONCLUSIONS: Accurately quantifying the prevalence of mental disorders in adolescents is essential for service planning. NAMHS will address this lack of prevalence data, both within the NAMHS countries and within their respective regions, while establishing a gold-standard methodology for data collection on adolescent mental health in low- and middle-income countries. More broadly, NAMHS will encourage capacity building within each country by establishing linkages between researcher, clinician, government, and other networks.

Human resources for health in southeast Asia: shortages, distributional challenges, and international trade in health services.

In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the context of the international trade in health services. Although there is no shortage of health workers in the region overall, when analysed separately, five low-income countries have some deficit. All countries in southeast Asia face problems of maldistribution of health workers, and rural areas are often understaffed. Despite a high capacity for medical and nursing training in both public and private facilities, there is weak coordination between production of health workers and capacity for employment. Regional experiences and policy responses to address these challenges can be used to inform future policy in the region and elsewhere. A distinctive feature of southeast Asia is its engagement in international trade in health services. Singapore and Malaysia import health workers to meet domestic demand and to provide services to international patients. Thailand attracts many foreign patients for health services. This situation has resulted in the so-called brain drain of highly specialised staff from public medical schools to the private hospitals. The Philippines and Indonesia are the main exporters of doctors and nurses in the region. Agreements about mutual recognition of professional qualifications for three groups of health workers under the Association of Southeast Asian Nations Framework Agreement on Services could result in increased movement within the region in the future. To ensure that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues.

Health and health-care systems in southeast Asia: diversity and transitions.

Southeast Asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. These factors have not only contributed to the disparate health status of the region's diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. Rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. While novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. New challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. Juxtaposed between the emerging giant economies of China and India, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. In this first paper in the Lancet Series on health in southeast Asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health.

The Efficacy of Divabirth Vaginal Dilator to Prevent Pelvic Floor Trauma During Labor: A Protocol Study.

Background: Vaginal birth may have a negative impact on nerve structure and function, pelvic floor muscle structure, and function. Reducing the risk of pelvic floor injuries during vaginal birth is one of the most effective ways to prevent labor morbidity in women. There is a lack of tools developed based on this approach, especially in Indonesia. Therefore, we aimed to know the efficacy of a vaginal dilator called Divabirth based on labor outcomes. Methods: This clinical study involved subjects who are randomly grouped in to the control and treatment groups. Subjects in the treatment group are told to utilize vaginal dilator devices for 20 minutes each session, a maximum of two sessions per day, lasting 5 minutes every cycle, from 35 weeks of gestation until delivery. Discussions: The current research contributes valuable information to developing a vaginal dilator intervention program for pregnant women to reduce perineal laceration and improve labor outcomes. It may also help to lower their medical and treatment expenditures. We expect its success to be a step forward in improving reproductive health status. Highlights: Vaginal birth may have negative impact on nerve and pelvic floor muscle structure and functionLack of tool has been developed to reduce the risk of pelvic floor injuries during vaginal birthA study protocol of vaginal dilator usage to know the efficacy based on labor outcomes.

Violence Perpetration in Early Adolescence: A Study of Four Urban Communities Worldwide.

PURPOSE: Violence perpetration is common among adolescents worldwide but existing research largely focuses on boys, older adolescents, and partner violence. Our study sought to identify individual, family, and neighborhood/peer factors associated with violence perpetration in a multinational sample of male and female young adolescents. METHODS: We used cross-sectional data from 5,762 adolescents in four sites in the Global Early Adolescent Study: Flanders, Belgium; Kinshasa, Democratic Republic of the Congo; Shanghai, China; and Semarang, Indonesia. Adolescents resided in high-poverty urban areas and were aged 10 to 14 years. Logistic regression examined pooled and stratified associations between independent variables with peer violence perpetration in the past six months. Factors included media viewing habits, gender norms, victimization, agency/empowerment, adversity, depression, familial relationships, neighborhood cohesion, and peer behaviors. RESULTS: Restricted-model analyses found increased odds of violence perpetration associated with high media consumption, pornography viewing, violence or bullying victimization, having drank alcohol, depressive symptoms, adverse childhood experiences, greater behavioral control, greater decision-making, feeling unsafe in the neighborhood/school, peer alcohol/tobacco use, and witnessing peers start a fight. Decreased odds of violence perpetration were associated with more egalitarian views on two gender norms scales, closer parental relationships, neighbors looking out for one another, and greater availability of adult help. DISCUSSION: Among young adolescents, increased odds of violence perpetration were related to a perceived lack of safety and risky peer behaviors. Parental and neighborhood connections were often associated with decreased perpetration. Further research examining the interplay of such factors among young adolescents is needed to inform effective intervention and policy.

A Multi-Country Study of Risk and Protective Factors for Emotional and Behavioral Problems Among Early Adolescents.

PURPOSE: Early adolescence (ages 10-14) is a critical period for psychosocial development, but few studies have focused on risk and protective factors for emergent psychosocial challenges among youth living in low- and middle-income countries. This study explored the contribution of social environmental factors to patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries. METHODS: Participants were drawn from the Global Early Adolescent Study, and included 10,437 early adolescents from six low-resource urban settings in the Democratic Republic of Congo, Malawi, Indonesia, and China. Multivariate latent class regression was used to examine the associations between distinct patterns of emotional and behavioral problems and risk and protective factors across the family, peer, school, and neighborhood levels. RESULTS: Across countries, childhood adversity, peer bullying behaviors, and a perceived lack of school safety were consistently associated with emotional and behavioral problems. With some contextual variability, peer substance use and a perceived lack of neighborhood safety also emerged as significant risk factors. The magnitude of these associations was generally greatest among a subgroup of early adolescents with co-occurring emotional and behavioral problems. DISCUSSION: The overall consistency of findings across countries is suggestive of the generalizability of risk factors in early adolescence and indicates that interventions bolstering psychosocial adjustment among this age group may have applicability in diverse cross-national settings. Given the significance of peer bullying behaviors and school safety, multicomponent school-based interventions may be an especially applicable approach.