Assessing the health, social, educational and economic impact of the COVID-19 pandemic on adolescents in low- and middle-income countries: a rapid review of the literature.

COVID-19 has caused profound health, social, educational and economic devastation around the world, especially among the lives of adolescents in low- and middle-income countries. This paper looks at a wide array of outcomes impacting adolescents' daily lives including health (mental, physical, sexual and reproductive health, vaccine perceptions and overlap between these topics), social relationships (family and peer), education and socio-economic disparities. Both scientific and grey literature between December 2019 and February 2022 were sought from PubMed, Google Scholar and organisations conducting research among adolescents, and coded. A total of 89 articles were included, 73% of which were peer-reviewed; 37% of the articles were from WHO's Western Pacific region; 62% of the articles were cross-sectional; 75% were quantitative. Three major topics emerged in more than half the articles: mental health (72%), education (61%) and socio-economic ramifications (55%). However, there were regional differences in topics and many of them overlapped. The results indicate that, where there has been research, almost all findings have been linked to worse mental health during the pandemic. Overall, remote education was seen as a negative experience. The ramification of school closures on future aspirations, in particular early school leaving, highlights the importance of prioritising education during future pandemics based on the situation within the country. Gender and other disparities have made marginalised adolescents vulnerable to the economic ramifications of containment measures. Given the risks identified, there is a pressing need to put adolescents at the centre of establishing priorities for their health agenda for post-pandemic recovery.

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.

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.

"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.

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.

Identifying challenges in promoting adolescent preventive health care in the primary care setting of urban Japan.

BACKGROUND: Despite the assurance of free medical access through the universal health insurance system, over the past three decades Japanese youth have experienced an increase in developmental and behavioral problems, psychosomatic disorders, and psychiatric illnesses. OBJECTIVES: To identify the challenges in promoting comprehensive preventive health services to adolescents in Japan, specifically in Tokyo. METHODS: A cross-sectional online survey was conducted of physicians who are members of the Tokyo Pediatric Association. The questionnaire assessed primary care pediatricians' practice settings and their attitudes toward outpatient services to adolescent patients. RESULTS: Out of 617 member pediatricians, 69 valid responses were obtained. Majority were private pediatricians. 52% indicated that they had specialties in addition to general pediatrics; however, no one reported specializing in adolescent medicine. Approximately 70% answered the optimal patient encounter time would be under 10 min. More than 90% of respondents reported challenges providing health services to adolescent patients. Nearly half indicated that they did not routinely evaluate height, heart rate or blood pressure. Few providers asked about reproductive health, violence, or smoking/alcohol use. CONCLUSION: This survey is the first exploration of adolescent health care in an urban area of Japan. While the sample is small, the magnitude of challenges was great with limited training in adolescent medicine, severe time constraints and limited appreciation for the value of health screening at each encounter. Developing a standardized practical assessment tool for adolescent patients may help guide primary care pediatricians to better meet the needs of their adolescent patients.

Measuring young adolescent perceptions of relationships: A vignette-based approach to exploring gender equality.

This paper reports the development and baseline data of a vignettes-based measure of gender equality. METHODS: Vignettes were developed through 3-day long focus groups. After piloting in 13 sites and repiloting a revised version in 6 countries, responses were categorized by the construct tapped and a scoring system developed. Finalized vignettes were then tested in DR Congo, Ecuador and China. RESULTS: Young adolescents can successfully respond to vignettes; and can differentiate self from hypothetical protagonists of same and opposite sex. Response differences by sex of respondent and protagonist were statistically significant across a range of scenarios and settings. CONCLUSION: This is the first vignettes-based measure for young adolescents assessing young adolescent perceptions of relationships differentiated by sex of the protagonist.

Opportunity Youth: Insights and Opportunities for a Public Health Approach to Reengage Disconnected Teenagers and Young Adults.

