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Aggressive reactions to peer victimization may be tempered by hormone levels. Grounded on the dualhormone hypothesis (DHH), which proposes that testosterone (T) is associated with aggressive behavior only when cortisol (C) is low, this study assessed whether the combination of T and C moderated adolescents’ aggressive responses to peer victimization. The study involved 577 adolescents (50.4% girls, aged 12–17 years), who completed measures of online and offline victimization and perpetration of aggressive behavior in three waves over the course of one year. Moreover, they provided salivary samples to measure T and C levels. Multilevel analyses showed a three-way interaction between T, C, and victimization levels for both online and offline aggressive behaviors. In both cases, the adolescents with high T and high C or low T and low C responded with more aggressive behaviors when victimized or provoked by peers. The T/C ratio was only associated with aggressive behavior in the girls’ sample. The results are opposite to those predicted by the DHH, but they are consistent with the findings of other studies that examined aggressive behaviors as reactions to provocations. These results suggest that some combinations of T and C predict higher aggressive reactions to peer victimization.
The emergence of non-communicable diseases (NCDs) in childhood poses a serious risk to a healthy adult life. The present study aimed to estimate the prevalence of NCDs among children and adolescents in slums and non-slums areas of four metropolitan cities of India, and in rural areas of the respective states The study further, investigated the effect of the place residence as slum vs. non-slum and other risk factors of the NCDs. Nationally representative data from the Comprehensive National Nutrition Survey (CNNS) was used.. Estimates were based on children (5-9 years) and adolescents (10-19 years) for whom biomarkers predicting diabetes, high total cholesterol, high triglycerides and hypertension were determined. Weight, height and age data were used to calculate z-scores of the body mass index. Overweight and obesity was higher in urban areas than in rural areas among children and adolescents. Regional differences in the prevalence of diseases were observed; children in Delhi and Chennai had a higher likelihood of being diabetic while children in Kolkata were at a greater risk of high total cholesterol and high triglycerides. The risk of hypertension was strikingly high among non-slum children in Delhi. Children from slums were at a higher risk of diabetes compared to the children from non-slums, while children and adolecents from non-slums were at a greater risk of high triglycerides and hypertension respectively than their counterparts from slums. Male children and adolecents had a higher risk of diabetes and high cholesterol. Screening of children for early detection of NCDs should be integrated with the already existing child and adolescent development schemes in schools and the community can help in prevention and control of NCDs in childhood.
Youth violence has become a worrying public health issue worldwide. In Europe and the USA, research has shown a prevalence of this phenomenon ranging from 30 to 70% in boys.
This descriptive study aimed to evaluate psychological profiles of male adolescents involved in fights with their peers.
Identity consolidation was evaluated with the Self-Concept and Identity Measure; defence strategies were assessed by the Response Evaluation Measure for Youth; emotion regulation was assessed with the Difficulties in Emotion Regulation Scale and mentalisation capacity was evaluated by the Reflective Functioning Questionnaire.
Through a series of multivariate analyses of variance, our results showed that adolescents reporting four or more fights in the past year, when compared with peers reporting none or fewer than four fights, displayed lower identity consolidation, greater use of immature defence strategies, poorer emotion regulation processes and poorer mentalisation capacity.
The results of this study could be useful for the promotion of prevention and intervention programmes to stem fights among adolescents.
The present study examined high-risk personality traits and associations with psychopathology across multiple levels of a hierarchical-dimensional model of psychopathology in a large adolescent, general population sample. Confirmatory factor analyses were run using data from two randomized controlled trials of Australian adolescents (N = 8,654, mean age = 13.01 years, 52% female). A higher-order model – comprised of general psychopathology, fear, distress, alcohol use/harms, and conduct/inattention dimensions – was selected based on model fit, reliability, and replicability. Indirect-effects models were estimated to examine the unique associations between high-risk personality traits (anxiety sensitivity, negative thinking, impulsivity, and sensation seeking) and general and specific dimensions and symptoms of psychopathology. All personality traits were positively associated with general psychopathology. After accounting for general psychopathology, anxiety sensitivity was positively associated with fear; negative thinking was positively associated with distress; impulsivity was positively associated with conduct/inattention; and sensation seeking was positively associated with alcohol use/harms and conduct/inattention, and negatively associated with fear. Several significant associations between personality traits and individual symptoms remained after accounting for general and specific psychopathology. These findings contribute to our understanding of the underlying structure of psychopathology among adolescents and have implications for the development of personality-based prevention and early intervention programs.
