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.

Establishing spirituality as an intermediary determinant of health among 42,843 children from eight countries.

The World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) conceptual framework identifies socio-economic position as a structural determinant of health. Recognized intermediary determinants include biological, behavioural, and psychosocial factors. We examined whether connections afforded by a healthy spirituality potentially act as unrecognized intermediary determinants in adolescent populations, contributing to inequities in mental health. Reports from 42,843 children (21,007 boys, 21,836 girls) from eight countries who participated in the 2017-2018 Health Behaviour in School-aged Children (HBSC) study were used to describe correlations between family affluence and positive levels of mental health, using a cross-sectional design. Based on the CSDH conceptual framework and multivariable regression analyses, we then examined whether these associations were mediated by spiritual health. Connections afforded by a high level of spiritual health were universally correlated with positive mental health status. In three Western European nations (England, Scotland, and Wales) and Canada affluence was correlated with better mental health and this was partially mediated by spiritual health. Among the four Eastern European countries (Latvia, Lithuania, Moldova, Poland), our findings did not support aspects of the CSDH framework that focus on affluence as a direct determinant of health. Spiritual health potentially is an intermediary determinant of children's health in some Western countries, but not in Eastern countries. The universality of social determinants of health models and the measures used in their evaluation require careful assessment across cultures, political contexts, and health outcomes.

Feasibility of using health and wellbeing data for school planning: the SHINE pilot in Scotland.

Child and adolescent mental health and wellbeing (MHWB) have received greater attention in recent years due to increases in mental ill health and reports of decreasing subjective wellbeing. The School Health and Wellbeing Improvement Research Network (SHINE) was established to create a national infrastructure to support Scottish schools to collect and use health and wellbeing (HWB) data to inform school improvement action planning. This study aimed to evaluate a pilot of SHINE's provision of school-level HWB data reports from the Health Behaviour in School-aged Children survey and their impact on school action planning. Using a qualitative case study design, we collected data in four local authorities across Scotland via pupil and school staff focus groups (n = 23 groups), and from interviews with senior leaders, school SHINE Leads, other relevant school-level stakeholders, local authority (LA) HWB and data leads (n = 30 interviews). Data analysis was supported using Normalisation Process Theory as a guiding framework. Implementation was at an early stage. Participants indicated that the data reports were an accessible and valuable source of local information to support the improvement agenda. SHINE's expertise supported the lack of research capacity and strengthened HWB data literacy skills in schools. At the point of interview, data reports had not been shared widely within the school community, but there was some limited use of the reports to inform action planning around HWB. Through close working and further engagement with schools, SHINE has the potential to support them to deliver national commitments to improving HWB.

Scottish schools are required to support young people's health and wellbeing (HWB). Schools must demonstrate a robust framework of self-evaluation to understand pupils' HWB needs and find ways to support them. The School Health and Wellbeing Improvement Research Network (SHINE) was set up to support Scottish schools to better understand the HWB needs of pupils and make more effective use of HWB data. In SHINE's initial pilot phase, schools were given reports of findings from a survey of some of their pupils. This study asked schools and local authorities what they thought of these reports and whether they had used them to inform school improvement. Schools were enthusiastic about receiving reports with their own school's data. They liked the format and content of the reports. However, at the time of interview, only a few schools had used the reports to make changes within the school. Some limitations of the data reports were identified. They believed however that SHINE's expertise was valuable and were enthusiastic about the potential of network membership. SHINE will continue to develop in response to this study's feedback.

Structural gender inequality and gender differences in adolescent substance use: A multilevel study from 45 countries.

-Societal gender inequality relates to gender differences in adolescent substance use.-The gender gap in adolescent substance use is larger in countries with higher levels of gender inequality.-Girls in these countries were less likely to get drunk, use alcohol or smoke cigarettes than boys.

Priority Indicators for Adolescent Health Measurement - Recommendations From the Global Action for Measurement of Adolescent Health (GAMA) Advisory Group.

PURPOSE: This article describes the selection of priority indicators for adolescent (10-19 years) health measurement proposed by the Global Action for Measurement of Adolescent health advisory group and partners, building on previous work identifying 33 core measurement areas and mapping 413 indicators across these areas. METHODS: The indicator selection process considered inputs from a broad range of stakeholders through a structured four-step approach: (1) definition of selection criteria and indicator scoring; (2) development of a draft list of indicators with metadata; (3) collection of public feedback through a survey; and (4) review of the feedback and finalization of the indicator list. As a part of the process, measurement gaps were also identified. RESULTS: Fifty-two priority indicators were identified, including 36 core indicators considered to be most important for measuring the health of all adolescents, one alternative indicator for settings where measuring the core indicator is not feasible, and 15 additional indicators for settings where further detail on a topic would add value. Of these indicators, 17 (33%) measure health behaviors and risks, 16 (31%) health outcomes and conditions, eight (15%) health determinants, five (10%) systems performance and interventions, four (8%) policies, programmes, laws, and two (4%) subjective well-being. DISCUSSION: A consensus list of priority indicators with metadata covering the most important health issues for adolescents was developed with structured inputs from a broad range of stakeholders. This list will now be pilot tested to assess the feasibility of indicator data collection to inform global, regional, national, and sub-national monitoring.

