Kate Steinbeck: [00:00:01] Welcome, everyone, to the Wellbeing, Health & Youth, Centre of Research Excellence in Adolescent Health, funded by NHMRC. Just before we begin, I'd like to acknowledge all those universities that are connected with our research and make WH&Y what it is. I also need to acknowledge the traditional owners of the country throughout Australia, and recognise their continuing connection to land, waters and culture. We pay our respects to the elders past, present and emerging. 

Kate Steinbeck: [00:00:49] This is our website, I introduce it to you every time, but it's always good to go and have a look and see what's new. And just a few housekeeping rules before we start and I introduce our speaker. Your microphone and video will be switched off while we're presenting and you've got two ways of responding, you can do the regular chat, or if you have a question for our speaker, please use the question box on the right to ask the question and we'll answer them at the end of the session.

Kate Steinbeck: [00:01:39] So, it is my pleasure to introduce Associate Professor Peter Azzopardi. Peter works at the Burnet Institute, that's where he's based. He's a pediatrician and a researcher, and he leads a program of research on global adolescent health, with a strong focus on health equity, which I think is always important to us who work with adolescents. He was a contributor to the Lancet Commission on Adolescent Health and Well-Being and has consulted on adolescent health to governments in Australia and the region, as well as UNICEF, UNFPA and WHO. And I note that he co-chairs the World Health Organization's Global Action for Measurement of Adolescent Health, which I hope you will be talking a little bit about today, because it's an issue that really interests us all and troubles us all. Thank you, Peter. Welcome to our webinar.

Peter Azzopardi: [00:02:48] Thank you so much, Kate. And welcome to everybody on the call today. Thank you so much for the opportunity to be with you all. 

Peter Azzopardi: [00:03:09] I'm hoping you can see my screen. I'm going to be talking to you today about using data to bring greater visibility to this issue globally. I want to acknowledge that I'm meeting from the Wurundjeri people of the Kulin nation people and pay my respects to elders past, present and emerging. I want to acknowledge Aboriginal and Torres Strait Islander people that are on this call and many of my colleagues and friends who I've worked with for many years. And it really taught me a lot about public health research and actually around community engagement and translation of research findings, which is really at the core of a lot of what we're talking about today as well. And I also want to acknowledge my friends and colleagues that I can see have joined us from Myanmar today, so to all those on the call today. And appreciate it's a public holiday in Myanmar today. And I really appreciate you joining the call as well. 

Peter Azzopardi: [00:04:06] When it comes to institutions I work across two institutions, I worked at the Burnet Institute in Melbourne where we have a focus on global adolescent health with a particular focus in our region, the Asia-Pacific region. And also thrilled to work part-time in Adelaide, at the South Australian Health and Medical Research Institute (SAHMRI), where I lead a new program of work around adolescent health and wellbeing.

Peter Azzopardi: [00:04:29] Today's talk is going to be focusing a little bit more on the global work that we run through, Burnet but we will be making some reference to the work that we do at SAHMRI as well. I've put my University of Melbourne email there, but please do feel free to contact me if anything we talk about today is of interest or if you want to discuss opportunities in terms of being a student or collaboration, etc, we always like to make contact with new people.

Peter Azzopardi:: [00:04:59] So I just want to start on why we are talking today about data and health data, and I acknowledge that it can be potentially quite a dry and boring area, but it's a boring necessity. And I think that, you know, there's an old saying it sort of gets kicked around, that what gets measured and reported gets done. And I think that's absolutely true. And I want to share with you a case study in a minute that really highlights why we are so behind the eight ball in adolescent health compared to other areas of global health. 

Peter Azzopardi: [00:05:34] I think what happened in the last few years has been the introduction of the Sustainable Development Goals in 2015. They've brought a really sharp focus to targets and indicators, and the need to measure investments and any outcomes, those investments. And I think, you know, what's becoming much, much more important in global health policy and global health action is the need to measure and report what we're actually doing.

Peter Azzopardi: [00:06:58] So, I want to share a case study with you, and this is a paper that Russell Viner in the U.K. published a couple of years ago now, but really what this described was trends in mortality by age for a 50-year period. And what you can see very clearly in the purple line is that there have been profound changes, huge improvements in under-five mortality. And there's no doubt this coincides with the fact that countries regionally and globally, we have prioritised measurement and reporting of under-five mortality, and that's been a really important driver of investment and of action. And it certainly helped to drive the more than halving of under-five mortality over time. Whereas if you compare adolescent mortality and I've just shown this in the blue line here for males and females, you can see that there's actually been no shift at all. Now, some may argue that the rates are actually quite low, and that's true. But now for males 15 to 19 year old and definitely 20 to 24 year old males have a higher mortality than under fives do. And in actual fact because of the youth bulge in many countries, these seemingly low rates still translate to very large numbers of largely preventable adolescent deaths.