The present study identified dietary patterns (DP) and analyze their association with household composition. This is a cross-sectional school-based study, with a nationally representative sample of Brazilian adolescent students, aged 11-19 years-old, with data from National School Health Survey (N= 102,072). The independent variable was household composition. Food consumption was obtained through the weekly frequency of consumption of food markers and the Confirmatory Factor Analysis was applied to examine the latent variables “Healthy” (beans, legumes/vegetables, and fresh fruit/fruit salad) and “Unhealthy” (ultra-processed foods, sweets, soft drinks, and snacks) DP. The association between household composition and DP was estimated using multiple linear regression models, considering lives with both parents as reference category. Among adolescents aged 11-14-years-old, adherence to Healthy DP was lower for boys who lived only with mother (β=-2.1); and boys (β=-4.9) and girls (β=-4.5) who lived without any parents. Adherence to Unhealthy DP was higher among boys (β=7.6) and girls (β=6.0) who lived only with mother, and boys (β=4.6) and girls (β=5.3) who lived only with father. For older adolescents (15-19-years-old), adherence to the Unhealthy DP was higher among boys who lived only with mother (β=3.9) or only with father (β=5.3) and girls who lived only with mother (β=6.3). Adherence to Healthy DP was lower among girls who lived only with father (β=-9.0). Thus, adolescents who lived in single-parent households had lower adherence to healthy DP and greater adherence to unhealthy DP. Among younger adolescents of both sexes, living without any parent contributed to lower adherence to healthy DP.
Maternal diet during pregnancy has been associated with obesity among offspring. The extent to which trimester-specific dietary patterns are associated with markers of adiposity during adolescence remains unclear. We examined associations between prenatal diet patterns with adolescent offspring measures of adiposity and adipokines in 384 mother–adolescent dyads from the Mexico City ELEMENT cohort. Trimester-specific diet patterns were derived from principal component analysis of food frequency questionnaire data. Adolescent anthropometry and serum leptin and adiponectin were measured at 10–17 years. Three maternal diet patterns were identified: Prudent Diet (PD), high in fish and vegetables, the High Meat and Fat Diet (HMFD), high in pork and processed meats, and the Transitioning Mexican Diet (TMD), high in corn tortillas and sugar-sweetened beverages. Multiple linear regression was used to estimate sex-stratified associations among quartiles of diet patterns with adiposity and adipokines, adjusting for maternal marital status, education, and parity. First trimester TMD was associated with greater anthropometric measures and higher leptin in females, while third trimester HMFD was associated higher body fat percentage, triceps thickness, waist circumference, and leptin, but lower adiponectin among males. Contrary to expectation, there were positive associations between the trimester 1 PD pattern and anthropometric measurements in females, and for trimester 2 HMFD and TMD patterns with adipokines among males. Findings suggest maternal diet patterns may influence offspring adiposity markers during adolescence in a sex-specific manner.
The genetic load for major depressive disorder (MDD) may be higher in people who develop MDD earlier in life. This study aimed to investigate whether the parents of adolescents with MDD were more likely to have MDD, bipolar disorder (BD), schizophrenic disorder (SZ), alcohol use disorder, or substance use disorder than the parents of adolescents without MDD. We also examined whether the response to antidepressant treatment predicted the likelihood of parental psychiatric disorders.
In all, 1,758 adolescents aged 12–19 years with antidepressant-resistant depression, 7,032 (1:4) age-/sex-matched adolescents with antidepressant-responsive depression and 7,032 (1:4) age-/sex-matched controls were included. Parental psychiatric disorders of individuals enrolled were assessed.
The parents of the adolescents with MDD were more likely to be diagnosed with MDD, BD, SZ, alcohol use disorder, or substance use disorder than the parents of the control group. The parents of adolescents who were antidepressant resistant and the mothers of adolescents who were either treatment resistant or treatment responsive were more likely to be diagnosed with a psychiatric disorder.
Our study demonstrated that parents of adolescents with MDD may be more likely to be diagnosed with MDD, BD, SZ, alcohol use disorder, or substance use disorder than parents of adolescents without MDD, suggesting the within-disorder transmission and cross-disorder transmission of these psychiatric disorders. Furthermore, the parent’s sex and the response to antidepressant treatment may affect the within-disorder transmission of MDD.