Defining research priorities for youth public mental health: reflections on a coproduction approach to transdisciplinary working.

BACKGROUND: With most mental health problems established during childhood/adolescence, young people must be a key focus of public mental health approaches. Despite the range of factors known to influence mental health, evidence for effective interventions is lacking for this age group. This study aimed to define priorities for future public health intervention-focused research to support youth mental health by engaging with transdisciplinary stakeholder groups. METHODS: Our coproduction approach involved priority-setting workshops with young people, researchers, practitioners and policy-makers. Each workshop focused on three thematic areas: social connections and relationships; schools and other education settings; and key groups at greater risk of mental ill-health, specifically LGBTQ+ and care-experienced young people. Workshop outputs were synthesized to define research priorities. RESULTS: This paper presents the research priorities that were defined through the priority-setting workshops, and our reflections on the coproduction approach to guide future similar activities undertaken by others. Ten priorities for youth public mental health research were defined, covering the following areas: building supportive relationships; whole system approaches; social media; support at times of transition; improving links between different services; development and training for those who support young people; staff mental health; engaging with families; awareness of and access to services; and out-of-school and community settings. CONCLUSIONS: These research priorities can inform future intervention development to support youth public mental health. Our transdisciplinary approach means the identified research priorities are likely to be relevant to young people's experiences and needs, and to fit with the needs of those working in practice and policy to support young people.

Cross-national validation of the social media disorder scale: findings from adolescents from 44 countries.

BACKGROUND AND AIMS: There is currently no cross-national validation of a scale that measures problematic social media use (SMU). The present study investigated and compared the psychometric properties of the social media disorder (SMD) scale among young adolescents from different countries. DESIGN: Validation study. SETTING AND PARTICIPANTS: Data came from 222 532 adolescents from 44 countries participating in the health behaviour in school-aged children (HBSC) survey (2017/2018). The HBSC survey was conducted in the European region and Canada. Participants were on average aged 13.54 years (standard deviation = 1.63) and 51.24% were girls. MEASUREMENT: Problematic SMU was measured using the nine-item SMD scale with dichotomous response options. FINDINGS: Confirmatory factor analyses (CFA) showed good model fit for a one-factor model across all countries (minimum comparative fit index (CFI) and Tucker-Lewis index (TLI) = 0.963 and 0.951, maximum root mean square error of approximation (RMSEA) and standardized root mean square residual (SRMR) = 0.057 and 0.060), confirming structural validity. The internal consistency of the items was adequate in all countries (minimum alpha = 0.840), indicating that the scale provides reliable scores. Multi-group CFA showed that the factor structure was measurement invariant across countries (ΔCFI = -0.010, ΔRMSEA = 0.003), suggesting that adolescents' level of problematic SMU can be reliably compared cross-nationally. In all countries, gender and socio-economic invariance was established, and age invariance was found in 43 of 44 countries. In line with prior research, in almost all countries, problematic SMU related to poorer mental wellbeing (range ßSTDY = 0.193-0.924, P < 0.05) and higher intensity of online communication (range ßSTDY = 0.163-0.635, P < 0.05), confirming appropriate criterion validity. CONCLUSIONS: The social media disorder scale appears to be suitable for measuring and comparing problematic social media use among young adolescents across many national contexts.

TeenCovidLife: a resource to understand the impact of the COVID-19 pandemic on adolescents in Scotland.