Peter Azzopardi: [00:08:22] So I think that there's a growing recognition of the need for us to better measure and report even simple things like adolescent mortality to help drive action. And I think that this lack of measurement and this lack of reporting has also contributed to the fact that we have a relatively pretty dismal investment in adolescent health programming at a global level. So only, 1.6% of total developmental assistance targets adolescents currently.

Peter Azzopardi: [00:08:55] So, why are we in this situation? What are some of the barriers to actually measuring and reporting adolescent health? And I'll summarise them here as two complementary issues. The first is that we have limited and inconsistent indicators for adolescent health. So an indicator should be a really well defined metric that's measuring a particular area of health or a risk factor or access to services that can be populated, so it's harmonised with data, it's reproducible and it's traceable over time. So an indicator should allow us to understand how a particular country is going and how things are tracking over time with investment.

Peter Azzopardi: [00:09:45] But you can see that part of the issue has been that and here in an earlier piece of work we did with UNICEF, we just mapped some of the indicator frameworks for adolescent health from the UNICEF framework, from the Lancet series and from WHO. And you can see that just for a couple of indicators, the detail is not important, but you can just see how poor the alignment is. And you could see that for some indicator fragments for WHO for example, there are many, many indicators, but actually many of these remain poorly defined. So there's been a challenge for countries and for data folk, particularly for people mounting national surveys to understand what should be measured and reported. And either as a result of or either contributing to this has been the fact that we have really limited data for adolescents at the global level as well. So this was a really important piece of work that George Patton led as part of the Second Lancet Series on Adolescent Health, where he mapped the coverage and quality of data for adolescents across major regions and globally. And you can see that even for something like mortality that we would see as being a fairly fundamental and basic metric of health, you can see that we only have minimally sufficient data for 26 percent of the world's young people. And if you move into some of the other areas of health, particularly mental health, HIV, etc, we have even poorer data available as well.

Peter Azzopardi: [00:11:19] And so this has been one of the longstanding issues, I think, has been that we've had really poor quality indicators and we haven't had very good quality data. And both of these together have made the task of measuring and reporting adolescent health really challenging. And there's a real impatience around this. You know, many countries now have really prioritised the need to invest in adolescent health. So the improvements in child survival have actually resulted in up to a third of populations globally being adolescents and young people. And so there's a real need to invest, but without quality data, without quality indicators, it's really hard to know where we should invest. What should the priority investments be? And this was something that we really tried to address in the Lancet Commission, so the Lancet Commission, I know many of you would have interacted with and had seen multiple presentations around it in the past, but I wanted to just focus on one specific element. And that was a task that we actually reported the health of the world's adolescents at a global level, at a regional level. And to be able to do this in the absence of high quality primary data, we used model data. And I want to be really explicit and upfront about this. And I think it's really important because sometimes people misunderstand model data. I've certainly presented this work in the past and sort of had comments on its model data. you know, it's not really all that useful. But I think it's important to understand why we model data and the purposes of modeling data. 

Peter Azzopardi: [00:13:03] So, modeling data can actually help harmonise estimates over time. So sometimes in a survey we might have an estimate done in 1990 and an estimate in 2017 and another estimate in 2019. And sometimes some of those estimates can be a lot higher one year and a lot lower. And through modeling, you can actually try to bring those estimates together. And that was a particular issue in Papua New Guinea where we do a lot of work, where the estimates around maternal mortality ratio varied so much between year on year and actually using modeling to harmonise those estimates, to really understand were we actually seeing any decline or improvement in maternal mortality, or was this actually more an artifact of survey technique? 

Peter Azzopardi: [00:13:52] The second task that modeling can actually help address is to try to translate different metrics into a common measure. So if I give you the example of diabetes, diabetes can be measured as diabetes incidence, diabetes prevalence, diabetes, hospitalisation rate, diabetes mortality, complications rate, etc, etc. There are lots of different measures and sometimes you have really good data on one element and another survey, and you might have really good at another element. And the benefit of modeling is that you can bring all these slightly different measures together and translate them into a common measure that can be used to compare across time, across nations. 

Peter Azzopardi: [00:14:36] The third most important and particularly important for adolescent health is that modeling can help estimate missing data and particularly for some areas of adolescent health we have really poor quality data, and so what we can do is we can look at the patterns in childhood, later childhood and in adulthood, and we can look at what the risk factor profiles look like. We can look at what the situation looks like in other countries with comparable data and then estimate as best as we can what the prevalence or what that particular measure may be in that current context in that given time.