Recent investigations of adolescents’ beliefs about risk have led to surprisingly optimistic conclusions: Teens’ self estimates of their likelihood of experiencing various life events not only correlate sensibly with relevant risk factors (Fischhoff et al., 2000), but they also significantly predict later experiencing the events (Bruine de Bruin et al., 2007). Using the same dataset examined in previous investigations, the present study extended these analyses by comparing the predictive value of self estimates of risk to that of traditional risk factors for each outcome. The analyses focused on the prediction of pregnancy, criminal arrest, and school enrollment. Three findings emerged. First, traditional risk factor information tended to out-predict self assessments of risk, even when the risk factors included crude, potentially unreliable measures (e.g., a simple tally of self-reported criminal history) and when the risk factors were aggregated in a nonoptimal way (i.e., unit weighting). Second, despite the previously reported correlations between self estimates and outcomes, perceived invulnerability was a problem among the youth: Over half of the teens who became pregnant, half of those who were not enrolled in school, and nearly a third of those who were arrested had, one year earlier, indicated a 0% chance of experiencing these outcomes. Finally, adding self estimates of risk to the other risk factor information produced only small gains in predictive accuracy. These analyses point to the need for greater education about the situations and behaviors that lead to negative outcomes.
There is a broad spectrum of dietary supplements (DS) and their accessibility worldwide. However, little is known about the prevalence of DS use among Bangladeshi adolescents. This study estimates the prevalence, correlates and common conditions related to DS use.
A cross-sectional, convenient sampling strategy was adopted using an interviewer-administered, structured questionnaire.
Kurigram and Patuakhali districts of Bangladesh.
702 adolescents aged 10–19 years.
The overall prevalence of DS use was 83 %. The majority of participants (93·4 %) agreed that DS were good for health, and 28·3 % reported general health and well-being as the reason for using DS. The most frequently used supplements were multivitamins (38·6 %) and Ca (37 %). DS use was more common among adolescents who had ≤5 siblings, good health status, no chronic diseases, a positive impression that DS are good for health and who had the tendency to encourage DS to others. DS use was also higher among those who received DS information from healthcare providers, professional literature, friends, family and relatives.
The prevalence of DS use is relatively higher among Bangladeshi adolescents compared to Bangladeshi adults and adolescents from other countries, highlighting the inclination towards DS use. Guidelines for safe DS use for adolescents are warranted to control DS use and prevent adverse effects.
To examine energy drink consumption among adolescents in the UK and associations with deprivation and dietary inequalities.
Quantitative dietary and demographic data from the National Diet and Nutrition Survey (NDNS) repeated cross-sectional survey were analysed using logistic regression models. Qualitative data from semi-structured interviews were analysed using inductive thematic analysis.
Quantitative data: nationally representative sample of 2587 adolescents aged 11–18 years. Qualitative data: 20 parents, 9 teachers and 28 adolescents from Hampshire, UK.
NDNS data showed adolescents’ consumption of energy drinks was associated with poorer dietary quality (OR 0·46 per sd; 95 % CI (0·37, 0·58); P < 0·001). Adolescents from more deprived areas and lower income households were more likely to consume energy drinks than those in more affluent areas and households (OR 1·40; 95 % CI (1·16, 1·69); P < 0·001; OR 0·98 per £1000; 95 % CI (0·96, 0·99); P < 0·001, respectively). Between 2008 and 2016, energy drink consumption among adolescents living in the most deprived areas increased, but decreased among those living in the most affluent neighbourhoods (P = 0·04). Qualitative data identified three themes. First, many adolescents drink energy drinks because of their friends and because the unbranded drinks are cheap. Second, energy drink consumption clusters with other unhealthy eating behaviours and adolescents do not know why energy drinks are unhealthy. Third, adolescents believe voluntary bans in retail outlets and schools do not work.
This study supports the introduction of age-dependent legal restrictions on the sale of energy drinks which may help curb existing socio-economic disparities in adolescents’ energy drink intake.
Cardiac arrest prevention in schools has recently gained momentum. The survival benefit in schools who have access to defibrillators is clear, with far better survival outcomes in children or adults who sustain a cardiac arrest on school grounds. The main objectives of this study were to assess sudden cardiac arrest prevention in Maltese schools, specifically the availability of defibrillators and staff competence in delivering resuscitation.
