Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes.

BACKGROUND: Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh. METHODS AND ANALYSIS: AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort. ETHICS AND DISSEMINATION: AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

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.

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.

Quantifying differences in iron deficiency-attributable anemia during pregnancy and postpartum.

Pregnant women in resource-limited settings are highly susceptible to anemia and iron deficiency, but the etiology of postpartum anemia remains poorly defined. To inform the optimal timing for anemia interventions, changes in iron deficiency-attributable anemia through pregnancy and postpartum need to be understood. In 699 pregnant Papua New Guinean women attending their first antenatal care appointment and following up at birth and 6 and 12 months postpartum, we undertake logistic mixed-effects modeling to determine the effect of iron deficiency on anemia and population attributable fractions, calculated from odds ratios, to quantify the contribution of iron deficiency to anemia. Anemia is highly prevalent during pregnancy and 12 months postpartum, with iron deficiency increasing the odds of anemia during pregnancy and, to a lesser extent, postpartum. Iron deficiency accounts for ≥72% of anemia during pregnancy and 20%-37% postpartum. Early iron supplementation during and between pregnancies could break the cycle of chronic anemia in women of reproductive age.

Community perspectives and experiences of quality maternal and newborn care in East New Britain, Papua New Guinea.

BACKGROUND: Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members' perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG. METHODS: We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework. RESULTS: Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care. CONCLUSIONS: Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure.

Improving the care provided to, and experienced by, women and their families during pregnancy and childbirth is important for improving the health of mothers and babies. Community members should be involved in thinking about appropriate ways to improve care. Papua New Guinea (PNG) is a country in the Pacific which faces multiple challenges to improving care during pregnancy and birth. We aimed to understand what community members think about care provided and experienced during labour and birth in East New Britain, a rural province of PNG. We worked with five health facilities, health workers and community members in East New Britain to develop a qualitative research project. We carried out 10 focus group discussions with community members in East New Britain to understand what the provision and experience of care was like during labour and birth, and ways that it could be improved. We found that community members identified multiple challenges in getting to facilities and many facilities were found to have not enough supplies, equipment, or staff. Community members wanted staff that were good at their work but also caring and respectful. Women wanted to have support people present during labour and birth and many men wanted to be present too. Our results show that it is important to understand what the community thinks about the quality of care during labour and birth and this information is helpful to design effective activities to improve the care provided and experienced.

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.

Low knowledge of newborn danger signs among pregnant women in Papua New Guinea and implications for health seeking behaviour in early infancy - findings from a longitudinal study.

BACKGROUND: Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women's knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province. METHODS: This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth (n = 638) and again at one-month post-partum (n = 599). RESULTS: Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University 'Birth Preparedness and Complication Readiness' Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education. CONCLUSION: Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed.

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.

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines.

BACKGROUND: Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships. METHODS: The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines. FINDINGS: The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts. INTERPRETATION: This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

Enablers and barriers to primary healthcare for Aboriginal and Torres Strait Islander adolescents: study protocol for participatory mixed-methods research that builds on WHO global standards.

INTRODUCTION: One-third of Australia's Aboriginal and Torres Strait Islander population are adolescents. Recent data highlight their health needs are substantial and poorly met by existing services. To design effective models of primary healthcare, we need to understand the enablers and barriers to care for Aboriginal and Torres Strait Islander adolescents, the focus of this study. METHODS AND ANALYSIS: This protocol was codesigned with Apunipima Cape York Health Council that supports the delivery of primary healthcare for 11 communities in Far North Queensland. We framed our study around the WHO global standards for high-quality health services for adolescents, adding an additional standard around culturally safe care. The study is participatory and mixed methods in design and builds on the recommended WHO assessment tools. Formative qualitative research with young people and their communities (exploring concepts in the WHO recommended quantitative surveys) seeks to understand demand-side enablers and barriers to care, as well as preferences for an enhanced response. Supply-side enablers and barriers will be explored through: a retrospective audit of clinic data (to identify current reasons for access and what can be strengthened); an objective assessment of the adolescent friendliness of clinical spaces; anonymous feedback from adolescent clients around quality of care received and what can be improved; and surveys and qualitative interviews with health providers to understand their perspectives and needs to provide enhanced care. This codesigned project has been approved by Apunipima Cape York Health Council and Far North Queensland Human Research Ethics Committee. DISSEMINATION AND IMPLICATIONS: The findings from this project will inform a codesigned accessible and responsive model of primary healthcare for Aboriginal and Torres Strait Islander adolescents.

Mycoplasma genitalium and Other Reproductive Tract Infections in Pregnant Women, Papua New Guinea, 2015-2017.

Much about the range of pathogens, frequency of coinfection, and clinical effects of reproductive tract infections (RTIs) among pregnant women remains unknown. We report on RTIs (Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum subspecies pallidum, bacterial vaginosis, and vulvovaginal candidiasis) and other reproductive health indicators in 699 pregnant women in Papua New Guinea during 2015-2017. We found M. genitalium, an emerging pathogen in Papua New Guinea, in 12.5% of participants. These infections showed no evidence of macrolide resistance. In total, 74.1% of pregnant women had >1 RTI; most of these infections were treatable. We detected sexually transmitted infections (excluding syphilis) in 37.7% of women. Our findings showed that syndromic management of infections is greatly inadequate. In total, 98.4% of women had never used barrier contraception. These findings will inform efforts to improve reproductive healthcare in Papua New Guinea.