Peter Azzopardi: [00:15:14] So you can see that modeling has multiple benefits and what it enables us to do and this was a companion paper that we published along with the Lancet Commission, it allows you to describe things in a huge amount of detail. And so this was a paper that Alan Mockday at the Institute for Health Metrics and Evaluation, that the University of Washington led. And in a huge amount of detail, really describing the leading causes of death, disability, leading risk factors for adolescent health across the world and across regions. And this is only possible because of model data. And I think what this allows us to do is in the absence of otherwise good quality primary data make a really fair assessment of where the likely issues are, but also it helps inform us where we need to invest in better quality primary data collection as well.]

Peter Azzopardi: [00:16:14] One of the challenges, I think of having all this data, I think it creates a problem on the other extreme, is that there's almost too much information here for country partners and certainly for the global agencies as well. And I want to come back to that case study I started talking about at the beginning of the presentation around under-five mortality. This may look like a really simple graph. For me, when I first was introduced to this whole concept before the Lancet Commission, it was really a light bulb moment for me, and it really sort of helped change my thinking in the way that we should communicate health data. So I think that for a long time with many of us that work in adolescent health, talk about adolescents being a really complex developmental stage and lots of things change and health needs change. And I think we sort of dig ourselves into a bit of a hole because I think all of that's true but by making it so complex, it makes it very difficult for us to communicate to policymakers and to people that work in programming: what do we actually need to do to address adolescent health? 

Peter Azzopardi: [00:17:26] So if you think about child health, childhood is also a very complex period of life. It's a profoundly important developmental stage, lots of change. Health needs change. But what the child health folk did really well was they simplified and identified just a couple of key drivers of under-five mortality to really focus on policy and action.

Peter Azzopardi: [00:17:52] So what this graph shows here is that at different mortality levels, the contribution to total mortality of diarrhea and pneumonia, and to congenital anomalies and so what you can say here, I hope what this shows you is that at about 60 per thousand, anything about that, diarrhea and pneumonia make a really important contribution to childhood mortality. And less than 60 per thousand, it's possibly less important to be focusing on diarrhea and pneumonia and more important to be focusing on other causes of childhood mortality, and this very simple thinking was the basis of the integrated management for childhood illness package that UNICEF, WHO and other partners put together. And there were really important child survival strategies as well, which really focused on diarrhea and pneumonia control in settings where childhood mortality was greater than 60 per thousand per year. 

Peter Azzopardi: [00:19:00] So we tried to take this same sort of thinking, and this was certainly something that George Patton (check name) drove, and I think it was really, really important thinking at the time. But we tried to simplify the way that we think about adolescent health at a global level as well. And we couldn't really think of a single cause or causes, and I think what's a little bit different from adolescent health compared to child health, is that it's probably more morbidity rather than mortality that's the pressing need for action. But we thought about three country groupings, and I like to think about them going from the right to the left. We identified those countries. so countries like Australia, for example, when non-communicable diseases are the predominant driver of death and disability. We then thought about those countries where, in addition to non-communicable diseases, injuries were an important driver of the health needs of adolescents. And then we thought about those countries that had a multi-burden profile, so that they had non-communicable diseases and injuries and also communicable infectious diseases and particularly for adolescents with substantial unmet needs sexual reproductive health rights.

Peter Azzopardi: [00:20:20] And so what we were able to do in the Lancet Commission was actually describe how the world looked in terms of adolescent health programming. And this has proven to be really useful in terms of thinking, you know, at a global sort of planning level for agencies like the UN agencies, UNICEF, UNFPA, WHO, in terms of thinking about, the countries in our region, for example, there are some countries where we need to think about communicable, non-communicable and injuries for adolescents. Whereas in terms of Australian health policy, by and large, we need to think about non-communicable diseases.

Peter Azzopardi:: [00:21:07] But the other thing that we did in the Commission, and this is really the part that I want to focus on for the rest of this talk here, is we proposed a series of headline indicators to really help focus action. So, we really wanted to break down all that really complex information that we were able to obtain from model data to really identify, we've got a couple of really important country groupings now and here now we've got a couple of important indicators that were harmonised with data available that could potentially be populated and reported by countries and that would help track and trace key health issues, as we identified through the Commission for adolescents across the globe. 

Peter Azzopardi: [00:21:58] We identified three indicators that related to burden of disease or health outcomes for adolescents. We identified four important risk factors for adolescent health, so tobacco use, alcohol use, overweight and obesity and anemia as a marker of undernutrition, and we identified five key indicators for the determinants for adolescence health. So, two relating to educational attainment and transition to employment and training, adolescent birth rate and fertility, childhood marriage, and a final indicator around met need for contraception, largely as an indicator of health service access and quality.