Methodology and results:
An online-based questionnaire was distributed to all secondary schools across the Maltese archipelago. Data were collected, tabulated, and analysed using SPSS V.23. Most schools (n = 40, 74.1%) completed the questionnaire. Two schools documented a cardiac arrest in the past 10 years. 87.5% agreed that cardiac arrest prevention is an important health topic. Most have a defibrillator on the premises (n = 37, 92.5%). Only one defibrillator is usually available (n = 27, 75.0%). Despite the majority claiming its ease of accessibility (n = 35, 97.2%), most were not available on every floor (n = 37, 97.2%). Only one-third were close to a sporting facility (n = 11, 30.6%). Schools do not organise regular resuscitation courses (n = 21, 58.3%), with eight schools having five or more certified staff members (23.5%). The number of defibrillators did not influence the frequency of resuscitation courses at school (p = 0.607), and there was no association with the number of certified individuals (p = 0.860).
Defibrillators are not readily available at secondary schools and are often installed in low-risk areas. Most schools have only one staff member certified in resuscitation. These factors should be addressed with urgency.
The assessment of resilience as an outcome in adolescents remains a challenge, with few instruments available. Some studies have focused on risk factors, but few have focused on protective factors as a formula for measuring resilient outcomes.
To adapt a new Suicide Attempt Resilience Scale (SRSA-18) for use with adolescents, analysing its structural validity, the gender and age invariance of the measure, and divergent and convergent validity, together with its reliability.
The psychometric properties of the scale were assessed in 628 participants aged between 13 and 18 years, of whom 342 (54.5%) were girls.
After a process of adaptation for adolescents, exploratory and confirmatory factor analysis yielded a three-dimensional structure with adequate goodness-of-fit indices, invariance of the measure according to gender and age, adequate levels of reliability (ω = 0.91), high convergent validity with the 14-Item Resilience Scale and high divergent validity with the suicidal act/planning subdimension of the Adolescent Suicidal Behavior Assessment Scale.
There is a need to create and adapt instruments to measure resilience in some populations with high psychosocial vulnerability as a key aspect for measuring the impact of prevention and mental health promotion programmes in adolescents.
Providing the healthiest and safest environment in the first 1,000 days of life is the greatest gift which parents can give to their children. We return to the theme of control over our lives to ask who is in control of this gift, and whether today’s medicine and public health hold the answers. We explore the dilemmas facing today’s governments and the decisions that individuals make in terms of personal responsibility when maternal and child health are not prioritised by health policy-makers. We discuss sexual and reproductive rights, why women’s health has not been prioritised – especially during the pandemic – and reasons for high maternal mortality in some countries. We offer an optimistic close to the book; a call to action. We explain that, while planning for parenthood is important, the actions needed do not have to be sustained over a long period. We emphasise the many opportunities which adolescents and young people can seize as the parents of the future. This hope can generate the resolve to make the first 1,000 days of life as good as possible for the next generation. Knowing the secrets of our first 1,000 days is a vital part of this.
To examine changes in the proportions of daily, weekly and occasional consumers of sugar-sweetened soda in six European countries that introduced/updated a tax between 2001–2002 and 2017–2018 and in neighbouring comparison countries (without a tax).
Repeated cross-sectional surveys.
Health Behaviour in School-aged Children study, spanning five survey years (school years 2001–2002 to 2017–2018).
Nationally representative samples of 13-year- and 15-year-old adolescents (n 236 623, 51·0 % girls).
Tax sizes (€0·02/l to €0·22/l) and pre-tax soda consumption were heterogeneous across countries. Prevalence of daily soda consumption reduced in the survey year following tax implementation in Latvia (from 17·9 to 11·9 %, P = 0·01), Finland (4·2 to 2·5 %, P = 0·001), Belgium (35·1 to 27·8 %, P < 0·001) and Portugal (17·4 to 14·9 %, P = 0·02), but not in Hungary (29·8 to 31·3 %, P = 0·47) or France (29·4 to 28·2 %, P = 0·27). However, reductions were similar (Finland) or smaller (Belgium, Portugal) than those in the comparison countries, except in Latvia where the reduction was larger (Pinteraction < 0·001). Prevalence of weekly soda consumption remained stable (Finland, Hungary and France) or increased (Latvia, Belgium); only Portugal experienced a decline (P < 0·001), which was larger than in the comparison country (Pinteraction < 0·001). Prevalence of occasional soda consumption (<1x/week) did not rise after implementation of the tax in Latvia, Finland, Hungary, France or Belgium, or the rise was similar to the comparison country in Portugal (Pinteraction = 0·15).
