The global school-based student health survey as a tool to guide adolescent health interventions in rural Guatemala

Adolescence is a critical developmental period which strongly impacts future health and economic success. The cumulative effect of nutrition, mental health, violence, and sexual behaviors during the formative adolescent years can have negative long-term implications for their physical health and emotional well-being. Over 80% of the world’s adolescents live in low-middle income countries (LMICs) [1]; yet the physical and emotional developmental challenges in resource-limited environments are not well characterized [2], especially in rural areas characterized by low population density.

Adolescents in LMICs face major food insecurity challenges, resulting in both high prevalence of undernutrition and increasing rates of obesity. The global prevalence of overweight and obesity is projected to rise to 38% in adults and 9.1% in children by 2030 [3]. Obese children are at increased risk of becoming obese adults [4], and consequently at higher risk for cardiovascular disease, diabetes, and other costly chronic comorbidities. In addition, dietary behaviors in LMICs are rapidly shifting as calorie-dense, nutrient-poor foods become both more affordable and available [5]. Combined with high rates of food insecurity, these societal and behavioral factors may contribute to the double burden of undernutrition and overweight in these populations [6].

Mental health disorders often begin in adolescence, and, if left untreated, can result in poor education, health, and economic outcomes [7]. Globally, depression and suicide are among the top five major causes of disability-adjusted life years lost in children 10–19 years of age [8]. In addition, food insecurity has been found to be associated with increased levels of depression, suicidal ideation and substance use problems in adults in France and Canada [9, 10]. As many mental health conditions are both preventable and treatable, the identification of adolescents at risk for food insecurity, substance abuse, or poor mental health outcomes could inform targeted prevention efforts locally.

Sexual activity is often initiated in adolescence [11], leading to unique challenges and complications in LMICs, where sexual education and access to reproductive health care are often limited. Earlier initiation of sexual activity can lead to acquisition of sexually transmitted infections (STIs) and unplanned pregnancy [12, 13], resulting in poor health outcomes such as eclampsia or systemic infection in young mothers, and low birthweight or early neonatal death in their children [14]. Almost 50% of women in Latin America give birth for the first time during adolescence [15]. Furthermore, pregnant adolescent girls in LMICs often drop out of school, limiting both their education and lifetime potential economic attainment [16].

Despite the increasing recognition of the unique health challenges in LMIC adolescent populations, there is limited evidence available to guide decision-making and resource allocation for interventions, especially at the local level. Population-based cross-sectional surveys, such as the Global School-based Student Health Survey (GSHS), have been utilized worldwide to evaluate the prevalence of adolescent health needs and behaviors in a country, or for cross-country comparisons [17‐19]. However, country-level estimates may be less useful for informing the local, community-based interventions that are common in rural, resource-limited settings. Thus, administering these freely available surveys at the local level offers a solution for providing rapid, local estimates of health burdens in at-risk LMIC populations.

In early 2015, the Community Advisory Board for Research of the southwest Trifinio region of Guatemala expressed concern regarding the high rate of teen pregnancy reported by a local pregnancy registry, and requested assistance through their academic partnership with the University of Colorado [20] to describe sexual and other adolescent health behaviors among teens in the region. In response, we administered the GSHS to school-aged adolescents to determine the prevalence and predictors of health-related behaviors that were of particular concern to community leaders: overweight, stunting, dietary behaviors, food insecurity, mental health, sexual activity, and violence. Survey results were the shared with local school leaders, who then prioritized the use of scarce resources, and pursued school-based interventions in target sub-populations.

Out of 620 eligible students attending school the day the survey was administered, 557 surveys were received. Thirty-four students were absent the day of survey administration. Following WHO guidelines, surveys with more than 20 blank items were considered incomplete and excluded from analyses (n = 3), leaving 554 completed surveys (87% response rate). The majority of these participants (542, 98% of respondents) also had anthropometric measures taken. Table 1 shows the characteristics and prevalence measures of the study population overall and by gender. Participants were an average of 14.4 years old (SD 1.54 years) and 55% male. Gender distribution did not differ by community of the school’s location (p = 0.31), but differed significantly by age (p < 0.001), with older adolescents more likely to be male. Figure 1 shows the distribution of gender by age.

The WHO/CDC GSHS tool is useful for rapid and inexpensive data collection on adolescent health behaviors, in order to inform community health program design and decision-making in rural communities, such as the southwest Trifinio region of Guatemala. Within six months and using only volunteers, we administered the GSHS, analyzed the data, summarized the findings, reported back to community constituents, and began intervention planning. Early initiation of sexual activity, the high prevalence of children not eating breakfast, and surprisingly high prevalence of early alcohol use and its relationship to poor mental health were results highlighted in discussions with school and community leaders.