Peter Azzopardi: [00:22:50] What we were then able to do was to use model data to populate these indicators for 195 locations across the world. So for each country here is a row and the detail is not what's important here, but what we are able to do is for females and males for each indicator, actually describe what that indicator looked like and comparatively how that country was tracking compared to other countries on that indicator using this heat map. So red would indicate that a country's perhaps not doing as well and green would indicate that a country is doing very well as compared to other countries. And you can see that by and large, we were able to populate these indicators. for pretty much most countries, with the exception of a couple of data gaps, particularly around education, where we weren't able to model some of these indicators as much as we'd like to. But the purpose of this really was to start a conversation around the importance of measuring and reporting adolescent health, and it was also to put some estimates out there that could then be discussed, debated and challenged by the global health community. And we also hoped that each of the country-level estimates as well could help start a conversation in countries around adolescent health. 

Peter Azzopardi: [00:24:20] And so I have highlighted Myanmar here, and I just want to share a bit of a case study in terms of how we extended this work in Myanmar. So Myanmar is a very important country for us, certainly for Burnet Institute it's one of our partner countries, and we acknowledge that Myanmar had a very difficult time, with Covid and with recent political events. But we've had a country office in Myanmar now for more than 20 years and have partnered with a whole range of agencies in terms of supporting child health and more recently adolescent health and wellbeing. Myanmar is a country of 54 million people, a third of which are young people. So essentially the population of Australia being adolescents and young people in Myanmar. And I think what's really quite remarkable about Myanmar is that for a long time now recognised the need for investment in adolescent health. As you can see here, there's a five year strategic plan for young people's health in 2016-2020. 

Peter Azzopardi:[00:25:31] About the time of this strategy sort of being refreshed, we held a series of workshops really using the model data that we were able to draw from the Commission and from our colleagues at the Institute of Health Metrics and Evaluation. We brought together people from government, from the key U.N. agencies and from NGOs to really critique, to look at the model data that we had to actually look at what are the health issues that these data are showing us? How well are these issues reflected in our national policy and where does the reorientation need to be? I'm really excited that Karly Ciini who's a close colleague of ours at the Burnet Institute, and MCRI together with Dr Pon who's our country manager in Myanmar, led a really important publication where we actually summarise this whole process of bringing together really important stakeholders at looking at all this data and thinking about what the key issues were in Myanmar and then thinking about how health policy needs to change in Myanmar. 

Peter Azzopardi:[00:26:44] To summarise, what we found was actually that the health strategy, the health policy in Myanmar had a very strong focus on sexual reproductive health and rights and a strong focus on risk factors. In actual fact, compared to other countries in the region, Myanmar fairs pretty well in terms of those areas of health. So adolescent fertility, for example, is relatively low, it's lower than the global average, whereas an area where there is a particular need is Myanmar was around road traffic injuries and particularly around chronic illness and unmet acute health needs. And so this work really helped to bring a stronger focus to the need to address acute disease and injury in adolescents and really made some very clear recommendations, you know, about stronger investments in adolescent-friendly health care for Myanmar. 

Peter Azzopardi: [00:27:41] The other thing that we were able to do, sort of following up from this as well, was to reflect on the model data, but also to look at what's been happening in Myanmar in terms of existing research, existing investments, and think through going forward, where do we need to be investing our research efforts? You know, where are the particular research gaps? And just to acknowledge, Keith Lin who I know is on this call today, and his colleagues who did a really terrific job in terms of pulling together a huge range of stakeholders. They've held two workshops now, and I know those workshops have really come down with a very concrete set of research priority areas ,which serve as an important template for focusing research in Myanmar. I think it's a remarkable achievement and I actually don't think that we are anywhere near as organised in countries, for example, like Australia in this regard.

Peter Azzopardi: [00:28:54] So that's a country example, but I want to now take a couple of steps back and really think about, you know, how can we drive action in adolescent health metrics globally? And, Kate, you mentioned the GAMAH [Global Action for Measurement in Adolescent Health] Initiative, and I want to talk a little bit about that, because I think this is a really important initiative that WHO have led that is really helping to bring a greater focus to what do we need to measure for adolescent health and how do we need to do so. 