TeenCovidLife is part of Generation Scotland's CovidLife projects, a set of longitudinal observational studies designed to assess the psychosocial and health impacts of the COVID-19 pandemic. TeenCovidLife focused on how adolescents in Scotland were coping during the pandemic. As of September 2021, Generation Scotland had conducted three TeenCovidLife surveys. Participants from previous surveys were invited to participate in the next, meaning the age ranges shifted over time. TeenCovidLife Survey 1 consists of data from 5,543 young people age 12 to 17, collected from 22 May to 5 July 2020, during the first school closures period in Scotland. TeenCovidLife Survey 2 consists of data from 2,245 young people aged 12 to 18, collected from 18 August to 14 October 2020, when the initial lockdown measures were beginning to ease, and schools reopened in Scotland. TeenCovidLife Survey 3 consists of data from 597 young people age 12 to 19, collected from 12 May to 27 June 2021, a year after the first survey, after the schools returned following the second lockdown in 2021. A total of 316 participants took part in all three surveys. TeenCovidLife collected data on general health and well-being, as well as topics specific to COVID-19, such as adherence to COVID-19 health guidance, feelings about school closures, and the impact of exam cancellations. Limited work has examined the impact of the COVID-19 pandemic on young people. TeenCovidLife provides relevant and timely data to assess the impact of the pandemic on young people in Scotland. The dataset is available under authorised access from Generation Scotland; see the Generation Scotland website for more information.

The Impact of School Closure on Adolescents' Wellbeing, and Steps towards to a New Normal: The Need for an Assessment Tool Update?

Close to 200 countries have implemented school closures to decrease the spread of the COVID-19 coronavirus. Though the closures have seemed necessary, their effects on the wellbeing of children and adolescents have raised serious concerns. To truly understand the impact of such disruption on young people's wellbeing, and their views on how to move towards a new normal, we must adopt different approaches to gather the data to secure children's and adolescents' rights to be heard in the issues that concern their lives. Current ways to examine the impacts of school closure have been dominated by gathering information concerning the children and adolescents, using mainly existing wellbeing indicators and related questionnaire surveys. Although such sources of information are important, they provide limited understanding of how children and adolescents have experienced school closures, especially if they have been produced using measures developed purely by adults. There is a need for information produced by children and adolescents themselves, which may require going beyond existing and pre-COVID theoretical wellbeing frameworks. By capturing information produced by children and adolescents, we can more effectively guide the development and evaluation of public health policies and identify solutions to mitigate the negative impacts of school closure, or to acknowledge the possible positive effects, and respond accordingly.

Structural validity of a brief scale adapted to measure adolescent spiritual health.

Spiritual health is established as an important protective health asset in child populations. Measurement and assessment of this elusive concept are, however, challenging. Brief and age-appropriate instruments are required for surveys and related population health research. One longstanding model describing child spirituality suggests that scales and measures consider four standard domains describing connections to self, others, nature, and the transcendent. In this validation study, we tested the structural validity and internal consistency of a brief, literacy-level appropriate instrument for adolescents that was based on prior adaptations of this model. The 2018 cross-national study population included 47,180 children aged 11-15 years from 9 countries. Based upon theory, factor pattern matrices, and Scree plots, the exploratory factor analysis best supported the four-factor model, with items organized according to the original four domains. Internal consistency of the items was acceptable (alpha>.7) to good (alpha>.8) within domains, again within each of the 9 countries. The confirmatory factor analysis again supported the four-factor model (by country, SRMR: 0.020 to 0.042; and AGFI and NFI fit: >0.98). Model fit indices for the four-factor model were improved compared with its unidimensional version. Moving forward, our analysis establishes the structural validity and internal consistency of this adapted brief spiritual health instrument to be used in surveys of adolescents.

Cross-National Time Trends in Adolescent Mental Well-Being From 2002 to 2018 and the Explanatory Role of Schoolwork Pressure.

PURPOSE: Previous research has shown inconsistent time trends in adolescent mental well-being, but potential underlying mechanisms for such trends are yet to be examined. This study investigates cross-national time trends in adolescent mental well-being (psychosomatic health complaints and life satisfaction) in mainly European countries and the extent to which time trends in schoolwork pressure explain these trends. METHODS: Data from 915,054 adolescents from 36 countries (50.8% girls; meanage = 13.54; standard deviationage = 1.63) across five Health Behaviour in School-aged Children surveys (2002, 2006, 2010, 2014, and 2018) were included in the analyses. Hierarchical multilevel models estimated cross-national trends in adolescent mental well-being and schoolwork pressure. We also tested whether schoolwork pressure could explain these trends in mental well-being. RESULTS: A small linear increase over time in psychosomatic complaints and schoolwork pressure was found. No change in life satisfaction emerged. Furthermore, there was large cross-country variation in the prevalence of, and trends over time in, adolescent mental well-being and schoolwork pressure. Overall, declines in well-being and increases in schoolwork pressure were apparent in the higher income countries. Across countries, the small increase in schoolwork pressure over time partly explained the decline in psychosomatic health complaints. CONCLUSIONS: Our findings do not provide evidence for substantial declines in mental well-being among adolescents. Yet, the small declines in mental well-being and increases in schoolwork pressure appear to be quite consistent across high-income countries. This calls for the attention of public health professionals and policy-makers. Country differences in trends in both adolescent mental well-being outcomes and schoolwork pressure were considerable, which requires caution regarding the cross-national generalization of national trends.