Approximately 1 in 9 teenagers and young adults aged 16-24 in the United States is currently disconnected from school and employment. These disconnected young people (ie, opportunity youth) are not only at high risk for long-term emotional, behavioral, and health problems, but they also represent a loss of human capital, with high social and economic costs. In this article, we offer a public health perspective on opportunity youth by describing their distribution in the population and consequences of their disconnection; proposing a conceptual model of the issue based on epidemiological principles, life course development concepts, and ecological theory; and recommending multisector strategies for preventing disconnection of young people and reengaging opportunity youth. A public health approach to the problem of opportunity youth would involve developing and investing in youth monitoring data systems that can be coordinated across multiple sectors, consolidating both the delivery and funding of services for opportunity youth, developing policies and programs that encourage engagement of young people, and fostering systematic approaches to the testing and scaling up of preventive and reengagement interventions.

Exploration of Gender Norms and Socialization Among Early Adolescents: The Use of Qualitative Methods for the Global Early Adolescent Study.

PURPOSE: The Global Early Adolescent Study (GEAS) was launched in 2014 with the primary goal of understanding the factors in early adolescence that predispose young people to subsequent sexual risks, and conversely, those that promote healthy sexuality across different cultural contexts. The present article describes the methodology that was used for the first phase of GEAS, which consisted of conducting qualitative research to understand the gendered transitions into adolescence and the role that gender norms play within the key relationships of adolescents. Researchers from each of the sites that had completed data collection were also elicited for their feedback on the key strengths, challenges, and lessons learned from conducting research among 11- to 14-year-old adolescents. The purpose of this article is to present the description of each of the methods that were used in GEAS, as well as the researchers' perspectives of using the methods among early adolescents in their sites. METHODS: The GEAS is being implemented through a collaboration of university and nongovernmental institutions from 15 cities: Assiut (Egypt) Baltimore (U.S.), Blantyre (Malawi), Cape Town (South Africa), Cochabomba (Bolivia), Cuenca (Ecuador), Edinburgh (Scotland), Ghent (Belgium), Hanoi (Vietnam), Ile-Ife (Nigeria), Kinshasa (DRC), Nairobi (Kenya), New Delhi (India), Ouagadougou (Burkina Faso), and Shanghai (China). Approximately 30 in-depth interviews among adolescents and 30 in-depth interviews with their parent/guardian were conducted at each site, with adults and adolescents interviewed separately. To build trust and increase engagement among the adolescent participants, we used two different visual research methods: (1) timeline exercise which was small group based and (2) the Venn diagram exercise which was conducted individually and used at the start of the in-depth interview. RESULTS: The visual aspects of both the timeline and the Venn diagrams not only helped to produce data for the purposes of the study, but also were a successful way of engaging the adolescent participants across sites. While the narrative interviews produced extremely rich data, researchers did notice that there were a few challenges among the younger adolescents. Challenges were related to the length of the interview, comprehension of questions, as some of the questions were either too abstract or asked adolescents about an experience they had not yet had and therefore could not address or articulate. CONCLUSIONS: Conducting the first phase of GEAS revealed important insights for research with participants who are in this developmental phase of early adolescence. Methods that involve greater engagement and those that are visual were shown to work well irrespective of the cultural setting.

Marching to a Different Drummer: A Cross-Cultural Comparison of Young Adolescents Who Challenge Gender Norms.