Countries with a soda tax did not experience larger beneficial changes in post-tax adolescent consumption frequency of soda than comparison countries. Further studies, with different taxation types, are needed in the adolescent population.
This study aimed to investigate gender differences in social environmental factors of psychological distress among Indonesian adolescents.
This was a cross-sectional study using the data from the 2015 Indonesia Global School-based Student Health Survey. Binary logistic regression was used to assess the influences of main independent variables – social environmental factors (i.e., peer support, having close friends, bullying victimisation, physical fight, physical attack, parental supervision, connectedness, bonding), demographic characteristics, and health-related behaviours on the measures of psychological distress (loneliness, anxiety-induced sleep disturbance, and a combination of both measures as psychological distress).
The prevalence of psychological distress measured as loneliness, anxiety-induced sleep disturbance, and combined psychological distress was 6.12%, 4.52%, and 8.04%, respectively. Findings from multivariate analyses indicated that bullying victimisation, physical attack, experience of hunger (a proxy of socioeconomic status), and sedentary behaviour were associated with all measures of psychological distress. Meanwhile, age, gender, drug use, parental connectedness and bonding, and having no close friends were correlates of one or two measures of psychological distress. Based on gender-stratified analyses, experience of hunger, sedentary behaviour, bullying victimisation, and having no close friends were consistently associated with measures of psychological distress among both girls and boys. In addition, the influence of some social environmental factors, such as parental connectedness, peer support, and physical attack, were more salient among girls.
The findings suggest that social environmental factors, demographic characteristics, and health-related behaviours were associated with psychological distress, and the associations appeared to differ by gender. Interventions that include improving positive social environmental factors (e.g., reducing interpersonal violence, encouraging positive relationships with parents and peers) and promoting healthy behaviours (e.g., less sedentary behaviour, preventing substance use) might help reduce the risk of psychological distress among Indonesian adolescents.
The objective of this research was to determine if, based on gender, adolescents were exposed to different marketing techniques that promoted food and beverages over social media.
A secondary analysis of adolescent boy (n 26) and girl (n 36) exposures (n 139) to food and beverage marketing was conducted. Mann–Whitney U and Fisher’s exact tests were conducted to compare the number, healthfulness and the marketing techniques of exposures viewed by boys and girls.
Ottawa, Ontario, Canada.
Sixty-two adolescents aged 12–16 years.
Boys and girls were exposed to similar volumes of food marketing instances (median = 2 for both boys and girls, Mann–Whitney U = 237, P = 0·51) per 10-min period of social media use. More girls viewed products that were excessive in total fat compared to boys (67 % v. 35 %, P = 0·02). Boys were more likely to view instances of food marketing featuring a male as the dominant user (50 % v. 22 %, P = 0·03), appeals to achievement (42 % v. 17 %, P = 0·04), an influencer (42 % v. 14 %, P = 0·02) and appeals to athleticism (35 % v. 11 %, P = 0·03), whereas girls were more likely to view instances of food marketing featuring quizzes, surveys or polls (25 % v. 0 %, P = 0·01).
Food and beverage companies utilise marketing techniques that differ based on gender. More research examining the relationship between digital food and beverage marketing and gender is required to inform the development of gender-sensitive policies aimed at protecting adolescents from unhealthy food marketing.
Adolescence is a period of life when dietary patterns and nutrient intakes may greatly influence adult fatness. This study assesses the tracking of energy and nutrient intakes of Ho Chi Minh City adolescents over 5 years. It explores the possible relationships between energy and the percentage of energy from macronutrients with BMI.
Height, weight, time spent on physical activity, screen time and dietary intakes were collected annually between 2004 and 2009 among 752 junior high school students with a mean age of 11·87 years at baseline. The tracking was investigated using correlation coefficients and weighted kappa statistics (k) for repeated measurements. Mixed effect models were used to investigate the association between energy intakes and percentage energy from macronutrients with BMI.