Vigorous physical activity in relation to family affluence: time trends in Europe and North America.

OBJECTIVES: The aim of the study was to determine secular trends in vigorous physical activity (VPA) among adolescents in relation to family affluence across 34 countries. METHODS: This study used data from the Health Behaviour in School-aged Children (HBSC) study from 34 countries in Europe and North America. Adolescents (N = 501,647) aged 11, 13 and 15 years across three survey cycles (2006, 2010, 2014) self-reported data on VPA and a family affluence scale (FAS) using standardized questionnaires. RESULTS: A significant increase in VPA was found in low-FAS boys (girls) in four (10) countries and a decrease in four (three) countries. In high-FAS boys (girls), a significant increase was observed in nine (11) countries and a decrease in two(three) countries. An overall significant increase in meeting the VPA recommendations was found in high-FAS boys (OR 1.11; 95% CI 1.06-1.16) and in all FAS groups in girls, with the largest effect being found among high-FAS girls (OR 1.24; 95% CI 1.18-1.30). CONCLUSIONS: A country-specific increase in VPA was observed primarily in the medium- and high-FAS categories. This study suggests a need to focus on increasing VPA efforts, especially in low- and medium-FAS boys.

Do country-level environmental factors explain cross-national variation in adolescent physical activity? A multilevel study in 29 European countries.

BACKGROUND: Worldwide, roughly 80% of adolescents fail to meet World Health Organization (WHO) recommendations regarding physical activity, though there is substantial variation in adolescent physical activity prevalence across countries. This study explored whether country-level environmental differences explained cross-national variation in adolescent moderate- to vigorous-intensity physical activity (MVPA) and vigorous-intensity activity (VPA). METHOD: Using the data of 138,014 11- to 15-year-olds from 29 European countries in the 2013/2014 Health Behaviour in School-aged Children (HBSC) study, multilevel regression models examined the influence of four types of country-level environmental factors (physical, socio-cultural, economic, and political) on self-reported individual-level physical activity (MVPA and VPA). RESULTS: The environmental variables explained 38% of country-level variance in MVPA and 81% of country-level variance in VPA. Lower annual average national temperature, higher community safety, lower average national household income and a weaker physical education policy were significantly associated with more MVPA. Greater urbanisation, lower annual average national temperature, higher adult physical activity and higher average national household income were significantly associated with more VPA. CONCLUSIONS: The findings showed that national differences in the physical, socio-cultural and economic environment were related to adolescent physical activity. They point to potential avenues for future research looking at interactions between individual and environmental factors.

Domains of spirituality and their associations with positive mental health: a study of adolescents in Canada, England and Scotland.

Spirituality is a concept with ancient roots yet contemporary relevance to mental health. Its assessment in populations of young people, however, remains an immense challenge. Efforts to perform such assessments typically involve use of unidimensional scales incorporating items related to four domains (connections to "self", "others", "nature", and the "transcendent"). For adolescents, it remains unclear whether these domains equally influence mental health, or if one domain is particularly important. Here we analyzed reports from adolescents who participated in the 2014 Health Behaviour in School-aged Children (HBSC) study conducted in Canada (n = 21,173), England (n = 4339) and Scotland (n = 5603). Reports of positive mental health were modelled as a function of ordinal scores describing each spiritual health domain, controlling for age, the other domains, and potential confounders. Subsequent analyses focused on the centrality of connections to "self" in these relationships. We identified strong and consistent associations between positive mental health and higher scores for each of the four spiritual health domains. In fully adjusted models, these effects were diminished or changed direction for connections to "others", "nature", and the "transcendent", while the positive association with "connections to self" remained. While associations exist between each of the four domains of spiritual health and positive mental health, it appears that associations with connections to "others", "nature", and the "transcendent" are sometimes mediated by connections to "self". Implications for assessment, models and related interventions and health promotion strategies, based on the idea that inner connections may be central to the protective effects of spiritual health, are considered.

Comparisons in Screen-Time Behaviours among Adolescents with and without Long-Term Illnesses or Disabilities: Results from 2013/14 HBSC Study.