Peter Azzopardi: [00:29:26] So GAMAH we spent a lot of time thinking about what we should call our grouping but it is Global Action for Measurement in Adolescent Health. It was formed in 2018, it brought together 17 experts in adolescent health measurement from across the world through a competitive application process. And as part of that, there are six young professionals. So there are younger people below the age of 30 who are professionals, but also includes some astounding people like Lucy Fagan who's a professional youth advocate and brings that really important linkage with youth networks globally. So the tasks of GAMAH are really to try to bring together, and it's no small task, actually, all of the different measurement groups of interest, so UNICEF, UNFPA, WHO clearly, UNESCO, which is the education focus of the UN, the HIV, Injury folk, but also the key data collection efforts as well. So, USAID leads a global effort called The Demographic Health Survey, so they're part of this grouping, and UNICEF has its own set of national surveys called the Multi-indicator Cluster Survey or MICS. 

Peter Azzopardi: [00:30:56] So, the idea is to bring together all of these people around the table to really agree on what should we be measuring for adolescent health and what do we need to do around data to ensure that we can measure and report adolescent health to bring it really up to scratch compared to other stages of the life course. This runs in parallel to an initiative which is focused on child health called CHAT, another initiative which is focusing more on maternal and newborn health monitors. So, you know, really terrific for WHO to make this substantial commitment. 

Peter Azzopardi:[00:31:36] But one of the first tasks that we've completed as a group is to actually identify the priority areas for adolescent health measurement. And I think this is such an important foundation, if we go with where the data are, highlighted earlier that the data are deficient in many areas and so you potentially won't be measuring things that are of importance to adolescent health or adolescent health policy. And clearly, the indicators that exist are really important, but they also may not be measuring or reporting, you know, what's really of fundamental importance to adolescent health. And so this is a huge body of work, which we've just completed and it's in this month's Journal for Adolescent Health, so we'd like to share it with you. But it really lays out globally what are the priority areas for adolescent health measurement. And I just want to share with you a couple of the key elements of this work, and I would really encourage you for something of interest to please engage with the paper, because I think it's a huge piece of work, and a lot of investment has gone into this. 

Peter Azzopardi: [00:32:48] To actually define priority areas we considered four key inputs. We considered young people, what do they identify as being a priority need? We thought about what countries identify as priority areas of need for adolescents. We looked at the burden of disease, and we also looked at existing initiatives and existing indicators.

Peter Azzopardi: [00:33:15] I want to focus on this first one here for a little bit, so for a whole range of issues and particularly for ethical issues, we weren't able to engage with young people directly at a global level. But what we were able to do was to reach out to youth representatives, youth organizations, youth advocates across the globe. And the idea of this being as well, that if you're able to engage with a youth advocate or youth network, that their responses that you get back will actually represent many, many more young people's thoughts, needs and aspirations. And so I think this was a really good way to go on balance. We were able to survey 946 youth advocates, youth networks globally, from low-income countries to high-income countries, and to really get their perceptions on what they thought the priority areas should be. And we didn't have as many males as we would like to, and unfortunately we didn't record gender diverse young people as well. But this was a really important first step in terms of measuring and reporting some of the priority needs. 

Peter Azzopardi:: [00:34:29] The second element that we brought in were from countries, and so WHO has a system in place already in terms of engaging with country counterparts, and so we were able to incorporate the feedback from 148 countries across the globe in terms of what they thought, this was the WHO posting in each country, and reflecting on policies, reflecting on frameworks that existed in their country- what were the adolescent-health-specific needs in that country?

Peter Azzopardi: [00:35:12] So what we did was we brought together all of these different inputs, and I suppose they are four individual studies in their own right, and we were able to bring all these together, map them across each other and come up with six domains of adolescent health and well-being. The ordering here is a little bit unusual, but I suppose another way of thinking about this is that we brought together a whole series of elements of adolescent health that sort of fit within subjective well-being. We included really important structural and social determinants of health. We included policies, programs and laws as they relate to adolescent health. We included health risk behaviors in states, health outcomes and health system performance interventions. And against these we were then able to map out 99 elements of adolescent health that may represent really important priority areas for measurement. And what we then went to do is we used this framework 99 and all the input data that went into this and use a delphi-like approach with our expert network to actually then prioritise and identify what were some core elements of adolescent health that we should carry forward with through the GAMAH. 

Peter Azzopardi: [00:36:28] I just want to share this table with you, and I think this is really interesting. And it just shows what the different inputs actually identified as key priorities for adolescent health. So, youth representative surveys, mental health, weight, having support from parents, were the three top things that were identified. If you look at what was currently being measured in initiatives so adolescent fertility, child marriage, contraception, so you can see a very heavy focus on sexual reproductive health, which sort of carries through within an existing policy country mapping as well, and burden of disease, bringing in a different perspective again with skin diseases, road traffic injuries and anxiety disorders being the the most important contributors to morbidity and mortality across this life stage. 