PURPOSE: Little is known about how gender norms regulate adolescents' lives across different cultural settings. This study aims to illustrate what is considered as violating gender norms for boys and girls in four urban poor sites as well as the consequences that follow the challenging of gender norms. METHODS: Data were collected as part of the Global Early Adolescent Study, a 15-country collaboration to explore gender norms and health in early adolescence. The current study analyzed narrative and in-depth interviews conducted in urban poor sites in two middle-income (Shanghai, China; and New Delhi, India) and two high-income countries (Baltimore, U.S.; and Ghent, Belgium). A total of 238 participants, 59 boys and 70 girls aged 11-13 years old and 109 of their parents/guardians (28 male adults and 81 female adults), were interviewed. A thematic analysis was conducted across sites using Atlas.Ti 7.5 software. RESULTS: Findings revealed that although most perceptions and expressions about gender were regulated by stereotypical norms, there was a growing acceptability for girls to wear boyish clothes and engage in stereotypical masculine activities such as playing soccer/football. However, there was no comparable acceptance of boys engaging in traditional feminine behaviors. Across all sites, challenging gender norms was often found to lead to verbal, physical, and/or psychological retribution. CONCLUSIONS: While it is sometimes acceptable for young adolescents to cross gender boundaries, once it becomes clear that a behavior is socially defined as typical for the other sex, and the adolescent will face more resistance. Researchers, programmers, and clinicians working in the field of adolescent health need not only attend to those who are facing the consequences of challenging prevailing gender norms, but also to address the environment that fosters exclusion and underscores differences.

Facilitators and Barriers to Implementing Church-Based Adolescent Sexual Health Programs in Baltimore City.

PURPOSE: Black churches are an important community resource and a potentially powerful actor in adolescent health promotion. However, limited research exists describing the factors that may influence the successful implementation of evidence-based adolescent sexual health programs in churches. In the present study, a multi-informant approach was used to identify facilitators and barriers to implementing adolescent sexual health programs in black churches. METHODS: Nine Black churches located in Baltimore, MD, were recruited to participate in this study. The senior pastor and youth minster from each congregation participated in an in-depth interview (N = 18). A total of 45 youth (ages 13-19 years) and 38 parents participated in 15 focus groups. Qualitative data were transcribed verbatim and analyzed using a qualitative content analytic approach. RESULTS: Participants agreed that comprehensive adolescent sexual health education should be available for youth in black churches. They also believed that abstaining from sex should be discussed in all adolescent sexual health programs. Three facilitators were discussed: widespread endorsement of church-based adolescent sexual health education, positive influence of youth ministers on youth, and life lessons as teaching tools. Four barriers are described: perceived resistance from congregants, discomfort among youth, lack of financial resources, and competing messages at home about sexual health. CONCLUSIONS: Our findings suggest that churches are a preferred place for adolescent sexual health education among some parents and youth. Study findings also reinforce the feasibility and desirably of church-based adolescent sexual health programs.

Bringing Evidence-Based Sexual Health Programs to Adolescents in Black Churches: Applying Knowledge From Systematic Adaptation Frameworks.

Previous studies have documented Black churches' receptivity to implementing adolescent sexual health programs within their congregations. Some authors have argued for new sexual health programs to be designed specifically for churches, similar to the development of school- and community-based interventions. However, strategies and curricula used in secular settings may also be effective in influencing sexual behaviors among youth in churches. The current study examined the ways in which the phases of two theorized intervention adaptation frameworks were reflected in the desired key components of a church-based sexual health program. Participants in this community-based participatory research project were youth, parents, and faith leaders from nine Black churches in Baltimore, Maryland. Our findings suggest that the priorities of church stakeholders are consistent, rather than discordant, with the current paradigms of evidence-based sexual health programs and intervention adaptation. Future research and practical implications are discussed.

Gender-based violence against adolescent and young adult women in low- and middle-income countries.