There were increases in the mean BMI annually, but greater in boys than in girls. Correlation coefﬁcients (0·2 < r < 0·4) between participants’ intakes at baseline and 5-year follow-up suggest moderate tracking. Extended kappa values were lowest for energy from carbohydrate (CHO) in both girls and boys (k = 0·18 & 0·24, respectively), and highest for protein in girls (k = 0·47) and fat in boys (k = 0·48). The multilevel models showed the following variables significantly correlated with BMI: CHO, fat, percentage of energy from CHO, fat, time spent for moderate to vigorous physical activity, screen time, age and sex.
The poor to fair tracking observed in this cohort suggests that individual dietary patterns exhibited in the first year are unlikely to predict energy and nutrient intakes in the fifth year.
This paper explores the role that sensitively portrayed literary representations of hallucinations and dissociation may have in counteracting stigma associated with these experiences. In it, we focus on narratives of young people experiencing hallucinatory and dissociative phenomena in two award-winning, young adult novels: How It Feels to Float by Helena Fox and A Monster Calls by Patrick Ness. We identify and discuss three literary devices in these two novels that promote empathy for the characters and their experiences. The narrative accounts in both novels challenge conceptions of hallucinations and dissociation as unknowable and unrelatable experiences with their empathic portrayals of relatable characters that create comprehensible accounts of adolescents grappling with their sense of reality. Importantly, they highlight the potential role that literature can play in stigma reduction by positively shaping young peoples’ understandings of unfamiliar mental health experiences.
The Keyhole is an internationally recognised front-of-pack nutrition label, guiding consumers to healthier food options. It indicates products in accordance with specific criteria for dietary fats, sugars, fibres, salt and wholegrains. The objective of this study was to simulate the potential impact of the Keyhole on adolescents’ energy and nutrient intakes by modelling a shift from reported food intakes to foods meeting the Keyhole criteria.
Self-reported dietary intake data were derived from a cross-sectional survey. Multiple replacement scenarios were calculated, where foods meeting the Keyhole criteria replaced reported non-compliant foods with varying proportions of replacement.
Dietary survey ‘Riksmaten Adolescents 2016–2017’ in schools across Sweden.
A nationally representative sample of 3099 adolescents in school years 5, 8 and 11 (55 % girls).
Overall, replacement with foods meeting the Keyhole criteria led to more adolescents meeting nutrition recommendations. Largest median intake improvements were seen for wholegrains (+196 %), SFA (-13 %), PUFA (+17 %) and fibres (+15 %). Smallest improvements were seen for free sugars (-3 %) and salt (-2 %), partly explained by the ineligibility of main food sources of free sugars for the Keyhole, and non-inclusion of ready meals that are often high in salt. Most micronutrient intakes were stable or improved. Unintentional effects included decreases in vitamin A, MUFA and energy intakes. Largest potential improvements in fat and fibre sources were observed in the youngest age group.
A shift to Keyhole alternatives for everyday foods would improve adolescents’ nutrient intakes, even with smaller exchanges.
Indian adolescents experience body dissatisfaction. However, empirically supported interventions are lacking, particularly in lower socio-economic regions of India. This paper describes the acceptability testing of a six-session teacher-led comics-based intervention, aiming to improve body image and related outcomes among adolescents in Indian Hindi medium schools.
Thirty-five students (50% girls; Mage, girls = 12.3 years; Mage, boys = 13 years) and nine teachers (11% women) from Hindi medium schools in Rajasthan, India, completed a quantitative acceptability questionnaire regarding comics that target body dissatisfaction and associated risk factors. They also participated in online or telephone semi-structured interviews to share in-depth feedback, with teachers providing additional feedback on an accompanying teacher guide. The quantitative data were analysed descriptively, with the interviews analysed using qualitative codebook thematic analysis.
Quantitative analyses revealed that 73% of students felt the comics made them feel good about themselves. Qualitative analyses revealed four themes: (1) body dissatisfaction is a concern; (2) the comics are powerful; (3) increasing ease of understanding; (4) a teacher guide to aid delivery.
This study demonstrates acceptability of a novel teacher-led comics-based body image intervention for adolescents in Indian Hindi medium schools from lower socio-economic settings. These findings are currently informing intervention optimizations, which will be evaluated in a randomized controlled effectiveness trial. If found to be effective, this intervention will be disseminated across eight Indian states by UNICEF. Trial registration. This trial has been registered with ClinicalTrials.gov; a database of privately and publicly funded studies conducted around the world. Registration date: 2nd May 2020; Registration ID: (NCT04317755). https://clinicaltrials.gov/ct2/show/NCT04317755?term=NCT04317755&draw=2&rank=1.