Peter Azzopardi:[00:37:19] So you can see they all brought in a unique perspective and that bringing all these together, we mapped all of these and then using our modified delphi approach, were able to come up with a couple of really core areas that we've been able to carry through for adolescent health at a global level for the GAMAH Initiative. 

Peter Azzopardi: [00:37:44] Now, mindful of time, but I just wanted to share a couple of other thoughts with you as we sort of wrap up this presentation here. What I've talked about so far has been focused on looking at adolescent health at a global level, at a regional level, on a national level. But we know that equity, equality are really important dimensions for health across the life course, but particularly during adolescence I think where we know that adolescence is a really important time, or many of us assume adolescence to be a really important time, where inequities emerge. And certainly it's something that we recommended as part of the Lancet Commission. So when we put these 12 indicators forward, we recommended that they should all be stratified or they should be disaggregated by gender, by remoteness, by wealth and by education as well. The reality is, though, that when we tried to actually pull these data together and report and we were able to only do this for six, that was the only dimension where data were available for. And it's actually interesting, you know, when you look across some of the indicators, like if you look at injuries, for example, it was almost consistent that males had an excess risk of injury compared to females. If you looked at anemia, for example, it was largely consistent that females had a larger burden of anemia than males. But if you looked at something like non=communicable disease burden, it was really a mixed picture across the globe in terms of in some countries, females had a larger burden, in some countries males did.

Peter Azzopardi: [00:39:21] And I thought it was a really important question. I suppose it sort of started to exist at the back of my mind in terms of which are the really important indicators, given resources for measurement and for reporting are limited, which are the really important ones that we need to recommend, should be disaggregated by gender. I think perhaps related to that, when did gender inequalities, and other inequalities actually first emerge across the life course. 

Peter Azzopardi: [00:39:56] This was a huge piece of work and I'm really excited to share it with you. It was a piece of work that we did in UNICEF East Asia-Pacific office over two years. And we really tried to answer that question. We really tried to understand when did gender inequalities first manifest in the first two decades of life and what are the particular gender inequalities that are really important from a policy perspective? There are four in-depth regional reports, and there's an overarching paper that we published late last year in Lancet Global Health, which has actually attracted quite a bit of commentary, and we can talk about maybe more in discussion time if people are interested. But to do this work, what we actually did was we first developed the conceptual framework for what we might want to measure across childhood and adolescence. We strategically aligned it to UNICEF's Strategic Framework for Health and Wellbeing, and we had four main domains: health, education, transition to employment, protection and safe environments. And across those, we actually identified more than 100 indicators that were harmonised with data that we could actually report across the life course. We didn't actually go into this work thinking that inequalities would emerge markedly during adolescence, we thought it would actually exist all across the life course. But when we mapped out the data, what it really shows is that it's during adolescence where inequalities most markedly emerge. 

Peter Azzopardi: [00:41:34] To orientate you to this graph, these are key stages of the first two decades of life: under one year, zero to four, five to nine, 10 to 14, 15 to 19. This is on a log scale, and so anything on this side here means it's more common in males compared to females. And anything on this side here means it's more common in females than it is for males. And each coloured dot represents a country for which we are able to access data for and there are 40 countries here. But you can see that when you line them up and again we included all the indicators that we could, and these indicators were defined, I think we had input from more than one hundred stakeholders from across the region that work in gender and programing and child health and adolescent health, so we weren't biased towards adolescent health indicators, but when we lined them all up, you can see it's clearly in adolescence where, you know, these inequalities most markedly emerge. And if we really focus down on this, you can see that there are some indicators like child marriage, for example, that I think we often assume it to be a female-specific issue. We know that in many countries young boys are also married as children as well. But by and large, it does impact on girls more than it impacts on boys. And we can see that there are really important risk factors that are such as tobacco smoking and binge drinking, which also have very gendered patterns, and where males are at excess risk compared to females. But you can see that there are some countries here in Central Asia where the gender disparities are nowhere near as marked as you would expect. And you can see that there are some really important differences as well. So, for example, not being in secondary school there's a very mixed pattern compared to the region that we're living in. So I think this was a really important piece of work in terms of informing what dimensions of gender inequality should be measured and reported. 