PURPOSE: Gender-based violence (GBV) is a global health and human rights issue with individual and social determinants. Youth are considered high risk; national influences include norms, policies and practices. By age, nation, and region, we contrast key GBV indicators, specifically intimate partner violence (IPV) and forced sexual debut among adolescent and young adult women using Demographic and Health Surveys across low- and middle-income countries. METHODS: National prevalence estimates were generated among adolescents (15-19 years) and young adults (20-24 years) for lifetime and the past-year physical and sexual IPV among ever-married/cohabitating women (30 nations) and forced sexual debut among sexually experienced women (17 nations). Meta-analyses provided regional estimates and cross-national comparisons, and compared the past-year IPV prevalence among adolescent and young adult women to adult women. RESULTS: An estimated 28% of adolescent and 29% of young adult women reported lifetime physical or sexual IPV, most prevalent in the East and Southern Africa region. Regional and cross-national variation emerged in patterns of violence by age; overall, young adult women demonstrated higher risk for the past-year IPV relative to adult women (meta-analysis odds ratio, 1.20; 95% confidence interval, 1.10-1.37) and adolescents had a comparable risk (meta-analysis odds ratio, 1.07; 95% confidence interval, .91-1.23). Forced sexual debut was estimated at 12% overall, highest in the East and Southern Africa region. CONCLUSIONS: GBV is pervasive among adolescent and young adult women in low- and middle-income countries. The unique risk to youth varies across nations, suggesting an age-place interaction. Future research is needed to clarify contextual determinants of GBV. Findings provide direction for integrating youth within GBV prevention efforts.

Changes in and challenges for intentional injury in Vietnam: evidence from 2 national adolescent health surveys, 2004 and 2009.

OBJECTIVE: To describe the current situation of intentional injury among Vietnamese youth as well as risk and protective factors. METHOD: The Sample of Survey Assessment of Vietnamese Youth 2009 (SAVY2) involving 10,044 youth aged 14 to 25 in 2009 was used and compared with SAVY1 in this study. The data were analyzed using bivariate and multivariate statistical techniques. RESULTS: Of the sample in 2009, 3% of the young people reported that they had been injured by a family member. The proportion who were intentionally injured by others outside their home was 7.6%. Youth who were most likely to hurt others included urban males, those who had ever been drunk, those who had been intentionally injured by others, and those who had weak family connectedness. Having suicidal thoughts (both sexes) is related to alcohol consumption. CONCLUSIONS: The rate of violent behaviors was low, but several risk and protective factors were found and confirmed.

A global study on the influence of neighborhood contextual factors on adolescent health.

PURPOSE: This study uses data collected as part of the Well-Being of Adolescents in Vulnerable Environments study to (1) compare the perceptions of neighborhood-level factors among adolescents across five different urban sites; (2) examine the associations between factors within the physical and social environments; and (3) examine the influence of neighborhood-level factors on two different health outcomes-violence victimization in the past 12 months and ever smoked. METHODS: Across five urban sites (Baltimore, New Delhi, Johannesburg, Ibadan, and Shanghai), 2,320 adolescents aged 15-19 years completed a survey using audio computer-assisted self-interview technology. To recruit adolescents, each site used a respondent-driven sampling method, which consisted of selecting adolescents as "seeds" to serve as the initial contacts for recruiting the entire adolescent sample. All analyses were conducted with Stata 13.1 statistical software, using complex survey design procedures. To examine associations between neighborhood-level factors and among our two outcomes, violence victimization and ever smoked, bivariate and multivariate analyses were conducted. RESULTS: Across sites, there was great variability in how adolescents perceived their neighborhoods. Overall, adolescents from Ibadan and Shanghai held the most positive perceptions about their neighborhoods, whereas adolescents from Baltimore and Johannesburg held the poorest. In New Delhi, despite females having positive perceptions about their safety and sense of social cohesion, they had the highest sense of fear and the poorest perceptions about their physical environment. The study also found that one of the most consistent neighborhood-level factors across sites and outcomes was witnessing community violence, which was significantly associated with smoking among adolescents in New Delhi and Johannesburg and with violence victimization across nearly every site except Baltimore. No other neighborhood-level factor exerted greater influence. CONCLUSIONS: This study confirms the important associations between perceptions of a neighborhood and adolescent health. At the same time, it demonstrates that not all neighborhood-level factors are associated with adolescent health outcomes in the same way across different urban contexts. Further longitudinal research is needed to examine the direction of causation between adolescent health neighborhood contexts and health outcomes and the reasons for why different urban contexts may exert varying levels of influence on the health of adolescents.