Matching action to need: an analysis of Global Burden of Disease 2017 and population health data to focus adolescent health policy and actions in Myanmar.

Background: Myanmar is a country undergoing rapid transitions in health. Its national strategic policy for young people's health is being revised but there is a paucity of population data to inform local priorities and needs. Objective: In this paper we describe a comprehensive profile of adolescent health in Myanmar to focus policy and health actions. Methods: We used available primary data, and modelled estimates from the GBD 2017, to describe health outcomes (mortality and morbidity), health risks and determinants for adolescents in Myanmar between 1990-2017. A governance group of key stakeholders guided the framing of the study, interpretation of findings, and recommendations. Results: Overall health has improved for adolescents in Myanmar since 1990, however adolescent mortality remains high, particularly so for older adolescent males; all-cause mortality rate for 10-24 years was 70 per 100,000 for females and 149 per 100,000 for males (16,095 adolescent deaths in 2017). Overall, the dominant health problems were injuries for males and non-communicable disease for females in a context of ongoing burden of communicable and nutritional diseases for both sexes, and reproductive health needs for females. Health risks relating to undernutrition (thinness and anaemia) remain prevalent, with other health risks (overweight, binge alcohol use, and substance use) relatively low by global and regional standards but increasing. Gains have been made in social determinants such as adolescent fertility and modern contraception use; however, advances have been more limited in secondary education completion and engagement in employment and post education training. Conclusions: These results highlight the need to focus current efforts on addressing disease and mortality experienced by adolescents in Myanmar, with a specific focus on injury, mental health and non-communicable disease.

Risk factors and knowledge associated with high unintended pregnancy rates and low family planning use among pregnant women in Papua New Guinea.

Unintended pregnancy is a major driver of poor maternal and child health in resource-limited settings. Data on pregnancy intention and use of family planning (FP) is scarce in Papua New Guinea (PNG), but are needed to inform public health strategies to improve FP accessibility and uptake. Data from a facility-based cross-sectional sample of 699 pregnant women assessed prevalence and predictors of unintended pregnancy and modern FP use among pregnant women in East New Britain Province, PNG. More than half (55%) the women reported their pregnancy as unintended. Few (18%) reported ever having used a modern FP method, and knowledge of different methods was low. Being single, separated or divorced (AOR 9.66; 95% CI 3.27-28.54), educated to a tertiary or vocational level (AOR 1.78 CI 1.15-2.73), and gravidity > 1 (AOR 1.43 for each additional pregnancy CI 1.29-1.59) were associated with unintended pregnancy; being accompanied by a male partner to ANC was associated with a reduced unintended pregnancy (0.46 CI 0.30-0.73). Factors associated with modern FP use included male partner involvement (AOR 2.26 CI 1.39-3.67) and gravidity > 1 (AOR 1.54 for each additional pregnancy CI 1.36-1.74). FP use also varied by the facility women attended. Findings highlight an urgent need for targeted interventions to improve FP knowledge, uptake and access, and male partner involvement, to reduce unintended pregnancies and their complications.

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region.

BACKGROUND: By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life. METHODS: We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks. FINDINGS: Although son preference is evident in some settings-as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations-it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20-24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15-24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking. INTERPRETATION: These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. FUNDING: UNICEF.

Understanding mental health and its determinants from the perspective of adolescents: A qualitative study across diverse social settings in Indonesia.

Poor mental health is a leading contributor to the burden of disease experienced by adolescents, including in resource constrained settings. However, little is known about how adolescents in these countries conceptualise mental health and its determinants which is essential to informing effective responses. This study aimed to explore how adolescents in Indonesia (a populous and rapidly developing country) conceptualise mental health and what they identify as important determinants. Eight focus group discussions (FGDs) were conducted with 86 Indonesian adolescents (aged 16-18 years), sampled from schools and community settings from Jakarta and South Sulawesi. FGDs were recorded, transcribed, translated and thematically analysed. Mental health was recognised as a significant concern by adolescents in Indonesia. Good mental health was conceptualised as emotional wellbeing and happiness. By contrast, poor mental health was predominantly described in terms of substantial mental illness manifesting as behavioural and physical disturbance. Further, poor mental health only happened to 'other' people, with stigmatising views prevalent. Absent from the discussions were common symptoms of poor mental health (stress, loneliness, poor sleep) and common mental disorders (e.g. depression, anxiety) or a conceptualisation that reflected poor mental health to be a normal human experience. Discussions around determinants of poor mental health suggested that family connections (particularly with parents), school pressures, and adverse exposures on social media were important drivers of poor mental health, with religion also surfacing as an important determinant. In highlighting mental health as an important issue for Indonesian adolescents, this study provides a foundation for targeted responses.

Direct assessment of mental health and metabolic syndrome amongst Indonesian adolescents: a study design for a mixed-methods study sampled from school and community settings.

Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally, with the burden largely borne by people living in low- and middle-income countries. Adolescents are central to NCD control through the potential to modify risks and alter the trajectory of these diseases across the life-course. However, an absence of epidemiological data has contributed to the relative exclusion of adolescents from policies and responses. This paper documents the design of a study to measure the burden of metabolic syndrome (a key risk for NCDs) and poor mental health (a key outcome) amongst Indonesian adolescents. Using a mixed-method design, we sampled 16-18-year-old adolescents from schools and community-based settings across Jakarta and South Sulawesi. Initial formative qualitative enquiry used focus group discussions to understand how young people conceptualise mental health and body weight (separately); what they perceive as determinants of these NCDs; and what responses to these NCDs should involve. These findings informed the design of a quantitative survey that adolescents self-completed electronically. Mental health was measured using the Centre for Epidemiologic Studies Depression Scale-Revised (CESD-R) and Kessler-10 (both validated against formal psychiatric interview in a subsample), with the metabolic syndrome measured using biomarkers and anthropometry. The survey also included scales relating to victimisation, connectedness, self-efficacy, body image and quality of life. Adolescents were sampled from schools using a multistage cluster design, and from the community using respondent-driven sampling (RDS). This study will substantially advance the field of NCD measurement amongst adolescents, especially in settings like Indonesia. It demonstrates that high quality, objective measurement is acceptable and feasible, including the collection of biomarkers in a school-based setting. It demonstrates how comparable data can be collected across both in-school and out of school adolescents, allowing a more comprehensive measure of NCD burden, risk and correlates.

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.

Menstrual hygiene management and school absenteeism among adolescent students in Indonesia: evidence from a cross-sectional school-based survey.

OBJECTIVE: To assess the prevalence of menstrual hygiene management (MHM) knowledge and practices among adolescent schoolgirls in Indonesia, and assess factors associated with poor MHM and school absenteeism due to menstruation. METHODS: A cross-sectional survey enrolled a representative sample of urban and rural school-going girls aged 12-19 years in four provinces of Indonesia. A semi-structured, self-administered questionnaire obtained socio-demographic characteristics, knowledge, practices and attitudes related to menstruation, MHM and school absenteeism. School water, sanitation and hygiene (WASH) facilities were also assessed. Univariate weighted population prevalence was estimated and multivariable logit regression analyses applied to explore associations. RESULTS: A total of 1159 adolescent girls with a mean age of 15 years (SD = 1.8) participated. Most girls (90.8%, 95% confidence interval (95% CI) = 79.7-96.1) had reached menarche. Over half (64.1%, 95% CI = 49.9-76.2) reported poor MHM practices, and 11.1% (95% CI = 8.1-15.2) had missed one or more days of school during their most recent menstrual period. Poor MHM practices were associated with rural residence (Adjusted odds ratio (AOR) = 1.73, 95% CI = 1.13-2.64), province (various AOR), lower school grade (AOR = 1.69, 95% CI = 1.05-2.74) and low knowledge of menstruation (AOR = 3.49, 95% CI = 1.61-7.58). Absenteeism was associated with living in rural areas (AOR = 3.96, 95% CI = 3.02-5.18), province (various AOR), higher school grade (AOR = 3.02, 95% CI = 2.08-4.38), believing menstruation should be kept secret (AOR = 1.47, 95% CI = 1.03-2.11), experiencing serious menstrual pain (AOR = 1.68, 95% CI = 1.06-2.68) and showed mixed associations with school WASH facilities. CONCLUSIONS: High prevalence of poor MHM and considerable school absenteeism due to menstruation among Indonesian girls highlight the need for improved interventions that reach girls at a young age and address knowledge, shame and secrecy, acceptability of WASH infrastructure and menstrual pain management.

Youth-centred research to help prevent and mitigate the adverse health and social impacts of pregnancy amongst young Papua New Guineans.

Despite persistent international attention, adolescent pregnancy remains a major public health concern in low- and middle-income countries, like Papua New Guinea (PNG), where health inequities related to social and cultural norms, gender power imbalance, education and socio-economic deprivation affect young and unmarried women in particular. In PNG - where there is high adolescent fertility, high early childbearing and high maternal mortality ratio, and evidence of high rates of unintended pregnancy and abortion among young women - adolescent pregnancy is a policy priority. Yet there are no youth-specific sexual, reproductive and maternal health services or community-based outreach programmes. There is limited in-depth qualitative data on young women's and young men's experiences of pregnancy, the social contexts within which these pregnancies occur, young people's contraception practices and experiences with existing sexual, reproductive and maternal health services. These issues inhibit the design and delivery of youth-friendly health services and outreach support programmes that could prevent or mitigate adverse health and social outcomes associated with adolescent pregnancy. In this commentary article, we propose the need for novel youth-centred research to inform the development of policies, health services and outreach programmes that pay honest and respectful attention to young people's lived experiences of pregnancy. Whilst we focus on the situation in PNG, these ideas are relevant to diverse low resource settings where the harmful impacts of health inequities among young people persist and are particularly detrimental.