Peter Azzopardi: [00:43:47] We're doing some work at the moment with UNFPA. So UNFPA is the UN agency, which is really responsible for population health, and they lead efforts really around sexual reproductive health and rights at a global and regional level. And we've been partnering with them to really understand some of the inequities that exist around key indicators of sexual reproductive health and rights. This has been a two-year project, we're just at the end of this as well. What we've done is we're using the Guttmacher framework for sexual and reproductive health and rights. We've defined 40 indicators, and we've pulled this data together for 18 countries and explored them in detail by geography, by age, by wealth, by education and by location of residence. And so each country has a very detailed country-led report that details all these indicators. These are the ones around fertility. And you can see Myanmar, this is Timor-Leste and this is Indonesia, this is Papua New Guinea, this is Lapita. And you can see just the profound differences within a country by geography and the very different patterns by age and by wealth and by education by residence. And so this has already proven to be really useful in the current COVID pandemic to help work with countries to think about where they need to be prioritising efforts, where do the inequities already largely exist, where in the country, for example, was this indicator already, for example fertility where was already high to really focus efforts in the context of limited resources to maximize benefit.

Peter Azzopardi:[00:45:35] I think it's one thing to point out where all the issues of data are clearly an important part of the task as well, is to inform better quality data. And it's something that we've made a pretty strong commitment to in our group as well. And I just want to share one project here, and this is the last thing I want to talk about. We're doing a project in partnership with UNFPA again to understand contemporary pathways to adolescent pregnancy. And so the important context here is that for a long time, the assumption has been that very young adolescents are married with children. So that child marriage is the driver of adolescent pregnancy in many countries, whereas we know increasingly that in many countries where child marriage is not all that high, that adolescent pregnancy remains. And we've actually seen, despite quite a bit of work at addressing child marriage in many countries, a pretty much a plateauing of adolescent pregnancy in many countries across the world. So what we're doing in partnership with four countries, so we're doing this work in Malaysia, Indonesia, Laos and Cambodia is a series of in-depth qualitative interviews using a timeline method to actually understand the timeline, the pathway to that young person becoming pregnant. We're going to be doing this with 140 young people in each country, so it's quite a large task. And using this data and this information to then identify what may be some common pathways and common determinants of adolescent pregnancy, which we will then translate into a set of quantitative tools and measures which can then be embedded in national surveys. So it's trying to really inform what should a contemporary set of measures for adolescent pregnancy should look like in 2021 and beyond? 

Peter Azzopardi: [00:47:54] Thank you. I can't see if anyone's still on the call, I hope some of you are anyway. I hope you've enjoyed it was a bit of a quick tour of some of the work that we've been doing and a bit of an overview of the adolescent health measurement landscape globally. If I can leave you with one last thought. It really is what gets measured and reported gets done and just really highlighting the importance of measuring and reporting adolescent health as a really important foundation to effective policy action. 

Kate Steinbeck: [00:48:25] Thank you, Peter. Indeed, that was a great presentation. And we've got time for a couple of questions and I'm just going to find the first one which came from Lena Sanchi. "Great presentation, Peter. Just wondering about a survey of youth groups in high-income countries, which groups within these as needs are different across different groups on the basis of vulnerability factors?" 

Peter Azzopardi:[00:49:08] Yeah, really great question, Lena. I suppose what you're referring to is the effort with the GAMAH initiative where we sought to bring in inputs from young people. You're right, I don't think we were able to access all of the groups that we would like to. But certainly this was a really important first step in terms of defining priority areas for adolescent health measurement. I'm really pleased that we were able to include the views of young people in all of this. We did the best that we could to ensure diversity of response. So we had the survey translated into six languages, the six formal U.N. languages, and we used our own networks to actually ensure that this was disseminated as broadly as it could be. 

Kate Steinbeck: [00:50:14] And the next question is from Louise Baur, it's on morbidity and adolescence: "Obesity, increasing prevalence, especially in the AYA age groups. Great to see that the youth reps want weight stages to be recorded. However, it seems to be under-recognised to date, particularly also because it is seen as a risk factor and not just a disease." 

Peter Azzopardi: [00:50:45] It's a really good question Louise, and I think that there are a couple of other issues like adolescent pregnancy, for example, where some people like myself, I would frame adolescent pregnancy as a life stage, whereas others may frame it more as a risk and some people may frame it as an outcome. I think you're absolutely right, though, that adolescent obesity, whether you classify it as a risk or an outcome, has not been an appropriate focus of global health policy. It astounds me, for example, that the Sustainable Development Goals have a focus on childhood obesity, and childhood underweight, but not on adolescent obesity. And there was a linked comment actually that accompanies the paper that we just published, which actually brought a focus to that very element. I know that there is a lot of work happening in the adolescent obesity space, and I know that there's some really important work that's about to land globally and that will help continue to bring a greater emphasis on addressing adolescent obesity.

Kate Steinbeck: [00:52:07] And Louis Baur is the president-elect of World Obesity so a great person to know. Thanks. And we also have a question from James McDougal. "Peter, where would you want to see the conversation about adolescent health data head next in Australia, in the region, and internationally?"