While the GSHS was implemented in a representative sample of Guatemalan urban and rural areas country-wide in both 2009 and 2015, those data are not always generalizable to communities like the rural southwest Trifinio. For example, 2015 national estimates of the prevalence of age of first sexual intercourse before 14 years for males was 47% vs. 27.4% in Trifinio [23]. Estimates for females were similarly overestimated in the national sample, at 50% vs. 23.1% in Trifinio. Though this likely reflects the more urbanized sample of the national survey; the non-urban sexual activity data from the national survey were not available for comparison until late 2017. There were similar limitations in the mental health and violence modules of the GSHS national surveys. The reported prevalence of considering suicide for males was very similar nationally compared to southwest Trifinio (12.3% vs. 10.7%), but female adolescents reported almost double the rate of suicide ideation in the national survey compared to southwest Trifinio (21.2% vs. 12.7%). As with studies in other adolescent populations [24‐26], we found that alcohol use, sexual activity, being bullied/attacked and aggressive behavior were all associated with poor mental health outcomes. However, compared to the rest of Guatemala in 2015, southwest Trifinio had less current alcohol use, suicidal ideation (in females), and recent participation in physical fights [21]. Gender and age differences in school attendance may also differ between county-wide versus local samples, and thus impact intervention planning. The observation of a higher proportion of boys in older ages in Trifinio may reflect community norms where boys begin schools older due to household economic responsibilities, or where girls drop out of school earlier to fulfill household responsibilities or begin their own families.

For nutrition, there was a high population prevalence of both undernutrition (unhealthy dietary behaviors, food insecurity, stunting) and overweight. These results are consistent with global trends showing increases in the double burden of malnutrition and obesity in other developing countries [27], though these trends are not yet apparent on the individual level as only 4% of our participants qualified as ‘double burden’ (both stunted and overweight). We identified a high prevalence of stunting (31%) which is comparable to prevalence reported in Guatemalan infants [28], and in adolescent populations in nearby Central American countries [29]. Overall, sexual activity was disproportionately higher among the males in this rural community. A GSHS study conducted in Venezuela in 2003–2004 reported a similar gender disparity among the prevalence of students reporting having initiated sexual activity [24].

Local administration of the GSHS allowed for faster generation of evidence to be used in community decision-making. Overall and individual school reports were presented in oral and written form to school and community leaders within 6 months of the survey, while the national 2015 data were not available until the last quarter of 2017. From the facilitated discussion that followed, several directions for future interventions were agreed upon as warranted, feasible, and fundable. Due to the availability, affordability, and adoption of nutrient-poor diets in this area, it will be difficult to address undernutrition problems without concurrently increasing obesity rates [27]. However, providing healthy breakfast in schools may be one promising avenue of intervention that is being considered by local leaders. Results from other pediatric populations indicate that eating breakfast leads to increased cognitive and academic performance, better nutrient intake profiles, and lower BMI [30‐32]. High prevalence of loneliness and suicidal ideation were concerning, but are amenable to intervention as well. School-based mental health promotion interventions have been shown to be effective, practical, feasible, and scalable in LMICs [33], and are being further explored by the Trifinio communities.

Finally, to address high prevalence of sexual activity and early initiation, a sexual education program (adapted Big Decisions®, [34]) is being introduced in the middle and high schools in these communities. The southwest Trifinio schools historically have had no reproductive and sexual health curriculum despite the national policy agreement by the Ministry of Education that introduced the Integrated Strategy of Sexual Education and Violence Prevention in 2010. Since school-level attitudes toward sex are predictive of age at sexual initiation in both boys and girls [35], introducing the Big Decisions program is a promising strategy to reduce unhealthy sexual behaviors and consequential unintended outcomes (pregnancy, STIs, etc.). These efforts complement broader initiatives to improve access to adolescent sexual and reproductive health education and services throughout Latin America [36].

Utilization of the pre-existing GSHS tool made this a feasible strategy to conduct a rapid assessment of the burden of adolescent health risks in a low-resource setting where the existing national-level evidence was not generalizable or quickly made available to the local population. We achieved excellent participation from local schools, and a high student response rate. However, our description of these health risk behaviors is limited to adolescents who attend school. School attendance has been associated with fewer health risk behaviors and better health outcomes in LMICs [37, 38], therefore the associations presented may be underestimates for the total southwest Trifinio adolescent population. Poverty and food insecurity are highly correlated in southwest Trifinio and may have created a selection bias due to their influence on both the likelihood of attending school and the presence of health risk behaviors. The finding that older children were less likely to be overweight or obese may reflect a selection bias in which economically disadvantaged students are less likely to stay in school as they age.

Similarly, the sexual activity results may reflect a selection bias in which sexually active females became pregnant, were not attending school, and thus were not present to take the survey. A census conducted in the same communities in 2015 found that 9% of adolescent females aged 17–19 years were pregnant (Bunge-Montes S, internal communication), providing some evidence of the proportion of sexually active females that are not represented by these survey findings. This low reporting rate and subsequent small sample size of sexually active adolescents restricted our ability to test for predictors of early initiation of sexual activity. As with all cross-sectional studies, we are unable to determine the temporal relationship between health risk behaviors and outcomes.

In addition to implementing interventions based on the southwest Trifinio 2015 GSHS results, the community has decided to administer the survey every two to three years for ongoing surveillance and secular trend comparisons of adolescent health behaviors. There is growing health infrastructure in the region through the Center for Human Development of the Foundation for the Integral Health of Guatemalans, a public-private partnership initiated in 2011 that has been integrating healthcare service delivery, community development, research, and education locally using a population health model [20]. The results of the 2015 survey will serve as a baseline for evaluating trends in this adolescent population over time, and evaluating the effects of ongoing community-based health interventions.

We have demonstrated the utility of GSHS as a low-cost tool for assessment of adolescent health in localized areas of LMICs, as well as the effectiveness of working closely with school and community leaders to translate GSHS findings into school-based interventions aimed at reducing adolescent health risk behaviors and associated poor health outcomes.