Reducing sedentary behaviours can help prevent non-communicable diseases, particularly among young adolescents with long term illnesses or disabilities (LTID). Much of young people's voluntary sedentary time is related to screen-time behaviours (STBs) such as TV viewing, playing computer games, and using the computer for other activities. Although public health data on adolescents' STB is growing, information about adolescents with LTID is currently lacking in a European context. The purpose of this study is to compare time on STBs between adolescents with and without LTID in European Countries through the HBSC 2013/14 study. Young adolescents (n = 61,329; boys 47.8%) from 15 European countries reported the time spent on TV viewing, playing computer games, and using the computer for other purposes on weekdays and the weekend. STBs were dichotomised based on international recommendations of less than 2 h per day, and Chi-square tests of independence were performed to investigate differences. STB time was combined to produce a sum score as dependent variable in multiple analysis of covariance with age and family affluence as covariates. There were statistically significant differences in computer gaming among boys and other computer use among girls for both weekdays and weekends, whereby adolescents with LTID reported higher use. In addition, both boys and girls with LTID spent more time on STBs than their same sex peers without LTID (Boys, F = 28.17, p < 0.001; Girls, F = 9.60, p = 0.002). The results of this study indicate a need for preventive strategies to address high levels of STB among young adolescents with LTID and reduce the risk of poor health outcomes associated with higher levels of sedentary behaviour.

Self-reported weight and predictors of missing responses in youth.

OBJECTIVE: The aims of the present manuscript are to analyse self-reported data on weight, including the missing data, from the 2014 Scottish Health Behaviour in School-Aged Children (HBSC) Study, and to investigate whether behavioural factors related with overweight and obesity, namely dietary habits, physical activity and sedentary behaviour, are associated with weight non-response. RESEARCH METHODS & PROCEDURES: 10839 11-, 13- and 15-year-olds participated in the cross-national 2014 Scottish HBSC Study. Weight missing data was evaluated using Little's Missing Completely at Random (MCAR) test. Afterwards, a fitted multivariate logistic regression model was used to determine all possible multivariate associations between weight response and each of the behavioural factors related with obesity. RESULTS: 58.9% of self-reported weight was missing, not at random (MCAR p < 0.001). Weight was self-reported less frequently by girls (19.2%) than by boys (21.9%). Participants who reported low physical activity (OR 1.2, p < 0.001), low vegetable consumption (OR 1.24, p < 0.001) and high computer gaming on weekdays (OR 1.18, p = 0.003) were more likely to not report their weight. CONCLUSIONS: There are groups of young people in Scotland who are less likely to report their weight. Their weight status may be of the greatest concern because of their poorer health profile, based on key behaviours associated with their non-response. Furthermore, knowing the value of a healthy weight and reinforcing healthy lifestyle messages may help raise youth awareness of how diet, physical activity and sedentary behaviours can influence weight.

Spirituality as a protective health asset for young people: an international comparative analysis from three countries.

OBJECTIVES: Spirituality has been proposed as a potential health asset a 'developmental engine' that works by fostering the search for connectedness, meaning and purpose. The aim is to examine to what extent spiritual health might be protective of young people's overall health and well-being. METHODS: In 2014, young people aged 11, 13, and 15 years in England, Scotland and Canada were surveyed as part of the HBSC study (n = 26,701). The perceived importance of spiritual health and domains (connections with self, others, nature, and the transcendent) was measured in these countries. Multi-level log-binomial models were used to explore relationships between spiritual health and three self-reported positive health outcomes: general health status, subjective life satisfaction and health complaints. RESULTS: Higher levels of perceptions of the importance of spiritual health, both overall and within the four domains, were associated with higher likelihoods of reporting each of the positive health outcomes. CONCLUSIONS: Spiritual health appears to operate as a protective health asset during adolescence and is significantly shaped by external relationships and connections.

Trends in the perceived body size of adolescent males and females in Scotland, 1990-2014: changing associations with mental well-being.

OBJECTIVES: This paper explores trends in Scottish adolescents' body size perceptions and associated mental well-being outcomes. METHODS: Data were collected on Scottish 11-, 13-, and 15-year-olds by the Health Behaviour in School-aged Children study between 1990 and 2014 (n = 42,312). Logistic regression was used to examine changes in the prevalence of over- and underweight perceptions. Ordinal and linear regressions were used to examine changes in the association between body perception and mental well-being. RESULTS: Little change was observed in over- or underweight perceptions. However, relative to those perceiving their body as 'about right', those perceiving themselves as overweight reported decreasing confidence (all groups), decreasing happiness (11- and 13-year-old girls), and increasing psychological health symptoms (all girls and 15-year-old boys). Perceived underweight is associated with poor well-being, especially in males, but we present little evidence that this is a recent phenomenon. CONCLUSIONS: We present evidence suggesting that the association between body size perception and poor mental health in adolescence is changing over time. This may play a role in the recently observed worsening of mental well-being in Scottish adolescents.