Peter Azzopardi: [00:52:36] It's a really great question, James. It's something we've been thinking a lot about. So if I think about Australia, the work that I do in Australia mostly has a focus on Aboriginal and Torres Strait Islander young people's health, but I think that the work that we do in that sphere could certainly more broadly be applied to think about adolescent health and wellbeing more broadly. We've just launched a new program, it's a road map to Aboriginal and Torres Strait Islander adolescent health and it's a NHMRC four year funded, two million dollar project where we're really establishing what are the priority areas of need for Aboriginal and Torres Strait Islander adolescent health and what are the priority areas for action. But a big focus within that is what data do we need and how does it need to be captured. We are answering that question by assembling a governance group of young people from across the nation and really being led by young people, them telling us what's important to them and what are some ways that we can capture that data. I think that's an approach that could work in other settings as well. I think that if you look at the data that we have currently, if you think about the sort of broad groups of health metrics, we've got some good data on some health risks, we've got some data on some elements of health outcome. We probably have poorer data on determinants. And I think we have pretty dismal data on health system response and on the adequacy of health system response. This is particularly at a global and a regional level. So I think that in terms of the answer to that question, I think that we need to be guided by young people, key stakeholders, but also that we can look at what we already have assembled and you can see where some of the big gaps are. 

Kate Steinbeck: [00:54:44] I think we're almost out of time, but I would actually like to ask you two questions. The first one is, is there any indicator that you think is missing that you would like to see there? Again, there's an enormous amount of data and it looks very comprehensive when you imagine adolescents' lives. That was the first one. And the second question, which troubles me a lot, why do you think adolescents remain so ignored? Why do you think we are still struggling with that? 

Peter Azzopardi: [00:55:31] Two great questions, Kate, I think the first question for me is the set of indicators I think that are missing are measures of well-being from the perspective of young people. There's been some really good work that's been happening in this space, but I think that we still don't have the data there to be able to monitor well-being from the perspective of adolescents and young people, and I think that's really important and the determinants as well. It's interesting, we're doing a separate project looking at how we can implement mental health and psychosocial support services across the Asia-Pacific region. If we think that data on mental health outcomes is poor, when you look at some of the determinants of mental health across the region there is pretty much little to nothing there at all. So I think that there are a bunch of indicators that we need to think about. 

Peter Azzopardi: [00:56:34] Why are adolescents ignored? I think that for a big part of it, this is at a global level. I think that it was absolutely the right thing to actually focus on under five mortality, maternal mortality back when the Millennium Development Goals were framed, because that was where many communities were experiencing high rates of mortality. But we have continued with that focus and I think that despite the substantial changes that we've seen in epidemiology and substantial change, we've seen a huge reduction in communicable diseases, we've seen non-communicable diseases emerge and injuries emerge, we haven't really caught up with all of that. And I think adolescence is a really important developmental stage for addressing these important issues. And I think as well, they kind of follow each other, you need indicators and data to prioritize funding, but you need funding to actually do any work in adolescent health. And I think that it's pleasing to see that the last couple of years have seen kind of a correction of that. And I think there are now opportunities globally to do work in adolescent health. And I hope that will just continue to improve.

Kate Steinbeck: [00:57:51] I would imagine everyone who's on this thing would agree with that. I'm just going to ask you one last question from Liz Elliott, who says, "I'm working with an adolescent cohort in very remote Australia. How can we adequately represent their needs which are so unique?" 

Peter Azzopardi: [00:58:15] I'm not sure if I understand your question Liz, but I suppose the fact that you are working with them sort of demonstrates that there's an opportunity to actually represent their needs. I suppose that's part of the challenge that often populations in very remote areas aren't engaged in broader research initiatives, and their needs aren't met. It's interesting as well. While the focus of my talk has largely been quantitative data, I think there's an incredible strength to qualitative data and it really enables young people to express key issues in ways that otherwise may not be able to be captured in data. And something that we've tried to do in many of our research studies is to try to embed a qualitative and quantitative approach together so that you don't lose the depth that's possible through qualitative inquiry. But you then also have the quantitative element, which is then able to give you more of a population perspective. I'm not sure if I've answered your question, but you saw my email there, so I would be very happy to have a follow up conversation any time. 

Kate Steinbeck: [00:59:43] Look, I think we're going to have to call it to an end Peter. Thank you very much for joining us for a fantastic talk and to our audience for being so interactive. I've just got another question. Yes. The webinar is being recorded. I think I forgot to say that, and the slides will be shared. And Peter, I think we'll be asking you back again maybe to talk about your work in indigenous health. Thank you again, everyone. 

Peter Azzopardi: [01:00:16] Thank you so much.